A multimodality approach Locoregional staging (T-staging) Systemic staging (N- & M-staging) Jung Hoon Kim. MD. Bijan Bijan, MD, MBA Department of Radiology Seoul National University Hospital Seoul, Korea Professor of Radiology & Nuclear Medicine (WOS) University of California Davis Sacramento, California Kim Jung Hoon & Bijan Bijan Society of Abdominal Radiology - 2016 Cholangiocarcinoma Imaging JHK: None BB: None Content Part-I • Introduction • Classification • T-Staging system • CT evaluation of resectability: Focus on perihilar Cholangiocarcinoma Part-II •MR Application in T-staging •DW Imaging Application •PET/CT & PET/MR Application •N-Staging / M-Staging •Conclusion Kim Jung Hoon & Bijan Bijan Society of Abdominal Radiology - 2016 Financial Disclosure Dx: Hilar Cholangiocarcinoma T2: Mod Hyper lesion MRCP-Cor: Hilar bil ductal narrwoing + Bilat BTD MRCP-Ax: Mult strictures at different segments DWI (1000): Area of hypoperfusion (=tumor infiltration) Better seen than T2 T2+DWI fusion: Hypoperfused mass IP-T1: Hypo mass Gd(Art/Ven/PV): Progressive-delayed enhancement (hypoperfused) Kim Jung Hoon & Bijan Bijan Society of Abdominal Radiology - 2016 MRA/MRV: Segmental HA /PV narrowing Bilat BTD MR Application in Cholangiocarcinoma Imaging DWI- Fundamentals • DWI evaluates tissue cellularity by measuring the impedance of water molecule diffusion within the tissue. •Higher impedance of water called Restricted Diffusion: Seen bright on DWI • Many tumors of high cellularity (eg: prostate cancer), display restricted diffusion. ADC- Fundamentals • Apparent diffusion coefficient (ADC) measures the magnitude of water molecule diffusion, and appears dark on ADC images. DWI/ADC Oncologic Application: 1. Lesion identification &characterization 2. Evaluation of loco-regional spread 3. Guide for targeted biopsy 4. Assessment of response to therapy 5. Evaluation for recurrence Kim Jung Hoon & Bijan Bijan Society of Abdominal Radiology - 2016 Part-II: Part-II: MR Application in Staging Intrahepatic Cholangiocarcinoma T-staging: Hilar Cholangiocarcinoma (Sloan-Kettering) TNM: Perihilar Cholangiocarcinoma Kim Jung Hoon & Bijan Bijan Society of Abdominal Radiology - 2016 TNM: Part-II: MR Application in Staging Intrahepatic Cholangiocarcinoma T-staging: Hilar Cholangiocarcinoma (Sloan-Kettering) TNM: Perihilar Cholangiocarcinoma Kim Jung Hoon & Bijan Bijan Society of Abdominal Radiology - 2016 TNM: •Biliary ductal dilatation •Hyperenhancement •Rim enhancement •Capsular enhancement (>50% of tumoral volume) (Art) •Target sign (HepBil phase): •Target sign (DWI): Point: Central enhancement + Central hypo + Hypo-enhancing rim Hyper rim DWI Target Appearance: Most reliable feature differentiating mass-forming ICC from small HCC Kim Jung Hoon & Bijan Bijan Society of Abdominal Radiology - 2016 MR Imaging Findings: Lobulated enhancing mass Hypointense Target sign 60 YM – Mass forming ICC • Gadoxetic Acid-Gd (Art Phase): •Gadoxetic Acid-Gd (HepBil Phase): •DWI (b; 800) Lobulated enhancing mass Hypointense Hi Signal with no Target sign DWI Target Appearance: Most reliable feature differentiating mass-forming ICC from small HCC Kim Jung Hoon & Bijan Bijan Society of Abdominal Radiology - 2016 57 YM – Mass forming ICC •Gadoxetic Acid-Gd (Art Phase): •Gadoxetic Acid-Gd (HepBil Phase): •DWI (b; 800) Round Hi SI with central low SI Rim enhancing mass Target: Central Hi & Rim Low SI Target sign DWI Target Appearance: Most reliable feature differentiating mass-forming ICC from small HCC Kim Jung Hoon & Bijan Bijan Society of Abdominal Radiology - 2016 55 YM – Mass forming ICC •T2: •Gadoxetic Acid-Gd (Art Phase): •Gadoxetic Acid-Gd(HepBil Phase): •DWI (b; 800) Round Hi SI Rim enhancing mass Homogenous Low SI Homogenous Hi SI DWI Target Appearance: Most reliable feature differentiating mass-forming ICC from small HCC Kim Jung Hoon & Bijan Bijan Society of Abdominal Radiology - 2016 61YM – Edmondson-II HCC •T2: •Gadoxetic Acid-Gd (Art Phase): •Gadoxetic Acid-Gd(HepBil Phase): •DWI (b; 800) Sources for misdiagnosis: •Lesion is too small •Lesion is hypervascular Kim Jung Hoon & Bijan Bijan Society of Abdominal Radiology - 2016 Typical features: •Capsular retraction •Satellite Nodules •Peripheral BDD 56 YM - C/o: CP 3y f/u MR: Dx: Pulm-CTA: flash enhancing hemangioma rim enhancing lesion + Capsular retractions + Delayed enhancement Cholangiocarcinoma Cholangiocarcinoma Mimicker Kim Jung Hoon & Bijan Bijan Society of Abdominal Radiology - 2016 3y 59 YM – Abnormal LFT - No Cirrhosis Gd: Diffuse, homogenous enhancement (T2: Artifactual) - Dx: Likely Hemangioma 28 month after: T2: Heterogeneous, larger lesion Gd: Heterogeneous enhancement Dx: Cholangiocarcinoma Cholangiocarcinoma Mimicker Kim Jung Hoon & Bijan Bijan Society of Abdominal Radiology - 2016 28 mon 64 YF – H/o: Cirrhosis – Routine surveillance CECT: Faint art enhancing area – No capsular contraction 38 months after: T2: Larger hypointense mass Gd: Irregularly enhancing mass without washout Dx: Cholangiocarcinoma Dx: Perfusion phenomenon? Cholangiocarcinoma Mimicker Kim Jung Hoon & Bijan Bijan Society of Abdominal Radiology - 2016 38 mon 64 y F – H/o: RCC & Breast CA T2: Small Hi-SI focus Gd: Art hyperenhancing focus + Delayed retention of contrast 2 years after: Gd: Capsular retraction + central hypo/rim enhancing Dx: Cholangiocarcinoma Dx: Perfusion phenomenon Cholangiocarcinoma Mimicker Kim Jung Hoon & Bijan Bijan Society of Abdominal Radiology - 2016 2y Part-II: MR Application in Staging Intrahepatic Cholangiocarcinoma T-staging: Hilar Cholangiocarcinoma (Sloan-Kettering) TNM: Perihilar Cholangiocarcinoma Kim Jung Hoon & Bijan Bijan Society of Abdominal Radiology - 2016 TNM: DWI addition to MRCP does NOT improve assessment of longitudinal extension. Kim Jung Hoon & Bijan Bijan Society of Abdominal Radiology - 2016 DWI addition to MRCP does NOT improve characterization of perihilar stricture. DWI addition to MRCP does NOT improve characterization of perihilar stricture. DWI addition to MRCP does NOT improve assessment of longitudinal extension. Kim Jung Hoon & Bijan Bijan Society of Abdominal Radiology - 2016 64YM – Chronic Cholangitis MRCP: Multifocal dilatation/strictures Gd: Segmental wall enhancement DWI (800): Hi @ stricture ADC: restriction at stricture: Suggested malignancy Bx: chronic inflammation DWI addition to MRCP does NOT improve characterization of perihilar stricture. DWI addition to MRCP does NOT improve assessment of longitudinal extension. Kim Jung Hoon & Bijan Bijan Society of Abdominal Radiology - 2016 60YF – Bismuth IIIa hilar CCA MRCP: Bilateral IH-BTD Gd: 1- Hilar duct thickening 2- R-2ndry duct enhancement DWI (800): Restriction Point: Combination of MRCP & Gd made the correct preop staging possible Point: 1- R-hilum 1- Hilum 2- R 2ndry duct confluence 1- Hilum 2- R 2ndry duct confluence 3- L-confluence (overestimated) Thick section along z-axis causes partial volume averaging: Over-estimation!!! DWI addition to MRCP does NOT improve characterization of perihilar stricture. DWI addition to MRCP does NOT improve assessment of longitudinal extension. Kim Jung Hoon & Bijan Bijan Society of Abdominal Radiology - 2016 75 YF- Bismuth IIIa hilar CCA MRCP: Involvement @ Gd: Enhancing wall @ DWI: Restriction @ Part-II: MR Application in Staging Intrahepatic Cholangiocarcinoma T-staging: Hilar Cholangiocarcinoma (Sloan-Kettering) TNM: Perihilar Cholangiocarcinoma Kim Jung Hoon & Bijan Bijan Society of Abdominal Radiology - 2016 TNM: SNR and CNR between Tumor & Liver drop Tumor SI increases •SNR, CNR, Tumor SI: DWI > T2 •As b-values increases: •As tumor differentiation decreases: ADC values decrease ADC values decrease Most efficient b value: 800 Lower ADC: Lower differentiation of Cholangiocarcinoma Kim Jung Hoon & Bijan Bijan Society of Abdominal Radiology - 2016 •As b-value increases: •As b-value increases: Point: Most efficient b value: 800 Point: Lower ADC: Lower differentiation of Cholangiocarcinoma Kim Jung Hoon & Bijan Bijan Society of Abdominal Radiology - 2016 56YM – Extrahepatic CCA (Poorly diff CCA) •T2 (Ax/Cor): Biliary Cut-off sign IH/EH-BTD Tumor: Mildly Hi •DWI: 100/300/500/800/1000: •As b increases: SNR & CNR drop (lower b: Better discrimination) •ADC: 0.89E-3 As b increases: Point: Most efficient b value: 800 Point: Lower ADC: CNR & SNR drop Lower differentiation of Cholangiocarcinoma Kim Jung Hoon & Bijan Bijan Society of Abdominal Radiology - 2016 75 YM – EH-CCA (Well-diff CCA) T2: Iso tumor DWI: 100/300/500/800/1000: ADC: 1.35 E -3 MRCP Sensitivity Specificity 95% 100% 73% 71% Accuracy 96% 73% PPV: NPV: 91% 91% 62% 63% Extra-hepatic Cholangiocarcinoma detection sensitivity : DWI > MRCP Kim Jung Hoon & Bijan Bijan Society of Abdominal Radiology - 2016 DWI Point: Extra-hepatic Cholangiocarcinoma detection sensitivity : DWI > MRCP Kim Jung Hoon & Bijan Bijan Society of Abdominal Radiology - 2016 55 YM-Extrahepatic Cholcangioca MRCP: CBD cut-off IH/EH-BTD DWI (500): HI-SI ADC: Low SI (1.3E-3) Sensitivity Specificity: Accuracy: PPV: NPV: DWI 91% 93% 92% 95% 87% > > > > > > MRCP 73% 65% 73% 81% 65% DWI > MRCP for DDx Malignant versus Benign Strictures Significant meanADC difference between Malignant vs Benign strictures Strictures: Malignant ADC < Benign ADC Kim Jung Hoon & Bijan Bijan Society of Abdominal Radiology - 2016 For DDx Malignant versus Benign Strictures: DWI > MRCP for DDx Malignant versus Benign Strictures Significant mean ADC difference between Malignant vs Benign strictures Strictures: Malignant ADC < Benign ADC Kim Jung Hoon & Bijan Bijan Society of Abdominal Radiology - 2016 69 YM – CHD CCA MRCP: Diffuse CHD irregularity & cut-off IH-BTD DWI (800): Hi-SI @ CHD with extension to LHD ADC: Low (1.1E-3) ? Malignant DWI > MRCP for DDx Malignant versus Benign Strictures Significant mean ADC difference between Malignant vs Benign strictures Strictures: Malignant ADC < Benign ADC Kim Jung Hoon & Bijan Bijan Society of Abdominal Radiology - 2016 38 YF – Distal CBD stricture (benign) MRCP: IH/EH-BTD Abrupt distal CBD cut-off: T2: Smooth circumferential thickening of distal CBD DWI (800): No diffusion restriction ADC: Hi-SI (1.8E-3) Part-II: MR Application in Staging Intrahepatic Cholangiocarcinoma T-staging: Hilar Cholangiocarcinoma (Sloan-Kettering) TNM: Perihilar Cholangiocarcinoma Kim Jung Hoon & Bijan Bijan Society of Abdominal Radiology - 2016 TNM: Part-II: MR Application in Staging Practical Checklist: Longitudinal & Radial Tumor spread US / CT / MR 2. Vascular Involvement US / CT / MR / PET 3. Lymph Node 4. Distant Metastases CT / MR(DWI) / PET Preoperative information: 1. Liver Volume 2. Anomalies: 1. Biliary 2. Arterial 3. Portal Vein 3. Coexisting disease Kim Jung Hoon & Bijan Bijan Society of Abdominal Radiology - 2016 1. Part-II: PET/CT & PET/MR Application FDG: A glucose which is taken up but is not metabolized Labeled with F18 (a positron emitter) Hyper-metabolic tissues pick it up – accumulate it by time Most malignancies are hyper-metabolic Most benign entities are hypo-metabolic Issues: Some malignancies are hypo-metabolic Some benign entities are hyper-metabolic A lesion in a hypermetabolic background: hard to see Hot organs: Brain/Heart/Kidney-GU Warm organs: Liver! Kim Jung Hoon & Bijan Bijan Society of Abdominal Radiology - 2016 PET (FDG)- Fundamentals Kim Jung Hoon & Bijan Bijan Society of Abdominal Radiology - 2016 40YF – IH-CCA FDG: Primary CCA: Segment 5/6 Satellite CCA: Segment 7 CT: Numerous pulmonary foci (not seen by FDG) Dx: Heterogonous/Ihyper mass Iso on delayed Hypermetabolic mass Mediastinal focus IH-CCA + Distant Met (No Radical Surgery) Kim Jung Hoon & Bijan Bijan Society of Abdominal Radiology - 2016 T2: Gd: FDG: Part-II: PET/CT & PET/MR Application Kim Jung Hoon & Bijan Bijan Society of Abdominal Radiology - 2016 PET (FDG) & Cholangiocarcinoma: Part-II: N-Staging Regional nodes (Along triad) Distant nodes: •Peri-aortic •Peri-caval •SMA •Celiac Conventional modalities for N-staging: US / CT / MR Criteria: •Size •Shaped •Architecture •Enhancement •Number Other modalities for N-staging: PET: Hypermetabolic node is abnormal regardless of size DWI: Diffused restriction in a node is sign of involvement Kim Jung Hoon & Bijan Bijan Society of Abdominal Radiology - 2016 Review of perihepatic lymphatics: M-Staging AJCC: Klatskin Tumors staging: Conventional modalities: For local mets: CT/MR PET (FDG): Modality of choice Whole body DWI: On Horizon! Kim Jung Hoon & Bijan Bijan Society of Abdominal Radiology - 2016 Part-II: CONCLUSION: Part-I: Defining longitudinal & vertical extent of perihilar CC are essential for evaluation of resectability Accuracy of MDCT is improved, but tendency toward underestimation Part-II: Addition of DWI to MR protocol increases the conspicuity of lesions (improves detection) Small CCA and Hypervascular CCA still pose a diagnostic challenge for CT & MR PET & MR (DWI) improve T/N/M-staging of CCA Kim Jung Hoon & Bijan Bijan Society of Abdominal Radiology - 2016 Understanding pathologic features & morphologic classification of CC are important 여러분의 관심 에 감사드립니다 Thank you for your attention For any questions, comments, suggestions: jhkim2008@gmail.com drBijanBijan@gmail.com Kim Jung Hoon & Bijan Bijan Society of Abdominal Radiology - 2016 CONCLUSION: Kim Jung Hoon & Bijan Bijan Society of Abdominal Radiology - 2016 You are here! Persian/Solar Calendar Summer Spring You are here! Fall Winter