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SAR 2016 Cholangiocarcinoma JHK

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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
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