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77
c
...
..
-
.
‘‘:
_
Case
‘
#{149}.
Intrahepatic Jennifer
Report
Cholangiocarcinoma:
Hamrick-Turner,1’2
Patricia
L. Abbitt,1
and
Pablo
Peripheral
or intrahepatic cholangiocarcinoma is a primary of the liver that originates in a small bile duct. The tumor manifests as a focal mass, usually in or near the porta hepatis [1 2]. Several reports of the radiologic findings of intrahepatic cholangiocarcinoma [2-5] and a report of the MR appearance of extrahepatic cholangiocarcinoma [6] have been published. However, no reports as yet have adenocarcinoma
MR Appearance R. Ros1
showed
no thrombosis
or invasion
of the right hepatic
and portal
veins.
A subsequent
exploratory
percutaneous
laparotomy
biopsy
was therefore
was
nondiagnostic,
performed.
and
The tumor
an
was
,
described the MR imaging giocarcinoma. We present
appearance of intrahepatic cholanthe MR findings in one case.
Case Report Abdominal CT, performed in a 72-yean-old man after IV injection of 150 ml of 60% iothalamate meglumine, revealed a 10-cm mass in the liven, in the region of the porta hepatis and extending superiorly towand the hepatic veins (Fig. fetopnotein, and carcinoembryonic
1A). Serum levels of bilinubin, antigen were within normal limits.
Subsequently, MR images were obtained scanner (Siemens, lselin, NJ). Ti -weighted, gradient-echo
images
were obtained.
with a Magnetom 1 .0-T long TA double-echo and
In addition,
Ti-weighted
images
were obtained immediately and at 3, 5, and 8 mm after IV injection of 10 ml of gadopentetate dimeglumine. On Ti -weighted (450/i 5 [TA/TEl) images, the mass was hypointense relative to liven. The double-echo (2000/45, 90) images showed increasing hypenintensity of the mass relative to liven (Fig. i B). In addition, a central hypointensity that was not seen on the Ti-weighted images on CT scans was noted on the double-echo sequence. The sequences obtained after IV administration of gadopentetate dimeglumine showed initial rim enhancement with progressive, concentric fill-in
echo
(Figs.
1 C and
images
Received
iD).
(31/12,
This
enhancement
15#{176} flip angle)
June 24, 1991 : accepted
was
moderate.
confirmed
after revision
August
Department of Radiology, University of Florida College Present address: Department of Radiology, University to J. Hamrick-Turner. I
2
AJR 158:77-79,
January
1992 0361 -803x/92/1
581 -0077
Gradient-
encasement
but
found
to be a moderately
in the bile
differentiated
adenocarcinoma
originating
duct.
Discussion Intrahepatic cholangiocarcinoma is a relatively uncommon tumor, although it represents 1 O% of primary liver tumors and is the second most common hepatic malignant neoplasm after hepatocellular carcinoma [1 ]. The average age of patients with intrahepatic cholangiocarcinoma ranges from 50 to 60 years, with no strong sexual preponderance [1 ]. Because of its peripheral location relative to the common hepatic duct, the tumor rarely produces symptoms until late in its course [1 ]. As a consequence, these patients may have abdominal pain, weight loss, or a palpable mass, but it is unusual for them to have jaundice at presentation [2]. The serum level of a-fetoprotein is occasionally elevated, and the serum level of carcinoembryonic antigen is elevated in 75% ofthese patients [1]. CT findings have previously been described as somewhat nonspecific. homogeneous
This tumor usually manifests as a low-attenuation mass that may contain calcification [2, 4]. After
IV administration exhibit minimal them to invade
5, 1991. of Medicine, of Mississippi
Gainesville, FL 32610. Medical Center, 2500
© American
Roentgen
Ray Society
N. State
of contrast material, these tumors may peripheral enhancement [4]. It is unusual for the portal or hepatic venous system [2].
St. , Jackson,
MS 39216-4505.
Address
reprint
requests
HAMRICK-TURNER
78
ET AL.
AJA:158,
Fig.
l.-72-year-old
January
man
who
1992
was
Downloaded from www.ajronline.org by 186.190.28.215 on 11/02/15 from IP address 186.190.28.215. Copyright ARRS. For personal use only; all rights reserved
found to have a 10-cm mass in liver. A, Transverse CT scan of abdomen obtained after IV administration of contrast material shows a homogeneous, hypodense 10-cm central mass with a lobulated contour. Peripheral enhancement is minimal. Right hepatic and portal veins are encased. B, Transverse T2-weighted (2000/ 90) MR image shows mass is hyperin-
tense relative to liver, with an irregular central
area of hypointensity.
C, Transverse Ti-weighted (302/15) MR image obtained immediately after administration
of
shows moderate
rim
contrast material enhancement of
mass. 0, Transverse
Ti-weighted (302/15) MR image obtained 8 mm after contrast administration shows progressive concentric fill-in of mass, with a residual irregular area of central hypointensity. Also seen is a thin, hypointense rim
B
A
surrounding mass.
The MR findings in intrahepatic cholangiocarcinoma have not been described. Dooms et al. [6] examined the MR appearance of cholangiocarcinoma involving the common bile and hepatic ducts and the bifurcation, as well as the cystic duct, and found a mixed appearance. Well-differentiated adenocarcinoma
variants
showed
high
signal
intensity
weighted images and scirrhous subtypes showed intensity only slightly higher than that of liver [6]. after administration of gadopentetate dimeglumine performed. Our case suggests a possible characteristic MR ance of mntrahepatic cholangiocarcmnoma. A central, hypomntense
area
was
seen
on the
double-echo
on T2-
a signal Imaging was not appearirregular
sequences,
most prominent on T2-weighted images. Review of the radiologic findings of another patient with intrahepatic cholangiocarcinoma showed a similar irregular central hypointensity on the double-echo sequence. Pathologically, it is known that these tumors frequently show dense fibrous tissue centrally [1 2], which would suggest that the irregular hypomntense area seen centrally in these two cases on T2-weighted images is due to the presence of central dense fibrosis or scar. The presence of central scars in primary liver tumors on MR images is not specific, and has been described for focal nodular hyperplasia, hepatocellular carcinoma, giant heman,
a portion
of periphery
of
gioma, and hepatic adenoma [7]. However, central scar is not usually seen in metastatic tumors [7], and this should help in further narrowing differential diagnostic possibilities. The hyperintense appearance of the more peripheral aspect of these tumors on T2-weighted images is nonspecific, and previous findings have suggested that the amount of intensity may be related to the degree of differentiation and/or the amount of scirrhous component [6]. The findings of progressive, concentric moderate enhancement, sparing the central area, suggest that the mass contains tissue with abundant interstitial space, in keeping with the known pathologic finding of a large amount of fibrous stroma seen in these tumors [1 3]. To our knowledge, no other primary liver tumor to date has been described as showing progressive, concentric fill-in of these characteristics. Hemangiomas are well known to exhibit a pattern of concentric fill-in, but the more intense nature of the enhancement in hemangiomas readily differentiates this enhancement pattern from that of intrahepatic cholangiocarcinoma [8]. A thin, hypointense rim surrounded a portion of the tumor on the MR image obtained 8 mm after IV contrast administration. This finding may be related to minimal relative hypervascularity at the periphery of the tumor, as suggested by the CT findings of minimal postcontrast peripheral enhancement. ,
AJR:i58,
MR
January 1992
This slight hypervascularity could result in a “wash-out”
Downloaded from www.ajronline.org by 186.190.28.215 on 11/02/15 from IP address 186.190.28.215. Copyright ARRS. For personal use only; all rights reserved
as a consequence
and resultant phenomenon
of clearance
OF
INTRAHEPATIC
increase in perfusion on delayed images
of contrast
material
from this
most peripheral thin rim of tissue. Gradient-echo imaging may be helpful in confirming patency of the portal and hepatic veins, which can be of additional help in differentiating this tumor from hepatocellular carcinoma
[2]. The presence of a central scar suggests that the tumor is a primary liver tumor, and the enhancement pattern of mild to moderate enhancement and concentric and progressive fill-in with delayed imaging has not as yet been described for other primary liver tumors. We conclude that these MR findings may be characteristic of intrahepatic cholangiocarcmnoma, although further MR imaging data are needed to confirm this possibility. The MR findings, along with CT, clinical, and laboratory
results,
narrow the diagnosis, other abnormalities.
may
allow
the
radiologist
if not to differentiate
to
these
extensively
tumors
from
CHOLANGIOCARCINOMA
79
REFERENCES 1 . Craig JA, Peters bile ducts:
atlas
AL, Edmonson of tumor
HA. Tumors
of the liver and intrahepatic
pathology,
2nd series, fascicle 26. Washington, DC: Armed Forces Institute of Pathology, 1989:197-211 2. Aos PR, Buck JL, Goodman ZD, Ros AMy, Olmsted WW. Intrahepatic cholangiocarcinoma: radiologic-pathologic correlation. Radiology 1988: 167: 689-693 3. Takayasu K, Ikeya 5, Mukai K, Muramatsu Y, Mukuuchi M, Hasegawa H.
CT of hilar cholangiocarcinoma: 4. 5.
6. 7.
8.
late contrast enhancement
in six patients.
AJR 1990:154:1203-1206 Thorsen MK, Quiroz F, Lawson TL, Smith DF, Foley WD, Stewart ET. Primary biliary carcinoma: CT evaluation. Radiology 1984:152:479-483 ltai Y, Ohtomo K, Kokubo T, et al. CT of hepatic masses: significance of prolonged and delayed enhancement. AJR 1986:146:729-733 Dooms GC, Kerlan AK Jr, Hricak H, Wall SD, Margulis AR. Cholangiocarcinoma: imaging by MA. Radiology 1986;1 59:89-94 Rummeny E, Weissleder A, Sironi 5, et al. Central scars in primary liver tumors. Radiology 1989:171:323-326 Yoshida H, ltai Y, Ohtomo K, Kokubo T, Minami M, Yashiro N. Small hepatocellular carcinoma and cavemous hemangioma: differentiation with dynamic FLASH MA imaging with Gd-DTPA. Radiology 1989:171:
339-342
77
c
...
..
-
.
‘‘:
_
Case
‘
#{149}.
Intrahepatic Jennifer
Report
Cholangiocarcinoma:
Hamrick-Turner,1’2
Patricia
L. Abbitt,1
and
Pablo
Peripheral
or intrahepatic cholangiocarcinoma is a primary of the liver that originates in a small bile duct. The tumor manifests as a focal mass, usually in or near the porta hepatis [1 2]. Several reports of the radiologic findings of intrahepatic cholangiocarcinoma [2-5] and a report of the MR appearance of extrahepatic cholangiocarcinoma [6] have been published. However, no reports as yet have adenocarcinoma
MR Appearance R. Ros1
showed
no thrombosis
or invasion
of the right hepatic
and portal
veins.
A subsequent
exploratory
percutaneous
laparotomy
biopsy
was therefore
was
nondiagnostic,
performed.
and
The tumor
an
was
,
described the MR imaging giocarcinoma. We present
appearance of intrahepatic cholanthe MR findings in one case.
Case Report Abdominal CT, performed in a 72-yean-old man after IV injection of 150 ml of 60% iothalamate meglumine, revealed a 10-cm mass in the liven, in the region of the porta hepatis and extending superiorly towand the hepatic veins (Fig. fetopnotein, and carcinoembryonic
1A). Serum levels of bilinubin, antigen were within normal limits.
Subsequently, MR images were obtained scanner (Siemens, lselin, NJ). Ti -weighted, gradient-echo
images
were obtained.
with a Magnetom 1 .0-T long TA double-echo and
In addition,
Ti-weighted
images
were obtained immediately and at 3, 5, and 8 mm after IV injection of 10 ml of gadopentetate dimeglumine. On Ti -weighted (450/i 5 [TA/TEl) images, the mass was hypointense relative to liven. The double-echo (2000/45, 90) images showed increasing hypenintensity of the mass relative to liven (Fig. i B). In addition, a central hypointensity that was not seen on the Ti-weighted images on CT scans was noted on the double-echo sequence. The sequences obtained after IV administration of gadopentetate dimeglumine showed initial rim enhancement with progressive, concentric fill-in
echo
(Figs.
1 C and
images
Received
iD).
(31/12,
This
enhancement
15#{176} flip angle)
June 24, 1991 : accepted
was
moderate.
confirmed
after revision
August
Department of Radiology, University of Florida College Present address: Department of Radiology, University to J. Hamrick-Turner. I
2
AJR 158:77-79,
January
1992 0361 -803x/92/1
581 -0077
Gradient-
encasement
but
found
to be a moderately
in the bile
differentiated
adenocarcinoma
originating
duct.
Discussion Intrahepatic cholangiocarcinoma is a relatively uncommon tumor, although it represents 1 O% of primary liver tumors and is the second most common hepatic malignant neoplasm after hepatocellular carcinoma [1 ]. The average age of patients with intrahepatic cholangiocarcinoma ranges from 50 to 60 years, with no strong sexual preponderance [1 ]. Because of its peripheral location relative to the common hepatic duct, the tumor rarely produces symptoms until late in its course [1 ]. As a consequence, these patients may have abdominal pain, weight loss, or a palpable mass, but it is unusual for them to have jaundice at presentation [2]. The serum level of a-fetoprotein is occasionally elevated, and the serum level of carcinoembryonic antigen is elevated in 75% ofthese patients [1]. CT findings have previously been described as somewhat nonspecific. homogeneous
This tumor usually manifests as a low-attenuation mass that may contain calcification [2, 4]. After
IV administration exhibit minimal them to invade
5, 1991. of Medicine, of Mississippi
Gainesville, FL 32610. Medical Center, 2500
© American
Roentgen
Ray Society
N. State
of contrast material, these tumors may peripheral enhancement [4]. It is unusual for the portal or hepatic venous system [2].
St. , Jackson,
MS 39216-4505.
Address
reprint
requests
HAMRICK-TURNER
78
ET AL.
AJA:158,
Fig.
l.-72-year-old
January
man
who
1992
was
Downloaded from www.ajronline.org by 186.190.28.215 on 11/02/15 from IP address 186.190.28.215. Copyright ARRS. For personal use only; all rights reserved
found to have a 10-cm mass in liver. A, Transverse CT scan of abdomen obtained after IV administration of contrast material shows a homogeneous, hypodense 10-cm central mass with a lobulated contour. Peripheral enhancement is minimal. Right hepatic and portal veins are encased. B, Transverse T2-weighted (2000/ 90) MR image shows mass is hyperin-
tense relative to liver, with an irregular central
area of hypointensity.
C, Transverse Ti-weighted (302/15) MR image obtained immediately after administration
of
shows moderate
rim
contrast material enhancement of
mass. 0, Transverse
Ti-weighted (302/15) MR image obtained 8 mm after contrast administration shows progressive concentric fill-in of mass, with a residual irregular area of central hypointensity. Also seen is a thin, hypointense rim
B
A
surrounding mass.
The MR findings in intrahepatic cholangiocarcinoma have not been described. Dooms et al. [6] examined the MR appearance of cholangiocarcinoma involving the common bile and hepatic ducts and the bifurcation, as well as the cystic duct, and found a mixed appearance. Well-differentiated adenocarcinoma
variants
showed
high
signal
intensity
weighted images and scirrhous subtypes showed intensity only slightly higher than that of liver [6]. after administration of gadopentetate dimeglumine performed. Our case suggests a possible characteristic MR ance of mntrahepatic cholangiocarcmnoma. A central, hypomntense
area
was
seen
on the
double-echo
on T2-
a signal Imaging was not appearirregular
sequences,
most prominent on T2-weighted images. Review of the radiologic findings of another patient with intrahepatic cholangiocarcinoma showed a similar irregular central hypointensity on the double-echo sequence. Pathologically, it is known that these tumors frequently show dense fibrous tissue centrally [1 2], which would suggest that the irregular hypomntense area seen centrally in these two cases on T2-weighted images is due to the presence of central dense fibrosis or scar. The presence of central scars in primary liver tumors on MR images is not specific, and has been described for focal nodular hyperplasia, hepatocellular carcinoma, giant heman,
a portion
of periphery
of
gioma, and hepatic adenoma [7]. However, central scar is not usually seen in metastatic tumors [7], and this should help in further narrowing differential diagnostic possibilities. The hyperintense appearance of the more peripheral aspect of these tumors on T2-weighted images is nonspecific, and previous findings have suggested that the amount of intensity may be related to the degree of differentiation and/or the amount of scirrhous component [6]. The findings of progressive, concentric moderate enhancement, sparing the central area, suggest that the mass contains tissue with abundant interstitial space, in keeping with the known pathologic finding of a large amount of fibrous stroma seen in these tumors [1 3]. To our knowledge, no other primary liver tumor to date has been described as showing progressive, concentric fill-in of these characteristics. Hemangiomas are well known to exhibit a pattern of concentric fill-in, but the more intense nature of the enhancement in hemangiomas readily differentiates this enhancement pattern from that of intrahepatic cholangiocarcinoma [8]. A thin, hypointense rim surrounded a portion of the tumor on the MR image obtained 8 mm after IV contrast administration. This finding may be related to minimal relative hypervascularity at the periphery of the tumor, as suggested by the CT findings of minimal postcontrast peripheral enhancement. ,
AJR:i58,
MR
January 1992
This slight hypervascularity could result in a “wash-out”
Downloaded from www.ajronline.org by 186.190.28.215 on 11/02/15 from IP address 186.190.28.215. Copyright ARRS. For personal use only; all rights reserved
as a consequence
and resultant phenomenon
of clearance
OF
INTRAHEPATIC
increase in perfusion on delayed images
of contrast
material
from this
most peripheral thin rim of tissue. Gradient-echo imaging may be helpful in confirming patency of the portal and hepatic veins, which can be of additional help in differentiating this tumor from hepatocellular carcinoma
[2]. The presence of a central scar suggests that the tumor is a primary liver tumor, and the enhancement pattern of mild to moderate enhancement and concentric and progressive fill-in with delayed imaging has not as yet been described for other primary liver tumors. We conclude that these MR findings may be characteristic of intrahepatic cholangiocarcmnoma, although further MR imaging data are needed to confirm this possibility. The MR findings, along with CT, clinical, and laboratory
results,
narrow the diagnosis, other abnormalities.
may
allow
the
radiologist
if not to differentiate
to
these
extensively
tumors
from
CHOLANGIOCARCINOMA
79
REFERENCES 1 . Craig JA, Peters bile ducts:
atlas
AL, Edmonson of tumor
HA. Tumors
of the liver and intrahepatic
pathology,
2nd series, fascicle 26. Washington, DC: Armed Forces Institute of Pathology, 1989:197-211 2. Aos PR, Buck JL, Goodman ZD, Ros AMy, Olmsted WW. Intrahepatic cholangiocarcinoma: radiologic-pathologic correlation. Radiology 1988: 167: 689-693 3. Takayasu K, Ikeya 5, Mukai K, Muramatsu Y, Mukuuchi M, Hasegawa H.
CT of hilar cholangiocarcinoma: 4. 5.
6. 7.
8.
late contrast enhancement
in six patients.
AJR 1990:154:1203-1206 Thorsen MK, Quiroz F, Lawson TL, Smith DF, Foley WD, Stewart ET. Primary biliary carcinoma: CT evaluation. Radiology 1984:152:479-483 ltai Y, Ohtomo K, Kokubo T, et al. CT of hepatic masses: significance of prolonged and delayed enhancement. AJR 1986:146:729-733 Dooms GC, Kerlan AK Jr, Hricak H, Wall SD, Margulis AR. Cholangiocarcinoma: imaging by MA. Radiology 1986;1 59:89-94 Rummeny E, Weissleder A, Sironi 5, et al. Central scars in primary liver tumors. Radiology 1989:171:323-326 Yoshida H, ltai Y, Ohtomo K, Kokubo T, Minami M, Yashiro N. Small hepatocellular carcinoma and cavemous hemangioma: differentiation with dynamic FLASH MA imaging with Gd-DTPA. Radiology 1989:171:
339-342
