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Ni t t a y a Cham a do l MD Radiolo g ist Department of Radiology Faculty of Medicine

Ni t t a y a Cham a do l MD Radiolo g ist Department of Radiology Faculty of Medicine. Khon Kaen University. Hypothesis. Repeated infection with O. viverrini by consumption of fresh water fish. Worms inhabit in biliary tree. Chronic inflammation of biliary tree.

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Ni t t a y a Cham a do l MD Radiolo g ist Department of Radiology Faculty of Medicine

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  1. NittayaChamadolMD Radiologist Department ofRadiology Faculty ofMedicine Khon KaenUniversity

  2. Hypothesis Repeated infection with O. viverrini byconsumption of fresh waterfish Worms inhabit in biliarytree Chronic inflammation of biliarytree _Periductal fibrosis (PDF) fibrosis(PDF)fibrosis (PDF) US BIOMARKER CCA CCA

  3. Cholangiocarcinoma ( CCA) Razumilava N, Gores GJ. Classification, diagnosis, and management of cholangiocarcinoma. Clin Gastroenterol Hepatol. 2013 Jan;11(1):13-21 e1; quiz e3-4 CatalanoOA,SahaniDV,ForcioneDG,CzermakB, LiuCH,SoricelliA,etal.Biliaryinfections:spectrumofimagingfindingsandmanagement. Radiographics.2009;29:2059–80. .

  4. Cholangiocarcinoma in NE Thailand 2009-2011 221CASES 37 %Intrahepatic Cholangiocarcinoma ( I-CCA) ( MF 88%, ID 11%, PI 1%) meanage57.7 M:F 1.6 :1 57 % Extrahepatic Cholangiocarcinoma (E-CCA) 53% PerihilarCholangiocarcinoma (P-CCA)(PI44%,MF 41% ,ID16%) meanage58.9 M:F 2.7 :1 4%Distal Cholangiocarcinoma (D-CCA)( ID) meanage52.7 M:F 2 :1 6 % Intra andExtra ( ID)meanage58.3 M:F4.5 :1 C. Pairojkul , International symposium in Cholangiocarcinoma Tokyo,2013

  5. MASSFORMING TYPE(MF) Liver Cancer Study Group of Japan.Classification of primary liver cancer.Tokyo,Japan;Kanehara,1997 PERIDUCTAL INFILTRATING TYPE (PI) INTRADUCTAL (ID)

  6. Imagingstudy Ultrasonography CT MRI Cholangiography PET /PET-CT Detection Diagnosis Guideaspiration, biopsy Staging Follow upafter treatment Intervention management.

  7. Mass forming type( MF CCA)

  8. US Mass forming type (MF) • US • Usually the initial imagingtest Mass formingtype • Livermass lack of specificUS • features • hypoecho,isoecho,hyperecho,mixed echowithorwithouthypoechoic rim • ColorDoppler forportalvenous invasion Alfiffy M; World J Gastroenterol2009;15(34)4240-4262

  9. Ultrasound feature ofCCA Varied Hypo,iso,hyperecho,mixed-echo with bile ductdilatation

  10. 75% 40.40% 39.30% 17% Bileduct dilatation Atrophic change Capsular retraction Calcification

  11. Dilataion ofintrahepaticducts ( 75%)

  12. Mass1.5 cm Mass and dilatedIHD DilatedIHD

  13. Mass1.5 cm D Mass and dilatedIH DilatedIHD

  14. Capsularretraction

  15. Our study Our study Other study Yoshiko etal CCA (N=53) 19% CCA (N=89) 23.3% HCC (N=40) 37.5% HCC 12.5-70 % Yoshiko etal Combined Hepatocellular and Cholangiocarcinoma: A clinicopathologic Study of 26 Resected Cases. Jpn J Clin Oncol 2003 Otherstudy Takizawa D, et al. : clinical characteristic, prognosis,and patient survival analysis. Dig Dis Sci2007 Abdel- Wahab M, et al. Hepatogastroenterology 2007. 3.Elefsiniotis IS, Eur J Gastroenterol Hepatol 2003;15:721- 726. 4.Fujii T, et al. Jpn J Clin Oncol 1993. 5.Rabe C, et al. World J Gastroenterol 2001. 6.Connolly GC, et al. Pubmed2008.

  16. Mass-forming CCAwith portal veininvolvement HCC with Portalvein involvement Intraluminal Extraluminal Intraluminal Extraluminal 7% 95% 93% 5%

  17. Periductal Infiltratingtype ( PI CCA)

  18. Characterized by a dilated or narrowed bile duct withoutmass formation manifested as elongate,spiculate,or branch-like abnormality US Diffuse bile duct thickening with or without obliterationof ductlumen Crowded of thedilated duct in atrophiclobe

  19. Intraductal type ( ID CCA)

  20. Intraductal Cholangiocarcinoma Segmentaldilated duct Aneurysmal Dilatedduct Lobardilated duct nittayachamadol

  21. Ultrasound Focal dilatationof intrahepaticduct ( up stream duct) Diffuse dilatation of bileduct ( up stream and down stream) Intraductal echoic mass comparing to bile in the dilatedduct Irregular low echoalong distribution of bileduct   

  22. CCA have non specific sonographicfeature • MF type may be hypo-iso-hyper echo withor without hypoechoicrim • Associated bile duct dilatation may be found in MF-CCAor ID-CCA

  23. CCA have variety of tumormorphology andlocation. CCA have non specific clinical signand symptom in early stage of thedisease. Uptodatethereisnosensitivetumor marker. Operationistheonlyhopeforcure. Early detection ischallenge. Ultrasonography may helpofmass and biliarydilatationdetection in riskgroup.

  24. Role of imaging fortumor screening /surveillance • Highrisk group • Tumormarker • USexamination

  25. Important abnormalsonographic findinginsurveillance US • Abnormal echo masslesion • Dilatation of intrahepaticduct • Combination

  26. US of biliarydilatation -Accuracyof detection dilatation of thebile ducts >95% Baron RL,Radiol Clin N Amer 40:1325-1354,2002 Niederau C, J Clin Ultrasound 11:23-27,1983 Reinus WR, Am J Gastro-enterol 87:489-492,1992 Cooperberg P,Radiology135:141,1980 • Determine level of obstruction92-95% • Detection ofunderlyingcause 70-88% • Laing FC : Diagnostic Ultrasound ,2nd ed St. Louis,CVMosby • ,1998,pp175-224 • Laing FC: Radiology160:39-42,1986 • Mittelstaedt CA: Semin Roentgenol 32:161-171,1997 Baron RL,Radiol Clin N Amer40:1325-1354,2002

  27. Intrahepaticbile duct Dilatation of Biliarytree Ultrasound • Accuracy of detection dilatation of the bile ducts >95% • Determine level of obstruction92-95% • Detection ofunderlyingcause 70-88% • Duct caliber does not always correlate with the presence or absence of biliary obstruction ( obstruction without dilatation-cholangitis –small stone / dilatation without obstruction- post op) Criteria fordilatation Normal intrahepatic duct diameter 1-2mm orlessthan40%ofdiameterofaccompanying portalvein “ parallel-channel”sign

  28. Extrahepatic bileduct Normalsize CHD 4-5mm CBD 4-6mm 6-7 mmequivocal more than 8 mm indicate ductal dilatation post cholecystectomy 10mm Range 4-8 mm Increase with age 40yearsold 4mm 50 yearsold 5mm 60 yearsold 6mm upper limits size of normal in elderly may be up to 10mm Dilatation of biliarytree

  29. USof dilatedbile duct Normal “Too-many tubes–sign”

  30. Tumor mass in distal CBD Large stone in distal CBD

  31. USdetection of CBD stone sensitivity 70-89 %in experience hand sensitivity of proximal duct stone> distal

  32. Gallstone CBDstone 15% ass with CBDstone 95% ass withgallstone

  33. Ascarisin CBD

  34. Bile duct dilatation should be further evaluated • ID-CCA may present with segment /lobar dilatation • PI-CCA may present with discontinuation of dilatedduct • MF-CCA may present with mass with/without dilatation of bileduct

  35. Periductal fibrosis ( PDF) Increase periportal echo ( IPE ) Periportal fibrosis ( PPF ) Periductal fibrosis ( PDF)

  36. Endemic area ofCholangiocarcinoma North easternThailand O.Viverrini Classified as Group 1 carcinogen byWHO O.V Infection National average ≈ 16% Khon Kaen average ≈37%

  37. Hypothesis Repeated infection with O. viverriniby consumption of fresh waterfish Worms inhabit in biliarytree Chronic inflammation of biliarytree Periductal fibrosis (PDF) Ultrasound Bio-tumormarker CCA CCA

  38. Periductalfibrosis ( PDF)

  39. Parasite

  40. Increased periportal echo ( IPE)

  41. PDF1 •

  42. Normal PDF2 LeftPV s3s2

  43. Normal PDF3

  44. Increased periportal echo (IPE)grading IPE Grade 1 is diffuse echogenic foci ( „starry sky‟) minimalwall thickening of portal and segmental branches. IPE Grade 2 is Ring echoes around vessels in cross-section,pipe- stems parallel with portalvein IPE Grade3is echogenic ruff around portal bifurcation and main stem ;main portal vein vessels wallthickening Berhe N,Geitung J, Medhin G,Gunderson SG : Large scale of WHO’s ultrasonographic staging system of schistosomal periportalfibrosisinEthiopia;TropicalMedicineandInternationalhealth,volumIINo8,August2006,1286-1294

  45. Increase periportal echo ( IPE) =Periductal fibrosis (PDF)

  46. Conclusions from Tokyo2013 1 2 3 • Increased periportal echo ( IPE ) in theendemic area of opisthorchiasis represents periductal fibrosis (PDF ) from chronic inflammation of bililary tree withproven histopathology • We documented periductal fibriosis (PDF) byultrasound in CCA cases • PDF has potentialto be sonographicsignto closely follow up in a riskgroupof CCA surveillance

  47. IPE=PDF PDF1 Diffuse echogenic foci“starry sky” Minimal wall thickening of portal and segmental branches PDF 2 Ring echo around vessels in cross-section ; pipe-stemspararellwith portalvessels Echogenic ruff around portal bifurcation and main stem ; mainportal vessels wallthickening PDF 3

  48. PDF1

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