Intrahepatic bile duct cancer Imaging findings and diagnosis

In this video, Dr. Gunjan Desai, a hepatobiliary and pancreatic surgeon in Mumbai, at Lilavati Hospital, discusses the imaging findings and diagnosis of intrahepatic bile duct cancer (cholangiocarcinoma). Intrahepatic cholangiocarcinoma (iCCA) is a rare but aggressive malignancy that arises from the bile ducts within the liver. Early and accurate diagnosis is critical for determining the optimal management strategy and improving patient outcomes.

Dr. Desai begins by explaining the clinical presentation of intrahepatic cholangiocarcinoma, which often includes nonspecific symptoms such as jaundice, abdominal pain, weight loss, and elevated liver function tests. Given the subtle nature of early-stage disease, imaging plays a pivotal role in diagnosis, staging, and surgical planning.

Key Imaging Modalities and Findings:

Dr. Desai provides an in-depth review of the imaging characteristics of iCCA across various modalities, including:

Ultrasound (USG):

Often the first-line imaging modality, ultrasound may reveal a hypoechoic or heterogeneous mass in the liver, sometimes with peripheral vascularity. However, it lacks specificity in distinguishing iCCA from other hepatic tumors.

Computed Tomography (CT) Scan:

Contrast-enhanced multiphasic CT imaging is a cornerstone in the diagnosis. Typical findings of intrahepatic cholangiocarcinoma include:

Arterial phase: Peripheral rim enhancement
Portal venous phase: Progressive centripetal enhancement
Delayed phase: Persistent enhancement due to the desmoplastic stroma
Capsular retraction: A hallmark feature in larger tumors
Biliary dilatation: May be absent in intrahepatic tumors, unlike perihilar cholangiocarcinoma

Magnetic Resonance Imaging (MRI) with MRCP:

MRI with contrast and magnetic resonance cholangiopancreatography (MRCP) is superior in characterizing soft tissue details and bile duct involvement. Typical MRI findings include:

T1-weighted imaging (T1WI): Hypointense mass
T2-weighted imaging (T2WI): Hyperintense lesion with irregular margins
DWI (Diffusion-Weighted Imaging): Restricted diffusion, aiding differentiation from benign lesions
MRCP: Helps assess bile duct invasion and differentiate iCCA from other biliary tumors

Positron Emission Tomography (PET-CT):

Useful in detecting distant metastases and lymph node involvement, though it is not routinely performed for primary diagnosis.

Histopathological Diagnosis & Staging:

Dr. Desai discusses the importance of biopsy and tumor markers for confirming the diagnosis. A CT- or ultrasound-guided biopsy is often performed when imaging is inconclusive. Key tumor markers include:

CA 19-9 – Frequently elevated but not specific to iCCA
CEA (Carcinoembryonic Antigen) – May also be elevated in some cases

Dr. Desai also highlights the TNM staging system and its impact on surgical decision-making, emphasizing how imaging helps determine resectability and guides the choice between surgery, locoregional therapies, or systemic treatment.

This comprehensive discussion provides valuable insights for radiologists, oncologists, hepatobiliary surgeons, and medical professionals seeking to enhance their understanding of intrahepatic cholangiocarcinoma imaging and diagnosis. Be sure to watch till the end for expert recommendations on optimizing diagnostic accuracy and treatment planning.

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