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Biliary Malignancy
Paula Vergara-Wentland, MD; Paige Bennett, MD
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KEY FACTS

  • Imaging

    TERMINOLOGY

    • Definitions

      • Cholangiocarcinoma (CCA)
        • Arises from simple columnar epithelium of intra/extrahepatic biliary tree
        • Intrahepatic tumors (10% of CCA) originate from distal 2nd-order bile ducts within hepatic parenchyma
          • Histopathology resembles adenocarcinoma; mass-forming subtype (most common), periductal infiltrating subtype, papillary subtype
        • Extrahepatic tumors
          • Perihilar tumors (25-50%): Arise anywhere from 2nd-order biliary ducts to common bile duct (CBD) and at site of cystic duct origin (Klatskin tumor)
          • Distal tumors (40-65%): Originate between cystic duct and ampulla of Vater without its involvement
          • Histopathology subtype: Nodular, sclerosing or periductal infiltrating (most common), and papillary
      • Gallbladder (GB) carcinoma
        • Tumors arise from simple columnar epithelium of GB or cystic duct
        • From fundus (60%), body (30%), neck & cystic duct (10%)
        • 98% of tumors of epithelial origin, 90% adenocarcinoma
          • Remaining subtypes: Adenosquamous, squamous cell carcinoma, small cell neuroendocrine, sarcoma, lymphoma
      • Detection of regional lymph node metastasis
        • Intrahepatic CCA: Demonstrates laterality of drainage
          • Right liver: Hilar (CBD, hepatic artery, portal vein, and cystic duct), periduodenal and peripancreatic → caval and periaortic
          • Left liver: Hilar and gastrohepatic → celiac
          • Positive celiac, periaortic, caval nodes considered M1
          • Inferior phrenic nodes considered regional
        • Perihilar CCA: Prevalence of nodal metastasis increased directly with T category
          • Hilar → caval and periaortic
        • Distal bile duct CCA: Staging surgical
          • Analysis includes minimum of 12 nodes
          • Hilar, periduodenal, and peripancreatic
        • GB cancer
          • Regional nodes: Hilar
          • Celiac, superior mesentery, peripancreatic, and periduodenal nodes considered M1
      • Detection of regional lymph node metastasis
        • Superficial pathway of lymphatic drainage of liver: Extensive and located beneath hepatobiliary capsule
          • Hepatoduodenal and gastrohepatic ligament pathway
          • Anterior, middle, posterior, and inferior diaphragmatic pathway
          • Falciform ligament pathway
        • Deep path of liver drainage
          • Portal pathway → hepatoduodenal ligament nodes
          • Hepatic vein pathway → juxtaphrenic and paraesophageal nodes
        • GB

    IMAGING

    • F-18 FDG PET/CT Findings

      • Imaging Recommendations

        DIFFERENTIAL DIAGNOSIS

          PATHOLOGY

          • General Features

            • Staging, Grading, & Classification

              CLINICAL ISSUES

              • Treatment

                DIAGNOSTIC CHECKLIST

                • Consider

                  Selected References

                  1. Paspulati RM et al: PET/MR imaging in cancers of the gastrointestinal tract. PET Clin. 11(4):403-23, 2016
                  Related Anatomy
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                  Related Differential Diagnoses
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                  References
                  Tables

                  Tables

                  KEY FACTS

                  • Imaging

                    TERMINOLOGY

                    • Definitions

                      • Cholangiocarcinoma (CCA)
                        • Arises from simple columnar epithelium of intra/extrahepatic biliary tree
                        • Intrahepatic tumors (10% of CCA) originate from distal 2nd-order bile ducts within hepatic parenchyma
                          • Histopathology resembles adenocarcinoma; mass-forming subtype (most common), periductal infiltrating subtype, papillary subtype
                        • Extrahepatic tumors
                          • Perihilar tumors (25-50%): Arise anywhere from 2nd-order biliary ducts to common bile duct (CBD) and at site of cystic duct origin (Klatskin tumor)
                          • Distal tumors (40-65%): Originate between cystic duct and ampulla of Vater without its involvement
                          • Histopathology subtype: Nodular, sclerosing or periductal infiltrating (most common), and papillary
                      • Gallbladder (GB) carcinoma
                        • Tumors arise from simple columnar epithelium of GB or cystic duct
                        • From fundus (60%), body (30%), neck & cystic duct (10%)
                        • 98% of tumors of epithelial origin, 90% adenocarcinoma
                          • Remaining subtypes: Adenosquamous, squamous cell carcinoma, small cell neuroendocrine, sarcoma, lymphoma
                      • Detection of regional lymph node metastasis
                        • Intrahepatic CCA: Demonstrates laterality of drainage
                          • Right liver: Hilar (CBD, hepatic artery, portal vein, and cystic duct), periduodenal and peripancreatic → caval and periaortic
                          • Left liver: Hilar and gastrohepatic → celiac
                          • Positive celiac, periaortic, caval nodes considered M1
                          • Inferior phrenic nodes considered regional
                        • Perihilar CCA: Prevalence of nodal metastasis increased directly with T category
                          • Hilar → caval and periaortic
                        • Distal bile duct CCA: Staging surgical
                          • Analysis includes minimum of 12 nodes
                          • Hilar, periduodenal, and peripancreatic
                        • GB cancer
                          • Regional nodes: Hilar
                          • Celiac, superior mesentery, peripancreatic, and periduodenal nodes considered M1
                      • Detection of regional lymph node metastasis
                        • Superficial pathway of lymphatic drainage of liver: Extensive and located beneath hepatobiliary capsule
                          • Hepatoduodenal and gastrohepatic ligament pathway
                          • Anterior, middle, posterior, and inferior diaphragmatic pathway
                          • Falciform ligament pathway
                        • Deep path of liver drainage
                          • Portal pathway → hepatoduodenal ligament nodes
                          • Hepatic vein pathway → juxtaphrenic and paraesophageal nodes
                        • GB

                    IMAGING

                    • F-18 FDG PET/CT Findings

                      • Imaging Recommendations

                        DIFFERENTIAL DIAGNOSIS

                          PATHOLOGY

                          • General Features

                            • Staging, Grading, & Classification

                              CLINICAL ISSUES

                              • Treatment

                                DIAGNOSTIC CHECKLIST

                                • Consider

                                  Selected References

                                  1. Paspulati RM et al: PET/MR imaging in cancers of the gastrointestinal tract. PET Clin. 11(4):403-23, 2016