Which imaging modalities are used in the workup of cholangiocarcinoma?

Updated: Apr 13, 2018
  • Author: Mahesh Kumar Neelala Anand, MBBS, DNB, FRCR; Chief Editor: John Karani, MBBS, FRCR  more...
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The first-line investigation in a patient with jaundice or right upper quadrant pain is ultrasonography (US). Biliary duct dilatation is easily demonstrated with US, but the tumor mass is seldom localized with it. [2, 3]

CT may demonstrate the tumor if the malignancy is nodular and masslike, but tumors of the diffuse sclerosing variety are difficult to detect. [4, 5]

Compared with the other techniques, endoscopic retrograde cholangiopancreatography (ERCP) is a more definitive investigation that can depict the periampullary tumor. However, with the advent of magnetic resonance cholangiopancreatography (MRCP), easy demonstration of stricture-causing tumors is possible. [6] The disadvantages of MRCP are its inability to distend the duct and the equivocal findings due to long segments and minimal narrowing in diffuse sclerosing tumors. Celiac axis arteriography is required to assess the vascular supply and the potential for resectability.

MR angiography has shown some promising results, with a sensitivity similar to that of conventional angiography in demonstrating the mesenteric circulation.

The role of endoscopic and intraductal US in the management of these tumors is yet to be defined. Furthermore, determination of the preferred examination is complex in the presence of a predisposing condition such as primary sclerosing cholangitis (PSC). Some study findings have demonstrated the potential role of positron emission tomography (PET), which improves the depiction of cholangiocarcinoma superimposed on PSC.

Plain radiographs usually have no diagnostic value. Calcifications occur in 18% of intrahepatic cholangiocarcinomas. They may appear on plain radiographs when they are large, nodular, and located in the right upper quadrant. Extrahepatic tumors may cause an extrinsic impression, with indentation or infiltration of the stomach or duodenum on an upper gastrointestinal barium series.

Angiographic features of cholangiocarcinoma include arterial encasement, obstruction, and neovascularity and focal encasement of the portal vein. Angiographic findings alone are poor in confirming a diagnosis of cholangiocarcinoma because the features may occur in both hepatocellular and pancreatic malignancies.

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