Cholangiocellular Carcinoma CCC

Cholangiocellular carcinoma (CCC) is usually classed as "intrahepatic" or "extrahepatic" depending on the site of origin. Intrahepatic cholangio-carcinoma (ICC) is a malignant neoplasm arising from the epithelium of the intrahepatic bile ducts and represents approximately 10% of all CCC. Hilar (Klatskin's) and bile duct cholangiocarcinomas account for the remaining 90% of the lesions. The neoplasm is usually a large, firm mass and in 1020% of cases there are several satellite nodules around the main lesion. Pathologically, the stroma can contain extremes of dense fibrous material or mucinous glandular material or a combination of both. The pattern that predominates has a substantial impact on the imaging appearance. Variable amounts of central necrosis may be present within the tumor, especially in large lesions, although hemorrhage is rare.

On pre-contrast Tl-weighted images CCC is generally iso- to hypointense relative to the normal liver. Conversely, on T2-weighted images the SI of the tumor ranges from markedly hyperin-tense to mildly hyperintense. Tumors with a high fibrous content tend to have lower SI on T2-weighted images, while those with high mucin content tend to have very high SI [34].

On serial dynamic Tl-weighted images enhanced with conventional Gd agents, CCC usually show minimal or moderate incomplete rim enhancement at the tumor periphery on arterial phase images with progressive central contrast enhancement on portal venous and early equilibrium phase images [34]. Rarely, small homogeneously enhancing tumor nodules that simulate HCC can be seen on arterial phase imaging. Contrast enhancement is frequently better seen on portal venous and delayed equilibrium phase images in CCC with dense fibrous stroma [15].

Imaging with Gd-BOPTA is similar to imaging with conventional non-specific Gd-based contrast agents during the dynamic phase of contrast enhancement. However, delayed imaging with Gd-BOPTA during the hepatobiliary phase reveals contrast enhancement in the fibrotic areas of the lesion. The degree of enhancement depends on the type of CCC: greater peripheral enhancement is noted in large CCC, whereas stronger enhancement in the fibrous core is noted in the case of "scirrhous" CCC [35].

Significant uptake of Mn++ mangafodipir trisodium infusion is not observed on delayed Tl-weighted images and hence the lesions generally appear hypointense. However, some peripheral rim enhancement may be observed. The hepatobiliary phase after administration of liver-specific contrast agents may add useful information for the identification of small satellite lesions.

Analogously, no significant uptake is observed after SPIO administration due to the absence of Kupffer cells within CCC. Consequently, there is increased liver-to-lesion contrast-to-noise ratio on delayed T2-weighted images.

Delayed Enhancement Liver

Fig. 31a-e. Hypovascular metastases from colon cancer after Gd-BOPTA. The pre-contrast TSE T2-weighted image (a) reveals a heterogeneous, slightly hyperintense nodule (arrows). On the corresponding pre-contrast GRE Tl-weighted image (b) the lesion is heterogeneously hypointense. Rim enhancement can be seen in the arterial phase (c) after the bolus injection of Gd-BOP-TA while progressive enhancement and a peripheral hypointense rim (arrowhead) can be seen in the subsequent equilibrium phase (d). In the hepatobiliary phase (e) the lesion does not show any capacity to take up Gd-BOPTA, and appears heterogeneously hypointense

Fig. 32a, b. Metastases from cholangiocellular carcinoma after Mn-DPDP. The pre-contrast GRE Tl-weighted image (a) reveals a small, round, homogeneously hypointense nodule (arrow). In the hepatobiliary phase after Mn-DPDP administration (b), the nodule is better delineated and appears markedly hypointense. Two additional small lesions (arrowheads) can be seen on the post-contrast image

Fig. 32a, b. Metastases from cholangiocellular carcinoma after Mn-DPDP. The pre-contrast GRE Tl-weighted image (a) reveals a small, round, homogeneously hypointense nodule (arrow). In the hepatobiliary phase after Mn-DPDP administration (b), the nodule is better delineated and appears markedly hypointense. Two additional small lesions (arrowheads) can be seen on the post-contrast image

Mri Images Liver Cancer

Fig. 33a-f. Metastases from colon cancer after SH U 555 A. On the pre-contrast TSE T2-weighted image (a), several small, slightly hyperintense nodules (arrowheads) can be seen. Conversely, on the pre-contrast GRE Tl-weighted image (b) the lesions (arrowheads) are heterogeneous in appearance, presenting as either hypo- or hyperintense. In the arterial (c) and portal venous (d) phases of the dynamic evaluation after SH U 555 A administration, the nodules do not show significant enhancement. Conversely, in the equilibrium phase (e) they appear homogeneously hyperintense. In the reticuloendothelial phase (f) the lesions do not show significant signal drop, and are therefore better delineated. Additional nodules can also be seen

Fig. 33a-f. Metastases from colon cancer after SH U 555 A. On the pre-contrast TSE T2-weighted image (a), several small, slightly hyperintense nodules (arrowheads) can be seen. Conversely, on the pre-contrast GRE Tl-weighted image (b) the lesions (arrowheads) are heterogeneous in appearance, presenting as either hypo- or hyperintense. In the arterial (c) and portal venous (d) phases of the dynamic evaluation after SH U 555 A administration, the nodules do not show significant enhancement. Conversely, in the equilibrium phase (e) they appear homogeneously hyperintense. In the reticuloendothelial phase (f) the lesions do not show significant signal drop, and are therefore better delineated. Additional nodules can also be seen

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