1. Biliary Tract
Tumours
Dr. Abubakar
Postgraduate Resident
Radiology Department
BVH Bahawalpur

2. Normal Biliary Anatomy

3. TYPES OF BILIARY
TRACT TUMOURS
Tumours of bile ducts:
a).Cholangiocarcinoma
b).Biliary cystadenoma
/cystadenocarcinoma
Gallbladder Carcinoma
Ampullary and
pancreatic carcinoma
03
01
02

4. CHOLANGIOCARCINOMAS
Epidemiology:Cholangiocarcinomas (commonest type of bile duct cancers) are malignant
epithelial tumours arising from the biliary tree, excluding the gallbladder or ampulla of
Vater. Cholangiocarcinoma is the third most common primary hepatobiliary malignancy
after hepatocellular carcinoma (HCC) and gallbladder cancer 23. They tend to have a poor
prognosis and high morbidity.
Epidemiology
Risk factors:
Caroli disease / choledochal cysts: lifetime risk of 10-15%
choledocholithiasis: more than cholelithiasis
primary sclerosing cholangitis (PSC): especially in Western countries
recurrent pyogenic cholangitis: especially in Southeast Asia
cirrhosis

6. There are three main subtypes:
1.Mass forming cholangiocarcinoma:Definite mass in the liver
parenchyma
2.Periductal cholangiocarcinoma: most oft en at the confluence of the
right and left hepati c biliary ducts(known as Klatskin tumor). extends
longitudinally along the bile duct, often causing peripheral bile duct
dilation
3. Intraductal cholangiocarcinoma: proliferates in the lumen of the bile
duct-like a papilla or tumour thrombus
Japanese liver cancer study group
classification:

8. Mass forming

15. Periductal infiltrating Carcinoma

16. Klatskin tumour is a term that was
traditionally given to a hilar
(perihilar) cholangiocarcinoma,
occurring at the bifurcation of the
common hepatic duct
klatskin's
tumour

20. Cholangiocarcinoma with correlative cholangiogram. A, Oblique view of the porta hepatis shows a dilated
duct (D) and an infiltrative mass (arrows) obliterating the lumen of the duct. B, Endoscopic cholangiogram
shows the dilated duct (D) and the long stricture of the bile duct (arrows).
A
D
D
D
B

22. Intraductal cholangiocarcinoma
Types
1.Diffuse and marked duct ectasia with a grossly visible
papillary mass.
2.Diffuse and marked duct ectasia without mass.
3.Intraductal polypoid mass with a localized ductal
dilatation.
4.Intraductal castlike lesions within a mildly dilated duct.
5. A focal stricture like lesion with mild proximal duct
dilatation

23. A B
D
D
D
1.Diffuse and marked duct ectasia with a grossly visible papillary mass.

25. 2.Diffuse and marked duct ectasia without mass.

26. 3.Intraductal polypoid mass with a localized ductal dilatation.

27. 4.Intraductal castlike lesions within a mildly dilated duct.

28. 5.A focal stricture like lesion with mild proximal duct dilatation

29. A B
C
Cholangiocarcinoma in different patients. A and B, Multiple ducts (cursors) from the right and left lobe
terminate abruptly near their confluence without communicating with each other. The site of termination
defines a central isoechoic mass. C View showing obstructed, dilated ducts (cursors), all of which terminate at
the level of a soft-tissue mass (M)

30. Differential diagnosis
liver metastases:central necrosis (high T2 signal) is more common
hepatocellular carcinoma (HCC):tumour thrombus more common,capsular
retraction uncommon.May appear very similar
other primary liver tumours
hepatic abscess
benign stricture:usually short-segment regular margin, but there are exceptions to
this,symmetric narrowing,no ductal enhancement,no lymph node enlargement,no
periductal soft-tissue mass
periportal lymphangitic metastasis
intraductal invasion by hepatocellular carcinoma (HCC)
extraductal mass
hepatolithiasis/Biliary cysadenoma/cystadenocarcinoma/benign stricture
or a mass-forming cholangiocarcinoma consider the following:
For a periductal infiltrating cholangiocarcinoma consider the following:
For an intraductal cholangiocarcinoma consider:

31. Biliary cystadenoma and cystadenocarcinoma:
These rare tumours of the biliary epithelium present as complex,
often cystic masses within liver parenchyma which may infiltrate segmental bile
ducts. Histological categories
include a better prognostic group containing ovarian stroma
but there is no radiological criterion by which these may be
distinguished.
Radiological assessment is based on determining respectability
on the segmental distribution and vascular relationships rather than
on cholangiographic criteria.

32. Biliary cystadenoma. A, Transverse sonogram shows a cyst with multiple internal septations. Note the
excellent through transmission. B, Color Doppler view shows some detect-able blood flow in the
septations.
A B

33. Precontrast ( C), postcontrast ( D), and T2-weighted ( E) magnetic resonance images show
enhancing septations in an otherwise simple cystic mass.
C D E

34. Ampullary and pancreatic carcinoma
These are the most common causes of a malignant bile duct stricture . Pancreatic
pathologies are covered elsewhere
but, in summary, specific indications for radiological assessment are
to:
1. Define the site and size of the tumour.
2. Confirm a tissue diagnosis by guided biopsy.
3. Determine operability by excluding: (i) local involvement of
the coeliac trunk, superior mesenteric and splenic arteries and
(ii) the portal venous system, particularly at the junction of the
superiorior mesenteric and splenic veins; (iii) regional pathological
lymphadenopathy; (iv) ascites; (v) distant metastatic spread to the
lungs and mediastinum. All these are exclusion criteria for curative
surgery.
4. Determine suitability for palliative biliary drainage, either
percutaneous, endoscopic or surgical.
Ampullary and pancreatic carcinoma

35. Double duct' sign. Concomitant strictures of pancreatic duct
and bile duct (arrows) diagnostic of carcinoma of head of pancreas.

36. Pancreatic adenocarcinoma of the head causing the double duct sign: Two coronal
images from a contrastenhanced CT show marked dilation of the common bile
duct (CBD), moderate dilation of the pancreatic duct
(PD), and the obstructing, ill-defined hypoattenuating mass in the pancreatic head
(red arrows).
CBD
PD
PD

37. Adenocarcinoma of the gallbladder is associated with stones in over 90% of patients.
There is a female to male ratio of 3:1. Porcelain gallbladder and sclerosing cholangitis
are predisposing factors. Characteristically the tumours are scirrhous and locally
infiltrative, involving the intrahepatic biliary tree and common duct, with resulting
obstruction and jaundice as a common presenting feature.
Gallbladder carcinoma
Risk factors
chronic cholecystitis
gallstones are seen in 70-90% of cases
familial adenomatous polyposis syndrome (FAP)
inflammatory bowel disease (IBD)
porcelain gallbladder
gallbladder polyps 1 cm that are sessile and solitary
primary sclerosing cholangitis
anomalous junction of pancreaticobiliary ducts
Risk factors include 1:

38. Clinical presentation:
Clinical presentation depends where the biliary obstruction is created then
jaundice is often the first presentation. If the malignancy is located in the
gallbladder's body or fundus, extending into the liver or adjacent colon or small
bowel can lead to local pain or bowel obstruction, respectively.
Other symptoms include right upper quadrant pain, weight loss and anorexia
Radiographic features
intraluminal mass
diffuse mural thickening
mass replacing the gallbladder
presumably the end result of progression from either 1 or 2
most common presentation
Gallbladder adenocarcinomas present in one of three morphologies
1.
2.
3.
Gallstones are commonly present (60%–90%)

39. Intraluminal Mass

40. intraluminal heteroechoic mass that occupied nearly the whole gallbladder
(arrowheads), with focal extraluminal invasion (arrows),and extrahepatic invasion

41. Thickened wall gall bladder with gallstones and cholecystitis

42. A
B
Gallbladder cancer. A, Transverse view shows marked focal wall thickening of the
gallbladder fundus (cursors). B, CT scan shows similar focal fundal wall thickening.

43. B
A
A.Hypoechoic mass arising from the
fundus of the gallbladder and
invading the liver. The lumen of the
gallbladder is partially obliterated.
B.Focal thickening of the medial
wall of the gallbladder with
detectable internal blood flow.

44. Diffuse infiltrative carcinoma of the
gallbladder with irregular wall
thickening and invasion of liver
parenchyma. Medially the plane with
second part of duodenum is invaded.
Inferiorly right perinephric fat plane
invaded
Large polypoidal fungating
gallbladder mass with gross invasion
of liver parenchyma. Hepato-
duodenal ligament invaded. Left lobe
shows discrete secondaries

45. infiltrative carcinoma with
ascites cholelithiasis and
peritoneal enhancement.
Aggressive malignancy with
porteanlocoregional and distant spread

46. Coronal T2-weighted (left image) and post-contrast T1-weighted (right image) MRI
demonstrates an
intraluminal enhancing mass within the gallbladder (yellow arrows) and an associated
porta hepatis mass (red arrows) resulting in severe intra- and extrahepatic biliary
ductal dilatation. Pathology upon resection showed gallbladder carcinoma with
metastatic pancreatico duodenal lymph node.

47. (Biopsy-proved papillary adenocarcinoma of the gallbladder in a 64-year-old woman. (a) Axial T2-weighted
image shows a lesion (arrow) that is mildly hyperintense relative to the liver parenchyma. (b) Axial contrast-
enhanced T1-weighted image shows heterogeneous enhancement of the lesion (arrow). The large tumor
nearly filling the entire gallbladder was found to involve only the muscular layer (T1b). Radical
cholecystectomy was performed with curative intent.

48. Gallbladder carcinoma in a 63-year-old woman with an incidentally found polypoid
gallbladder lesion. (a) Axial T2-weighted image shows a 2.3-cm hypointense polypoid
gallbladder lesion (arrow). (b) Axial contrast-enhanced T1-weighted image shows
enhancement of the polypoid mass (arrow). The mass was surgically proved to be
gallbladder carcinoma (T2NXM0).

49. (a) Axial T2-weighted image shows asymmetric wall thickening involving the
gallbladder body (arrow). (b) Axial contrast-enhanced T1-weighted image shows
heterogeneous enhancement of the wall thickening (arrow)( Continued)

50. c) Diffusion-weighted image (b value = 500 sec/mm2) shows high signal intensity of the wall
thickening (arrow) from restricted diffusion. (d) On an apparent diffusion coefficient (ADC)
map, the wall thickening is dark (arrow). The wall thickening was surgically proved to be
gallbladder cancer with liver invasion (T2NXM1).

51. Differential diagnosis
intraluminal masses
gallbladder polyp: see differentiating benign vs malignant gallbladder polyps
gallbladder metastasis:melanoma is the most frequent.other described
primaries include: lung, oesophagus, pancreas, colon, and kidney carcinomas
mural thickening has a limited differential but is difficult to distinguish on
imaging alone, possibilities include:cholecystitis,gallbladder wall thickening due
to portal hypertension,adenomyomatosis,gallbladder tuberculosis ,porcelain
gallbladder
large tumours differentials include a number of nearby primaries with extension
to the gallbladder,cholangiocarcinoma,colorectal carcinoma (CRC),duodenal and
pancreatic tumours ,hepatocellular carcinoma (HCC)
tumefactive sludge
tumours from adjacent organs (pancreas, duodenum) invading gallbladder fossa
The differential will depend on the growth pattern of the tumour

52. Thank you