Abdominal imaging ph cholangiok jm tubiana

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Abdominal imaging ph cholangiok jm tubiana

  1. 1. PERIHILAR CHOLANGIOCARCINOMA New Classification and Treatment JM.TUBIANA Hôpital Saint-Antoine jean-michel.tubiana@sat.aphp.fr
  2. 2. PERIHILAR CHOLANGIOCARCINOMA •  In the past two decades , with the advances in diagnostic ,interventional imaging and surgical techniques , many surgeons have adopted an agressive approch to perihilar CC as surgical resection is the only way to cure this intractable disease . •  So the surgical outcomes and survival rates have gradually improved .
  3. 3. PERIHILAR CHOLANGIOCARCINOMA •  Tumors located in the extra-hepatic biliiary tract proximal to the origine of the cystic duct. •  Potentially include 2 types of tumors : one arising from the large hilar bile duct and the other with intrahepatic component and secondary invasion of the porta hepatis.
  4. 4. AJCC 7EME EDITION 2011 INTRA-HEPATIQUE 10 % EXTRA-HEPATIQUE PROXIMAL 60 % EXTRA-HEPATIQUE DISTAL 30% 30 %
  5. 5. Mass-forming CC 12%   Periductal  infiltra.ng  CC   84% sub-mucosal extension Intraductal 4% Mucosal extension   The  Liver  Cancer  Study  Group  of  Japan    
  6. 6. PERIHILAR CHOLANGIOCARCINOMA Role of Imaging •  Imaging US ,CT, MRI , IR, is mandatory for : •  •  •  - Diagnostic - Tumor extent - Before surgery
  7. 7. PERIHILAR CHOLANGIOCARCINOMA Role of Imaging •  Imaging US ,CT, MRI , IR, is mandatory for : •  •  •  - Diagnostic - Tumor extent - Before surgery
  8. 8. Frequently the initial Imaging modality performed
  9. 9. CT / MRI •  The accuracy of CT and MRI with MRCP for prediction of the extent of ductal involvement ( 84-91 % ) , hepatic artery and portal invasion (86 – 98 % ) ,hepatic volumetry , lymph nodes and metastasis ( 74 – 84 % ) .
  10. 10. INFILTRATING INTRADUCTAL
  11. 11. CCH INFILTRANT
  12. 12. DETECTION ADC ADC
  13. 13. PERIHILAR CHOLANGIOCARCINOMA Role of Imaging •  Imaging US ,CT, MRI , IR, is mandatory for : •  •  •  - Diagnostic - Tumor extent - Before surgery
  14. 14. Longitudinal Extension : Bismuth /Corlette classification Mucosal extension : intraductal ,nodular, mean length 10-20mm ,surgical margin >2 cm for negative margins Submucosal extension : infiltrative form,length 6-10mm , surgical for negative margin>10 mm Direct infiltration along lymphatic and perineural tissues
  15. 15. CCH B / C I
  16. 16. CCH II B / C •  Reverchon
  17. 17. CCH B / C III b
  18. 18. CCH B / C IV
  19. 19. VERTICAL EXTENSION •  Direct invasion of the surrounding structures : •  - Pancreas , Duodenum . •  - Hepatoduodenal ligament including adjacent hepatic artery and portal vein . •  - Hepatic parenchyma . •  Distant metastasis and lymph nodes .
  20. 20. INVOLVEMENT HA / PV
  21. 21. INVOLVEMENT HA / PV
  22. 22. INVOLVEMENT LPV
  23. 23. INVOLVEMENT MAIN PV
  24. 24. HEPATIC INVOLVEMENT
  25. 25. STAGING N
  26. 26. METASTASIS MALIGNANT ASCITIS
  27. 27. PERIHILAR CHOLANGIOCARCINOMA Role of Imaging •  Imaging US ,CT, MRI , IR, is mandatory for : •  •  •  - Diagnostic - Tumor extent - Before surgery
  28. 28. PORTAL VEIN EMBOLIZATION •  Now widely used in the presurgical treatmentof patients undergoing an extended hepatectomy to minimize the post-operative liver dysfunction .
  29. 29. PORTAL VEIN EMBOLIZATION •  Can benefit patients requiring a future liver remnant of 25 % of the total liver volume if liver function is normal and 40 % if liver function is compromised .
  30. 30. BILIARY DRAINAGE •  Remain controversial •  Has provred to be beneficial in case of cholangitis , severe malnutrion and coagulation abnormalities . •  Absolutely indicated for patients requiring major hepatic resection . •  Unilateral BD for future remnant lobe is recommanded in B / C III and IV tumors .
  31. 31. B.Guiu. Cardiovasc Intervent Radiol 2013
  32. 32. STAGING / CLASSIFICATION •  Staging should ideally be performed before and after surgery to include all inta-operative informations and results from macroscopic and microscopis examinations
  33. 33. STAGING / CLASSIFICATION Systems most commonly used to evaluate PCH •  - Bismuth / Corlette •  - MSKCC ( Memorial Sloan-Kettering Cancer Center ) •  - AJCC ( American Joint Commission on Cancer Staging 7 th edition ) : TNM •  - EHPBA (European Hepato-Pancreato-Biliary Association )
  34. 34. SURGERY
  35. 35. SURGERY •  Resectional procedures depend on the location of the primary tumor. •  - Rigth hepatectomy is applied to B/C I ,II and III a tumor. •  - Left hepatectomy to B/C IIIb .
  36. 36. SURGERY •  In B / C IV , the type of hepatectomy is determined by considering the predominant tumor location , the presence or absence of portal vein or hepatic artery invasion and liver function.
  37. 37. SURGERY •  In B / C IV •  - Right predominant tumor : right trisectionectomy ( trisegmentectomy or hight extensive hepatectomy ) 4,5,6,7,8+ 1 •  - Left predominant : left trisectionectomy : 2,3,4,5,8 + 1
  38. 38. OTHERS THERAPIES •  •  •  •  •  Neo-adjuvant / Adjuvant therapy . Photodynamics therapy . Intra-luminal brachytherary . External radiation . Liver transplantation .
  39. 39. REPORT •  •  •  •  •  •  •  •  •  Tumor morphology : localisation ,size , form . Vascular anatomy : PV , HA , Arcuate ligament Longitudinal extension : B / C . Vertical extension : PV , HA ,Liver . Liver remnant volume . Underlying liver disease . Lymph nodes . Metastasis . IR necessary .

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