| Background：It is difficult to diagnose cholangiocarcinoma in earlystage but was mostly clinically diagnosed in advanced cases with poorprognosis. Current imaging methods to diagnose cholangiocarcinomainclude ultrasound, computed tomography (CT), magnetic resonanceimaging (MRI), positron emission tomography (PET), endoscopicretrograde cholangiopancreatography (ERCP), percutaneous transhepaticcholangiography (PTC), intraductal ultrasonography (IUDS). PTC andERCP can display intraductal structure which is considered to be one ofthe most effective methods; however, they are invasive and expensive.Ultrasound (US) which is sensitive to diagnose the biliary tract dilatationis still the preferred imaging method of biliary tract disease.Objective：The aim of this study was to evaluate the value ofultrasound in diagnosing cholangiocarcinoma and differential diagnosisby analyzing the clinical data and ultrasound findings. Methods：①General Information：The study population was19hospitalized patients with cholangiocarcinoma which were pathologicallyproven presenting from December2010to December2012in the1sthospital, Jilin University including9males and10females, aged35-79years old, mean age of61years. Clinical manifestations include8patientswith upper abdominal discomfort and pain,17patients with jaundice,3patients with nausea and vomiting,3patients with dark stained urine and1patient with abdominal palpable mass.②Ultrasound Method：Allpatients fasting for8-12h were examined by GE LOGIC9color Dopplerultrasound, probe frequency was3.5MHz (slim patients could beexamined by high frequency probe), and patients with obesity should takethe laxative to reduce intestinal gas interference the day before theexamination. Patients were lying in the spine or left lateral decubitusposition, the liver, gallbladder and biliary tract were detectedconventionally. Once bile duct dilation was found, it was necessary tolook for the site of obstruction, surrounding tissues invasion, possiblecause of the bile duct obstruction, focus on lesion size, shape and echo patterns. Then a possible diagnosis was made combined with clinicaldata.Result：In this study, the accuracy rate of ultrasound diagnosingcholangiocarcinoma was84.2%, the misdiagnosis rate was15.78%. In19cases of cholangiocarcinoma only1patient was intrahepaticcholangiocarcinoma compliance with pathological result which waspresenting heterogeneous mass, irregular, unclear border and intrahepaticbile duct dilatation in the adjacent liver parenchyma.18patients wereextrahepatic cholangiocarcinoma,15cases (83.3%) were completecompliance with pathological diagnosis and3cases (16.6%) were misseddiagnosed. Location: We had4cases of hilar cholangiocarcinomapresenting as intraductal nodular mass (left and right hepatic duct to thebeginning part of the common bile duct). The total number of distalcholangiocarcinoma (suprapancreatic and intrapancreatic level) was11.We had8cases of suprapancreatic distal cholangiocarcinoma(intraluminal nodular mass forming type=5, periductal infiltrating type=3),and3cases of intraluminal mass forming intrapancreatic (ampullary) cholangiocarcinoma.Ultrasound appearance of the extrahepatic cholangiocarcinomaIntraluminal mass forming type appeared as hypoechoic tohyperechoic well defined mass with clear border and dilation of the bileduct proximal to the mass. In periductal-infiltrating type, the bile ductwall was thickened irregularly with luminal stenosis.Discussion：Cholangiocarcinoma (CCA) is a primary malignanttumor of the biliary duct system that arises from the neoplastictransformation of cholangiocytes, which can occur in any part of thebiliary system, including the intrahepatic bile duct, hilar bile duct,common bile duct and ampulla. Cholangiocarcinoma, especiallyintrahepatic and hilar cholangiocarcinoma, is the main cause of clinicalmisdiagnosis due to the lack of typical clinical symptom and signs whichis often associated with cholangitis, cholelithiasis, and hepatic abscess.Therefore, the early diagnosis of cholangiocarcinoma is still a clinicalproblem. It is important to look for a sensitive and accurate method inorder to treat this patient as early as possible and improve the outcomes. This study demonstrated that the direct sonographic feature ofcholangiocarcinoma is visible solid intraductal mass or irregular marginsto lumen. In this study the size of intraductal tumor was4-25mm withdifferent echogenicities without distal shadowing. The tumor masses werenot visible in some cases. The bile duct dilation is indirect sonographicfeature of cholangiocarcinoma. In this study almost all casesaccompanied with biliary tract dilatation. It is possible to determine thesite of obstruction according to the length of bile duct dilatation,gallbladder size or pancreatic duct dilation. This study demonstrated thatthe extrahepatic bile duct dilated with normal size of the gallbladder andwithout extrahepatic bile duct dilation in intrahepatic cholangiocarcinoma;however, the extrahepatic bile duct dilated with enlarged gallbladder inextrahepatic cholangiocarcinoma; and the extrahepatic bile and pancreaticduct dilated with enlarged gallbladder in ampullary cholangiocarcinoma.The reason of misdiagnosis by ultrasound may be the mass ofcholangiocarcinoma was hyperechoic lesion which was misdiagnosed asbile duct stone. The differential point is: in cholelithiasis there is a distal shadow and a clear boundary between the stone and bile duct wall andpostural changes can move stone, on the contrary, hyperechoiccholangiocarcinoma does not caste distal shadow, cannot move and theboundary is unclear because the wall is often infiltrated.Conclusion： Ultrasound can improve the diagnosis ofcholangiocarcinoma by detecting the site of the biliary tract dilation,analyzing the site of obstruction and characteristic of bile duct wallcombined with the clinical manifestations. Moreover, it is helpful indiagnosing the site and classification of cholangiocarcinoma. Therefore,ultrasound, which is non-invasive and inexpensive method, is the firstimaging modality of choice in patients presenting with jaundice. |
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