53 HCC in Cirrhosis XII – With Intrahepatic Bile Duct Dilatation

Hepatocellular carcinomas (HCCs) rarely may show invasion with dilatation of the bile ducts and cause jaundice mimicking an intrahepatic cholangiocarcinoma. The treatment options and prognosis may differ. Therefore, early distinction is important. Intraductal cholangiocarcinoma is frequently limited to the mucosa but can invade the ductal wall at a late stage. It usually follows a relatively benign course, and long-term survival can usually be expected after complete surgical resection. In contrast, the bile duct invasion is a late and rare presentation in HCC with a relatively poor prognosis. Definitive surgical intervention is often not feasible because of tumor extension and associated advanced liver cirrhosis.

MR Imaging Findings

At MR imaging, segmental dilatation of the bile ducts in combination with a liver mass may suggest the presence of a cholangiocarcinoma. However, the history of parenchymal liver disease with cirrhosis may strongly indicate the presence of an underlying HCC. Also the mosaic pattern, tumor capsular enhancement, and portal vein thrombosis are indicators of HCC. In rare cases, several intrahepatic confluent nodules of HCC may be present that may also show intrahepatic bile duct dilatation. Such HCCs may be unusually bright on T2-weighted images and show intense arterial enhancement (Figs. 53.1 – 53.3).

Differential Diagnosis

The differential diagnosis should include (1) cholangiocarcinoma,

(2)primary sclerosing cholangitis with a cholangiocarcinoma, and

(3)liver metastases of a hepatoid type of stomach or gallbladder tumor, which often have an elevated alpha-fetoprotein value and clinically mimic HCC.

Management

Percutaneous biliary drainage and transarterial chemoembolization may be used for palliation.

Literature

1.Jung AY, Lee JM, Choi SH, et al. (2006) Computed tomography features of an intraductal polypoid mass differentiation between hepatocellular carcinoma with bile duct tumor invasion and intraductal papillary cholangiocarcinoma. JCAT 30:18 – 24

2.Kojiro M, Kawabata K, Kawano Y, et al. (1982) Hepatocellular carcinoma presenting as intrabile duct tumor growth: a clinicopathologic study of 24 cases. Cancer 49:2144 – 2147

3.Tamada K, Isoa N, Wada S, et al. (2001) Intraductal ultrasonography for hepatocellular carcinoma with tumor thrombi in the bile duct; comparison with polypoid cholangiocarcinoma. J Gastroenterol Hepatol 16:801 – 805

4.Lauffer JM, Mai G, Berchtold D, et al. (1999) Multidisciplinary approach to palliation of obstructive jaundice caused by a central hepatocellular carcinoma. Dig Surg 16:531 – 536

Fig. 53.1. HCC, with dilated bile ducts in a cirrhotic liver, drawings. SSTSE: HCC is slightly hyperintense to the liver and causes compression, encasement, and dilatation of the bile ducts; T1 in-phase: HCC is almost isointense to the

Fig. 53.2. HCC, dilated bile ducts in a cirrhotic liver, MRI findings. A Axial SSTSE image (SSTSE): HCC is slightly hyperintense and causes compression, encasement, and dilatation of the bile ducts (arrow). B Axial in-phase image (T1 in-phase): HCC is isointense to the liver. C Axial arterial phase image (ART): HCC shows faint heterogeneous enhancement. D Axial delayed phase image (DEL): HCC shows washout without any enhancing tumor cap-

liver; ART: HCC shows faint heterogeneous enhancement; DEL: HCC shows washout without a tumor capsule

sule. E Coronal reformat based on the axial delayed phase image (MRCP – dark lumen) shows dark, dilated bile ducts in an enhanced liver. F Coronal SSTSE image (SSTSE) shows the enlarged spleen indicating portal hypertension. G Coronal delayed phase image (DEL) shows unenhanced dilated bile ducts in the left liver with normal common bile duct (arrow). H Drawing shows HCC with dilated bile ducts

Fig. 53.3. HCC, dilated bile ducts, MRI findings in another patient with increased alpha-fetoprotein. A Coronal SSTSE image (SSTSE) shows a large multifocal HCC with interspersed dilated bile ducts. B Axial SSTSE image (SSTSE) of

the massive HCC with dilated bile ducts. C Axial arterial phase image (ART) shows intense enhancement of the nodules within HCC. D Axial delayed phase image (DEL) shows washout with septa enhancement