Primary biliary tract malignant melanoma

Primary melanoma is rarely diagnosed in the biliary tract; only three cases of primary melanoma of the bile ducts have been reported previously. The skin and squamous mucous membranes are the most common primary sites. We report two patients who represent the fourth and fifth reported cases of primary bile duct melanoma. Received: 24 March 1995/Accepted: 3 May 1995     

Icteric-type hepatoma: magnetic resonance imaging and magnetic resonance cholangiographic features

Background: We evaluated the imaging features of magnetic resonance imaging (MRI) and magnetic resonance cholangiography (MRC) of icteric-type hepatoma and correlated these with the findings of endoscopic retrograde cholangiography (ERC), percutaneous cholangiography, and surgery. Methods: Thirteen patients with viral hepatitis complicated by cirrhosis of the liver and obstructive jaundice underwent MRC and dynamic MRI. Five patients received percutaneous transhepatic cholangiography and drainage; one of these patients also underwent resection of the left hepatic lobe. Another patient received MRC followed by thrombectomy and T-tube insertion. ERC and endoscopic nasobiliary drainage were performed in another patient for bile diversion. Results: Primary liver tumors and dilatation of biliary system were demonstrated in all patients. No capsule formation could be found in any primary liver tumors. MRI showed the simultaneous presence of an intraluminal tumor in the portal trunk and common hepatic duct in eight patients. Three different MRC features were found: (a) an oval defect in the hilar bile duct(s) with dilated intrahepatic ducts (n= 9), (b) dilated intrahepatic ducts with missing major bile ducts (n= 2), and (c) localized stricture of the hilar bile duct(s) (n= 2). Conclusion: The presence of one or more of the following features in multiplanar MRI and MRC help to identify this rare, specific type of hepatocellular carcinoma: (a) the presence of an intraluminal tumor in both the portal trunk and the common hepatic duct, (b) enhancement of the intraluminal tumor in the common hepatic duct on the arterial phase, (c) type I MRC feature, and (d) hemobilia, blood clot within the gallbladder, and/or type II MRC feature. Received: 12 January 2000/Revision accepted: 12 July 2000     

Preoperative evaluation of Klatskin tumor: accuracy of spiral CT in determining vascular invasion as a sign of unresectability

Background: To assess the accuracy of spiral computed tomography (CT) in predicting the resectability of Klatskin tumor as determined by vascular invasion. Methods: Twenty-one consecutive patients with Klatskin tumor who had undergone laparotomy were included in this study. The preoperative thin-section (5-mm-thick) spiral CT scans of these patients were assessed for the surgical resectability of tumor by evaluating the vascular invasion. The criterion for vascular invasion indicating unresectability was the tumoral invasion of the proper hepatic artery or main portal vein or simultaneous invasion of one side of the hepatic artery and the other side of the portal vein. Results: All nine patients with tumors thought to be unresectable on the basis of CT findings had tumors that were unresectable at surgery (positive predictive value, 100%). Of 12 patients with tumors thought to be resectable, six had resectable tumors (negative predictive value, 50%). Spiral CT failed to detect small hepatic metastasis (n= 1), lymph node metastasis (n= 1), extensive tumor (n= 2) and variation of bile duct (n= 2), which precluded surgical resection. Conclusion: Spiral CT is a reliable method for detecting vascular invasion and unresectable tumors. However, it has limitations in detecting variations of the bile duct or the intraductal extent of tumor. Received: 24 November 1999/Accepted: 26 January 2000     

Neoplasms containing normal hepatic vessels: imaging features

Background: We investigated the incidence and imaging features of hepatic neoplasms containing normal hepatic vessels. Methods: Among 3183 patients with various hepatic neoplasms, we found nine patients with normal hepatic vessels traversing hepatic neoplasms. The presence of mass effect on the vessel traversing hepatic neoplasms was evaluated. Other suggestive findings of neoplasms such as altered hepatic contour, portal vein thrombosis, mass effect on extratumoral vessel, and bile duct dilatation were analyzed. Results: Thirteen hepatic vessels (nine hepatic veins and four portal veins) extended through hepatic neoplasms in nine patients. Undisturbed hepatic vessels within the neoplasms were found in five patients with either primary or metastatic hepatic neoplasm. In one patient with undisturbed hepatic vessels within the neoplasm, there were no associated abnormal findings such as biliary dilatation, change of hepatic contour, or any changes involving the vessels external to neoplasms. Conclusion: Although rare, various primary and secondary hepatic neoplasms can have normal hepatic vessels passing through them without mass effect. However, correct diagnosis in most neoplasms would be possible with careful examination of associated findings. RID=" ID=" <E5>Correspondence to:</E5> J. K. Han Received: 2 February 2000/Accepted: 5 April 2000     

Ultrasound appearances of intra- and extrahepatic biliary ascariasis

Background: To determine the range of ultrasonographic (US) appearances of Ascaris lumbricoides roundworms in the biliary system, their distribution in the intra- and extrahepatic parts of the system, and associated features. Methods: All cases of biliary ascariasis during a 10-year period were reviewed. There were 42 cases in which diagnosis was based on established US criteria, and 2 cases diagnosed surgically in which US had been negative. These 44 cases occurred in 36 patients. Results: In the US-diagnosed cases, worms were present in intrahepatic ducts in 32 cases, in the main duct in 37, and in the gallbladder in eight. In six cases, the liver was lifted off the main portal vein by a bundle of worms obliterating the lumen of the main bile duct. Worms packing and dilating intrahepatic ducts produced pseudotumorous appearances in the liver in four cases and bundlelike appearances in three. Worms were also seen in the pancreatic duct in two cases. Stones in intrahepatic ducts were present in 12 patients. Conclusion: Biliary ascariasis should be searched for inside and outside the liver. The appearances of bundles and boluses are different from those of single worms. Intra- and extrahepatic biliary stones may be present. Received: 7/30/96/Accepted: 9/4/96     

Safe percutaneous canalization of the biliary tree using a sheath in patients with malignant biliary stenosis

Background: Percutaneous canalization of the bile duct is essential for radiologic interventions of the biliary tract. This study discusses technical considerations for safe approaches for canalization of the bile duct when using a sheath. Methods: During early and late periods, percutaneous canalization was performed in 104 patients and 79 patients with malignant biliary stenosis, respectively. The late period differed from the early period in that the bile duct was canalized with a previously placed sheath to prevent catheter dislodgement during the procedure. Results: During the early and late periods, catheter dislodgement during canalization occurred in three of 104 patients (3%) and none of 79 patients (0%), respectively. The success rate of canalization without cholangioscopy in the late period (99%) was better than that in the early period (89%; p < 0.05). Conclusion: Placement of a sheath into the biliary tree increases the safety and success of canalization in patients with malignant stenosis. Received: 13 March 13, 2001/Revision accepted: 17 May 2001     

The normal retrograde cholangiogram: a definition of normal caliber

Purpose: To evaluate normal retrograde cholangiograms to determine a normal range of ductal calibers and identify its variation with age. Materials and methods: The retrograde cholangiograms of 136 patients (age range: 17–84 years; mean age 49.8 years ± 17.3 [standard deviation]) with clinical follow-up and subsequent studies suggesting normal biliary trees were evaluated. Patients with previous cholecystectomy, choledocholithiasis, or pancreatitis were excluded. Common bile duct (CBD) and common hepatic duct (CHD) sizes were measured. Results: Measurements uncorrected for radiographic magnification of CBD revealed a mean of 8.5 mm ± 2.7 mm [standard deviation] and CHD had a mean of 8.1 mm ± 2.6 mm. There was an increase in CBD caliber by 0.5 mm per decade of increasing age (p < 0.001) and an increase in CHD caliber by 0.35 mm per decade of age (p < 0.01). Conclusion: The range of normal cholangiographic bile duct caliber is wide and a CBD caliber of 13.9 mm occurs at the top of this range (mean plus two standard deviations). There is a small but statistically significant trend of ductal dilatation with advancing age. Received: 13 December 1995/Accepted after revision: 24 April 1996     

Dysplastic nodules of the liver: imaging findings

Background: To verify characteristic features of hepatic dysplastic nodules at different imaging modalities. Methods: Twenty-eight patients with 37 dysplastic nodules of the liver (0.8–3.0 cm) underwent sonography (28 patients), computed tomography (CT; 24 patients), magnetic resonance (MR; 11 patients), and angiography (12 patients). Each nodule was analyzed for echogenicity, attenuation, signal intensity, and vascularity. Results: Echogenicity of nodules was high in 16 (43%), homogeneous in two (6%), and low in 19 (51%) of 37 nodules. Attenuation of nodules was high in one (7%), homogeneous in four (26%), and low in 10 (67%) of 15 nodules on the arterial-phase CT images; homogeneous in five (33%) and low in 10 (67%) of 15 nodules on the portal-phase CT images; and high in four (17%), homogeneous in six (26%), and low in 13 (57%) of 23 nodules on the delayed-phase CT images. Signal intensity of nodules was high in 15 (94%) and homogeneous in one (6%) of 16 nodules on T1-weighted MR images and was homogeneous in seven (44%) and low in nine (56%) of 16 nodules on T2-weighted MR images. Vascularity of nodules was avascular in 14 (88%) and slightly vascular in two (12%) of 16 nodules. Conclusions: Hepatic dysplastic nodules show diverse imaging characteristics with different imaging techniques; however, common imaging findings of hepatic dysplastic nodules are low echo, low attenuation, and high, low, or homogeneous intensity on T1- and T2-weighted MR, and avascularity. Received: 13 May 1998/Accepted: 1 July 1998     

Balloon catheter sphincteroplasty and biliary stone expulsion into the duodenum in patients with an indwelling T tube

Background: To present an alternate approach for treating residual biliary stones in patients with indwelling T tube that uses the immature tract created by the T tube to carry out both sphincteroplasty and expulsion of the calculi with the same angioplasty balloon catheter. Methods: This technique was performed in five patients. Access to the bile duct was through an 8-Fr T tube. First a guidewire was inserted and advanced beyond the obstructing stone to the duodenal lumen. The T tube was removed over the guidewire, and a balloon catheter was introduced. Sphincteroplasty was carried out. Then the balloon was deflated and retracted to a position proximal to the stone. It was then reinflated and used to push the stone, expelling it into the duodenum. Results: In all cases, all biliary stones were expelled without pain, in a single session, and with no immediate complications. All patients showed rapid clinical and analytic improvement. During clinical and echographic follow-up of 2–22 months (mean = 12.4 months), there were no complications or relapses. Conclusions: Our limited experience indicates that sphincteroplasty and expulsion of biliary stones with angioplasty balloon catheters through the T tube immature tract is a simple, safe, low-cost technique that gives good results. RID="ID="<e5>Correspondence to:</e5> J. Muchart Received: 8 September 1997/Accepted: 22 October 1997     

Struma ovarii: MR appearances

Background: Analysis of unenhanced and contrast-enhanced magnetic resonance (MR) images of struma ovarii, a rare benign neoplasm of the ovary, is the aim of this study. Methods: T2-weighted and Gd-DTPA-enhanced T1-weighted MR images of five histologically proven struma ovarii were evaluated retrospectively. Results: In all patients, unenhanced and contrast-enhanced T1-weighted MR images showed complex cystic masses composed of multiple cysts and a solid component, indicating the presence of large and small thyroid follicles. In four patients, the cyst fluid was hypointense on T1-weighted images and hyperintense on T2-weighted images. In one patient, the fluid was hyperintense on T1-weighted images and hypointense on T2-weighted images due to hemorrhage. Conclusion: A complex mass composed of multiple cysts and a solid component, indicating the presence of large and small thyroid follicles, appeared to be a characteristic MR finding of struma ovarii. Received: 11 December 1995/Accepted: 15 December 1995     

Carcinosarcoma of the extrahepatic bile ducts: cholangiographic and CT appearance

A case of histologically proven carcinosarcoma arising in the extrahepatic biliary tree is presented. The tumor appeared on cholangiography and computed tomography as a large expansile intraluminal mass causing biliary obstruction. Received: 19 May 1995/Accepted: 24 June 1995     

Struma ovarii: appearance on MR images

Background: The purpose of this multi-institutional study was to examine the appearance of struma ovarii on magnetic resonance (MR) images. Methods: MR images of 12 patients with histologically proven struma ovarii were retrospectively reviewed. All patients underwent T1-weighted and T2-weighted imaging. Contrast-enhanced T1-weighted images with Gd-DTPA were available in 10 patients. The following determinations were made: tumor morphology, signal intensities, contrast-enhancement effects of solid components with Gd-DTPA, and comparison of MR images with resected specimens. Results: All 12 patients had both cystic and solid components, with a multilobulated surface and thickened septa. Signal intensities on T1-weighted images were mainly low, partly intermediate to high, or high, and those on T2-weighted images were mainly high, with different signal intensities. Contrast-enhancement effects were marked or moderate. The contents that showed low signal intensities on T1-weighted images and signal voids or low signal intensities on T2-weighted images were viscid gelatinous materials. Conclusions: A multicystic tumor with a solid component, a multilobulated surface, and signal intensities that indicate the presence of viscid gelatinous materials appear to be a characteristic MR finding of struma ovarii. Received: 10 April 1997/Accepted after revision: 7 July 1997     

Diagnostic pitfalls in the cholangiographic diagnosis of choledochoceles: cholangiographic quality and its effect on visualization

Background: We wanted to establish reasonable cholangiographic diagnostic criteria by determining the sensitivity of cholangiography in detecting choledochoceles and those factors that could compromise visualization of choledochoceles. Methods: Over 4 years, 21 patients (seven male, 14 female; mean age = 67 years) were confirmed as having choledochoceles on endoscopic retrograde cholangiopancreatography (ERCP). Cholangiographic diagnosis was made by following three criteria: a radiolucent halo around the distal common bile duct (CBD), bulbous dilatation of the distal CBD, and the presence of sequential morphologic changes on serial cholangiography. Any two or more combinations of these three criteria were considered enough to diagnose a choledochocele on cholangiography. We compared cholangiographic imaging findings with the ERCP results. Results: Of 21 patients with choledochoceles, nine (43%) were correctly diagnosed on cholangiography. A radiolucent halo was present in six (28%) patients; four of these cases showed optimal duodenal filling, one showed faint duodenal filling, and one showed poor duodenal filling. The shapes of the distal CBD were bulbous, conelike, and blunt. Morphologic changes such as collapsing and bulging of the choledochocele could be seen in 12 (57%) patients on serial cholangiography. Waists were seen in 11 (52%), pseudowebs in four (19%), and wrinkling of the distal CBD in seven (33%). Conclusion: Cholangiography should be obtained with optimal timing and adequate conditions to diagnose choledochocele correctly. Received: 20 January 2000/Revision accepted: 31 May 2000     

Santorinicele in pancreas divisum: diagnosis with secretin-stimulated magnetic resonance pancreatography

A Santorinicele, or cystic dilatation of the dorsal pancreatic duct at the minor papilla, is seen in a small number of patients with pancreas divisum and may indicate obstruction at the minor papilla, a risk factor for pancreatitis. We present a case of a Santorinicele that was diagnosed with secretin-stimulated magnetic resonance pancreatography and treated with minor papillotomy. Received: 13 July 2000/Accepted: 23 August 2000     

CT imaging of biliary enteric fistula

Background: To define the signs useful for differentiating between gallbladder–enteric fistula (GB-EF) and common bile duct–enteric fistula (CBD-EF) on computed tomography (CT) because the prognosis and management of the two are different. Methods: CT scans in 13 patients with pneumobilia, who had not had surgical biliary–enteric anastomosis and endoscopic sphincterotomy, were reviewed. The presence of fistula itself, the location of air in the biliary system, and the appearance of the gallbladder were assessed. Results: The causes of pneumobilia were GB-EF in seven patients, CBD-EF in three patients, emphysematous cholecystitis (EC) in one patient, gallbladder cancer (GBC) in one patient, and incompetent sphincter of Oddi in one patient. In three of seven GB-EF patients (43%) and in none of the three CBD-EF patients (0%), the fistula itself was detected. Air was detected in the common bile duct in four of seven GB-EF (57%) and in all three CBD-EF (100%) patients, and GBC. In six of seven GB-EF (86%) and in one of three CBD-EF (33%) patients, the gallbladder was contracted. Thus, the location of air and the contraction of gallbladder were useful signs to differentiate GB-EF from CBD-EF. Conclusion: CT can distinguish between GB-EF and CBD-EF. Received: 17 December 1996/Accepted: 5 February 1997     

Intraductal ultrasonography of traumatic neuroma of the bile duct

We report a case of a 70-year-old female with traumatic neuroma of the bile duct. Transpapillary intraductal ultrasonography showed a cystic duct stump, from which a smooth and homogeneous hypoechoic mass arose; the adjacent bile duct wall had a normal structure. Intraductal ultrasonography is useful for distinguishing traumatic neuroma from bile duct carcinoma. Received: 17 January 2001/Accepted: 21 February 2001     

Preoperative assessment of local tumor extent in advanced rectal cancer: CT or high-resolution MRI?

Background: We compared high-resolution magnetic resonance imaging (MRI) with computed tomography (CT) in the assessment of tumor infiltration in surrounding structures for locally advanced primary and recurrent rectal cancer. Methods: Twenty-six patients with operable, locally advanced rectal cancer (15 recurrent and 11 primary) were evaluated with conventional pelvic CT and 1.5-T high-resolution MRI with a quadrature phased-array coil. The images were scored for invasion of nine neighboring pelvic structures, and the results were compared with surgical and histologic findings. Results: A total of 234 structures in 26 patients was evaluated for tumor invasion. For MRI the, sensitivity was 97% and the specificity 98%; for CT, the sensitivity was 70% and the specificity was 85%. The difference in performance was statistically significant (p < 0.001). The failure most frequently made on CT was the false-positive prediction of pelvic floor and piriform muscle invasion (14), whereas MRI showed only four false-positive predictions. MRI correctly predicted all four cases of sacral bone invasion, three of which were missed by CT. MRI was accurate in 20 patients (80%) and CT in only five patients (19%). Conclusion: High-resolution MRI using a quadrature phased-array coil is highly accurate and superior to CT in predicting tumor infiltration in surrounding structures for locally advanced primary or recurrent rectal cancer and is recommended in the preoperative work-up of these tumors. Received: 21 September 1999/Revision accepted: 26 January 2000     

Mature teratomas of the adrenal gland: imaging features

Background: We describe the imaging features of three, histologically confirmed, mature teratomas of the adrenal gland not described previously in the radiologic literature and discuss the differential diagnosis of lipomatous tumors of the adrenal gland. Methods: Computed tomographic (n= 3), magnetic resonance imaging (n= 1), and sonographic (n= 1) features were reviewed retrospectively and the findings correlated with gross pathology and histology. Results: There were two females (age 8 and 18 years) and one male (age 17 years). Tumor size ranged from 5 to 11 cm (mean = 7.3 cm). All tumors were well circumscribed and contained fat components. Calcification was demonstrated in two tumors and was the predominant component in one. Only one was cystic. Conclusion: The radiologic features of these tumors were typical of mature teratomas occurring elsewhere in the body. This should be considered in the differential diagnosis of lipomatous tumors of the adrenal gland, especially in children and adolescents. Received: 29 March 2001/Revision accepted: 13 June 2001     

Polyorchidism and rete testis adenoma: ultrasound and MR findings

Polyorchidism is an uncommon congenital anomaly. It is associated with an increased frequency of testicular malignancy, cryptorchidism, inguinal hernia, and torsion. Sonography may be used to confirm the clinically suspected diagnosis. We present a case of polyorchidism in which a rete testis adenoma was present in one of the testicles. Sonographic and magnetic resonance findings are illustrated. Received: 21 August 1995/Accepted: 24 August 1995     

Intraductal ultrasonography for evaluating the patency of biliary metallic stents: correlation with cholangioscopic findings

Background: This is the first study to correlate intraductal ultrasonography (IDUS) with cholangioscopy in evaluating the patency of biliary metallic stents. Methods: The findings of IDUS (probe 2.0 mm in diameter and 20-MHz frequency) through a percutaneous transhepatic (n = 24) or transpapillary (n = 2) approach were retrospectively reviewed without other information. Criteria for IDUS are as follows: type 1, the inside of the stent is free; type 2, the inner edge is smooth; type 3, the inner edge is irregular; type 4, the inside of the stent is totally occupied; type 5, the solid echo is connected to the outside mass; type 2+D, a hypoechoic line is seen between the bile duct wall and the inside solid component and the inner edge of the bile duct wall is smooth; type 3+D, an irregular hypoechoic line is seen between the bile duct wall and the inside solid component. Results: In the control group (n = 11), IDUS showed type 1 (n = 9) or type 2 (n = 2). In the occluded group (n = 15), when IDUS showed type 3 or 5, the patients (n= 5) required additional stents (n = 3), microwave coagulation of the tumor (n= 1), or transient external drainage (n= 1). When IDUS showed type 4 (n = 5), after washing, the findings changed to type 2+D (n = 4). When IDUS after washing showed a smooth inner edge (type 2+D), the patients were treated without additional stents more frequently than the other groups (eight of nine vs. two of six), a significant distinction (p < 0.05). Conclusion: IDUS is useful in assessing the patency of metallic stents. When the inside of the stent is totally occupied, however, examination after washing is necessary. Received: 19 May 2000/Accepted: 28 June 2000