Hilar cholangiocarcinoma. An evaluation of subtypes with CT and angiography.

Sixty-seven patients had hilar cholangiocarcinomas which were divided into 3 types based on tumor morphology as observed on cholangiography and CT. The pathology, vascularity, and pattern of tumor spread of these types were compared. Most of the infiltrative tumors (n = 44) were scirrhous adenocarcinomas, which on CT showed poor or no contrast enhancement with frequent lymph node metastases and liver atrophy. At angiography, there was vascular encasement in 52%, in rare cases neovascularity, and tumor stain. The exophytic type (n = 19) was divided into 2 subgroups depending on the main location of the tumor. The nodular subtype (n = 16) was mainly inside the liver and somewhat hypervascular similar to peripheral cholangiocarcinoma, often with intrahepatic metastases. The periductal subtype (n = 3) was hypovascular, similar to the infiltrative cholangiocarcinoma, and had a tendency to spread along the portal vein. The intraductal type (n = 4) was observed as a filling defect on cholangiography. CT revealed an intraluminal low density mass. Histologically, they were papillary adenocarcinomas. The radiologic types of hilar cholangiocarcinoma showed different characteristics with regard to pathologic findings, vascularity, and pattern of spread.     

Preoperative imaging of biliary tract cancers

Many imaging techniques are available for the evaluation of patients with malignant obstructive jaundice. Ultrasonography, in experienced hands, is valuable for evaluating the local extent of the disease, but its usefulness for staging distant metastases is limited. When used properly, CT and MR imaging can provide valuable information about the extent of local tumor involvement and distant metastases. These noninvasive techniques provide images of the bile ducts and vascular images that are comparable in quality to those obtained with more invasive procedures, such as PTC, ERCP, and angiography, and do not have the risk for complications of these invasive techniques.     

Staging of pancreatic cancer with multidetector CT in the setting of preoperative chemoradiation therapy

Background Preoperative chemoradiation can potentially improve outcomes in patients with pancreatic cancer. This study addresses its effect on staging pancreatic cancer with multidetector computed tomography (MDCT). Methods Fifty-five patients underwent a dual-phase MDCT pancreas protocol for proved pancreatic cancer. Of these, 16 patients underwent preoperative chemoradiation. Three radiologists independently reviewed images to assess for locally advanced disease, liver and peritoneal metastases on baseline studies of all 55 patients, and on follow-up preoperative studies for the 16 patients receiving preoperative therapy. Overall score for resectability was graded on a scale from 1 to 5 (1, definitely resectable; 5. definitely unresectable). Receiver operating characteristic curves and weighted (κ statistics were determined. Results The areas under the receiver operating characteristic curves for readers 1, 2, and 3 were 0.98, 0.96, and 0.90, respectively. Weighted κ values for reader 1 versus reader 2, reader 1 versus reader 3, and reader 2 versus reader 3 were 0.90, 0.57, and 0.54, respectively. Interpreting scores of 1 to 3 for resectability as resectable disease, the mean values for sensitivity, specificity, negative predictive value, positive predictive value, and accuracy were 0.92, 0.91, 0.74, 0.98, and 0.92 respectively. Conclusion The negative predictive value for MDCT for identifying unresectable pancreatic cancer in the setting of preoperative therapy is comparable to that reported in the absence of neoadjuvant therapy.     

Preoperative chemoradiation and pancreaticoduodenectomy for adenocarcinoma of the pancreas.

Chemoradiation prior to pancreaticoduodenectomy ensures that all patients who undergo resection complete multimodality therapy, avoids resection in patients with rapidly progressive disease, and allows radiation therapy to be delivered to well-oxygenated cells before surgical devascularization. Twenty-eight patients with cytologic or histologic proof of localized adenocarcinoma of the pancreatic head received preoperative chemoradiation (fluorouracil, 300 mg/m2 per day, and 50.4 Gy) with the intent of proceeding to resection; all 28 completed this preoperative therapy. Hospital admission because of gastrointestinal toxic effects was required in nine patients, yet no patient experienced a delay in operation. Restaging was performed 4 to 5 weeks after completion of chemoradiation, and five patients were found to have metastatic disease; the 23 patients without evidence of progressive disease underwent laparotomy. At laparotomy, three patients were found to have unsuspected metastatic disease, three patients had unresectable locally advanced disease, and 17 patients were able to undergo pancreaticoduodenectomy. One perioperative death resulted from myocardial infarction, and perioperative complications occurred in three patients. Histologic evidence of tumor cell injury was present in all resected specimens. Our results suggest that pancreaticoduodenectomy can be performed with a low incidence of complications after chemoradiation for localized adenocarcinoma of the pancreas.     

Portal-hepatic venous malformation: Ultrasound,computed tomographic,and angiographic findings

A 59-year-old woman was evaluated for a mass in the right lobe of the liver. Ultrasonography (US) demonstrated multiple anechoic areas with enlargement of portal and hepatic veins. These areas were enhanced uniformly after bolus injection of contrast material during computed tomography (CT). The diagnosis of portal-hepatic venous fistula was confirmed by the portal venous phase of a superior mesenteric angiogram.     

Hepatic arterial flow distribution with hepatic neoplasms: significance in infusion chemotherapy

Hepatic artery radionuclide flow studies and hepatic angiography in eight patients with various hepatic neoplasms were evaluated to determine the patterns of arterial flow distribution in the presence of portal vein occlusion. Increased hepatic arterial blood flow to the lobe or segment supplied by the occluded portal vein was observed in all patients. This phenomenon must be taken into account when positioning catheters for hepatic artery infusion chemotherapy; while it may improve the flow of chemotherapeutic agents to tumors located in the area of an occluded portal vein branch, it may also result in diversion of flow to the normal hepatic parenchyma away from tumors occupying the hepatic segments with patent portal venous flow. Hepatic angiography and radionuclide flow studies provide the necessary information for correct positioning of hepatic artery infusion catheters.     

Repositioning misplaced central venous catheters

Central venous catheters inserted through the subclavian or basilic veins may be misplaced in the internal jugular vein. A simple technique employing a deflector guide wire allows catheter reposition in a very short time without the need for catheter withdrawal. In this manner, radiation exposure, the risk of catheter contamination, and patient discomfort are lessened.