DOI: 10.1148/rg.232025030
(Radiographics. 2003;23:447-455.)
© RSNA, 2003
Papillary Neoplasms of the Bile Duct That Mimic Biliary Stone Disease1
Jae Hoon Lim, MD,
Myung-Hwan Kim, MD,
Tae Kyoung Kim, MD,
Moon-Gyu Lee, MD,
Sang Soo Lee, MD,
Jin Wook Lee, MD,
Kyu Taek Lee, MD,
Jong Kyun Lee, MD and
Hyo Keun Lim, MD
1 From the Departments of Radiology (J.H.L., J.W.L., H.K.L.) and Gastroenterology (K.T.L., J.K.L.), Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Ilwon-dong, Kangnam-ku, Seoul, Korea 135-710; and the Departments of Internal Medicine (M.H.K., S.S.L.) and Radiology (T.K.K., M.G.L.), Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea. Presented as an education exhibit at the 2001 RSNA scientific assembly. Received February 19, 2002; revision requested April 23; final revision received July 12; accepted July 15. Address correspondence to J.H.L. (e-mail: jhlim@smc.samsung.co.kr).
 |
Abstract
|
|---|
Papillary tumors of the bile duct are intraductal tumors with innumerable minute, frondlike papillary projections. These tumors may be either fixed to or detached from the bile duct wall. However, because the papillary projections on the surface of papillary tumors are long and slender, the tumors are friable and slough easily. The sloughed tumor fragments may float within the bile ducts, resulting in intermittent partial biliary obstruction and mimicking bile duct stones at clinical examination and at ultrasonography (US), computed tomography (CT), and cholangiography. A tumor manifests radiologically as thickening and irregularity of the bile duct wall or as a fixed or sloughed intraductal mass. A nonshadowing intraductal echogenic cast seen at US, an intraductal noncalcified soft-tissue mass with asymmetric wall thickening seen at CT, and an intraductal mass with a papillary surface and a serrated bile duct margin seen at cholangiography are all appearances that suggest a papillary tumor and may be helpful in differentiating a tumor from a bile duct stone.
© RSNA, 2003
Index Terms: Bile duct radiography, 76.1222 • Bile ducts, calculi, 76.289 • Bile ducts, CT, 76.1211 • Bile ducts, neoplasms, 76.3192, 76.321 • Bile ducts, stenosis or obstruction • Bile ducts, US, 76.1298
|
LEARNING OBJECTIVES
|
|---|
After reading this article and taking the test, the reader will be able to:
- Describe the histopathologic characteristics of papillary bile duct neoplasms that mimic biliary stones.
- List the US, CT, and cholangiographic features of papillary neoplasms of the bile duct.
- Discuss how bile duct stones can be differentiated from papillary neoplasms at US, CT, and cholangiography.
|
Introduction
|
|---|
A papillary tumor of the bile ducts is an intraductal tumor with innumerable frondlike papillary infoldings of the tumor surface that consist of slender fibrovascular stalks covered with columnar epithelial cells (Fig 1). The tumor is usually small and sessile or polypoid. Occasionally, the tumor spreads superficially along the mucosal surface, forming multiple tumors (papillomatosis) along a varying length of the bile duct (1–7). At histopathologic analysis, the tumor may prove to be adenocarcinoma, adenoma, or dysplasia, and different histologic patterns frequently coexist (6,8,9). Papillary adenocarcinoma is a low-grade malignancy that is often limited to the mucosa; it infiltrates and penetrates the bile duct wall in its late phase (4,5). Occasionally, papillary adenocarcinoma produces a profuse amount of mucus (4,5,10,11). Sometimes, papillary tumors may be associated with intrahepatic stones (hepatolithiasis) or clonorchiasis (4,7,10,11). They may rarely demonstrate pancreatic duct involvement (12,13), which may be related to the shared embryologic origin of the liver and pancreas and the homology of the pathologic condition.
View larger version (187K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 1. Intrahepatic intraductal papillary adenocarcinoma. Photomicrograph (original magnification, x40; hematoxylin-eosin [H-E] stain) shows myriad frondlike papillary infoldings that consist of slender fibrovascular stalks (open arrow) covered with columnar epithelial cells. The word papillary refers to these projections. Solid arrows indicate the wall of the intrahepatic bile duct.
|
|
Because the papillary projections of papillary tumors are long and slender (Fig 1), the tumors are friable and may slough spontaneously (3,7,14). At surgery, the tumors are soft and friable and easily detach with mere touching, with rubbing, or with vacuum suction (15). The sloughed tumor debris floats within the bile ducts; it may proliferate substantially and drain through the duodenal papillary orifice. Consequently, these neoplasms can be confused with bile duct stones (15). Because papillary tumors are relatively benign and the tumors slough continuously, the disease process can be protracted and repeated (7).
In this article, we discuss the clinical significance of papillary bile duct neoplasms that mimic biliary stones and describe and illustrate pertinent radiologic findings with histopathologic correlation.
|
Clinical Significance
|
|---|
Papillary neoplasms of the biliary tract are rare, having been reported only sporadically in the English medical literature (2,6,14). Their true prevalence is perhaps underestimated because the tumors often go unrecognized or are misdiagnosed as biliary stones. As a result of recent developments in diagnostic imaging techniques, clinicians and radiologists now encounter increasing numbers of patients with papillary tumors of the biliary tract (4,5,7,11).
The clinical and radiologic diagnosis is frequently bile duct stone with cholangitis. This is because clinical manifestations are caused by intermittent partial biliary obstruction and papillary tumors resemble stones at imaging (7). However, endoscopic intervention will yield only tissue debris, not stones (14), a phenomenon that is recognized by some endoscopists (Fig 2).
View larger version (152K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 2. Papillary adenoma in a 60-year-old man with recurrent abdominal pain. Endoscopic image of the duodenum obtained after the extraction of "lumps" in the common bile duct (CBD) shows innumerable fragments of tumor debris (arrows) at the orifice of the papilla of Vater. d = duodenal lumen, e = endoscopic tube. The histologic diagnosis was papillary adenoma.
|
|
|
Radiologic Findings
|
|---|
In papillary bile duct neoplasms, imaging studies including ultrasonography (US), computed tomography (CT), endoscopic retrograde cholangiopancreatography (ERCP), and magnetic resonance cholangiography reveal bile ducts that are incompletely obstructed by intraductal masses. The extrahepatic bile ducts may be dilated as far as the ampulla of Vater irrespective of the location of papillary tumor.
These tumors involve both the intrahepatic and extrahepatic bile ducts. At US, papillary tumors manifest as an echogenic cast that fills the bile ducts. This echogenicity is similar to that of the liver, and there is no acoustic shadow (Figs 3 –6). Bile duct wall integrity is usually preserved. At CT, the tumors manifest as intraluminal masses that are enhancing or nonenhancing depending on whether the tumor is fixed to or detached from the wall. There may be segmental asymmetric thickening of the bile duct wall with enhancement (Figs 4, 6, 7). At ERCP or percutaneous transhepatic cholangiography, these tumors manifest as single or multiple nodular filling defects of variable size (Figs 3, 5, 6), and the wall of the bile duct is ragged or serrated for a variable length (Figs 3–7).
View larger version (171K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 3a. Papillary adenomatosis in the intrahepatic ducts in a 60-year-old man with a 1-week history of pain in the right upper abdomen. (a) US image shows dilatation of the left intrahepatic bile duct and a nonshadowing intraductal echogenic focus (arrow). (b, c) Sequential percutaneous transhepatic cholangiograms obtained after forceful injection of contrast material show biliary dilatation and innumerable small, round or oval filling defects that mimic stones in the intrahepatic ducts (arrowheads in b). Note the small, movable filling defects in the second portion of the duodenum (arrows in c); these filling defects represent tumor fragments that became detached and drained into the duodenum. (d) Cholangioscopic image shows innumerable small (1-mm), round, pink-white intraluminal masses that represent papillary tumors. At surgery, there were innumerable small papillary masses in the left and right intrahepatic ducts and CBD. Pathologic examination revealed papillary adenomas with high-grade dysplasia.
|
|
View larger version (164K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 3b. Papillary adenomatosis in the intrahepatic ducts in a 60-year-old man with a 1-week history of pain in the right upper abdomen. (a) US image shows dilatation of the left intrahepatic bile duct and a nonshadowing intraductal echogenic focus (arrow). (b, c) Sequential percutaneous transhepatic cholangiograms obtained after forceful injection of contrast material show biliary dilatation and innumerable small, round or oval filling defects that mimic stones in the intrahepatic ducts (arrowheads in b). Note the small, movable filling defects in the second portion of the duodenum (arrows in c); these filling defects represent tumor fragments that became detached and drained into the duodenum. (d) Cholangioscopic image shows innumerable small (1-mm), round, pink-white intraluminal masses that represent papillary tumors. At surgery, there were innumerable small papillary masses in the left and right intrahepatic ducts and CBD. Pathologic examination revealed papillary adenomas with high-grade dysplasia.
|
|
View larger version (167K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 3c. Papillary adenomatosis in the intrahepatic ducts in a 60-year-old man with a 1-week history of pain in the right upper abdomen. (a) US image shows dilatation of the left intrahepatic bile duct and a nonshadowing intraductal echogenic focus (arrow). (b, c) Sequential percutaneous transhepatic cholangiograms obtained after forceful injection of contrast material show biliary dilatation and innumerable small, round or oval filling defects that mimic stones in the intrahepatic ducts (arrowheads in b). Note the small, movable filling defects in the second portion of the duodenum (arrows in c); these filling defects represent tumor fragments that became detached and drained into the duodenum. (d) Cholangioscopic image shows innumerable small (1-mm), round, pink-white intraluminal masses that represent papillary tumors. At surgery, there were innumerable small papillary masses in the left and right intrahepatic ducts and CBD. Pathologic examination revealed papillary adenomas with high-grade dysplasia.
|
|
View larger version (117K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 3d. Papillary adenomatosis in the intrahepatic ducts in a 60-year-old man with a 1-week history of pain in the right upper abdomen. (a) US image shows dilatation of the left intrahepatic bile duct and a nonshadowing intraductal echogenic focus (arrow). (b, c) Sequential percutaneous transhepatic cholangiograms obtained after forceful injection of contrast material show biliary dilatation and innumerable small, round or oval filling defects that mimic stones in the intrahepatic ducts (arrowheads in b). Note the small, movable filling defects in the second portion of the duodenum (arrows in c); these filling defects represent tumor fragments that became detached and drained into the duodenum. (d) Cholangioscopic image shows innumerable small (1-mm), round, pink-white intraluminal masses that represent papillary tumors. At surgery, there were innumerable small papillary masses in the left and right intrahepatic ducts and CBD. Pathologic examination revealed papillary adenomas with high-grade dysplasia.
|
|
View larger version (103K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 4a. Papillary adenoma of the CBD in a 67-year-old woman with a 1-month history of intermittent severe pain in the epigastrium and right upper abdomen. (a) US image of the extrahepatic ducts shows an intraluminal echogenic cast. Note the integrity of the echogenic wall of the CHD (arrows). (b) Contrast-enhanced CT scan shows eccentric thickening of the CBD wall (arrow). (c) ERCP image shows nodular and papillary filling defects along the extrahepatic ducts (curved arrow). Note the serrated margin of the CBD (straight arrows), a finding that indicates papillary tumors rather than stones. (d) Endoscopic extraction of the possible stones with a basket maneuver was attempted. This ERCP image was obtained after innumerable tumor fragments and debris had been extracted at the orifice of the papilla of Vater. The histopathologic diagnosis was papillary adenoma.
|
|
View larger version (116K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 4b. Papillary adenoma of the CBD in a 67-year-old woman with a 1-month history of intermittent severe pain in the epigastrium and right upper abdomen. (a) US image of the extrahepatic ducts shows an intraluminal echogenic cast. Note the integrity of the echogenic wall of the CHD (arrows). (b) Contrast-enhanced CT scan shows eccentric thickening of the CBD wall (arrow). (c) ERCP image shows nodular and papillary filling defects along the extrahepatic ducts (curved arrow). Note the serrated margin of the CBD (straight arrows), a finding that indicates papillary tumors rather than stones. (d) Endoscopic extraction of the possible stones with a basket maneuver was attempted. This ERCP image was obtained after innumerable tumor fragments and debris had been extracted at the orifice of the papilla of Vater. The histopathologic diagnosis was papillary adenoma.
|
|
View larger version (168K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 4c. Papillary adenoma of the CBD in a 67-year-old woman with a 1-month history of intermittent severe pain in the epigastrium and right upper abdomen. (a) US image of the extrahepatic ducts shows an intraluminal echogenic cast. Note the integrity of the echogenic wall of the CHD (arrows). (b) Contrast-enhanced CT scan shows eccentric thickening of the CBD wall (arrow). (c) ERCP image shows nodular and papillary filling defects along the extrahepatic ducts (curved arrow). Note the serrated margin of the CBD (straight arrows), a finding that indicates papillary tumors rather than stones. (d) Endoscopic extraction of the possible stones with a basket maneuver was attempted. This ERCP image was obtained after innumerable tumor fragments and debris had been extracted at the orifice of the papilla of Vater. The histopathologic diagnosis was papillary adenoma.
|
|
View larger version (151K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 4d. Papillary adenoma of the CBD in a 67-year-old woman with a 1-month history of intermittent severe pain in the epigastrium and right upper abdomen. (a) US image of the extrahepatic ducts shows an intraluminal echogenic cast. Note the integrity of the echogenic wall of the CHD (arrows). (b) Contrast-enhanced CT scan shows eccentric thickening of the CBD wall (arrow). (c) ERCP image shows nodular and papillary filling defects along the extrahepatic ducts (curved arrow). Note the serrated margin of the CBD (straight arrows), a finding that indicates papillary tumors rather than stones. (d) Endoscopic extraction of the possible stones with a basket maneuver was attempted. This ERCP image was obtained after innumerable tumor fragments and debris had been extracted at the orifice of the papilla of Vater. The histopathologic diagnosis was papillary adenoma.
|
|
View larger version (145K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 5a. Papillary adenocarcinoma of the extrahepatic duct in a 73-year-old man with a 2-month history of jaundice. (a) US image shows a slightly dilated CBD that contains an echogenic cast. The wall of the bile duct is well preserved and appears as a thin echogenic line (arrow). GB = gallbladder. (b, c) Unenhanced (b) and contrast material-enhanced (c) CT scans show an intraluminal mass in the CBD (arrow). Attenuation of the mass increased from 24 HU on b to 95 HU on c, indicating that the mass represents a tumor attached to the bile duct wall. (d) ERCP image shows multiple large, oval filling defects in the CBD. The filling defects with smooth surfaces (open arrow) are stones, whereas those with papillary surfaces are tumors. The margin of the common hepatic duct (CHD) (solid arrow) is serrated. The bile ducts are dilated as far as the ampulla of Vater. Note the normal duodenal mucosal surface. (e) ERCP image obtained after an attempt to extract the "lumps" with a basket maneuver shows innumerable filling defects of varying size that represent tumor fragments. A stone (open arrow) remains in the bile duct, and only small tissue debris could be removed. The serrated margin of the CHD (solid black arrow) is unchanged (cf d). Note the small and medium-sized filling defects in the second portion of the duodenum (solid white arrows), which represent tumor fragments. Surgery revealed several pigmented stones as well as many tiny (3-5-mm-diameter) fragments of papillary tumor and debris within the extrahepatic ducts. (f) Photomicrograph (original magnification, x40; H-E stain) of tissue debris obtained from the bile ducts at surgery shows innumerable papillary tumor fragments (arrowheads). (g) Low-power photomicrograph (original magnification, x10; H-E stain) of a cut section of the proximal portion of the CHD shows tiny flat papillary carcinomas lining the mucosal surface (curved arrow). A defect caused by bile duct exploration performed during surgery is also seen (straight arrow). Because the superficial papillary tumors were sloughed or denuded before or during surgery, there are no polypoid masses as were seen at US, CT, and ERCP.
|
|
View larger version (147K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 5b. Papillary adenocarcinoma of the extrahepatic duct in a 73-year-old man with a 2-month history of jaundice. (a) US image shows a slightly dilated CBD that contains an echogenic cast. The wall of the bile duct is well preserved and appears as a thin echogenic line (arrow). GB = gallbladder. (b, c) Unenhanced (b) and contrast material-enhanced (c) CT scans show an intraluminal mass in the CBD (arrow). Attenuation of the mass increased from 24 HU on b to 95 HU on c, indicating that the mass represents a tumor attached to the bile duct wall. (d) ERCP image shows multiple large, oval filling defects in the CBD. The filling defects with smooth surfaces (open arrow) are stones, whereas those with papillary surfaces are tumors. The margin of the common hepatic duct (CHD) (solid arrow) is serrated. The bile ducts are dilated as far as the ampulla of Vater. Note the normal duodenal mucosal surface. (e) ERCP image obtained after an attempt to extract the "lumps" with a basket maneuver shows innumerable filling defects of varying size that represent tumor fragments. A stone (open arrow) remains in the bile duct, and only small tissue debris could be removed. The serrated margin of the CHD (solid black arrow) is unchanged (cf d). Note the small and medium-sized filling defects in the second portion of the duodenum (solid white arrows), which represent tumor fragments. Surgery revealed several pigmented stones as well as many tiny (3-5-mm-diameter) fragments of papillary tumor and debris within the extrahepatic ducts. (f) Photomicrograph (original magnification, x40; H-E stain) of tissue debris obtained from the bile ducts at surgery shows innumerable papillary tumor fragments (arrowheads). (g) Low-power photomicrograph (original magnification, x10; H-E stain) of a cut section of the proximal portion of the CHD shows tiny flat papillary carcinomas lining the mucosal surface (curved arrow). A defect caused by bile duct exploration performed during surgery is also seen (straight arrow). Because the superficial papillary tumors were sloughed or denuded before or during surgery, there are no polypoid masses as were seen at US, CT, and ERCP.
|
|
View larger version (153K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 5c. Papillary adenocarcinoma of the extrahepatic duct in a 73-year-old man with a 2-month history of jaundice. (a) US image shows a slightly dilated CBD that contains an echogenic cast. The wall of the bile duct is well preserved and appears as a thin echogenic line (arrow). GB = gallbladder. (b, c) Unenhanced (b) and contrast material-enhanced (c) CT scans show an intraluminal mass in the CBD (arrow). Attenuation of the mass increased from 24 HU on b to 95 HU on c, indicating that the mass represents a tumor attached to the bile duct wall. (d) ERCP image shows multiple large, oval filling defects in the CBD. The filling defects with smooth surfaces (open arrow) are stones, whereas those with papillary surfaces are tumors. The margin of the common hepatic duct (CHD) (solid arrow) is serrated. The bile ducts are dilated as far as the ampulla of Vater. Note the normal duodenal mucosal surface. (e) ERCP image obtained after an attempt to extract the "lumps" with a basket maneuver shows innumerable filling defects of varying size that represent tumor fragments. A stone (open arrow) remains in the bile duct, and only small tissue debris could be removed. The serrated margin of the CHD (solid black arrow) is unchanged (cf d). Note the small and medium-sized filling defects in the second portion of the duodenum (solid white arrows), which represent tumor fragments. Surgery revealed several pigmented stones as well as many tiny (3-5-mm-diameter) fragments of papillary tumor and debris within the extrahepatic ducts. (f) Photomicrograph (original magnification, x40; H-E stain) of tissue debris obtained from the bile ducts at surgery shows innumerable papillary tumor fragments (arrowheads). (g) Low-power photomicrograph (original magnification, x10; H-E stain) of a cut section of the proximal portion of the CHD shows tiny flat papillary carcinomas lining the mucosal surface (curved arrow). A defect caused by bile duct exploration performed during surgery is also seen (straight arrow). Because the superficial papillary tumors were sloughed or denuded before or during surgery, there are no polypoid masses as were seen at US, CT, and ERCP.
|
|
View larger version (166K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 5d. Papillary adenocarcinoma of the extrahepatic duct in a 73-year-old man with a 2-month history of jaundice. (a) US image shows a slightly dilated CBD that contains an echogenic cast. The wall of the bile duct is well preserved and appears as a thin echogenic line (arrow). GB = gallbladder. (b, c) Unenhanced (b) and contrast material-enhanced (c) CT scans show an intraluminal mass in the CBD (arrow). Attenuation of the mass increased from 24 HU on b to 95 HU on c, indicating that the mass represents a tumor attached to the bile duct wall. (d) ERCP image shows multiple large, oval filling defects in the CBD. The filling defects with smooth surfaces (open arrow) are stones, whereas those with papillary surfaces are tumors. The margin of the common hepatic duct (CHD) (solid arrow) is serrated. The bile ducts are dilated as far as the ampulla of Vater. Note the normal duodenal mucosal surface. (e) ERCP image obtained after an attempt to extract the "lumps" with a basket maneuver shows innumerable filling defects of varying size that represent tumor fragments. A stone (open arrow) remains in the bile duct, and only small tissue debris could be removed. The serrated margin of the CHD (solid black arrow) is unchanged (cf d). Note the small and medium-sized filling defects in the second portion of the duodenum (solid white arrows), which represent tumor fragments. Surgery revealed several pigmented stones as well as many tiny (3-5-mm-diameter) fragments of papillary tumor and debris within the extrahepatic ducts. (f) Photomicrograph (original magnification, x40; H-E stain) of tissue debris obtained from the bile ducts at surgery shows innumerable papillary tumor fragments (arrowheads). (g) Low-power photomicrograph (original magnification, x10; H-E stain) of a cut section of the proximal portion of the CHD shows tiny flat papillary carcinomas lining the mucosal surface (curved arrow). A defect caused by bile duct exploration performed during surgery is also seen (straight arrow). Because the superficial papillary tumors were sloughed or denuded before or during surgery, there are no polypoid masses as were seen at US, CT, and ERCP.
|
|
View larger version (167K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 5e. Papillary adenocarcinoma of the extrahepatic duct in a 73-year-old man with a 2-month history of jaundice. (a) US image shows a slightly dilated CBD that contains an echogenic cast. The wall of the bile duct is well preserved and appears as a thin echogenic line (arrow). GB = gallbladder. (b, c) Unenhanced (b) and contrast material-enhanced (c) CT scans show an intraluminal mass in the CBD (arrow). Attenuation of the mass increased from 24 HU on b to 95 HU on c, indicating that the mass represents a tumor attached to the bile duct wall. (d) ERCP image shows multiple large, oval filling defects in the CBD. The filling defects with smooth surfaces (open arrow) are stones, whereas those with papillary surfaces are tumors. The margin of the common hepatic duct (CHD) (solid arrow) is serrated. The bile ducts are dilated as far as the ampulla of Vater. Note the normal duodenal mucosal surface. (e) ERCP image obtained after an attempt to extract the "lumps" with a basket maneuver shows innumerable filling defects of varying size that represent tumor fragments. A stone (open arrow) remains in the bile duct, and only small tissue debris could be removed. The serrated margin of the CHD (solid black arrow) is unchanged (cf d). Note the small and medium-sized filling defects in the second portion of the duodenum (solid white arrows), which represent tumor fragments. Surgery revealed several pigmented stones as well as many tiny (3-5-mm-diameter) fragments of papillary tumor and debris within the extrahepatic ducts. (f) Photomicrograph (original magnification, x40; H-E stain) of tissue debris obtained from the bile ducts at surgery shows innumerable papillary tumor fragments (arrowheads). (g) Low-power photomicrograph (original magnification, x10; H-E stain) of a cut section of the proximal portion of the CHD shows tiny flat papillary carcinomas lining the mucosal surface (curved arrow). A defect caused by bile duct exploration performed during surgery is also seen (straight arrow). Because the superficial papillary tumors were sloughed or denuded before or during surgery, there are no polypoid masses as were seen at US, CT, and ERCP.
|
|
View larger version (133K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 5f. Papillary adenocarcinoma of the extrahepatic duct in a 73-year-old man with a 2-month history of jaundice. (a) US image shows a slightly dilated CBD that contains an echogenic cast. The wall of the bile duct is well preserved and appears as a thin echogenic line (arrow). GB = gallbladder. (b, c) Unenhanced (b) and contrast material-enhanced (c) CT scans show an intraluminal mass in the CBD (arrow). Attenuation of the mass increased from 24 HU on b to 95 HU on c, indicating that the mass represents a tumor attached to the bile duct wall. (d) ERCP image shows multiple large, oval filling defects in the CBD. The filling defects with smooth surfaces (open arrow) are stones, whereas those with papillary surfaces are tumors. The margin of the common hepatic duct (CHD) (solid arrow) is serrated. The bile ducts are dilated as far as the ampulla of Vater. Note the normal duodenal mucosal surface. (e) ERCP image obtained after an attempt to extract the "lumps" with a basket maneuver shows innumerable filling defects of varying size that represent tumor fragments. A stone (open arrow) remains in the bile duct, and only small tissue debris could be removed. The serrated margin of the CHD (solid black arrow) is unchanged (cf d). Note the small and medium-sized filling defects in the second portion of the duodenum (solid white arrows), which represent tumor fragments. Surgery revealed several pigmented stones as well as many tiny (3-5-mm-diameter) fragments of papillary tumor and debris within the extrahepatic ducts. (f) Photomicrograph (original magnification, x40; H-E stain) of tissue debris obtained from the bile ducts at surgery shows innumerable papillary tumor fragments (arrowheads). (g) Low-power photomicrograph (original magnification, x10; H-E stain) of a cut section of the proximal portion of the CHD shows tiny flat papillary carcinomas lining the mucosal surface (curved arrow). A defect caused by bile duct exploration performed during surgery is also seen (straight arrow). Because the superficial papillary tumors were sloughed or denuded before or during surgery, there are no polypoid masses as were seen at US, CT, and ERCP.
|
|
View larger version (100K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 5g. Papillary adenocarcinoma of the extrahepatic duct in a 73-year-old man with a 2-month history of jaundice. (a) US image shows a slightly dilated CBD that contains an echogenic cast. The wall of the bile duct is well preserved and appears as a thin echogenic line (arrow). GB = gallbladder. (b, c) Unenhanced (b) and contrast material-enhanced (c) CT scans show an intraluminal mass in the CBD (arrow). Attenuation of the mass increased from 24 HU on b to 95 HU on c, indicating that the mass represents a tumor attached to the bile duct wall. (d) ERCP image shows multiple large, oval filling defects in the CBD. The filling defects with smooth surfaces (open arrow) are stones, whereas those with papillary surfaces are tumors. The margin of the common hepatic duct (CHD) (solid arrow) is serrated. The bile ducts are dilated as far as the ampulla of Vater. Note the normal duodenal mucosal surface. (e) ERCP image obtained after an attempt to extract the "lumps" with a basket maneuver shows innumerable filling defects of varying size that represent tumor fragments. A stone (open arrow) remains in the bile duct, and only small tissue debris could be removed. The serrated margin of the CHD (solid black arrow) is unchanged (cf d). Note the small and medium-sized filling defects in the second portion of the duodenum (solid white arrows), which represent tumor fragments. Surgery revealed several pigmented stones as well as many tiny (3-5-mm-diameter) fragments of papillary tumor and debris within the extrahepatic ducts. (f) Photomicrograph (original magnification, x40; H-E stain) of tissue debris obtained from the bile ducts at surgery shows innumerable papillary tumor fragments (arrowheads). (g) Low-power photomicrograph (original magnification, x10; H-E stain) of a cut section of the proximal portion of the CHD shows tiny flat papillary carcinomas lining the mucosal surface (curved arrow). A defect caused by bile duct exploration performed during surgery is also seen (straight arrow). Because the superficial papillary tumors were sloughed or denuded before or during surgery, there are no polypoid masses as were seen at US, CT, and ERCP.
|
|
View larger version (130K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 6a. Papillary adenocarcinoma of the CBD in a 53-year-old man who presented with a 5-month history of intermittent epigastric pain. The patient’s serum bilirubin level was elevated (2.5 mg/dL [42.75 mmol/L]). (a) US image of the extrahepatic duct shows a large, intraluminal soft-tissue mass with a papillary surface (arrows). GB = gallbladder. (b) Contrast-enhanced equilibrium phase CT scan shows a dilated CBD with an intraluminal soft-tissue mass (arrow). (c, d) Sequential ERCP images show small, round or ovoid filling defects of variable size in the CBD. The filling defects changed shape on subsequent images. At the time of ERCP, the endoscopist did not attempt to remove the filling defects. (e) Contrast-enhanced CT scan obtained immediately after ERCP shows the dilated CBD, which contains numerous filling defects floating in contrast material. The soft-tissue mass that was seen in the middle of the CBD in b has moved to the proximal portion of the CBD and floats in the nondependent part of the dilated CHD (arrow). Surgery revealed floating debris and several sessile or nodular superficial masses measuring 0.5-1.0 cm in diameter, but these masses were much smaller and less numerous than those seen at ERCP and CT. (f) Photograph of the inner surface of the CBD shows several small, sessile or polypoid papillary tumors less than 5 mm in diameter (straight arrows). Curved arrow indicates a tissue defect caused by frozen biopsy, arrowheads indicate tiny discrete tumors. p = duodenal papillae. (g) Photomicrograph (original magnification, x40; H-E stain) of the bile duct shows papillary carcinoma that consists of a fibrovascular core covered with columnar epithelial cells (arrowheads). Note the fragmented tumor debris. (Fig 6g reprinted, with permission, from reference 15.)
|
|
View larger version (122K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 6b. Papillary adenocarcinoma of the CBD in a 53-year-old man who presented with a 5-month history of intermittent epigastric pain. The patient’s serum bilirubin level was elevated (2.5 mg/dL [42.75 mmol/L]). (a) US image of the extrahepatic duct shows a large, intraluminal soft-tissue mass with a papillary surface (arrows). GB = gallbladder. (b) Contrast-enhanced equilibrium phase CT scan shows a dilated CBD with an intraluminal soft-tissue mass (arrow). (c, d) Sequential ERCP images show small, round or ovoid filling defects of variable size in the CBD. The filling defects changed shape on subsequent images. At the time of ERCP, the endoscopist did not attempt to remove the filling defects. (e) Contrast-enhanced CT scan obtained immediately after ERCP shows the dilated CBD, which contains numerous filling defects floating in contrast material. The soft-tissue mass that was seen in the middle of the CBD in b has moved to the proximal portion of the CBD and floats in the nondependent part of the dilated CHD (arrow). Surgery revealed floating debris and several sessile or nodular superficial masses measuring 0.5-1.0 cm in diameter, but these masses were much smaller and less numerous than those seen at ERCP and CT. (f) Photograph of the inner surface of the CBD shows several small, sessile or polypoid papillary tumors less than 5 mm in diameter (straight arrows). Curved arrow indicates a tissue defect caused by frozen biopsy, arrowheads indicate tiny discrete tumors. p = duodenal papillae. (g) Photomicrograph (original magnification, x40; H-E stain) of the bile duct shows papillary carcinoma that consists of a fibrovascular core covered with columnar epithelial cells (arrowheads). Note the fragmented tumor debris. (Fig 6g reprinted, with permission, from reference 15.)
|
|
View larger version (129K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 6c. Papillary adenocarcinoma of the CBD in a 53-year-old man who presented with a 5-month history of intermittent epigastric pain. The patient’s serum bilirubin level was elevated (2.5 mg/dL [42.75 mmol/L]). (a) US image of the extrahepatic duct shows a large, intraluminal soft-tissue mass with a papillary surface (arrows). GB = gallbladder. (b) Contrast-enhanced equilibrium phase CT scan shows a dilated CBD with an intraluminal soft-tissue mass (arrow). (c, d) Sequential ERCP images show small, round or ovoid filling defects of variable size in the CBD. The filling defects changed shape on subsequent images. At the time of ERCP, the endoscopist did not attempt to remove the filling defects. (e) Contrast-enhanced CT scan obtained immediately after ERCP shows the dilated CBD, which contains numerous filling defects floating in contrast material. The soft-tissue mass that was seen in the middle of the CBD in b has moved to the proximal portion of the CBD and floats in the nondependent part of the dilated CHD (arrow). Surgery revealed floating debris and several sessile or nodular superficial masses measuring 0.5-1.0 cm in diameter, but these masses were much smaller and less numerous than those seen at ERCP and CT. (f) Photograph of the inner surface of the CBD shows several small, sessile or polypoid papillary tumors less than 5 mm in diameter (straight arrows). Curved arrow indicates a tissue defect caused by frozen biopsy, arrowheads indicate tiny discrete tumors. p = duodenal papillae. (g) Photomicrograph (original magnification, x40; H-E stain) of the bile duct shows papillary carcinoma that consists of a fibrovascular core covered with columnar epithelial cells (arrowheads). Note the fragmented tumor debris. (Fig 6g reprinted, with permission, from reference 15.)
|
|
View larger version (132K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 6d. Papillary adenocarcinoma of the CBD in a 53-year-old man who presented with a 5-month history of intermittent epigastric pain. The patient’s serum bilirubin level was elevated (2.5 mg/dL [42.75 mmol/L]). (a) US image of the extrahepatic duct shows a large, intraluminal soft-tissue mass with a papillary surface (arrows). GB = gallbladder. (b) Contrast-enhanced equilibrium phase CT scan shows a dilated CBD with an intraluminal soft-tissue mass (arrow). (c, d) Sequential ERCP images show small, round or ovoid filling defects of variable size in the CBD. The filling defects changed shape on subsequent images. At the time of ERCP, the endoscopist did not attempt to remove the filling defects. (e) Contrast-enhanced CT scan obtained immediately after ERCP shows the dilated CBD, which contains numerous filling defects floating in contrast material. The soft-tissue mass that was seen in the middle of the CBD in b has moved to the proximal portion of the CBD and floats in the nondependent part of the dilated CHD (arrow). Surgery revealed floating debris and several sessile or nodular superficial masses measuring 0.5-1.0 cm in diameter, but these masses were much smaller and less numerous than those seen at ERCP and CT. (f) Photograph of the inner surface of the CBD shows several small, sessile or polypoid papillary tumors less than 5 mm in diameter (straight arrows). Curved arrow indicates a tissue defect caused by frozen biopsy, arrowheads indicate tiny discrete tumors. p = duodenal papillae. (g) Photomicrograph (original magnification, x40; H-E stain) of the bile duct shows papillary carcinoma that consists of a fibrovascular core covered with columnar epithelial cells (arrowheads). Note the fragmented tumor debris. (Fig 6g reprinted, with permission, from reference 15.)
|
|
View larger version (131K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 6e. Papillary adenocarcinoma of the CBD in a 53-year-old man who presented with a 5-month history of intermittent epigastric pain. The patient’s serum bilirubin level was elevated (2.5 mg/dL [42.75 mmol/L]). (a) US image of the extrahepatic duct shows a large, intraluminal soft-tissue mass with a papillary surface (arrows). GB = gallbladder. (b) Contrast-enhanced equilibrium phase CT scan shows a dilated CBD with an intraluminal soft-tissue mass (arrow). (c, d) Sequential ERCP images show small, round or ovoid filling defects of variable size in the CBD. The filling defects changed shape on subsequent images. At the time of ERCP, the endoscopist did not attempt to remove the filling defects. (e) Contrast-enhanced CT scan obtained immediately after ERCP shows the dilated CBD, which contains numerous filling defects floating in contrast material. The soft-tissue mass that was seen in the middle of the CBD in b has moved to the proximal portion of the CBD and floats in the nondependent part of the dilated CHD (arrow). Surgery revealed floating debris and several sessile or nodular superficial masses measuring 0.5-1.0 cm in diameter, but these masses were much smaller and less numerous than those seen at ERCP and CT. (f) Photograph of the inner surface of the CBD shows several small, sessile or polypoid papillary tumors less than 5 mm in diameter (straight arrows). Curved arrow indicates a tissue defect caused by frozen biopsy, arrowheads indicate tiny discrete tumors. p = duodenal papillae. (g) Photomicrograph (original magnification, x40; H-E stain) of the bile duct shows papillary carcinoma that consists of a fibrovascular core covered with columnar epithelial cells (arrowheads). Note the fragmented tumor debris. (Fig 6g reprinted, with permission, from reference 15.)
|
|
View larger version (149K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 6f. Papillary adenocarcinoma of the CBD in a 53-year-old man who presented with a 5-month history of intermittent epigastric pain. The patient’s serum bilirubin level was elevated (2.5 mg/dL [42.75 mmol/L]). (a) US image of the extrahepatic duct shows a large, intraluminal soft-tissue mass with a papillary surface (arrows). GB = gallbladder. (b) Contrast-enhanced equilibrium phase CT scan shows a dilated CBD with an intraluminal soft-tissue mass (arrow). (c, d) Sequential ERCP images show small, round or ovoid filling defects of variable size in the CBD. The filling defects changed shape on subsequent images. At the time of ERCP, the endoscopist did not attempt to remove the filling defects. (e) Contrast-enhanced CT scan obtained immediately after ERCP shows the dilated CBD, which contains numerous filling defects floating in contrast material. The soft-tissue mass that was seen in the middle of the CBD in b has moved to the proximal portion of the CBD and floats in the nondependent part of the dilated CHD (arrow). Surgery revealed floating debris and several sessile or nodular superficial masses measuring 0.5-1.0 cm in diameter, but these masses were much smaller and less numerous than those seen at ERCP and CT. (f) Photograph of the inner surface of the CBD shows several small, sessile or polypoid papillary tumors less than 5 mm in diameter (straight arrows). Curved arrow indicates a tissue defect caused by frozen biopsy, arrowheads indicate tiny discrete tumors. p = duodenal papillae. (g) Photomicrograph (original magnification, x40; H-E stain) of the bile duct shows papillary carcinoma that consists of a fibrovascular core covered with columnar epithelial cells (arrowheads). Note the fragmented tumor debris. (Fig 6g reprinted, with permission, from reference 15.)
|
|
View larger version (110K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 6g. Papillary adenocarcinoma of the CBD in a 53-year-old man who presented with a 5-month history of intermittent epigastric pain. The patient’s serum bilirubin level was elevated (2.5 mg/dL [42.75 mmol/L]). (a) US image of the extrahepatic duct shows a large, intraluminal soft-tissue mass with a papillary surface (arrows). GB = gallbladder. (b) Contrast-enhanced equilibrium phase CT scan shows a dilated CBD with an intraluminal soft-tissue mass (arrow). (c, d) Sequential ERCP images show small, round or ovoid filling defects of variable size in the CBD. The filling defects changed shape on subsequent images. At the time of ERCP, the endoscopist did not attempt to remove the filling defects. (e) Contrast-enhanced CT scan obtained immediately after ERCP shows the dilated CBD, which contains numerous filling defects floating in contrast material. The soft-tissue mass that was seen in the middle of the CBD in b has moved to the proximal portion of the CBD and floats in the nondependent part of the dilated CHD (arrow). Surgery revealed floating debris and several sessile or nodular superficial masses measuring 0.5-1.0 cm in diameter, but these masses were much smaller and less numerous than those seen at ERCP and CT. (f) Photograph of the inner surface of the CBD shows several small, sessile or polypoid papillary tumors less than 5 mm in diameter (straight arrows). Curved arrow indicates a tissue defect caused by frozen biopsy, arrowheads indicate tiny discrete tumors. p = duodenal papillae. (g) Photomicrograph (original magnification, x40; H-E stain) of the bile duct shows papillary carcinoma that consists of a fibrovascular core covered with columnar epithelial cells (arrowheads). Note the fragmented tumor debris. (Fig 6g reprinted, with permission, from reference 15.)
|
|
View larger version (116K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 7a. Papillary adenocarcinomatosis in the intrahepatic and extrahepatic bile ducts in a 78-year-old woman with a 3-day history of jaundice. Biopsy revealed atypical cells that were suggestive of adenocarcinoma. (a) Unenhanced CT scan shows dilated intrahepatic and extrahepatic ducts. The bile ducts are slightly hypoattenuating relative to the liver (arrow). (b) Contrast-enhanced CT scan shows a dilated extrahepatic duct that contains ill-defined, slightly hyperattenuating intraluminal lesions (arrow). The wall of the extrahepatic bile duct is thickened and enhanced. (c, d) Sequential ERCP images show innumerable small filling defects that represent papillary tumors in the intrahepatic and extrahepatic bile ducts (arrows). There were no bile duct stones. Note the irregularity along the extrahepatic ducts.
|
|
View larger version (127K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 7b. Papillary adenocarcinomatosis in the intrahepatic and extrahepatic bile ducts in a 78-year-old woman with a 3-day history of jaundice. Biopsy revealed atypical cells that were suggestive of adenocarcinoma. (a) Unenhanced CT scan shows dilated intrahepatic and extrahepatic ducts. The bile ducts are slightly hypoattenuating relative to the liver (arrow). (b) Contrast-enhanced CT scan shows a dilated extrahepatic duct that contains ill-defined, slightly hyperattenuating intraluminal lesions (arrow). The wall of the extrahepatic bile duct is thickened and enhanced. (c, d) Sequential ERCP images show innumerable small filling defects that represent papillary tumors in the intrahepatic and extrahepatic bile ducts (arrows). There were no bile duct stones. Note the irregularity along the extrahepatic ducts.
|
|
View larger version (128K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 7c. Papillary adenocarcinomatosis in the intrahepatic and extrahepatic bile ducts in a 78-year-old woman with a 3-day history of jaundice. Biopsy revealed atypical cells that were suggestive of adenocarcinoma. (a) Unenhanced CT scan shows dilated intrahepatic and extrahepatic ducts. The bile ducts are slightly hypoattenuating relative to the liver (arrow). (b) Contrast-enhanced CT scan shows a dilated extrahepatic duct that contains ill-defined, slightly hyperattenuating intraluminal lesions (arrow). The wall of the extrahepatic bile duct is thickened and enhanced. (c, d) Sequential ERCP images show innumerable small filling defects that represent papillary tumors in the intrahepatic and extrahepatic bile ducts (arrows). There were no bile duct stones. Note the irregularity along the extrahepatic ducts.
|
|
View larger version (125K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 7d. Papillary adenocarcinomatosis in the intrahepatic and extrahepatic bile ducts in a 78-year-old woman with a 3-day history of jaundice. Biopsy revealed atypical cells that were suggestive of adenocarcinoma. (a) Unenhanced CT scan shows dilated intrahepatic and extrahepatic ducts. The bile ducts are slightly hypoattenuating relative to the liver (arrow). (b) Contrast-enhanced CT scan shows a dilated extrahepatic duct that contains ill-defined, slightly hyperattenuating intraluminal lesions (arrow). The wall of the extrahepatic bile duct is thickened and enhanced. (c, d) Sequential ERCP images show innumerable small filling defects that represent papillary tumors in the intrahepatic and extrahepatic bile ducts (arrows). There were no bile duct stones. Note the irregularity along the extrahepatic ducts.
|
|
Because the radiologic features of these tumors are similar to those of bile duct stones, endoscopic interventional procedures may be attempted to extract the "lumps" within the bile ducts. ERCP performed after a basket maneuver demonstrates fragmented filling defects in the bile ducts and duodenum (Figs 2–6). Histologic examination of the tissue debris or brush biopsy material may reveal dysplastic columnar epithelial cells or fragmented tumor debris (Fig 4).
The most salient features of papillary tumors of the bile ducts are the inconsistency and changeability of the radiologic findings obtained with each modality. Because the intraluminal lesions change in size, shape, and position during a procedure or at subsequent follow-up imaging, radiologic findings differ from one imaging modality to another. There may be differences between the radiologic and surgical findings, and both may differ from the pathologic findings. Imaging demonstrates fairly large intraductal masses or wall thickening, but the surgical and pathologic findings may include no such masses or wall thickening. Rather, only a small, flat tumor or superficial tumors with sloughed surfaces are identified (Figs 3, 5–7). Some tiny, fragmented, friable tissue debris can be found (Fig 2).
After a tumor grows to a certain size, it typically sloughs spontaneously from the wall of the bile duct and mimics a bile duct stone. The sloughed and floating tumor debris may reside within the bile ducts, imbibing nutrients from the bile and growing substantially. These sizable tumors then float within the bile ducts and partially occlude bile flow, resulting in recurrent and incomplete bile duct obstruction. The tumor fragments may drain through the orifice of the papilla of Vater (7) and then disappear. Thus, the entire length of the extrahepatic bile ducts as far as the ampulla of Vater is dilated irrespective of tumor location, a finding that reflects the disturbance of bile flow through the papillary orifice. Similarly, hepatocellular carcinoma can detach from the bile duct wall and grow intraductally as an embolus (16,17).
|
Differentiation from Bile Duct Stones
|
|---|
At US, a floating papillary tumor does not cast a shadow. However, bile duct stones may also be nonshadowing in about 20% of cases (18). At CT, papillary tumors and bile duct stones manifest as soft-tissue masses with high or low attenuation. Findings at unenhanced CT are important because a tumor attached to the wall of the bile duct will enhance, whereas detached tumor fragments or stones will not enhance. At cholangiography, floating papillary tumors may be difficult to distinguish from bile duct stones. Stones usually have a smooth surface and are sometimes faceted (Figs 5, 8), whereas papillary tumors are irregular or serrated (Figs 3, 6, 7). Associated findings such as a serrated margin, luminal narrowing, or filling defects fixed to the bile duct wall at cholangiography (Figs 4, 7) and asymmetric wall thickening at CT (Fig 4) are indicative of papillary neoplasms and help differentiate them from stones. Occasionally, mucin and blood clots in the bile ducts cannot be easily differentiated because these lesions also vary in shape. Radiologic differentiation between carcinoma and adenoma is not possible. Radiologic findings in papillary tumors versus biliary stones are summarized in the Table.
View larger version (144K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 8. Recurrent pyogenic cholangitis in a 45-year-old man. ERCP image shows three stones in the intrahepatic and extrahepatic bile ducts that manifest as filling defects with smooth margins (arrows). The filling defect in the extrahepatic duct moved readily.
|
|
|
Conclusions
|
|---|
Papillary tumors of the biliary tree are intraluminal masses that may be either fixed to or detached from the bile duct wall. These tumors produce intermittent partial obstruction of the bile ducts and may mimic bile duct stones at clinical and radiologic examination. A nonshadowing intraductal echogenic cast at US, an intraductal noncalcified soft-tissue mass with asymmetric wall thickening at CT, and an intraductal mass with a papillary surface and a serrated bile duct margin at cholangiography suggest papillary tumors rather than bile duct stones and may help distinguish between the two.
|
Acknowledgments
|
|---|
We thank Bonnie Hami, MA, Department of Radiology, University Hospitals of Cleveland, Ohio for copyediting the manuscript.
|
Footnotes
|
|---|
Abbreviations: CBD = common bile duct,
CHD = common hepatic duct,
ERCP = endoscopic retrograde cholangiopancreatography,
H-E = hematoxylin-eosin
|
References
|
|---|
- Taguchi J, Yasunaga M, Kojiro M, et al. Intrahepatic and extrahepatic biliary papillomatosis. Arch Pathol Lab Med 1993; 117:944-947.[Medline]
- Holtkamp W, Reis HE. Papillomatosis of the bile ducts: papilloma-carcinoma sequence. Am J Gastroenterol 1994; 89:2253-2255.[Medline]
- Lam CM, Yeun ST, Yuen WK, Fan ST. Biliary papillomatosis. Br J Surg 1996; 83:1715-1716.[Medline]
- Lee JW, Han JK, Kim TK, et al. CT features of intraductal intrahepatic cholangiocarcinoma. AJR Am J Roentgenol 2000; 175:721-725.[Abstract/Free Full Text]
- Yoon KH, Ha HK, Kim CG, et al. Malignant papillary neoplasms of the intrahepatic bile ducts: CT and histopathologic features. AJR Am J Roentgenol 2000; 175:1135-1139.[Abstract/Free Full Text]
- Kawakatsu M, Vilgrain V, Zins M, Vullierme M, Belghiti J, Menu Y. Radiologic features of papillary adenoma and papillomatosis of the biliary tract. Abdom Imaging 1997; 22:87-90.[CrossRef][Medline]
- Kim YS, Myung ST, Kim SY, et al. Biliary papillomatosis: clinical, cholangiographic and cholangioscopic findings. Endoscopy 1998; 30:763-767.[Medline]
- Neumann RD, LiVolsi VA, Rosenthal NS, et al. Adenocarcinoma in biliary papillomatosis. Gastroenterology 1976; 70:779-782.[Medline]
- Ohta T, Nagakawa T, Ueda N, et al. Mucosal dysplasia of the liver and the intraductal variant of peripheral cholangiocarcinoma in hepatolithiasis. Cancer 1991; 68:2217-2223.[CrossRef][Medline]
- Suh KS, Roh HR, Koh YT, et al. Clinicopathologic features of the intraductal growth type of peripheral cholangiocarcinoma. Hepatology 2000; 31:12-17.[CrossRef][Medline]
- Chen TC, Nakanuma Y, Zen Y, et al. Intraductal papillary neoplasia of the liver associated with hepatolithiasis. Hepatology 2001; 34:651-658.[CrossRef][Medline]
- Hubens G, Delvaux G, Willems G, Bourgain C, Kloppel G. Papillomatosis of the intra- and extrahepatic bile ducts with involvement of the pancreatic duct. Hepatogastroenterology 1991; 38:413-418.[Medline]
- Kim HJ, Kim MH, Lee SK, et al. Mucin hypersecreting bile duct tumor characterized by a striking homology with an intraductal papillary mucinous tumor (IPMT) of the pancreas. Endoscopy 2000; 32:389-393.[CrossRef][Medline]
- D’Abrigeon G, Blane P, Bauret P, et al. Diagnostic and therapeutic aspects of endoscopic retrograde cholangiography in papillomatosis of the bile ducts: analysis of five cases. Gastrointest Endosc 1997; 46:237-243.[CrossRef][Medline]
- Lim JH, Yi C, Lim HK, et al. Radiological spectrum of intraductal papillary tumors of the bile ducts. Korean J Radiol 2002; 3:57-63.[Medline]
- Kiev J, Dyslin DC, Vitenas P, Jr, Kerstein MD. Obstructive jaundice caused by hepatoma fragments in the common bile duct. J Clin Gastroenterol 1990; 12:207-213.[Medline]
- Buckmaster MJ, Schwartz RW, Carnahan GE, Strodol WE. Hepatocellular carcinoma embolus to the common hepatic duct with no detectable primary hepatic tumor. Am Surg 1994; 60:699-702.[Medline]
- Lim JH, Ko YT, Lee DH, Hong KS. Oriental cholangiohepatitis: sonographic findings in 48 cases. AJR Am J Roentgenol 1990; 155:511-514.[Abstract/Free Full Text]
This article has been cited by other articles:
|
|
|
|
 
Y. E. Chung, M.-J. Kim, Y. N. Park, J.-Y. Choi, J. Y. Pyo, Y. C. Kim, H. J. Cho, K. A. Kim, and S. Y. Choi
Varying Appearances of Cholangiocarcinoma: Radiologic-Pathologic Correlation
RadioGraphics,
May 1, 2009;
29(3):
683 - 700.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. H. Lim, K.-T. Jang, and D. Choi
Biliary Intraductal Papillary-Mucinous Neoplasm Manifesting Only as Dilatation of the Hepatic Lobar or Segmental Bile Ducts: Imaging Features in Six Patients
Am. J. Roentgenol.,
September 1, 2008;
191(3):
778 - 782.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. H. Lim, K.-T. Jang, D. Choi, W. J. Lee, and H. K. Lim
Early Bile Duct Carcinoma: Comparison of Imaging Features with Pathologic Findings
Radiology,
February 1, 2006;
238(2):
542 - 548.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
A. Ahmetoglu, P. Kosucu, S. Kul, H. Dinc, A. Sari, M. Arslan, E. Alhan, and H. R. Gumele
MDCT Cholangiography with Volume Rendering for the Assessment of Patients with Biliary Obstruction
Am. J. Roentgenol.,
November 1, 2004;
183(5):
1327 - 1332.
[Abstract]
[Full Text]
[PDF]
|
|
|
Top
Abstract
LEARNING OBJECTIVES
