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Endoscopic retrograde cholangiography in primary biliary tract carcinoma
Clin. Radiol. (1978) 29, 647-649 ENDOSCOPIC RETROGRADE CHOLANGIOGRAPHY IN P R I M A R Y B I L I A R Y T R A C T C A R C I N O M A N. S. BROUGHTON, A. EVENSEN and M. OSNES From the Department o f Diagnostic Radiology and Department o f Gastroenterology, Ullevaal Hospital, University o f Oslo, Norway The appearance of primary biliary tract carcinoma revealed at endoscopic retrograde cholangiography in 16 patients and surgically confirmed, are classified as to location, type of margin of the lesion and degree of obstruction. Differential diagnosis towards infiltrating turnout of the gallbladder is considered. The conclusion is drawn that endoscopic retrograde cholangiography will establish the diagnosis of malignancy of the biliary tract with an acceptable certainty.
Primary biliary tract carcinoma is a relatively uncommon disease. Unfortunately at the time of presentation the patient is often jaundiced and traditional methods of investigation of the biliary tract using oral intravenous contrast media frequently fail to give adequate information. The technique of endoscopic cholangiography has been described by various authors (Takagi et al., 1970; Cotton, 1972; Kasugai et al., 1972a; Osnes et al., 1975a). The pathology of primary biliary tract carcinoma has been described by Cotton et al. (1972), Blumgart et al. (1972), Kasugai et al. (1972b) and Seifert et al. (1974), but the endoscopic procedure with cannulation of the common bile duct and the pancreatic duct is still so specialised that reports of endoscopies with an acceptable success rate are only few. One of the many advantages of satisfactory endoscopic experience is that ampullary carcinomas are easily excluded by inspection and biopsy through the duodenoscope. The purpose of this paper is to demonstrate the accuracy of endoscopic cholangiography in the diagnosis of primary tract carcinoma. MATERIAL AND METHODS
More than 1200 retrograde cannulations of the ampulla of Vater were performed. The cannulations were carried out with a side-viewing duodenoscope (Olympus JF B2) after an overnight fast. Premedication was not usually given, but some anxious patients received 2 - 5 mg Valium intravenously during the procedure. About 600 cannulations were performed on patients referred to endoscopy because of suspicion of disease of the biliary tract. In 17 patients ductal changes compatible with primary biliary tract carci-
noma were found, and the diagnosis was confirmed at operation in 16 cases. There were eight men and eight women, aged from 20 to 84 years with an average of 67 years. Fourteen had obstructive jaundice and 2 had a palpable mass in the upper quadrant of the abdomen. There was one false positive case. Primary carcinoma of the biliary tract was confirmed on microscopy in 14 patients and showed adenocarcinoma in all. Two patients were considered inoperable at laparotomy and no biopsy was taken.
RESULTS
Endoscopic retrograde cholangiography demonstrated that the type of bile duct abnormalities produced by biliary carcinomas was occlusion (Fig. l) or stenosis with prestenotic dilatation (Fig. 2). The boundary of the area of occlusion or stenosis was smooth (Fig. 3) or irregular (Fig. 4). The occlusion or stenosis was located either in one of the hepatic ducts, at the junction of the hepatic and common bile ducts, in the cystic duct or in the common bile duct. The involved duct was occluded in 13 patients and stenotic in three patients. Prestenotic dilatation was present in all three patients with stenosis (Table 1). The lesion found by retrograde cholangiography was, in seven cases, in an hepatic or cystic duct, in four cases in the area of the junction between the hepatic ducts and in five cases in the common bile duct (Table 2). In three hepatic duct lesions secondary to gallbladder carcinoma, contrast filling of the gallbladder failed, but was successful in two of the three cases with carcinoma originating from the hepatic duct.
648
CLINICAL RADIOLOGY
Fig, 1 - Occlusion of the common bile duct close to the hilum of the liver. Contrast filling of the pancreatic duct. No filling of the gallbladder.
Fig. 3 - Occlusion of the hepatic duct with smooth border. Gallbladder well filled. Table
1
Radiological diagnosis of
-
turnouts
Boundary o f abnormality
Occlusion Stenosis Table 2 -
Smooth
Irregular
6 1
7 2
Site of lesion
Radiologic location o f turnout
Hepatic duct or cystic Junction area Common bile duct
Surgical location of primary turnout Gallbladder
Common bile duct
Biliary tree
3 3 3
3 1 1
1 1
DISCUSSION
Fig. 2 - Stenosis of the common bile duet with prestenotic dilatation.
All t h e cases o f p r i m a r y biliary t r a c t c a r c i n o m a studied b y e n d o s c o p i c r e t r o g r a d e c h o l a n g i o g r a p h y d e m o n s t r a t e d a b n o r m a l i t i e s suggestive o f a m a l i g n a n t g r o w t h . T h e t y p i c a l a p p e a r a n c e was e i t h e r occlusion or stenosis o f t h e i n v o l v e d d u c t w i t h s m o o t h or
ENDOSCOPIC RETROGRADE CHOLANGIOGRAPHY IN BILIARY TRACT CARCINOMA
649
prepared for surgery. However, endoscopic retrograde ductography allows a simultaneous demonstration o f the pancreatic duct, and thus differentiates between primary biliary tract carcinoma and malignancies in the pancreas. Endoscopic retrograde ductography may also be combined with retrograde brush cytology in investigation of suspected malignancy (Osnes et al., 1975b), and thus increase the diagnostic accuracy of this technique. The endoscopic retrograde cholangio-pancreatography has thus great advantages compared to percutaneous transhepatic cholangiography. Acknowledgement. - This study was supported by grants from N. A. Stangs Legat and Helga Sembs Fond.
REFERENCES
Fig. 4 - Irregular boundary of the occlusion in the junctional area. Turnout infiltration of the gallbladder. irregular margin. We did not, therefore, find that the type of margins of the abnormal process could be used to distinguish between intrinsic or extrinsic tumours as suggested by Seifert et aL (1974). Diagnosis and determination of the site of primary biliary tract carcinoma prior to surgery is important. We were, however, unable to differentiate between primary duct carcinoma and infiltrating gallbladder carcinoma, but the tumour diagnosis was convincing and surgical intervention the only alternative to the patients. Percutaneous transhepatic cholangiography is usually successful in jaundiced patients in demonstrating the abnormality, but occasionally requires subsequent surgical intervention to prevent leakage of bile. A great advantage of percutaneous transhepatic cholangiography is that the bile can be drained through the catheter and the patient be better
Blumgart, L. H., Salmon, P., Cotton, P. B., Davies, G. T., Burwood, R., Beales, J. S. M., Lawrie, B. Skirving, A. & Read, A. E. (1972). Endoscopy and retrograde choledochopancreatography in the diagnosis of the jaundiced patient. Lancet, 2, 1269-1273. Cotton, P. B. (1972). Progress report: cannulat~on of the ampulla of Vater by endoscopy and retrograde cholangiopancreatography (ERCP). Gut, 13,1014-1025. Cotton, P. B., Salmon, P. R., Blumgart, L. H., Burwood, R. J., Davies, G. T., Lawrie, B. W., Pierce, J. W. & Read, A. E. (1972). Cannulation of papilla of Vater via fiberduodenoseope. Assessment of retrograde cholangiopancreatography in 60 patients. Lancet, 1,53-58. Kasugai, T., Kuno, N., Koayashi, S. & Hattori, K. (1972a). Endoscopic pancreatocholangiography. I. The normal endoscopic pancreatocholangiogram. Gastroenterology, 63, 217-226. Kasugai, T., Kuno, N., Koyashi, S. & Hattori, K. (1972b). Endoscopic pancreatoeholangiography. II. The pathological endoscopic pancreatocholangiogram. Gastroenterology, 63, 227-234. Osnes, M., Myren, J. & Swensen, T. (1975). Endoskopisk retrograd cholangiopancreaticografi (ERCP). T. norske Laegeforen., 95, 1529-1934. Osnes, M., Serck-Hanssen, A. & Myren, J. (1975b). Endoscopic retrograde cytology (ERBC) of the biliary and pancreatic ducts. Scandinavian Journal o f Gastroenterology, 10, 829-831. Seifert, E., Safrany, L., St Sender, H., Leseh, P., Lusaka, G. & Misaki, F. (1974). Identification of bile duct turnouts by means of endoscopic retrograde pancreato-cholangiography (ERCP). Endoscopy, 6,156-162. Takagi, K., Ikeda, S., Nakagawa, Y., Sakaguchi, N., Takahashi, T., Kumakura, K., Maruyama, M., Someya, N., Nakano, H., Takada, T., Takekoshi, T. & Kin, T. (1970). Retrograde pancreatography and eholangiography by fiber duodenoscope. Gastroenterology, 59, 445-452.
Primary biliary tract carcinoma is a relatively uncommon disease. Unfortunately at the time of presentation the patient is often jaundiced and traditional methods of investigation of the biliary tract using oral intravenous contrast media frequently fail to give adequate information. The technique of endoscopic cholangiography has been described by various authors (Takagi et al., 1970; Cotton, 1972; Kasugai et al., 1972a; Osnes et al., 1975a). The pathology of primary biliary tract carcinoma has been described by Cotton et al. (1972), Blumgart et al. (1972), Kasugai et al. (1972b) and Seifert et al. (1974), but the endoscopic procedure with cannulation of the common bile duct and the pancreatic duct is still so specialised that reports of endoscopies with an acceptable success rate are only few. One of the many advantages of satisfactory endoscopic experience is that ampullary carcinomas are easily excluded by inspection and biopsy through the duodenoscope. The purpose of this paper is to demonstrate the accuracy of endoscopic cholangiography in the diagnosis of primary tract carcinoma. MATERIAL AND METHODS
More than 1200 retrograde cannulations of the ampulla of Vater were performed. The cannulations were carried out with a side-viewing duodenoscope (Olympus JF B2) after an overnight fast. Premedication was not usually given, but some anxious patients received 2 - 5 mg Valium intravenously during the procedure. About 600 cannulations were performed on patients referred to endoscopy because of suspicion of disease of the biliary tract. In 17 patients ductal changes compatible with primary biliary tract carci-
noma were found, and the diagnosis was confirmed at operation in 16 cases. There were eight men and eight women, aged from 20 to 84 years with an average of 67 years. Fourteen had obstructive jaundice and 2 had a palpable mass in the upper quadrant of the abdomen. There was one false positive case. Primary carcinoma of the biliary tract was confirmed on microscopy in 14 patients and showed adenocarcinoma in all. Two patients were considered inoperable at laparotomy and no biopsy was taken.
RESULTS
Endoscopic retrograde cholangiography demonstrated that the type of bile duct abnormalities produced by biliary carcinomas was occlusion (Fig. l) or stenosis with prestenotic dilatation (Fig. 2). The boundary of the area of occlusion or stenosis was smooth (Fig. 3) or irregular (Fig. 4). The occlusion or stenosis was located either in one of the hepatic ducts, at the junction of the hepatic and common bile ducts, in the cystic duct or in the common bile duct. The involved duct was occluded in 13 patients and stenotic in three patients. Prestenotic dilatation was present in all three patients with stenosis (Table 1). The lesion found by retrograde cholangiography was, in seven cases, in an hepatic or cystic duct, in four cases in the area of the junction between the hepatic ducts and in five cases in the common bile duct (Table 2). In three hepatic duct lesions secondary to gallbladder carcinoma, contrast filling of the gallbladder failed, but was successful in two of the three cases with carcinoma originating from the hepatic duct.
648
CLINICAL RADIOLOGY
Fig, 1 - Occlusion of the common bile duct close to the hilum of the liver. Contrast filling of the pancreatic duct. No filling of the gallbladder.
Fig. 3 - Occlusion of the hepatic duct with smooth border. Gallbladder well filled. Table
1
Radiological diagnosis of
-
turnouts
Boundary o f abnormality
Occlusion Stenosis Table 2 -
Smooth
Irregular
6 1
7 2
Site of lesion
Radiologic location o f turnout
Hepatic duct or cystic Junction area Common bile duct
Surgical location of primary turnout Gallbladder
Common bile duct
Biliary tree
3 3 3
3 1 1
1 1
DISCUSSION
Fig. 2 - Stenosis of the common bile duet with prestenotic dilatation.
All t h e cases o f p r i m a r y biliary t r a c t c a r c i n o m a studied b y e n d o s c o p i c r e t r o g r a d e c h o l a n g i o g r a p h y d e m o n s t r a t e d a b n o r m a l i t i e s suggestive o f a m a l i g n a n t g r o w t h . T h e t y p i c a l a p p e a r a n c e was e i t h e r occlusion or stenosis o f t h e i n v o l v e d d u c t w i t h s m o o t h or
ENDOSCOPIC RETROGRADE CHOLANGIOGRAPHY IN BILIARY TRACT CARCINOMA
649
prepared for surgery. However, endoscopic retrograde ductography allows a simultaneous demonstration o f the pancreatic duct, and thus differentiates between primary biliary tract carcinoma and malignancies in the pancreas. Endoscopic retrograde ductography may also be combined with retrograde brush cytology in investigation of suspected malignancy (Osnes et al., 1975b), and thus increase the diagnostic accuracy of this technique. The endoscopic retrograde cholangio-pancreatography has thus great advantages compared to percutaneous transhepatic cholangiography. Acknowledgement. - This study was supported by grants from N. A. Stangs Legat and Helga Sembs Fond.
REFERENCES
Fig. 4 - Irregular boundary of the occlusion in the junctional area. Turnout infiltration of the gallbladder. irregular margin. We did not, therefore, find that the type of margins of the abnormal process could be used to distinguish between intrinsic or extrinsic tumours as suggested by Seifert et aL (1974). Diagnosis and determination of the site of primary biliary tract carcinoma prior to surgery is important. We were, however, unable to differentiate between primary duct carcinoma and infiltrating gallbladder carcinoma, but the tumour diagnosis was convincing and surgical intervention the only alternative to the patients. Percutaneous transhepatic cholangiography is usually successful in jaundiced patients in demonstrating the abnormality, but occasionally requires subsequent surgical intervention to prevent leakage of bile. A great advantage of percutaneous transhepatic cholangiography is that the bile can be drained through the catheter and the patient be better
Blumgart, L. H., Salmon, P., Cotton, P. B., Davies, G. T., Burwood, R., Beales, J. S. M., Lawrie, B. Skirving, A. & Read, A. E. (1972). Endoscopy and retrograde choledochopancreatography in the diagnosis of the jaundiced patient. Lancet, 2, 1269-1273. Cotton, P. B. (1972). Progress report: cannulat~on of the ampulla of Vater by endoscopy and retrograde cholangiopancreatography (ERCP). Gut, 13,1014-1025. Cotton, P. B., Salmon, P. R., Blumgart, L. H., Burwood, R. J., Davies, G. T., Lawrie, B. W., Pierce, J. W. & Read, A. E. (1972). Cannulation of papilla of Vater via fiberduodenoseope. Assessment of retrograde cholangiopancreatography in 60 patients. Lancet, 1,53-58. Kasugai, T., Kuno, N., Koayashi, S. & Hattori, K. (1972a). Endoscopic pancreatocholangiography. I. The normal endoscopic pancreatocholangiogram. Gastroenterology, 63, 217-226. Kasugai, T., Kuno, N., Koyashi, S. & Hattori, K. (1972b). Endoscopic pancreatoeholangiography. II. The pathological endoscopic pancreatocholangiogram. Gastroenterology, 63, 227-234. Osnes, M., Myren, J. & Swensen, T. (1975). Endoskopisk retrograd cholangiopancreaticografi (ERCP). T. norske Laegeforen., 95, 1529-1934. Osnes, M., Serck-Hanssen, A. & Myren, J. (1975b). Endoscopic retrograde cytology (ERBC) of the biliary and pancreatic ducts. Scandinavian Journal o f Gastroenterology, 10, 829-831. Seifert, E., Safrany, L., St Sender, H., Leseh, P., Lusaka, G. & Misaki, F. (1974). Identification of bile duct turnouts by means of endoscopic retrograde pancreato-cholangiography (ERCP). Endoscopy, 6,156-162. Takagi, K., Ikeda, S., Nakagawa, Y., Sakaguchi, N., Takahashi, T., Kumakura, K., Maruyama, M., Someya, N., Nakano, H., Takada, T., Takekoshi, T. & Kin, T. (1970). Retrograde pancreatography and eholangiography by fiber duodenoscope. Gastroenterology, 59, 445-452.