Klatskin
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A 56-year-old woman presented with jaundice, weight loss, itching, and loss of appetite. Laboratory tests showed elevated bilirubin and alkaline phosphatase. Ultrasound showed dilation of the bile ducts and a suspected gallbladder mass. CT showed a mass at the confluence of the right and left hepatic bile ducts, consistent with a Klatskin tumor or hilar cholangiocarcinoma. Cholangiocarcinomas are often diagnosed late as the symptoms present late, making resection difficult and prognosis generally poor.
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Klatskin
- 1. CASE STUDY DR. UmarTauqir PGR RADIOLOGY AL-NOOR DIAGNOSTICS
- 2. • 56 yearsold woman Mrs. Amina Bibi presented in Al-NOOR diagnostics with h/o jaundice, mild to moderate weight loss, itching and Loss of apetite • She was here in AL-NOOR Diagnostics for CECT abdomen
- 3. LABS • Labs ofthe patient done and it showed increase level of serum bilirubin with significant elevation of serum alkaline phosphatase and there was slight elevation of TLC count also with decreased level of hemoglobin • Rest of laboratory findings did not reveal any positive findings
- 4. • Report ofUltrasound of the patient , from the outside showed minimal dilatation of intrahepatic channels and bile duct with suspicion of G.B mass
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- 7. HALL MARKS OFBILIARY DUCT MEASUREMENTS • The upper limit of normal common bile duct (CBD) on ultra sound (US) is 6-8 mm ( lumen) and that of common hepatic duct (CHD) is 6mm. • ON CT scan it is more common to accept a value of 8-10 mm for CBD. This is because CT visualizes mid to distal CBD and the measurement includes the duct wall • ERCP and cholangiogram may reveal a duct diameter up to 10.6mm because of magnification of the cholangiogram and may also reflect ductal distension from contrast injection
- 10. NORMAL CT FEATURSOF ABDOMEN
- 14. GERALD KLATSKIN…………….……… • KLATSKINTHE READER • KLATSKIN THE GIANT OF LIVER PATHOLOGY • If you haven't spend a few hours listening to klatskin antecedotes told with great relish and verve then you have-not become a liver doc
- 16. KLATSKIN TUMOUR • AKlatskin tumor (or hilar cholangiocarcinoma) (cancer of the biliary tree) occurring at the confluence of the right and left hepatic bile ducts • One third of patients are present under the age of 50 years with a male and female predominance
- 17. • WHAT ISTHE MOST COMMON CAUSE OF CHOLANGIOCARCINOMA???
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- 19. Etiologic factors • Gallstones • Sclerosing cholangitis • Choledochal cyst (CAROLI DISEASE) • Association with inflammatory bowel disease • Further, industrial exposure to asbestos and nitrosamines, and the use of the radiologic contrast agent, Thorotrast (thorium dioxide), are considered to be risk factors for the development of cholangiocarcinoma.
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- 22. • Cholangiocarcinoma canbe hyperechoic hypoechoic and mixed echogenicity
- 23. • Out-of-phase gradient-echoT1-weighted MR image shows a hypo-intense lobulated mass in the right hepatic lobe (arrows)
- 24. • On afat-saturated T2-weighted MR image, the mass appears hyperintense (arrows)
- 25. • Early-phase contrast-enhancedT1-weighted MR image shows irregular peripheral enhancement of the mass (arrows)
- 26. Sequences in MRI FSE•BILIARY AND PANCREATIC CANCERS CE-FAST •CHOLEDOCOLITHIASIS
- 27. INVASIVE DIRECT CHOLANGIOGRAPHY PER CUTANEOUSBIOPSY ENDOSCOPIC USG
- 28. Cholangiography • ERC allowstissue samples to be obtained with a brush cytology technique, despite the low reported accuracy (9%–24%) of this technique . Percutaneous trans-hepatic cholangiography is performed when • (a) ERC is unsuccessful due to luminal obliteration by tumor tissue • (b) the biliary tree is insufficiently demonstrated with ERC, (c) lesions are proximally located. • With either of these techniques, once the diagnosis has been established, the obstruction can be relieved preoperatively with placement of a stent or drainage catheter, which can also provide palliation in patients with an inoperable condition.
- 29. Per-cutaneous biopsy • Percutaneousimaging-guided biopsy is typically performed for mass-forming lesions. In addition, for infiltrative lesions, biopsy can be attempted with this approach when endoscopy fails to establish the diagnosis. CT is usually the preferred modality, but in the hands of an experienced operator, US can be equally effective
- 30. EMERGING TECHNIQUES • PositronEmission Tomography and Hybrid Positron Emission Tomography/CT • Brachy-therapy • Trans arterial radio-embolization (TARE) • Trans-arterial chemoembolization
- 31. SCREENING • The tumormarker CA-19.9 with a cutoff of 129 U/mL has a sensitivity of 78.6% and a specificity of 98.5% for cholangiocarcinoma
- 32. TREATMENT AND PROGNOSIS •Because of their location, these tumors tend to become symptomatic late in their development and therefore are not usually resectable at the time of presentation.. Complete resection of the tumor offers hope of long-term survival, and of late there has been renewed interest in liver transplantation from deceased donors along with adjuvant therapy. Prognosis remains poor today.