Cholangiocarcinoma
Introduction
Introduction to cholangiocarcinoma Cholangiocarcinoma refers to extrahepatic bile duct malignancies originating from the confluence of the left and right hepatic ducts to the lower end of the common bile duct. The cholangiocarcinoma can be divided into three types: hilar cholangiocarcinoma or upper cholangiocarcinoma, middle cholangiocarcinoma and lower cholangiocarcinoma. Primary cholangiocarcinoma is rare, accounting for 0.01% to 0.46% of common autopsy, 2% of autopsy in cancer patients, 0.3% to 1.8% of biliary surgery, and 1.5 to 5 times of gallbladder cancer in Europe and America. The data is more cholangiocarcinoma than gallbladder cancer. The ratio of men to women is about 1.5 to 3.0. The age of onset is mostly 50 to 70 years old, but it can also be seen in young people. basic knowledge The proportion of the disease: the incidence of this disease in the middle-aged and elderly people over 50 years old is about 0.004%-0.005% Susceptible population: patients with ulcerative colitis, patients with congenital biliary cysts, patients with a history of biliary surgery. Mode of infection: non-infectious Complications: cirrhosis ascites
Cause
Causes of cholangiocarcinoma
The etiology of cholangiocarcinoma is still not well understood and has been found to be related to the following factors:
Chronic inflammation of the biliary tract, infection factors (20%):
Long-term chronic inflammatory stimuli are the basis of cholangiocarcinoma, because it is clinically found that diseases associated with cholangiocarcinoma can cause chronic inflammation of the bile duct, and certain substances in bile (such as metabolites of bile acids) have long-term stimulation of the biliary mucosa. Causes epithelial dysplasia.
Ulcerative colitis (15%):
It has been reported that the incidence of cholangiocarcinoma in patients with ulcerative colitis is 10 times higher than that of the general population. The age of onset of cholangiocarcinoma with ulcerative colitis is 20 to 30 years earlier than the average, with an average of 40 to 45 years old, often with long-term A history of colitis, chronic bacteremia in the patient's portal system may be the cause of cholangiocarcinoma and PSC. The lesions are multi-wave and the whole colon. The biliary tract cancer caused by ulcerative colitis may be related to chronic portal bacteremia.
Bile duct, gallstone (30%):
20% to 57% of patients with cholangiocarcinoma are associated with gallstones, so the chronic stimulation of stones may be considered a carcinogenic factor.
Cystic cystic malformation (congenital biliary dilatation) (10%):
Congenital biliary cysts are easy to become cancerous. The incidence of cholangiocarcinoma in patients with congenital biliary cysts is as high as 2.5% to 28%. The biliary cystic deformity is 20 to 30 years earlier than normal, although 75% of biliary cystic Malformations occur in infancy and childhood, but in the case of cholangiocarcinoma, 3/4 of the patients have symptoms of biliary cystic malformation in adulthood. The mechanism of biliary cystic malformation leading to cholangiocarcinoma is considered to be pancreatic. When the opening of the bile duct into the bile duct is abnormally high, the pancreatic juice will flow back into the bile duct to cause malignant transformation of the bile duct epithelium. Other factors that may cause malignant transformation include biliary stasis, stone formation and chronic inflammation in the cystic cavity.
Liver fluke (Chinese branch worm) infection (10%):
Clonorchis sinensis infection is also considered to be associated with the occurrence of cholangiocarcinoma. Although clonorchiasis is parasitic in the intrahepatic bile duct, it can also be parasitic in the extrahepatic bile duct, and the worm body itself and metabolites have long-term stimulation of the bile duct mucosal epithelium. , causing bile duct mucosal hyperplasia, resulting in tumor-like changes, cancer.
History of biliary surgery (5%):
Cholangiocarcinoma can occur after many years of surgery and can occur in bile ducts without stones, mainly due to epithelial changes in chronic biliary infections, often after drainage in the biliary tract.
Radioactive cerium oxide
Among patients with a history of exposure to sputum, the age of onset of cholangiocarcinoma was 10 years earlier than that of those without sputum exposure, and the average incubation period was 35 years (after contact with sputum), and more occurred in the distal end of the intrahepatic biliary tree.
Sclerosing cholangitis
Patients with malignant primary sclerosing cholangitis (PSC) have a higher chance of developing cholangiocarcinoma than the general population. PSC is also associated with ulcerative colitis.
Hepatitis B virus infection
Some patients with cholangiocarcinoma in China are associated with hepatitis B virus infection, and whether there is any relationship between them remains to be further clarified.
.K-ras gene mutation
In recent years, molecular biology studies have shown that the mutation rate of K-ras gene 12 codon in cholangiocarcinoma is 77.4%, indicating that K-ras gene mutation may play an important role in the occurrence of cholangiocarcinoma.
Pathogenesis
Cholangiocarcinoma can occur in various parts of the extrahepatic bile duct, of which the proximal bile duct (hepatic bile duct) is the most common, accounting for 58%; the middle and long bile ducts account for 13% and 18% respectively (Fig. 1), occurring in the cystic duct 4%, and another 7% is diffuse.
1, pathological features
(1) Gross morphological classification
According to the general morphology of the tumor, cholangiocarcinoma can be divided into four types: papillary type, sclerotic type, nodular type and diffuse infiltration type. Among them, the infiltrative type is more common, followed by the nodular type, while the nipple type is less common. Cholangiocarcinoma generally has less mass formation, but most of the wall infiltration, thickening, luminal occlusion; cancer tissue is easy to infiltrate surrounding tissues, often invading the nerves and liver; patients often suffer from intrahepatic and biliary infections and death.
1 papillary carcinoma: grayish white or pink fragile tissue with a general shape of papillary shape, often with multiple lesions in the tube, growing to the surface, forming papillary structures of varying sizes, arranged neatly, with normal tissue between cancer cells, good In the lower bile duct, it is easy to cause incomplete obstruction of the bile duct. This type of tumor mainly infiltrates along the bile duct mucosa. Generally, it does not infiltrate the bile duct surrounding tissue, blood vessels, nerve lymphatic space and liver tissue infiltration. The success rate of surgical resection is high and the prognosis is good.
2 sclerosing carcinoma: a grayish-white annular induration, often infiltrated along the lower layer of the bile duct mucosa, thickening the bile duct wall, a large amount of fibrous tissue hyperplasia, and infiltrating into the outside of the tube to form a fibrous lumps; with partial biliary obstruction, lesion bile duct accompanied Ulcer, chronic inflammation, and dysplasia, occur in the hilar bile duct, is the most common type of hilar cholangiocarcinoma, sclerosing cancer cells differentiate well, often scattered in a large number of fibrous connective tissue, easy It is confused with sclerosing cholangitis, scarring caused by chronic inflammation of the bile duct wall, and fibroplasia. Sometimes it is difficult to make a correct diagnosis even in the frozen histopathological biopsy. Sclerosing cancer has obvious infiltration along the bile duct wall. The tendency to invade the tissues around the bile duct and the invasion of the liver parenchyma, so it is often necessary to remove the liver lobe during radical surgical resection. However, the surgical margin often leaves cancerous tissue, and the true radical resection is not achieved, and the prognosis is poor.
3 nodular carcinoma: the mass forms a nodule that protrudes into the distal part of the bile duct. The base of the nodule is continuous with the wall of the bile duct. The inner surface of the bile duct is often irregular. The tumor is generally small, the base is wide, and the surface is irregular. Tumors often infiltrate along the bile duct mucosa, and the degree of infiltration into the tissues and blood vessels around the bile duct is lighter than that of sclerosis. The surgical resection rate is higher and the prognosis is better.
4 diffuse invasive carcinoma: less common, accounting for 7% of cholangiocarcinoma, cancer tissue extensively infiltrated into the liver along the bile duct wall, external bile duct, thickening of the wall, stenosis of the lumen, obvious inflammation of the connective tissue around the tube, difficult to determine The original bile duct site of cancer is generally inoperable and has a poor prognosis.
(2) Histological classification
More than 95% of cholangiocarcinomas are adenocarcinomas, and a few are squamous cell carcinomas, mucinous carcinomas, cystadenocarcinomas, etc. In primary extrahepatic cholangiocarcinoma, common bile duct cancer is the most common, 33% to 40%; Hepatic duct cancer, 30% to 32%; hepatic duct bifurcation, 20%; cystic duct 4%.
There is no uniform classification of histology of extrahepatic cholangiocarcinoma. It is commonly divided into 6 types according to the degree of differentiation and growth pattern of cancer cells:
1 papillary adenocarcinoma; 2 well-differentiated adenocarcinoma; 3 poorly differentiated adenocarcinoma; 4 undifferentiated carcinoma; 5 signet ring cell carcinoma; 6 squamous cell carcinoma.
Adenocarcinoma is more common, and the classification report is not consistent, but the most common histological type is still papillary adenocarcinoma, highly differentiated adenocarcinoma, accounting for more than 90%, and a few are poorly differentiated adenocarcinoma and mucinous adenocarcinoma. There are also rare reports of common bile duct leiomyosarcoma.
2. Transfer route
About 71.4% of cholangiocarcinoma has direct infiltration or metastasis, 33.3% of which affect the liver, 33.3% of which affect the lymph nodes, 17.5% of the peritoneal dissemination, due to blood vessels around the bile duct, lymphatic network and nerve bundles, cholangiocarcinoma can Through multiple channels along the bile duct to spread into the liver or outside the liver, retention, growth and reproduction, cholangiocarcinoma metastasis including lymphatic metastasis, hematogenous metastasis, nerve metastasis, infiltration and metastasis, etc., can be transferred to many other organs through various ways The hilar cholangiocarcinoma cells can spread and spread in the intrahepatic direction and the duodenal ligament through multiple channels along the lymphatic vessels around the bile duct, blood vessels and nerves, but less distant metastasis occurs.
(1) Lymphatic metastasis
More common, often metastasis to the hilar and peripancreatic lymph nodes, less distant lymphatic metastasis, lymph node metastasis rate of the above cholangiocarcinoma is higher, bile duct in the liver and portal vein, the branch of the hepatic artery is wrapped in the Glisson sheath, There are abundant nerve fibers and lymph, Glisson sheaths extend to the hepatoduodenal ligament, which is rich in nerve fibers, lymphatic vessels, lymph nodes and loose connective tissue, and the bile duct itself is rich in submucosal blood vessels and lymphatics. In recent years, with the development of high-grade cholangiocarcinoma resection, the lymph node drainage of the hepatic hilum has been paid attention to. Someone has confirmed the lymph node in the posterior portal vein of the liver transverse groove in the anatomy of 27 cases of hilar lymph nodes, and the massive draining lymph. The tube is accompanied by the portal vein, and there is a thick lymphatic communication between the common lymph node, the common bile duct lymph node and the hepatic artery lymph node.
Lymphatic metastasis is the most common metastasis pathway of cholangiocarcinoma and may occur at an early stage. It has been reported that only the pathological examination is limited to early stage cholangiocarcinoma in the mucosa. Regional lymph node metastasis occurs. The lymph node group of cholangiocarcinoma is:
1 cystic duct lymph node; 2 common bile duct lymph nodes; 3 small omental pore lymph nodes; 4 pancreaticoduodenal anterior and posterior lymph nodes; 5 pancreaticoduodenal lymph nodes; 6 portal vein posterior lymph nodes; 7 celiac para-aortic lymph nodes; 8 hepatic artery lymph nodes; 9 anterior and posterior lymph nodes of the common hepatic artery; 10 superior mesenteric lymph nodes, divided into superior mesenteric artery, lower pancreaticoduodenal artery and colonic artery root and the first jejunal artery root 4 groups of lymph nodes.
Overall, hilar cholangiocarcinoma lymph node metastasis is mainly along the hepatic artery; middle cholangiocarcinoma has extensive lymph node metastasis, in addition to invading the pancreatic lymph node, it can also involve the superior mesenteric artery and para-aortic lymph nodes; distal cholangiocarcinoma, Metastatic lymph nodes are mostly confined around the head of the pancreas.
(2) infiltration transfer
More common, biliary cancer cells directly infiltrating up and down the bile duct wall is one of the main features of cholangiocarcinoma metastasis. The upper cholangiocarcinoma infiltrates into the liver of the adjacent bile duct, the central cholangiocarcinoma infiltrates into the hepatic artery and portal vein, and the lower cholangiocarcinoma Pancreatic infiltration, cancer cells diffuse invasive growth in the bile duct wall, and coexist with the bile duct and surrounding connective tissue hyperplasia, making the invasive range of cholangiocarcinoma difficult to identify, which makes it difficult to determine the extent of resection during surgery, in addition, the result of direct infiltration It also causes important adjacent structures around the bile duct, such as large blood vessels, and the liver is invaded, which limits the scope of surgical resection and makes it difficult to achieve radical resection. Residual cancer tissue is one of the main causes of rapid recurrence after surgery. Liver metastasis is the upper part. The main mode of metastasis of cholangiocarcinoma is less common in peritoneal dissemination.
(3) Hematogenous transfer
Up to the whole body, the most common is lung, up to 10% to 25%. Pathological studies have shown that 58.3% to 77.5% of vascular invasion in and around cholangiocarcinoma specimens indicate that invasion of blood vessels is a common biology of cholangiocarcinoma cells. Phenomenon, vascular density of cholangiocarcinoma is significantly correlated with the incidence of cancer metastasis, and the incidence of metastasis increases with the increase of tumor vascular density, suggesting that tumor angiogenesis plays an important role in the invasion and metastasis of cholangiocarcinoma. It is observed that cholangiocarcinoma often occurs in lymphatic system metastasis. In fact, tumor angiogenesis and vascular invasion are closely related to lymphatic metastasis. Therefore, tumor angiogenesis and vascular invasion are the basic links in the process of infiltration and metastasis of cholangiocarcinoma.
(4) Spread along the nerve
The incidence of neurological invasion can reach 33.3%-83.4%, so the clinical manifestations of jaundice and pain are common symptoms. The vagus nerve and sympathetic nerve that innervates the extrahepatic biliary tract constitute the anterior plexus and posterior pons of the hepatic duodenal ligament. The plexus, surrounded by nerve fibers, has a complete outer membrane, a continuous gap called the perineural space. In the past, it was thought that the perivascular space was a component of the lymphatic system, but it was later confirmed by light and electron microscopy. The peripheral space is an independent system, which has nothing to do with the lymphatic system. Tumor cells can be transferred to the proximal or distal direction through the perivascular space. Statistics show that cancer cells infiltrate around the nerve and connect with the liver and hepatoduodenal ligament. The tissue metastasis was significantly correlated, suggesting that the liver metastasis of the liver, duodenal ligament and surrounding connective tissue may be achieved by the spread of cancer cells around the nerve interstitial space. Therefore, the perivascular infiltration should be the prognosis of cholangiocarcinoma. Key factor.
3. Clinical pathological staging of cholangiocarcinoma
At present, the clinical use of the International Union Against Cancer (UICC) TNM staging criteria is an important reference for measuring the condition, determining the treatment strategy and assessing the prognosis.
Bismuth-Corlette divides hilar cholangiocarcinoma into the following five types according to the location of the lesion. It is widely used in clinical practice at home and abroad:
Type I: The tumor is located in the common hepatic duct and does not invade the confluence;
Type II: The tumor is located in the confluence of the left and right hepatic ducts, and does not invade the left and right hepatic ducts;
Type III: The tumor is located in the bile duct of the confluence and has invaded the right hepatic duct (IIIa) or invaded the left hepatic duct (IIIb);
Type IV: The tumor has invaded the left and right bilateral hepatic ducts.
On this basis, domestic scholars have divided IV into IVa and IVb.
Prevention
Cholangiocarcinoma prevention
1. Maintain a pleasant psychological state, develop good eating habits, fast food, eat less thick food, and do not drink hard alcohol.
2, for people over the age of 40, especially women, regular B-ultrasound examination, found cholecystitis, gallstones or polyps, etc., should be followed up and found that changes in the condition should be treated early.
3, before actively treating cancer lesions, sooner or later, in addition to the cause of cancer may cause.
4, biliary tumor prevention should focus on the early treatment of its closely related diseases and precancerous lesions, non-invasive examination B-ultrasound should be used as the basic means of the disease screening.
1 primary prevention
The etiology of cholangiocarcinoma is unclear, and the relationship with cholelithiasis is not as close as gallbladder cancer. Therefore, primary prevention of cholangiocarcinoma lacks effective methods, mainly for the prevention and treatment of hepatolithiasis and regular systematic health examination.
2 secondary prevention
Secondary prevention is the focus of prevention of this disease. Patients with obstructive jaundice should be highly alert to the possibility of cholangiocarcinoma in the diagnosis of cholelithiasis, hepatitis, cirrhosis and other diseases. On the basis of detailed medical history and comprehensive physical examination, it should be done as soon as possible. B-ultrasound, CT, PTC and ERCP examination for early detection, early diagnosis, early treatment.
Complication
Cholangiocarcinoma complications Complications cirrhosis ascites
1, abdominal hemorrhage occurred in patients with combined hepatic lobe resection and intraoperative portal vein injury, also seen in the anastomotic bleeding of the biliary anastomosis, abdominal drainage >200ml / h, suggesting active bleeding in the abdominal cavity. Emergency surgery to stop bleeding.
2, the most common complications of biliary fistula, frequent hepatic lobe resection of the liver wound bile duct improper treatment or intrahepatic bile duct and jejunum respectively, due to numerous intrahepatic bile duct openings, sometimes difficult to properly handle, after the use of bile duct formation and jejunum anastomosis, bile Decreased sputum occurs; it can also occur at the surface of the liver through the transabdominal drainage tube.
3, acute renal failure and more secondary to severe jaundice. Often due to insufficient circulating blood volume, sympathetic excitation, increased renin angiotensin system activity, decreased renal prostaglandins, increased thromboxane A2 and endotoxemia. It is characterized by spontaneous oliguria or anuria, azotemia, dilute hyponatremia and low urinary sodium.
Symptom
Biliary duct cancer symptoms Common symptoms Abdominal pain Abdominal discomfort with joint swelling and pain, nausea, ascites, diarrhea, gallbladder, increased bile excretion blocked
Progressive jaundice is the main symptom of cholangiocarcinoma (80% to 90%). Others such as weight loss, thin body, enlarged liver, and sometimes can reach the enlarged gallbladder, are common symptoms of this disease.
1, clinical manifestations
Mainly for progressive jaundice with upper abdominal discomfort, loss of appetite, weight loss, itching, etc., such as gallstones and biliary tract infections, may have chills, fever, etc., and have paroxysmal abdominal pain and pain, such as located in one side of the liver Tube cancer, often asymptomatic, when it affects the contralateral hepatic duct opening, obstructive jaundice occurs, such as central bile duct cancer without gallstones and infections, mostly painless progressive obstructive jaundice, jaundice generally progress Faster, no volatility, examination shows hepatomegaly, hard, gallbladder is not swollen, such as the lower end of the common bile duct, it can be swollen and swollen gallbladder, such as tumor rupture bleeding, there may be black stool or stool Positive occult blood test, anemia and other performance.
(1) Symptoms:
1 Astragalus: the most common symptom, accounting for 36.5%, jaundice is the result of biliary obstruction, mostly progressive deepening, the extent of which is related to the location and extent of obstruction, jaundice is deeper in extrahepatic bile duct obstruction, and intrahepatic bile duct branch is blocked When the jaundice is shallow, the jaundice is deep when the complete bile duct is obstructed, and the jaundice is shallow when the incomplete bile duct is obstructed. Occasionally, the inflammation of the bile duct, the sputum and the tumor detachment and the papillary type tumor misalignment can cause the jaundice to fluctuate, and the middle and lower segments Cholangiocarcinoma often presents as painless cholestatic jaundice. The patient's urine is dark yellow or brown, and the stool becomes light or terracotta.
2 abdominal pain: may be mild discomfort in the upper abdomen after eating, or painful discomfort under the xiphoid, or back pain, or right upper quadrant colic, the manifestation of neurological invasion, may appear before or after jaundice.
3 fever: mostly caused by inflammation of the obstructive bile duct, the incidence is low.
4 Others: may have loss of appetite, oil, fatigue, weight loss, generalized skin itching, nausea and vomiting and other accompanying symptoms, or non-specific symptoms of cancer, a few may have portal hypertension symptoms, cancer caused by infiltration of portal vein.
(2) Signs:
1 liver enlargement: more than 80% of patients have large liver, mostly due to intrahepatic cholestasis.
2 gallbladder enlargement: If the cancer occurs in the lower part of the junction of the three tubes, the swollen gallbladder can be touched.
3 ascites: late due to peritoneal invasion, or invasion of the portal vein, leading to portal hypertension, ascites may occur.
2, the location and clinical manifestations of cancer
The specific clinical manifestations will vary depending on the location of the cancer and the course of the disease.
(1) Cancer located in the ampulla of the end of the common bile duct
Obstruction of the common bile duct and pancreatic duct is a prominent symptom, and due to the collapse of the cancer, there may be intestinal bleeding and secondary anemia. Patients often have progressive jaundice and persistent back pain, but if there are stones in the bile duct, the pain is also It may be colic, because the pancreatic duct is sometimes blocked, which may affect the endocrine of the pancreas and have hyperglycemia or hypoglycemia. It is more likely to cause fatty diarrhea due to the loss of exocrine. Because the bile duct is blocked, it will also affect the fatty food. Digestion, due to bile, pancreatic duct is blocked at the same time, magnetic resonance cholangiopancreatography (MRCP) examination can have a typical "double tube sign", and often have gallbladder bloat and liver enlargement, ampullary cancer lesions can appear very small Astragalus, and is prone to ulcer bleeding, feces can be tar-like and severe anemia, so patients with progressive jaundice, often intestinal bleeding, and stubborn fatty diarrhea, most likely ampullary cancer.
(2) Common bile duct cancer between the ampulla and the cystic duct
Symptoms are similar to pancreatic head cancer, but because the pancreatic duct is not involved, there should be no pancreatic endocrine and exocrine disorders in the clinic. If the patient has not had chronic cholecystitis in the past, the gallbladder will be significantly enlarged, in accordance with Courvoisier's law.
(3) Cancer located in the common hepatic duct
Astragalus is extremely prominent, and the liver enlargement is also very obvious; the gallbladder is not swollen, sometimes only contains mucus and white bile.
Examine
Cholangiocarcinoma examination
Laboratory inspection:
Fecal occult blood test may be positive, carcinoembryonic antigen (CEA) and carbohydrate antigens CA-199, CA-50, CA-242 in serum and bile have a certain positive rate in cholangiocarcinoma, which can be used for auxiliary diagnosis and postoperative follow-up.
1, direct bilirubin increased
Laboratory tests showed the performance of obstructive jaundice, and elevated serum total bilirubin and direct bilirubin were manifested as cholestatic jaundice.
2, the performance of secondary liver damage
In patients with long-term biliary obstruction, there may be secondary liver damage, mild elevation of ALT and AST is a manifestation of secondary liver damage, serum total protein and albumin reduction are manifestations of malnutrition and liver damage, prothrombin Time prolonged biliary obstruction and secondary liver damage, -GT and alkaline phosphatase increased, ALP, -GT increased in the early absence of jaundice, suggesting biliary obstruction.
3, blood test
More than half of patients with white blood cell counts above 8 × 109 / L, if significantly increased, suggesting biliary tract infection, 61% to 70% of patients may have varying degrees of Hb reduction.
Film degree exam:
The main purpose of imaging examination is to diagnose the location of the obstruction, to determine the nature of the lesion and to estimate the extent of the lesion and its relationship to surrounding tissues and organs.
1, B-ultrasound
In many imaging examinations, B-mode ultrasound is the preferred diagnostic method. Real-time ultrasound examination has a high diagnostic rate for the location and extent of bile duct obstruction. The detection rate of bile duct dilatation can reach more than 95%, which is the first choice for ultrasound examination. The fine needle aspiration cytology is a simple, safe and effective method. The endoscopic ultrasound (EUS) probe and the biliary system are separated by only one layer of the intestinal wall, excluding the interference of the chest and abdomen wall and the gastrointestinal tract overlap. The biliary tract can be observed more clearly. Intraductal-ultrasonography (IDUS) can directly enter the biliary tract scan through the PTC sinus or ERCP through the micro-ultrasound probe, completely eliminating the interference of covering the biliary tissue. The image is more EUS. More clearly, IDUS can detect biliary microcarcinoma, the accuracy of cholangiocarcinoma infiltration depth is 73%, and the accuracy of pancreas and duodenum involvement is 100%, and further use of intraluminal color Ultrasound Ultrasound (ECDUS) can detect blood flow around the biliary system and accurately determine whether the hepatic artery and portal vein are invaded by 100%.
(1) The intrahepatic bile duct expands to varying degrees.
(2) Lower bile duct or middle segment of the cancer with extrahepatic bile duct dilatation and gallbladder enlargement, hilar cholangiocarcinoma see gallbladder emptiness, extrahepatic bile duct does not expand.
(3) In the advanced cases on the bile duct, the middle and lower part of the cancer, respectively in the hilar area, the middle part of the bile duct or the lower part of the bile duct can be seen in the low echo group shadow, a small number of cholangiocarcinoma can be seen in the liver parenchymal tumor invasion or metastasis.
(4) B-ultrasound can also show the extent of tumor invasion, the extent of portal vein and hepatic artery compression or invasion; together with the doctor and clinician, B can provide the diagnosis basis and estimate the possibility of tumor resection.
2, CT
CT is still a routine examination method, which can show the expansion of the bile duct inside and outside the liver. It can be seen that the proximal bile duct is obviously dilated, the gallbladder is enlarged, the dilated bile duct is suddenly interrupted, the shape of the broken end is irregular, and the block shadow is seen. Sometimes the bile duct wall is enlarged. Thick, irregular lumen, enlarged gallbladder and surrounding tissues and organs, involvement of blood vessels, or small nodules from the bile duct wall into the cavity, provide a basis for the possibility of lesion staging and surgical resection, spiral CT blood vessels Contrast-enhanced (SCTA) technology can complete a series of thin-section cross-section vascular images in a short time. The three-dimensional revascularization technique also provides important information for understanding the relationship between tumor and blood vessels, and whether the hilar tumor can be removed. CT scan can be obtained with B-ultrasound. The same effect, and the image is clearer.
3, endoscopic ultrasound (EUS)
EUS is a new type of diagnostic tool combined with endoscopic and intracavitary ultrasound. The bile duct wall EUS can be divided into three layers: the first layer of high echo is equivalent to mucosa plus interface echo; the second layer of low echo is smooth muscle. Fiber and fiber elastic tissue; the third layer of high echo is loose connective tissue plus interface echo, cholangiocarcinoma EUS is a hypoechoic or hyperechoic mass, the detection rate is 96%, and can indicate the size of the tumor and the presence or absence of lymph nodes Transfer.
4, percutaneous transhepatic cholangiography (PTC)
It is the basic means for the diagnosis of biliary tumors. It can show the location and extent of tumors. The diagnosis rate is over 90%. PTC is suitable for patients with dilatation of intrahepatic bile duct. After surgery, catheter can be placed for bile drainage (PTCD). CT examination shows that patients with intrahepatic bile duct dilatation can perform PTC examination, which can not only directly display and confirm the location of the tumor, the upper edge of the lesion and the extent of the hepatic duct, but also the relationship between the tumor and the hepatic duct. Preoperative determination of the surgical plan is of great significance, the correct diagnosis rate of more than 90%, but this test is traumatic, and easy to cause bile leakage and cholangitis, in order to avoid the above complications, it is best to check the day before surgery, After the examination, try to drain the contrast agent and be ready to perform the operation.
5. Retrograde cholangiopancreatography (ERCP)
Applicable to cases of incomplete obstruction of the bile duct, the obstruction site can be displayed from the distal end of the bile duct, the extent of the lesion can be judged, and bile drainage (ENBD/ERBD) can be performed after operation. The combination of PTC and ERCP can significantly improve the diagnosis rate of cholangiocarcinoma. The bile can also be used for tumor marker detection and cytology. The use of ERCP alone can only show the middle and lower part of the common bile duct, but the combination with PTC can help to identify the location of the lesion, the upper and lower limits of the lesion and the nature of the lesion, especially suitable for Patients with biliary incomplete obstruction and coagulopathy were diagnosed with ERCP and the diagnostic coincidence rate was 75.5%.
6, fiber choledochoscopy
It can be used to identify the location and extent of the lesion, especially for the intrahepatic bile duct, the early stage of the duodenal pancreatic duct, and the choledochoscopy can not only show the shape of the lesion, but also can be used for biopsy to confirm the diagnosis. (PCS) and fiber choledochoscopy can directly look at the lesions in the bile duct and clamp tissue biopsy or cell brushing.
7. Selective angiography (SCAG) and transhepatic portal venography (PTP)
It can show the condition of the hepatic portal into the hepatic vasculature and its relationship with the tumor. The cholangiocarcinoma is mostly a tumor with less blood supply. The angiography generally cannot diagnose the nature and extent of the tumor. It can mainly show whether the blood vessel at the hilum is Invasion, if the liver proper arteries and portal veins are violated, it means that the tumor has extrahepatic expansion, and it is difficult to perform radical resection. This test is helpful to estimate the resectability of the tumor before surgery.
In order to achieve the purpose of preoperative diagnosis, in the past 10 years, PTC, ERCP and other methods have been used to take bile or live tissue for cytology and histological examination, but the positive rate is not high.
8, magnetic resonance cholangiopancreatography (MRCP)
It can show nearly 100% of extrahepatic bile ducts. 90% of non-dilated intrahepatic bile ducts can also be traced along the extrahepatic bile ducts. 85%100% can identify obstruction sites. Compared with PTC and ERCP, MRCP can show obstruction at the same time. The proximal and distal bile ducts can therefore calculate the length of the obstruction and the length of the ampulla, facilitating the development of a surgical plan. MRI routine transection and coronal scan can also provide information on the involvement of the liver and surrounding tissues.
Diagnosis
Diagnosis and diagnosis of cholangiocarcinoma
diagnosis
Patients with jaundice over 40 years of age, or unexplained upper abdominal discomfort, pain, anorexia and other digestive symptoms, liver enlargement with or without gallbladder enlargement, should be suspected of cholangiocarcinoma and further B-ultrasound, CT, MRI, ERCP, endoscopic ultrasonography, choledochoscopy, PTC, hypotonic duodenal angiography, or selective angiography can confirm the diagnosis.
In general, although Huangqi is a obvious symptom of this disease, it is often difficult to diagnose correctly. It is easy to be confused with common bile duct stones. Especially the clear diagnosis before the appearance of jaundice is not easy. It is often necessary to have pain or discomfort in the upper abdomen. Patients with obstructive jaundice can make a more accurate diagnosis by comprehensive and careful examination. The fashion can be used to confirm the truth after exploratory laparotomy. The previous literature and statistics preoperative diagnosis is only 1/3 of the case, but in recent years, With the development and improvement of imaging diagnostic techniques, the correct diagnosis rate before surgery is greatly improved. It is important to promptly select appropriate examinations for patients with suspiciousness, so that early diagnosis and treatment of the disease can be made.
Cholangiocarcinoma combined with clinical manifestations, laboratory and imaging studies can make a preliminary diagnosis.
The characteristics of cholangiocarcinoma are: 1 abdominal pain is more obvious than jaundice; 2 nighttime pain, rest pain mainly; 3ALP, -GPT early increase significantly; 4B super and CT can be seen obstructing upper biliary dilatation, rarely seen lumps; 5 direct Cholangiography shows a specific image of bile duct obstruction.
Preoperative diagnosis of extrahepatic cholangiocarcinoma includes:
1 to determine the nature of the lesion; 2 to determine the location and extent of the lesion; 3 to determine the presence or absence of metastases inside and outside the liver; 4 to understand whether the liver lobe with atrophy and hypertrophy; 5 to understand the difficulty of surgical resection.
Differential diagnosis
Cholangiocarcinoma needs to be differentiated from the following benign and malignant diseases.
1, biliary benign disease
(1) Benign tumor of the bile duct: In the medical history, physical examination and direct cholangiography, the identification of benign and malignant biliary tumors is difficult. Generally, it depends on histology and cytology. However, if the metastatic lesions are found before surgery, it is definitely malignant.
(2) common bile duct stones: a long history, a history of episodes of abdominal pain, jaundice is also intermittent, with obvious symptoms of remission, pain often accompanied by varying degrees of cholangitis, such as fever, chills, blood Increased, localized signs of peritonitis, etc., in the cholangiography can be seen in the stenosis of the sclerosing and cup shadow, and the bile duct wall is smooth, but the identification of polypoid cholangiocarcinoma is difficult, choledochoscopy is helpful for diagnosis.
(3) Mirrizzi syndrome: cholangiography can be seen on the right side of the common hepatic tube, the edge of which is smooth, B-ultrasound can be seen in the cystic duct embedded in the stone, can not be confirmed in the operation of the bile duct histological examination.
(4) benign biliary stenosis: more occurs after abdominal surgery, a small number of abdominal trauma, biliary tract stenosis can also be shown in cholangiography, but its edge is smooth, bilateral symmetry, if necessary, choledochoscopy can be used to identify tissue specimens.
(5) primary sclerosing cholangitis: more common in middle-aged people, more men than women, abdominal pain is mostly paroxysmal, rarely biliary colic, jaundice is intermittent progressive aggravation, laboratory tests for obstruction Sexual jaundice, cholangiography often seen extensive chronic stenosis and stiffness of the bile duct, but there are also lesions confined to only a part of the bile duct, this type is not easy to distinguish from cholangiocarcinoma, can only rely on the naked eye to see the naked eye and histological examination confirmed.
(6) Chronic pancreatitis: This disease can also cause jaundice or occlusion of the pancreatic duct, but the jaundice is longer, and the jaundice is lighter. In the cholangiography, the stenosis of the bile duct is bilaterally symmetrical and the edges are smooth. Further examination of pancreatic function, ERCP, CT and intraoperative biopsy are needed.
(7) Capillary biliary hepatitis: This disease can also appear nausea, anorexia, jaundice, itchy skin, clay-like stools, etc., easily confused with cholangiocarcinoma, but the difference is: gallbladder is not swollen, no biliary colic The amount of urinary urinary tract increased, the liver function test was abnormal, and B-ultrasound did not show bile duct dilatation. The diagnosis must rely on liver biopsy.
2, bile duct malignant disease
(1) Pancreatic cancer: This disease is often accompanied by obstruction of the pancreatic duct. Pancreatic duct stenosis or occlusion can be seen on the ERCP image. In the B-ultrasound and CT images, the pancreatic head mass and the pancreatic duct of the pancreatic body are significantly expanded. There is a significant reduction or lack of pancreatic enzyme in the diphthal drainage solution. Clinically, jaundice is more prominent, mostly painless and progressively aggravated.
(2) nipple cancer: low-end duodenal angiography can show the filling defect of the left margin of the descending part of the duodenum. The endoscope can directly look at the tumor and can be histologically examined.
(3) gallbladder cancer: this disease invades the hilar bile duct or upper bile duct is difficult to distinguish from cholangiocarcinoma, but B-ultrasound and CT can be seen gallbladder consolidation or occupying, selective angiography can be seen in the gallbladder area ischemic tumor Shadow.
(4) Liver cancer: intrahepatic cholangiocarcinoma and liver cancer are sometimes difficult to identify in cholangiography, but primary liver cancer has a history of cirrhosis, AFP detection is positive, so it is necessary to combine medical history, AFP, B-ultrasound, CT, selection Comprehensive angiography and other comprehensive judgments and analysis, sometimes need to be confirmed by histological examination of the resected specimens.
(5) Duodenal cancer or sarcoma: In some cases, abnormalities of the common bile duct, stenosis or even occlusion may occur in cholangiography, but the upper digestive tract barium can often see the occupying image in the duodenum. Mirror examination is more clear diagnosis.
(6) advanced gastric cancer: lymph node metastasis of gastric cancer can also cause biliary occlusion, but upper gastrointestinal barium meal and endoscopy are enough to confirm the diagnosis.
