Radiographic features predictive of recurrence and survival after surgical resection of perihilar cholangiocarcinoma.

Objective: To study which radiographic features were associated with recurrence and adverse outcome in patients undergoing surgical resection of perihilar cholangiocarcinoma (PCCA), as well as to evaluate the imaging patterns that signify recurrence after the resection of PCCA. Materials and methods: This study was conducted in a solitary tertiary center and utilized a retrospective, analytical, case-control design. The study population consisted of patients with pathologically confirmed PCCA who underwent surgical resection and were subsequently followed up from January 2009 to December 2017. A total of 77 patients were enrolled in the study and were categorized into two distinct groups, namely recurrent and non-recurrent. The analysis encompassed the examination of demographic data and recurrence patterns. Additionally, survival and multivariate analyses were employed to assess radiographic imaging data and surgical information. Results: Seventy-seven patients diagnosed with PCCA based on pathological evidence were included in the study. Among the participants, there were 28 females and 49 males, with ages ranging from 41 to 81 years (mean age of 60.65 ±â€¯7.66). A noteworthy finding was the recurrence rate of 65 % observed following surgical resection. The presence of regional lymph node (LN) metastasis, adjacent organ invasion, and surgical margin emerged as the three independent factors that exhibited a significant association with recurrence after post-operative resection (p = 0.023, p = 0.028, and p = 0.010, respectively). The patients with PCCA who experienced regional LN metastasis had a median overall survival (OS) of 22 months, which was significantly lower than the 46 months observed in those without regional LN metastasis (p < 0.018). Furthermore, the individuals with regional LN metastasis had a death rate that was 2.08 times higher than those without (p = 0.040). In addition, those with adjacent organ invasion had an OS duration of 21 months compared with 52 months in those without (p = 0.008), and the rate of death was 2.39 times higher (p = 0.018). Patients with an R1 resection margin had an OS duration of 36 months compared with 51.56 months in those with an R0 resection margin (p = 0.006), as well as a 2.13 times higher rate of recurrence (p = 0.010) and a 2.43 times higher mortality rate (p = 0.013). Conclusion: The presence of regional LN metastasis, invasion of adjacent organs, and R1 resection margin were identified as distinct factors that are linked to both disease recurrence and reduced OS. Local recurrence, as well as the spread of cancer to distant organs such as the lungs and liver, were frequently observed patterns of recurrence. To enhance the precision of staging, prognosis, and treatment, the inclusion of periductal fat or invasion of adjacent organs should be considered in the staging system for PCCA.

New Imaging Techniques.

The chapter discusses the advancement of new imaging techniques, the role of imaging in CCA diagnosis, anatomical and morphological classification, ultrasound screening of CCA, ultrasound findings of MF-CCA, PI-CCA, ID-CCA, the use of CT in CCA diagnosis, staging and treatment planning, CT volumetry and estimation of future liver remnant, post-treatment follow-up and surveillance, MRI imaging, Positron Emission Tomography (PET)/CT, limitations to contrast studies and resolution, internal receivers for CCA imaging, and in vitro imaging of CCA.

Prognostic significance of tumor-infiltrating lymphocytes in predicting outcome of distal cholangiocarcinoma in Thailand.

Patients with distal cholangiocarcinoma (dCCA) generally have poor outcomes because of late presentation and diagnosis. Therefore, prognostic factors for predicting outcomes are essential to improve therapeutic strategies and quality of life. Tumor-infiltrating lymphocytes (TILs) have been reported as a prognostic predictor in several cancers. However, their role in dCCA is still unclear. This study aimed to evaluate the association of TILs with outcome in patients with dCCA. Fifty-two patients were evaluated for the percentage rate of TILs in their cancers, and a median TIL level was used to divide the patients into two groups. Survival, multivariate, and correlation analyses were performed to determine the prognostic factors. Results showed that a low TIL level was associated with poor survival. Multivariate analysis revealed TILs as an independent factor for poor outcome. Moreover, TILs were markedly correlated with growth patterns, and both were applied to classify patients with dCCA. Subgroups of TILs with growth pattern incorporation improved stratification performance in separating good from poor patient outcomes. This study suggested that TILs could be a prognostic factor for predicting survival and for clustering patients with dCCA to improve prognostication capability. This finding may be incorporated into a new staging system for stratifying dCCA in Thailand.

Modification of the eighth AJCC/UICC staging system for perihilar cholangiocarcinoma: An alternative pathological staging system from cholangiocarcinoma-prevalent Northeast Thailand.

Aim: This study aims to improve the classification performance of the eighth American Joint Committee on Cancer (AJCC) staging system for perihilar cholangiocarcinoma (pCCA) by proposing the Khon Kaen University (KKU) staging system developed in cholangiocarcinoma-prevalent Northeast Thailand. Method: Four hundred eighty-eight patients with pCCA who underwent partial hepatectomy between 2002 and 2017 at the Srinagarind Hospital, Faculty of Medicine, Khon Kaen University, Thailand, were included. Overall survival (OS) related to clinicopathological features was analyzed using the Kaplan-Meier method. Logrank test was performed in univariate analysis to compare OS data of clinicopathological features to determine risk factors for poor survival. Significant features were further analyzed by multivariate analysis (Cox regression) to identify prognostic factors which were then employed to modify the eighth AJCC staging system. Results: Multivariate analysis showed that growth pattern (HR = 4.67-19.72, p < 0.001), moderately and poorly differentiated histological grades (HR = 2.31-4.99, p < 0.05 and 0.001, respectively), lymph node metastasis N1 and N2 (HR = 1.37 and 2.18, p < 0.05 and 0.01, respectively), and distant metastasis (HR = 2.11, p < 0.001) were independent factors when compared to their respective reference groups. There was a clear separation of patients with pCCA into KKU stage: I [OS = 116 months (mo.)], II (OS = 46 mo.), IIIA (OS = 24 mo.), IIIB (11 mo.), IVA (OS = 7 mo.), and IVB (OS = 6 mo.). Conclusion: The new staging system was based on the incorporation of growth patterns to modify the eighth AJCC staging system. The classification performance demonstrated that the KKU staging system was able to classify and distinctly separate patients with pCCA into those with good and poor outcomes. It was also able to improve the stratification performance and discriminative ability of different stages of pCCA classification better than the eighth AJCC staging system. Hence, the KKU staging system is proposed as an alternative model to augment the accuracy of survival prognostication and treatment performance for patients with pCCA.

Modification of the AJCC/UICC 8th edition staging system for intrahepatic cholangiocarcinoma: proposal for an alternative staging system from cholangiocarcinoma-prevalent Northeast Thailand.

BACKGROUND: Intrahepatic cholangiocarcinoma (iCCA) arises from bile ducts within the liver. Thailand has the highest incidence of CCA worldwide, with a high mortality rate. Early diagnosis and accurate prognostic stratification can improve overall survival. We aim to modify the AJCC/UICC 8th edition staging system for iCCA by creating the Khon Kaen University (KKU) staging system for more precise patient stratification and prognostic prediction. METHODS: A total of 298 iCCA patients who underwent hepatectomy were included in this retrospective study at the Srinagarind Hospital, Khon Kaen University, Thailand. Univariate and multivariate analysis were performed to examine survival rate, hazard ratio, and prognostic factors. RESULTS: Univariate and multivariate analysis of the cohort showed that growth patterns, histological type, histological grade, lymph node metastasis and distant metastasis were independent prognostic factors when compared to the respective reference groups. The 8th AJCC staging system incorporated growth patterns into the KKU staging system. This model modified AJCC stages I, II, and III for better prediction of patient survival. CONCLUSION: Growth patterns were incorporated to improve the 8th AJCC staging system for prognostication of iCCA patients in Northeast Thailand. We propose the KKU staging system as an alternative model for iCCA staging to augment the accuracy of survival prognostication.

Prognostic Significance of Growth Pattern in Predicting Outcome of Opisthorchis viverrini-Associated Distal Cholangiocarcinoma in Thailand.

Distal cholangiocarcinoma (dCCA) is a rare type of CCA in Asia, even in Opisthorchis viverrini-prevalent Northeastern Thailand. The clinical ambiguity and imprecision of diagnosis surrounding this malignancy result in high mortality due often to advanced/metastatic disease on presentation. We aim to identify a prognostic factor that can improve the performance stratification and influence the outcome of dCCA patients after curative resection. A total of 79 patients who underwent curative-intended surgery for dCCA was enrolled. Possible risk factors for survival were analyzed with log-rank test, and independent factors with Cox regression model. dCCA patients were staged and classified according to the 8th edition the American Joint Committee on Cancer (AJCC) Staging Manual. Results were then compared with the revised classification employing the prognostic factor identified from multivariate analysis. Multivariate analysis revealed that growth pattern (p < 0.01) and distant metastasis (p = 0.012) were independent factors. Growth patterns comprise intraductal (ID), periductal infiltrating (PI), mass-forming (MF), and mixed types. When dCCA patients were grouped into those having good and poor outcomes (with and without ID components, respectively). The survival outcomes significantly differed among patients with and without ID components, which was better than with the 8th AJCC staging system in our cohort. Furthermore, Chi-square test showed that patterns without ID components (PI, MF, PI + MF) correlated with lymph node and distant metastasis. Therefore, classification of dCCA patients after curative-intended surgical resection based on growth pattern provides additional beneficial information for the prediction of survival in dCCA patients.

Diffusion-weighted imaging as an imaging biomarker for assessing survival of patients with intrahepatic mass-forming cholangiocarcinoma.

BACKGROUND: Mass-forming cholangiocarcinoma is the most common form of intrahepatic cholangiocarcinoma and is associated with a worse prognosis. This study aimed to assess the role of diffusion-weighted imaging and other imaging features as prognostic markers to predict the survival of patients with intrahepatic mass-forming cholangiocarcinoma (IMCC). MATERIALS AND METHODS: The study included patients with pathologically proven IMCC from January 2011 to January 2018. Two radiologists retrospectively reviewed various imaging findings and manually estimated the area of diffusion restriction. Patients were grouped according to their restriction area into (group 1) restriction ≥ 1/3 of the tumor and (group 2) restriction < 1/3 of the tumor. Statistical analysis was performed to assess the relationship between various imaging features and patients' survival. RESULTS: Seventy-three patients were included in the study. IMCC patients with tumor size ≥ 5 cm had increased intrahepatic- and peritoneal metastases (p = 039 and p = 0.001 for reader 1 and p = 0.048 and p = 0.057 for reader 2). There was no significant relationship between the diffusion restriction area and tumor size, enhancement pattern, vascular involvement, lymph node metastasis, peritoneal- and distant metastasis. The number of deaths was significantly higher in patients with group 2 restriction (63.6% for group 1 vs. 96.6% for group 2; p = 0.001 for reader 1)(68.2% for group 1 vs. 89.7%% for group 2; p = 0.030 for reader 2). Patients with group 2 restriction had shorter 1- and 3-year survival rates and lower median survival time. Multivariable survival analysis showed two independent prognostic factors relating to poor survival outcomes: peritoneal metastasis (p = 0.04 for reader 1 and p = 0.041 for reader 2) and diffusion restriction < 1/3 (p = 0.011 for reader 1 and p = 0.042 for reader 2). Lymph node metastasis and intrahepatic metastasis were associated with shorter survival in the univariate analysis. However, these factors were non-significant in the multivariate analysis. CONCLUSION: Restriction diffusion of less than 1/3 and peritoneal metastasis were associated with shorter overall survival of IMCC patients. Other features that might correlate with the outcome are suspicious lymph nodes and multifocal lesions.

Accuracy of Nonenhanced CT vs Contrast-Enhanced CT for Diagnosis of Acute Appendicitis in Adults.

BACKGROUND: Acute appendicitis is one of the most common causes of acute abdominal pain requiring emergency intervention. It is often difficult for the clinician to make an accurate diagnosis due to nonspecific and overlapping clinical symptoms. Computed tomography (CT) has become the imaging modality of choice for the evaluation of suspected acute appendicitis. The main purpose of our study was to compare nonenhanced CT (NECT) with contrast-enhanced CT (CECT) for the diagnosis of acute appendicitis. MATERIAL AND METHODS: A total of 140 patients were enrolled in the study. Two abdominal radiologists-masked to both the clinical information and the final diagnosis-retrospectively reviewed the computed tomographic findings and made an imaging diagnosis based on (1) NECT only, (2) CECT only, and (3) both NECT and CECT. With the final diagnosis as the reference standard, the accuracy of each CT technique was estimated. RESULTS: The respective sensitivity, specificity, and accuracy for NECT, CECT, and NECT + CECT for the diagnosis of acute appendicitis were 80.7%, 86.7%, and 84.3%; 86.0%, 81.9%, and 83.6%; and, 87.7%, 80.7%, and 83.6%. There was no significant difference in the diagnosis of acute appendicitis among the 3 techniques. In order to make a correct diagnosis, the presence of at least 3 imaging findings for NECT or at least 4 for CECT had the best diagnostic accuracy. We also found that 9.25 mm was the optimal cut-off threshold for the detection of patients with acute appendicitis. CONCLUSION: Our study allowed direct comparison between NECT, CECT, and NECT + CECT combined. There was no difference in the ability of each CT technique for diagnosing patients with acute appendicitis. For a patient whom iodinated contrast media is contraindicated or a patient who has an increased risk of severe adverse reaction, we would encourage the use of NECT because it provides comparable diagnostic accuracy without further exposing such patient to the contrast media.

Imaging predictors of BRAF mutation in colorectal cancer.

BACKGROUND: Colorectal cancer (CRC) is one of the leading causes of cancer deaths and is associated with various genetic mutations. BRAF mutations, found in approximately 10% of all CRCs, are associated with negative predictive outcomes. The goal of this study was to assess the relationship between the imaging findings and BRAF statuses of CRC patients. MATERIALS AND METHODS: The study population was colorectal cancer patients who underwent biopsy or surgery in a single institution from September 2004 to October 2018, and in whom the pathologic specimens were tested for BRAF mutation. The exclusion criteria were (1) patients without pre-operative cross-sectional imaging, and (2) patients whose tumors were invisible on imaging. Two hundred and eighty-three patients met the inclusion criteria. Among them, 128 were excluded, and a total of 155 patients were enrolled in the study. RESULTS: BRAF mutations were significantly more common in female patients (p = 0.007). Patients with mutated BRAF were significantly older than those with wild-type BRAF (p = 0.001). BRAF-mutant tumors were predominant in right-sided colon (p = 0.001) with higher numbers of polypoid- or mass-like morphology (p = 0.019) and heterogeneous enhancement (p = 0.009). Compared to their wild-type counterparts, BRAF-mutated CRCs have a lower occurrence of non-peritoneal, and overall metastases (p = 0.013 and p = 0.004, respectively). Logistic regression analysis showed three significant factors for the prediction of BRAF mutations in CRC patients: right-sided location (p = 0.002), heterogeneous tumor enhancement (p = 0.039), and lack of non-peritoneal metastasis (p = 0.043). CONCLUSION: By recognizing the specific imaging features of BRAF-mutant CRCs, it would be possible to identify a patient who has a higher risk of carrying BRAF mutation.

Evaluation of the diagnostic performance of apparent diffusion coefficient (ADC) values on diffusion-weighted magnetic resonance imaging (DWI) in differentiating between benign and metastatic lymph nodes in cases of cholangiocarcinoma.

INTRODUCTION: Cholangiocarcinoma (CCA) is the primary tumor found in the bile duct and is associated with a high incidence of lymph node (LN) metastases and poor outcomes. The presence of metastatic lymph nodes, when shown by imaging, can influence patient treatment and prognosis. DWI is a promising, non-invasive imaging technique for differentiating between benign and malignant LNs. Many studies have shown that LN metastases have a lower apparent diffusion coefficient (ADC) value when compared to benign nodes. OBJECTIVE: To evaluate the performance of ADC values as a basis for diagnosis of LN metastasis in cholangiocarcinoma patients. MATERIALS AND METHODS: This was a retrospective imaging study that evaluated histopathologically proven intraabdominal LNs in cholangiocarcinoma patients who underwent a 1.5T abdomen MRI with DWI between January 2012 and July 2016. The ADC values and short-axis diameters of the LNs were measured and compared using student's t test. Receiver operating characteristic (ROC) curves were used to determine the threshold. RESULTS: A total of 120 lymph nodes-85 benign and 35 metastatic-were included. The mean short-axis diameter of the benign LNs (8.34 mm) was significantly lesser than that of the malignant LNs (9.56 mm). Receiver operating characteristic curve analysis using a size criterion of 1 cm yielded a value of 0.63. A diagnostic size criterion of 1 cm for the short axis was applied and yielded an accuracy of 66%, sensitivity/specificity of 41%/75%, and positive/negative predictive value of 34%/80%. The mean ADC values of metastatic (1.31 × 10-3 mm2/s) LNs were not significantly different from those of non-metastatic LNs (1.29 × 10-3 mm2/s). CONCLUSION: There was no difference in terms of ADC value between benign lymph nodes and those with metastatic cholangiocarcinoma. Isolated measurement of the ADC value does not contribute to a diagnosis of lymph node metastasis.

Difference in carotid intima-media thickness between pre and postmenopausal women.

OBJECTIVES: To examine whether carotid intima-media thickness (CIMT), the prevalence of increased CIMT, and the presence of carotid plaque differ according to menopausal status. METHODS: In this analytical cross-sectional study, we enrolled 61 premenopausal women and 61 postmenopausal women. We matched the two groups for age. Participants were classified as either premenopausal or postmenopausal according to menstrual history and follicular-stimulating hormone level. Two skilled radiologists measured CIMT and carotid plaque in all participants by using B-mode ultrasound. RESULTS: The mean age was 49.25 ±â€Š2.0 years. The mean number of years since menopause in the postmenopausal group was 1.9 ±â€Š0.92 years. After adjusted analysis, the mean CIMT of the common carotid artery of postmenopausal women was significantly higher than that of premenopausal women, with a mean difference of 0.068 mm (95% confidence interval 0.023, 0.113). There was no significant association between number of years since menopause and mean CIMT. Although the prevalence of increased CIMT and the presence of carotid plaque were significantly higher in the postmenopausal group than in the premenopausal group according to crude analysis, this difference was not statistically significant after adjusted analysis. Multiple linear regression analysis for assessing potential risk factors for the alteration of mean CIMT showed that only menopausal status and body mass index were independently associated factors. CONCLUSIONS: Our findings indicate that postmenopausal status is a significant factor of high mean CIMT. These findings add to the growing evidence showing that menopause transition is a critical period for subclinical atherosclerosis development.

Bone metastasis from cholangiocarcinoma mimicking osteosarcoma: A case report and review literature.

Cholangiocarcinoma is an aggressive tumor of the hepatic biliary system and it commonly spreads to the regional lymph nodes, liver and lungs. However, bone metastasis from cholangiocarcinoma is rare compared with other tumors. We herein present the case of a 61-year-old Asian woman who presented with pain in the right scapular area. Magnetic resonance imaging revealed bone destruction and an adjacent soft tissue mass at the right scapula. The findings on computed tomography imaging were compatible with cholangiocarcinoma. Bone biopsy was performed and the diagnosis of cholangiocarcinoma with bone metastasis was confirmed. The survival time was 10 months, despite administration of palliative radiotherapy and chemotherapy. Therefore, bone metastasis from cholangiocarcinoma should be considered as a differential diagnosis in patients who present with an osteolytic bone lesion and a liver mass.

Gastrointestinal stromal tumor: computed tomographic features.

OBJECTIVE: To describe anatomical distribution and CT findings of gastrointestinal stromal tumors in Srinagarind Hospital. MATERIAL AND METHOD: The abdominal CT images of 16 patients (12 men, 4 women: mean age 49 +/- 17SD) with pathologically proven GISTs during 1998-2005 were retrospectively reviewed. The tumor sites, sizes, borders, growth patterns, patterns of enhancement, and sign of malignancy were evaluated. The findings of benign and malignant GISTs were compared. RESULTS: Among sixteen patients, the most common location of GISTs was stomach (56.25%). The others were small bowel (43.75%), and tumor size larger than 5 cm. The present study found that the smooth and mixed smooth and irregular surface lesions are equal in number (50%). The growth was extraluminal in 56.25%. Almost all tumors had inhomogeneous density (n = 15). Intratumoral gas (43.75%), fluid (37.5%), and calcification (50.00%), were present in the tumors. All cases showed inhomogeneous contrast enhancement. The CT signs of malignancy found were invasion of the adjacent organ(s) (62.5%), lymphadenopathy (25%), liver metastasis/nodule (18.75%), ascites (6.25%), perilesional fat plane stranding (93.75%), and pleural effusion (6.25%). CONCLUSION: The most common site of GISTs is the stomach. The typical tumors appear as inhomogeneous enhancing inhomogeneous extraluminal mass with either well-defined or irregular border. The CT findings cannot be used as a single tool for differentiating the benign from malignant GISTs.