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Intrahepatic Cholangiocarcinoma

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Intrahepatic Cholangiocarcinoma 54) BY Prof Dr. Ahmed Al_Gebaly Case 1 54 Male Admitted with distended abdomen and vomiting. Case 2 Patient Data Male 47 years complaining Difficulty in swallowing liquids. Case 3 C/O: Recurrent chest infection Case 4 Axial contrast enhanced CT image of child with jaundice. Case 5 73 year old male with Jaundice Case 1 54 Male Admitted with distended abdomen and vomiting. Grossly distended stomach, containing a large volume of debris. Thickening and enhancement of the anturm/pylorus of the stomach, suggesting of a tumour Stenosing tumour, which caused the gastric outlet obstruction. Biopsy - proven adenocarcinoma. Gastric outlet obstruction is a syndrome resulting from mechanical obstruction of stomach emptying. an be due to malignant or benign causes. Malignant adenocarcinoma (second most common) GIST lymphoma (less commonly than other malignancies as it is a "soft" tumour) metastases Benign duodenal or gastric peptic ulcers (most common) pancreatic pseudocysts gastric varices granulomatous disease, e.g. Crohn disease, sarcoidosis, tuberculosis gallstones (Bouveret's syndrome): rare strictures, e.g. from caustic substance ingestion Gastric adenocarcinoma, commonly referred to as gastric cancer, refers to a primary malignancy arising from the gastric epithelium. It is the most common gastric malignancy (over 95% of malignant tumours of the stomach). Gastric cancer is rare before the age of 40 It often produces no specific symptoms such as dyspepsia. Patients may present with anorexia and weight loss (95%) as well as abdominal pain that is vague and insidious in nature. Nausea and vomiting, may occur (with bulky tumours that obstruct the gastrointestinal lumen or infiltrative lesions that impair stomach distension); late signs. CT is currently the staging modality of choice because it can help identify the primary tumour, assess for the local spread, and detect nodal involvement and distant metastases . Demonstration of lesions facilitated by negative contrast agents (water or gas): a polypoid mass with or without ulceration focal wall thickening with mucosal irregularity or focal infiltration of the wall ulceration: gas-filled ulcer crater within the mass infiltrating carcinoma: wall thickening and loss of normal rugal fold pattern 4 Calcifications are rare but when present, they are usually mucinous adenocarcinoma. There are several nodal metastases with eponymous names associated with gastric cancer has been described: sister Mary Joseph’s node Virchow’s node Krukenberg’s node Sister Mary Joseph (born Julia Dempsey, 1856-1939) was the surgical assistant to William Mayo in the early days of the Mayo ClinicA Sister Mary Joseph nodule is a metastatic lesion involving the umbilicus. The most common primary source is an intra-abdominal adenocarcinoma (include the stomach, ovary, colon and pancreas). solid subcutaneous or dermal nodule or focal umbilical thickening, generally in the context of widespread malignancy. For a lesion involving the umbilicus consider paraumbilical hernia surgical scar (e.g. laparoscopy) endometriosis granuloma primary umbilical tumour Metastasis to the umbilicus, known as a Sister Mary Joseph nodule, in a patient with metastatic ovarian cancer T of the abdomen and pelvis obtained with oral and intravenous contrast demonstrates a focal thickening of the sigmoid colon with stenosis of the lumen but no evidence of an established obstruction. No clear fat plane between the mass and the rectus muscle is identified although there is no convincing evidence of direct extension. A number of enlarged local lymph nodes are seen in the adjacent mesentery. No convincingly enlarged retroperitoneal nodes are noted, however an umbilical nodule is present. The liver contains a number of low attenuation ill-defined lesion, the largest in segment 5. Simple left renal cyst noted. Lungs and mediastinum appear unremarkable (although lung windows should of course be reviewed for small deposits). This case unfortunately demonstrates advanced colorectal carcinoma (pathologically proven well differentiated adenocarcinoma) in a young patient. It should act as a reminder that although typical age-range is a great way of limiting a differential diagnosis, most pathologies are sometimes encountered well outside the expected age groups and as such age alone is not enough to discount a diagnosis. Double-contrast barium enema demonstrates a focal narrowing in the sigmoid colon. It has rolled, heaped up shoulders and results in a severe stenosis. Features are typical of the so-called apple-core stenosis. The remainder of the imaged colon appears normal in calibre, and lined by normal mucosa. Troisier sign Troisier sign is the clinical finding of a hard and enlarged left supraclavicular node (Virchow node), and is considered a sign of metastatic abdominal malignancy. It is sometimes referred to as Virchow node, which is the name given by Dr Rudolf Virchow (1821-1902), a German pathologist, The left supraclavicular lymph node drains via the thoracic duct, the abdomen, and thorax. It is the junction where incoming lymph is introduced back in the venous circulation through the left subclavian vein. Hence, any malignancy arising in these territories can be responsible for Troisier sign. Krukenberg tumour, also known as carcinoma mucocellulare, refers to the "signet ring" subtype of metastatic tumour to the ovary. The colon and stomach are the most common primary tumours to result in ovarian metastases, followed by the breast, lung, and contralateral ovary. The tumours represent 5-10% of all ovarian tumours and up to 50% of all metastatic tumours to the ovary. Krukenberg tumours are metastatic tumours to the ovary that contain well defined histological characteristics - mucin-secreting “signet ring” cells and usually originate in the gastrointestinal tract 1 They can originate from : stomach cancer (signet-ring cells): most common colorectal carcinoma: second most common breast cancer lung cancer contralateral ovarian carcinoma pancreatic carcinoma cholangiocarcionoma/gallbladder carcinoma Most imaging features are non-specific, consisting of predominantly solid components or a mixture of cystic and solid areas. It is often difficult to differentiate from other ovarian neoplasms 4-5. There are a variety of metastatic carcinomas to the ovary that can mimic primary ovarian tumour These tumour are typically seen sonographically as bilateral, solid ovarian masses, with clear well defined margins. CT appearances can be indistinguishable from primary ovarian carcinoma 2. Features will favour towards a Krukenberg tumour if a concurrent gastric or colic mural lesion is seen. MR: The great majority of Krukenberg tumours are signet-ring cell carcinomas arising in the stomach. Signet- ring cells scatter in the ovarian stroma with abundant collagen formation or marked oedema. Therefore, Krukenberg tumours can occasionally show low or high signal intensity on T2-weighted images. internal hyperintensity (mucin) on T1 and T2 weighted MR images. Strong contrast enhancement is usually seen in the solid component or the wall of the intratumoural cys Follow-up CT in known peritoneal carcinosis from resected colon cancer. Solid mass of the left ovary. Coronal T2 Axial T1 Axial T2 Both ovaries are replaced by lobulated, well defined, heterogeneously high T2, enhancing lesions. Moderate volume ascites see in the pelvis. pathologically proven Krukenberg tumour of gastric origin. Axial T1, contrast fat sat Sag T2 Irregular stenosis with rigidity of the greater curvature of the stomach at prepyloric gastric antrum 66 years-old man who presented with general decline in health & epigastric heaviness an intra-luminal hypodense and heteregeneous mass. Also, there is a triangular hypodensity involving the upper pole of the spleen. (splenic artery thrombosis secondary to this infiltration) Case 2 Patient Data Male 47 years complaining Difficulty in swallowing liquids. Mediastinal widening. Trace amount of gastric air bubble seen. No air-fluid level in the mediastinal widening can be appreciated. Dysphagia and recurrent chest infection. Male, 40 years Chest x-ray is largely unremarkabl e. Minor patchy opacities in the left base are noted. A small gastric air bubble is visible. Upper GI study reveals uniform dilatation of the esophagus to the level of the gastroesophageal junction, where fixed narrowing is noted (bird peak sign or rat-tail sign) Case 3 C/O: Recurrent chest infection Note oesophageal dilatation CT scan of the abdomen showed uniform dilatation of esophagus with air-fluid level. Pulmonary infiltrates in the upper segment of the right lower lobe likely due to aspiration Achalasia (primary achalasia) refers to a failure of organised oesophageal peristalsis with an impaired relaxation of the lower oesophageal sphincter (LOS), resulting in often marked dilatation of the oesophagus and food stasis. Obstruction of the distal oesophagus (often due to tumour) has been termed "secondary achalasia" or "pseudoachalasia". Primary achalasia is most frequently seen in middle and late adulthood (30-70 years of age) with no gender predilection 6. In most cases achalasia is idiopathic; however, an identical appearance is seen in patients with Chagas disease. Authors differ as to whether they reserve the term achalasia for idiopathic cases, or whether they include Chagas disease. Typically patients present with dysphagia (which is for both solids and liquids, in comparison to
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