IMAGING OF BILIARY CARCINOMA, HELJÄ OIKARINEN FISTULA AND PRIMARY SCLEROSING CHOLANGITIS AND Department of Diagnostic Radiology, University of Oulu PERCUTANEOUS METALLIC STENTING IN MALIGNANT BILIARY OBSTRUCTION OULU 2001 HELJÄ OIKARINEN IMAGING OF BILIARY CARCINOMA, FISTULA AND PRIMARY SCLEROSING CHOLANGITIS AND PERCUTANEOUS METALLIC STENTING IN MALIGNANT BILIARY OBSTRUCTION Academic Dissertation to be presented with the assent of the Faculty of Medicine, University of Oulu, for public discussion in the Auditorium 7 of the University Hospital of Oulu, on March 23rd, 2001, at 12 noon. OULUN YLIOPISTO, OULU 2001 Copyright © 2001 University of Oulu, 2001 Manuscript received 27 February 2001 Manuscript accepted 6 March 2001 Communicated by Docent Matti Taavitsainen Docent Kari Haukipuro ISBN 951-42-5917-3 (URL: http://herkules.oulu.fi/isbn9514259173/) ALSO AVAILABLE IN PRINTED FORMAT ISBN 951-42-5916-5 ISSN 0355-3221 (URL: http://herkules.oulu.fi/issn03553221/) OULU UNIVERSITY PRESS OULU 2001 Oikarinen, Heljä, Imaging of biliary carcinoma, fistula and primary sclerosing cholangitis and percutaneous metallic stenting in malignant biliary obstruction Department of Diagnostic Radiology, University of Oulu, P.O.Box 5000, FIN-90014 University of Oulu, Finland 2001 Oulu, Finland (Manuscript received 27 February 2001) Abstract Biliary carcinoma, biliary fistula with occasional gallstone ileus and primary sclerosing cholangitis (PSC) are serious diseases and present specific diagnostic and therapeutic challenges. Stenting of biliary obstruction has also involved problems, but the reports are contradictory and partly limited. The aim of the present work was to evaluate and compare various imaging modalities in biliary diseases. The study also aimed to evaluate the usefulness of metallic stents in malignant biliary obstruction. The study population consisted of 210 patients with gallbladder carcinoma, bile duct carcinoma, biliary fistula, PSC or malignant biliary obstruction and eight control patients with various hepatobiliary diseases. The imaging findings of 80 patients with gallbladder carcinoma, 58 patients with bile duct carcinoma, and 16 patients with biliary fistula were reviewed. Nine patients with PSC underwent magnetic resonance cholangiography (MRC) and magnetic resonance imaging (MRI) of the liver, ultrasonography (US) of the liver and the bile ducts and endoscopic retrograde cholangiography (ERC). Eight control patients had had MRC and MRI of the liver and ERC. The medical records and radiographs of 39 patients with malignant biliary obstruction treated with percutaneously inserted metallic stents were also analysed. The stents included 48 Wallstents and seven Memotherm stents. In cases of gallbladder carcinoma, US visualised the primary tumour in 68 % and computed tomography (CT) in 57 % of the cases examined, but both methods were insufficient for accurate staging. In bile duct carcinoma, US revealed the primary tumour in 63 % and CT in 44 % of the cases examined. Both methods were sensitive in diagnosing peripheral intrahepatic cholangiocarcinoma, but inaccurate for more distal bile duct carcinoma or abdominal spread. The infiltrating type of gallbladder carcinoma and bile duct carcinoma were difficult to detect. US and CT were sensitive in revealing bile duct obstruction. The patients with biliary fistula and gallstone ileus had undergone various examinations with pathological, but not diagnostic results, and there was often a delay to diagnosis. Imaging did not reveal any of the ten spontaneous fistulas, but CT showed one of the five cases of gallstone ileus, and Gastrografin® meal revealed the single case of Bouveret's syndrome. Fistulography or cholangiography revealed all but one of the six iatrogenic fistulas. A nonvisualised or shrunken gallbladder at US should raise a suspicion of biliary enteric fistula in an appropriate clinical setting. MRC-MRI depicted the changes of PSC correctly in nine patients (radiologist 1) and in eight patients with one false positive finding (radiologist 2) in a blinded analysis. In the segmental comparison MRC missed especially bile duct dilatations. MRC was too pessimistic in the evaluation of the predictors of poor outcome. US detected features suggestive of PSC in eight patients (radiologist 3). US was unable to indicate the predictors of poor outcome. Of the patients with metallic stents in malignant biliary obstruction, 30 % had early and 66 % late complications, including stent obstructions, which occurred in 27 % of the patients at a mean of 4.4 months. The cause was mostly tumour ingrowth or overgrowth. The 25-week and 50-week patency rates were 71 % and 42 %. The patency rates of the patients with cholangiocarcinoma were significantly the lowest. There was also a tendency towards lower patency with less dilatation of the stents, an increasing number of the stents, longer strictures and hilar strictures. Many other complications were infectious. 31 % of the patients had late reinterventions. Keywords: primary sclerosing cholangitis, biliary carcinoma, biliary fistula, diagnostic im- aging, metal stents, cholestasis To Aarne, Raine and Iiro Acknowledgements The present work was carried out at the Department of Diagnostic Radiology, University of Oulu, Finland. I am deeply grateful to Professor Ilkka Suramo, my supervisor, for his kindness and constant support at all phases of this work. He has had an enthusiastic and optimistic attitude towards this research. He has given valuable advice and guidance, and he has always been available to answer my questions. All this and the fruitful conversations with him have been essential for the final completion of this thesis. I wish to express my sincere gratitude to Docent Osmo Tervonen, the present head of the Department of Diagnostic Radiology and my co-worker, for creating an encouraging atmosphere and optimal conditions for research. My warm thanks are also due to Eero Ilkko, MD, PhD, Chief Administrative Physician, who has kindly and patiently arranged time for my research. I am very grateful to Docent Markku Päivänsalo, who originally suggested the theme of this work to me. He has made me feel patient by his calm and confident personality. He has been a creative co-worker and always ready to give advice. I am also grateful to my co-worker, Docent Tapani Tikkakoski, who has been optimistic and encouraging. I wish to express my best thanks to my friend, Docent Eija Pääkkö for her kind support and expert co-operation and advice. My warm thanks go to Professor Juhani Lehtola, Professor Jyrki Mäkelä and Arto Saarela, MD, PhD, for their co-operation. They have introduced expert clinical aspects into the studies. This thesis would not have been possible without the sincere help given by several other co-workers. I wish to thank Docent Sami Leinonen, Docent Seppo Lähde, Jaakko Aukee, MD, Tiina Hetemaa, MD, Ari Karttunen, MD, PhD, and Keijo Puumala, MD. I extend my sincere thanks to Docent Kari Haukipuro and Docent Matti Taavitsainen for their expert and thorough evaluation of this thesis and for their valuable advice. My warm thanks go to Mrs. Kaisa Punakivi for her kind and helpful assistance in secretarial work and to Mrs. Sirkka-Liisa Leinonen for the careful revision of the English language of this work. I also wish to thank Risto Bloigu, MSc, for his assistance with the statistical analysis. I am very grateful to the staff of the library of the Medical Faculty and to the staff of the University Hospital Archives for all their kind assistance. I extend my special thanks to my parents, Anja and Eino Puhakainen, my sisters, Tuulikki, Kirsti and Kati, and my good old friends, Liisa Kylmänen and Elina Veijola, who have made me forget my research and brought me pleasure. My warm thanks also go to my colleague, Eeva-Liisa Leisti, MD, who has been a reliable friend during our joint efforts to complete our theses. My warmest thanks belong to my dear husband, Aarne, who has patiently encouraged me throughout this work – even at the most critical moments – and supported me to complete the thesis. Being a scientist himself, he has taught me critical thinking, toughness and optimism. Apart from this, he and our beloved sons, Raine and Iiro, have kept me in touch with everyday life and given me time for pleasure. Raine has also given expert advice about computers. I express my warmest thanks to my family. Finally, I must also thank our terrier, Wicke, for demanding me to take him regularly out for a walk, even when I was too concentrated on writing my thesis. This study was financially supported by grants from the Radiological Society of Finland, the Oulu University Scholarship Foundation (Helvi Hakulinen-Sipilä and Eino Sipilä Foundation) and the Pehr Oscar Klingendahl Foundation, which support is gratefully acknowledged. Oulu, March 2001 Heljä Oikarinen Abbreviations AIDS acquired immunodeficiency syndrome CE contrast-enhanced CEA carcinoembryonic antigen CT computed tomography 2 D / 3 D 2-dimensional / 3-dimensional ERC endoscopic retrograde cholangiography ERCP endoscopic retrograde cholangiopancreatography FFrench FNB fine-needle biopsy HIDA hepatoiminodiacetic acid MR magnetic resonance MRA magnetic resonance angiography MRC magnetic resonance cholangiography MRCP magnetic resonance cholangiopancreatography MRI magnetic resonance imaging pANCA perinuclear antineutrophil cytoplasm antibodies PSC primary sclerosing cholangitis PTC percutaneous transhepatic cholangiography PTCD percutaneous transhepatic cholangio drainage RARE rapid acquisition