0:01

So this patient is a somebody in his 60s and

0:04

presents with the right upper quadrant pain, got

0:06

a non contrast CT scan to start with, couldn't

0:10

give intravenous contrast for some reason.

0:12

And there's a lot of information that we

0:14

can glean from this CT scan, even without

0:17

intravenous contrast, if we just window

0:19

things and just focus on the liver.

0:21

Start to see that there's a very old defined

0:24

mass in the inferior right hepatic lobe.

0:27

Let me window this even more.

0:30

I'm going to mag up on it, magnify on it.

0:32

You can see.

0:34

Right over here, there's

0:35

the borders of this mass.

0:36

It's relatively hypodensive

0:38

compared to the liver parenchyma.

0:39

And the other thing that you notice

0:41

is that look what it's doing to

0:44

the outer border of the liver.

0:46

You were to take your finger

0:47

and run it across here.

0:48

It looks pretty smooth,

0:49

pretty smooth, pretty smooth.

0:50

And right over here.

0:52

Your finger would go inwards, and it

0:54

would go upwards again, and then pretty

0:56

smooth and consistent all the way around.

0:58

So, it's sort of tugging

1:00

at the liver parenchyma.

1:01

There seems to be some focal capsular retraction

1:04

associated with whatever this abnormality is.

1:08

The patient subsequently got an MRI.

1:10

So we'll start off with this

1:12

coronal T2 weighted sequence.

1:14

It's not one of our conventional sequences.

1:16

This was done at an outside institution,

1:18

but nevertheless, it has T2 weighting.

1:20

And so I think it will be useful just

1:21

to kind of show you the appearance

1:23

of this lesion on T2 weighted images.

1:27

So we're going to scroll through it and you

1:28

can see right over here, this is that lesion.

1:31

Notice that it has this sort

1:33

of intermediate T2 signal.

1:34

It certainly doesn't look very hyper

1:36

intense like normal fluid would look.

1:38

It looks more hyper intense

1:39

than the liver parenchyma.

1:41

It sort of has this sort of intermediate signal

1:42

that oftentimes when I see that signal, I'm

1:44

concerned about an underlying malignancy.

1:47

And if you notice very carefully, you can

1:49

see that sort of capsule retracted right

1:51

over there associated with this lesion.

1:54

Let's look at it on the T1 pre

1:55

contrast image and the post contrast

1:57

image in the arterial phase.

1:59

You can see the lesion right over here, it's

2:00

hypo intense with respect to liver parenchyma.

2:03

You can see that capsular

2:04

retraction beautiful over here.

2:05

And when we give contrast, we notice that

2:08

the lesion enhances right over there.

2:11

It's interesting to see what this lesion does

2:13

on the remaining post contrast sequences.

2:16

This is just the arterial phase where

2:18

it has some enhancement, but what

2:19

does it do on the portal venous phase?

2:20

What does it do on the equilibrium phase?

2:23

Let's have a look.

2:24

So let's look at what this lesion does on

2:26

the arterial portal venous and equilibrium.

2:29

equilibrium phase images.

2:30

Let's get down to the lesion itself.

2:32

Here we have the arterial phase, portal

2:35

venous phase, and equilibrium phase.

2:36

And there's a little bit of motion, a

2:37

little bit of artifact, but certainly as

2:39

you go from the arterial phase to the portal

2:42

venous phase, if we just focus perhaps on

2:44

this posterior aspect of the lesion to the

2:46

equilibrium phase, we notice that the lesion

2:49

enhances most on the more delayed phase.

2:53

That's it's brighter inside of it on this image.46 00:01:34,850 --> 00:01:36,660 It certainly doesn't look very hyper

1:36

intense like normal fluid would look.

1:38

It looks more hyper intense

1:39

than the liver parenchyma.

1:41

It sort of has this sort of intermediate signal

1:42

that oftentimes when I see that signal, I'm

1:44

concerned about an underlying malignancy.

1:47

And if you notice very carefully, you can

1:49

see that sort of capsule retracted right

1:51

over there associated with this lesion.

1:54

Let's look at it on the T1 pre

1:55

contrast image and the post contrast

1:57

image in the arterial phase.

1:59

You can see the lesion right over here, it's

2:00

hypo intense with respect to liver parenchyma.

2:03

You can see that capsular

2:04

retraction beautiful over here.

2:05

And when we give contrast, we notice that

2:08

the lesion enhances right over there.

2:11

It's interesting to see what this lesion does

2:13

on the remaining post contrast sequences.

2:16

This is just the arterial phase where

2:18

it has some enhancement, but what

2:19

does it do on the portal venous phase?

2:20

What does it do on the equilibrium phase?

2:23

Let's have a look.

2:24

So let's look at what this lesion does on

2:26

the arterial portal venous and equilibrium.

2:29

equilibrium phase images.

2:30

Let's get down to the lesion itself.

2:32

Here we have the arterial phase, portal

2:35

venous phase, and equilibrium phase.

2:36

And there's a little bit of motion, a

2:37

little bit of artifact, but certainly as

2:39

you go from the arterial phase to the portal

2:42

venous phase, if we just focus perhaps on

2:44

this posterior aspect of the lesion to the

2:46

equilibrium phase, we notice that the lesion

2:49

enhances most on the more delayed phase.

2:53

That's it's brighter inside of it on this image.

2:56

than it is on this image,

2:58

than it is on this image.

3:01

So putting it together we have this lesion in

3:03

the liver causing capsular retraction that sort

3:06

of progressively enhances and appears brightest

3:09

on the inside on the more delayed phase images.

3:12

This finding is highly concerning for a

3:14

cholangiocarcinoma and specifically the

3:18

least common type of cholangiocarcinoma.

3:20

The most common is in the hilar.

3:22

followed by these distal cholangiocarcinomas.

3:24

At least common there's these intra hepatic

3:26

or peripherally located cholangiocarcinomas.

3:30

You know, the key imaging findings are

3:32

that when, particularly when they're

3:34

located out in the periphery, they cause

3:35

capsular retraction because of that

3:37

fibrotic reaction that they elicit.

3:40

And also because of that fibrotic

3:41

reaction, they tend to enhance

3:43

more on the delayed phase images.

3:45

And that's true for all

3:46

these cholangiocarcinomas, no

3:47

matter where they're located.

3:49

Nevertheless, you know, the imaging

3:51

appearance is suggestive of it,

3:52

but we can't be pathognomonic.

3:54

It's not one of these things where you

3:55

say this is a cholangiocarcinoma and the

3:57

referring providers can initiate treatment.

4:00

They do need a tissue diagnosis,

4:02

but it is important to let them know

4:04

that this is most likely a diagnosis

4:06

based on the imaging appearance.

4:07

And when they get the histology, they can

4:09

then confirm that indeed the histology

4:12

matches what the imaging findings are seeing.

4:14

So once again, this is an example of a

4:17

peripheral or intrapathic cholangiocarcinoma.