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Abdomen » Hepatobiliary
Klatskin tumor
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Author(s) :
Chaitali Shah, FRCR
 
Presentation A 61 year old man with prior history of pancreatitis presented for an ultrasound.
 
 
 
Caption: Sagittal view of the liver
Description: There is evidence of intrahepatic biliary dilatation. The visualized liver parenchyma appears normal.
 
 
 
Caption: Oblique view of the liver
Description: This image shows the extensive biliary dilatation again, left greater than right.
 
 
 
Caption: Oblique view of the liver
Description: The biliary dilatation is seen again in this image. A small hyperechoic focus is seen within the biliary tree most likely within the common hepatic duct.
 
 
 
Caption: Sagittal view of the liver
Description: The hyperechoic mass is noted again in this image.
 
 
 
Caption: Color Doppler image
Description: The mass is clearly noted to be within the biliary duct system. The mass itself shows no intrinsic vascularity.
 
Differential Diagnosis Klatskin’s tumor
 
Final Diagnosis Klatskin’s tumor
 
Discussion Cholangiocarcinoma is the term used to describe primary malignant tumors of the biliary epithelium.  A majority [95%] of these tumors are adenocarcinomas and may produce mucin. 

Cholangiocarcinoma can be classified in various ways. One of the ways is peripheral, hilar and extra-hepatic, according to their relation relative to the duct. Another classification groups biliary tract cancers as intrahepatic, perihilar and distal extrahepatic. Perihilar bile duct tumors can be further classified as type 1 through type 4, depending on the site of involvement of the ducts. Tumor involving the confluence of the right and left hepatic ducts is known as Klatskin tumor.
As described by Bloom, et al  these tumors may be nodular (i.e. small sclerosing tumors that obliterate the duct), infiltrating (i.e. tumors that spread along the wall of the duct), or papillary (i.e. rare intraductal variants). 

Imaging: Cross-sectional imaging [ultrasound, CT and MRI] can non-invasively demonstrate well the biliary anatomy. The features of Klatskin tumor seen on ultrasound :
1. Ductal dilatation: Intrahepatic biliary radicle dilatation with normal extrahepatic bile ducts is commonly seen. Segmental ductal dilatation with non-union of right and left hepatic ducts at the porta hepatis is another feature commonly seen.
2. Visualization of tumor: A large mass can be easily identified on ultrasound. If the mass is small, a careful search could reveal an intraluminal tumor mass within the ducts. Sometimes the tumor manifests as irregular mural wall thickening with abrupt termination of the duct.
3. Atrophy of lobe: This is better demonstrated on CT. However, it can be appreciated on ultrasound as well and shows crowding of the ducts in the atrophied lobe.
4. Presence of hepatic metastases and metastastic adenopathy.
5. Evidence of vascular invasion.

Ultrasound thus has a role in the initial detection of these tumors, helps to stage the disease and also plays a role in the post-treatment follow-up.
 
Case References 1. Meyer D, Weinstein B. Klatskin tumors of the bile ducts: sonographic appearance. Radiology. 1983: Vol 148, 803-804.
2. Bloom C, Langer B, Wilson S. Role of US in the Detection, Characterization, and Staging of Cholangiocarcinoma. Radiographics. 1999; 19:1199-1218.
3. Groen P, Gores G, LaRusso N, et al. Biliary tract cancers. NEJM 1999; 341: 1365-1375.
4. Soyer P, Bluemke D, Reichle R, et al. Imaging of intrahepatic cholangiocarcinoma: 2. Hilar cholangiocarcinoma. AJR 1995; 165: 1433-1436.
5. Parulekar S. Gallbladder and bile ducts. In: McGahan JP, Goldberg BB, eds. Diagnostic ultrasound: a logical approach. Philadelphia, Pa: Lippincott-Raven, 1997; 693-755.
 
Follow Up An MRI and ERCP were performed which confirmed the ultrasound  findings, both demonstrating  a mass involving the confluence of the right and left hepatic ducts and extending into the common hepatic duct. A poorly differentiated adenocarcinoma [cholangiocarcinoma] was seen on histopathology. The patient was operated upon, underwent brachytherapy and stent placement and is currently doing well. 
 
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