Endoscopic Staging of Hilar Cholangiocarcinoma

Yoo, Byung Moo

Abstract

The prognosis of hilar cholangiocarcinoma is very poor due to its location and complicated anatomical characteristics. The bile duct cancer arising in the hilum easily invades the vascular structures and spreads along the bile duct. Complete curation could only be expected when curative resection of the hilar cholangiocarcinoma had been achieved. For the operability to be decided, the evaluation of longitudinal and vertical tumor extensions are important. Preoperative endoscopic staging work-up could be performed using endoscopic retrograde cholangiography (ERC), choledochoscopy, endoscopic ultrasonography (EUS) and intraductal ultrasonography (IDUS). ERC and choledochoscopic examinations have an advantage that these could take biopsy specimens. However ERC is not superior to either magnetic resonance cholangiography or percutaneous transhepatic cholangiography to make a better evaluation of the extent of the disease. Major problem of ERC is procedure-induced cholangitis, especially in Bismuth-Corlette type III and IV hilar cholangiocarcinoma. Percutaneous transhepatic choledochoscopic examination has an advantage that the stricture site could be examined directly with the availability of biopsy specimens. The diagnostic accuracy rates are different according to the morphological types of cholangiocarcinoma. EUS or IDUS could provide an information about the nodal involvement, the relationship with portal vein and the vertical extension of bile duct cancer. However, further study about the usefulness of EUS or IDUS would be needed in hilar cholangiocarcinoma. Above mentioned endoscopic examinations could be of help to decide the proximal margin of hilar cholangiocarcinoma. Each examination has its own limitations and advantages. Therefore appropriate combination of diagnostic modalities could be helpful to decide the best treatment option.