Malignant masquerade at the hilum of the liver

Abstract

Eight patients with biliary obstruction and a pre-operative diagnosis of a neoplastic lesion at the confluence of the hepatic ducts were found postoperatively to have benign disease. Cholangiography was highly suggestive of a malignant stricture in all patients. Angiography performed in six patients indicated that the lesions were potentially resectable. Seven patients underwent elective surgery; in six the ductal confluence including the lesion was removed, without mortality. Six patients are alive, five of them totally asymptomatic, in a median follow-up of 32 months. Many patients with hilar strictures are treated for what appears radiologically to be a neoplastic lesion. Since treatment often involves the placement of an endoprosthesis or palliative surgery, without histological diagnosis, some of these patients with benign disease are likely to be treated inappropriately, unless they are considered for a curative resection.

Cholangiocarcinoma of the extrahepatic bile ducts

“…Portal venous inflow and bile flow are important in the maintenance of liver cell size and mass [52]. Segmental or lobar atrophy may result from a portal venous occlusion or biliary obstruction.…”

“…Longstanding biliary obstruction may cause moderate atrophy, while concomitant portal venous compromise results in rapid and severe atrophy of the involved segments. Appreciation of gross atrophy on preoperative imaging is important since it often influences therapy [52]. We consider atrophy to be present if cross-sectional imaging demonstrates a small, often hypoperfused lobe (Figs.…”

“…Benign focal strictures (malignant masquerade) can occur at the hepatic duct confluence but are uncommon [52,54,68,69]. The finding of a smooth, tapered stricture upon cholangiography suggests a benign stricture.…”

Early bile duct cancer

“…MRC can facilitate overviews of longitudinal cancer spread by assessing bile ducts upstream and downstream of the tumor simultaneously and permits assessment of the vessels [38,39] . Radiographic findings alone may not distinguish reliably between malignant and benign lesions [40][41][42] . In addition, asymptomatic patients may be reluctant to undergo major operations without the certainty of a malignancy.…”

Biliary-Digestive Anastomosis to Very Peripheral Bile Ducts: Technique and Results

“…Prinicpal amongst these are cholan giocarcinoma, carcinoma of the gallbladder and primary or metastatic parenchymal liver disease (with or without associated lymph node involvement). Benign biliary stric tures may also mimic more sinister processes and must always be borne in mind when approaching obstruction at this site [1], With these difficult lesions the surgeon should always aim to curatively resect the affected area and decompress the remaining liver. However, this objective will be preoperatively assessed as impossible in a proportion of pa tients.…”