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16 Digital Diagnosis andManagement ofCholangiocarcinoma
377
for other treatments (Zhu and Knox 2012). Intrahepatic
metastasis is the most common, and surgical treatment is still
feasible if the metastatic lesion is single, and the patient’s
general condition is acceptable. Re-resection can be successfully performed in 9%–30% of recurrent patients. According
to our experience, timely close postoperative monitoring of
patients’ status can detect early recurrence, at which time
resection is safe and effective, and patients’ recurrence and
retreatment have a better prognosis. With the development of
other ICC therapies such as chemotherapy, ablation, embolization, and radiation, patients can receive various adjuvant
therapies such as adjuvant chemotherapy and local therapies
such as radiofrequency ablation, Yttrium-90 microsphere
radiotherapy (Y90-SIRT), and transarterial chemoembolization (TACE); before surgery. The survival prognosis of
patients with recurrent ICC can be further improved (Kim
etal. 2011a, b; Ra etal. 2013).
16.2.4 Multidisciplinary Team
It is difcult to realize the optimal therapeutic effect on
patients by a single discipline or single therapy. With the
progress of the tumor treatment model and concept.
Increasing importance has been attached to providing a multidisciplinary team (MDT) as a cooperative medical model.
Different from the traditional medical model, the MDT
model is characterized by a patient-centered and multidisciplinary treatment mode. The best diagnosis and treatment
scheme can be formulated through cooperation to improve
the survival rate of patients. In surgical removal of ICC,
MDT should be used throughout treatment. For patients
without a negative resection margin, postoperative radiotherapy should be formulated to prolong the survival period
(Song etal. 2015; Jia etal. 2015). For example, in a group of
38 patients with tumors adjacent to blood vessels, the tumor
was dissected from the surface of the blood vessels, and the
surgical margin almost achieved R0 resection. The tumorfree survival rate (12.5months vs. 5.5 months; P= 0.081)
was improved by postoperative intensity-modulated radiotherapy (IMRT) and overall survival rate (21.8 months vs.
15months; P=0.049) (Jia etal. 2015). At present, the treatment plan after the operation is determined by combining
multidisciplinary discussion with pathological characteristics, local inltration degree, and pathological stage of the
tumor. Although the anti-recurrence effect of postoperative
TACE, radiotherapy, and chemotherapy are still being studied, it has been shown that the survival prognosis of the
patients with positive resection margin, lymph nodes, or
early recurrence maybe thus improved (Kim etal. 2011a, b;
Ra etal. 2013; Song etal. 2015; Jia et al. 2015; Li etal.
2015). However, the results still need to be further conrmed
by a large sample of prospective randomized controlled
studies.
16.2.5 Conclusion
In conclusion, ICC is the second most common malignancy
in the liver next to hepatocellular carcinoma, and the number
of ICC patients is increasing year by year. Several risk factors for ICC have been studied, including infection, environment, and metabolism. Surgical resection is the only
treatment method that can achieve ICC radical resection at
present. The application of digital technology can play a
guiding role in precision surgery, while other therapeutic
strategies, such as local and systemic therapy, can provide
more options for unresectable cases, as well as prevention
and treatment of recurrence.
16.3 Digital Diagnosis andSurgical
Management ofHilar
Cholangiocarcinoma
16.3.1 Clinical Diagnosis andManagement
ofHilar Cholangiocarcinoma
16.3.1.1 Anatomy andIncidence ofHilar
Cholangiocarcinoma
Hilar cholangiocarcinoma, accounting for about 50% of
cholangiocarcinoma, refers to a malignant tumor originating
from the common hepatic duct, the left and right hepatic
ducts, and the bile duct epithelium at its conuence
(Razumilava and Gores 2014). In 1965, Klatskin rst
reported the unique clinicopathological features of adenocarcinoma originating from the hilar bifurcation of the bile duct.
Therefore, this tumor is also known as Klatskin’s tumor
(Rizvi and Gores 2013). At present, radical resection is still
the only way for patients to achieve long-term survival.
However, radical resection of high cholangiocarcinoma
remains one of the most challenging operations in hepatobiliary surgery due to various factors, such as the specic
tumor location, the complex anatomical structure of the
hepatic hilum, the multipolar growth pattern of tumors, and
biological behavior of lymph node metastasis, etc.
From the content throughout the bible of surgery, Annals
of Surgery, it is found that major hepatobiliary surgery centers worldwide have never stopped exploring the diagnosis
and management of hilar cholangiocarcinoma, ranging from
the imaging assessment of biliary variability and resectability, the signicance and mode of biliary drainage, to the evo-
378
F. Shen et al.
lution of surgical modalities of combined parenchymal
hepatectomy, trisectionectomy and liver transplantation, and
then to adjuvant radiotherapy, chemotherapy, and reoperation after recurrence. Thanks to improved imaging technology, surgical instruments, evolving surgical strategies, and
in-depth mechanism research, the diagnosis, resectability,
postoperative recurrence monitoring, and overall survival
rate of hilar cholangiocarcinoma have achieved considerable
progress in the past two or three decades.
16.3.1.2 Clinical Features andDiagnosis
The specic etiology of cholangiocarcinoma remains
unclear. The denite high-risk factors include primary sclerosing cholangitis, choledochal cyst, biliopancreatic duct
conuence malformation, recurrent suppurative cholangitis,
hepatolithiasis, biliary inammation, and hepatic trematodiasis. Possible risk factors include hepatitis B or C virus
infection, HIV infection, environmental or occupational
toxin exposure, and diabetes. However, in the actual diagnosis and treatment process, most patients do not have clear
risk factors.
Painless and progressive jaundice is the characteristic
clinical manifestation of hilar cholangiocarcinoma. Other
non-specic manifestations include cholangitis, abdominal
pain, abdominal distension, and weight loss. A small number
of patients were admitted to the hospital due to spaceoccupying or abnormal intrahepatic bile duct expansion
found in physical examination. Early hilar cholangiocarcinoma patients often have no obvious clinical symptoms,
abdominal pain, jaundice, and weight loss are more often in
the middle and late stage.
A combination of serology and imaging is currently the
most commonly used method for the diagnosis with an accuracy of more than 90%. Tumor marker CA19-9 plays an
important role in the diagnosis and treatment and is often
used in preoperative diagnosis and postoperative monitoring
Studies have shown that CA19-9≥1000U/ml is associated
with poor prognosis (Chaiteerakij etal. 2014). Meanwhile,
serum IgG4 concentration was measured to exclude IgG4related bile duct lesions. However, serum IgG4 levels may
also increase in cholangiocarcinoma.
Careful assessment of cross-sectional images and endoscopic ultrasonography can help to describe the location,
size, morphology, invasion of hepatic artery and portal vein,
residual volume of liver, lymph node metastasis, and distant
metastasis. However, at present, the quantity of research is
minimal, and the quality of evidence is not high. Contrastenhanced CT and MRI are the most commonly used imaging
techniques for diagnosis and resectable assessment. For hilar
cholangiocarcinoma patients with obstructive jaundice,
imaging evaluation must be completed before biliary drainage, otherwise, it will affect the actual invasion of the tumor.
MDCT has fast scanning speed and high imaging quality; its
accuracy of diagnosing biliary tract invasion is 86%. The
sensitivity and specicity of detecting invasion of the portal
vein, hepatic artery, and lymph node metastasis are 89% and
92%, 83% and 93%, 61%, and 88%, respectively (Razumilava
and Gores 2014). It is difcult to detect tiny foci of omentum
metastasis. MRI combined with MRCP can more clearly
show the extent of biliary tract involvement, the course and
conuence of the intrahepatic bile duct, and the accuracy of
judgment of biliary tract invasion is up to 95%. However, the
accuracy of judging vascular invasion and hepatic parenchymal involvement is only 67% ~ 73% and 75% ~ 80%
(Blechacz etal. 2011). In contrast, PET-CT is more valuable
in detecting metastatic lesions. However, the sensitivity of
actual PET-CT to lymph node metastasis is only 13%–38%.
There is a possibility of false-positives caused by an inammatory reaction and false negatives caused by a highly proliferative reaction of connective tissue. The sensitivity and
specicity of PET-CT for diagnosis of primary lesions are
only 69% and 67%, which is of low value for the judgment
of local resectability. When liver transplantation is performed
for hilar cholangiocarcinoma, a biopsy of the tumor should
not be performed when the tumor is evaluated by endoscopic
ultrasonography because of the risk of needle implantation,
and its inhibition of the potential cure. In contrast, neneedle aspiration of lymph node tissue is an important
adjunct to the diagnosis of locally advanced hilar
cholangiocarcinoma.
ERCP is a valuable method for displaying the entire biliary tract and can be used as the rst step in treatment. An
understanding of bile duct anatomy by MRI/MRCP or CT
scan prior to ERCP will facilitate endoscopic surgery. A biliary brush should be used for cytological examination in the
presence of local biliary stricture with or without upstream
biliary dilation. Percutaneous transhepatic cholangiography
(PTC) helps to reach narrow channels that ERCP cannot pass
through. However, at present, PTC is mainly an important
measure of preoperative yellowing reduction, and it is not
used in the diagnosis of cholangiocarcinoma.
16.3.1.3 Pathology andStaging
Hilar cholangiocarcinoma is mostly bile duct adenocarcinoma, which is characterized by highly lymphotropic epithelial and neurotropic biological behavior, leading to early
lymphatic metastasis, vascular invasion, and nerve inltration. Hilar cholangiocarcinoma can be classied into three
types according to the gross morphology of the tumors: mass
type, invasive type, and papillary type. Among them, the
invasive type is the most common, and the rst two types are
often mixed. Papillary tumors are usually well-differentiated
with no lymph node metastasis and a better prognosis after
radical resection. In the early stage, the tumor mainly grows
along the bile duct wall but after breaking through the bile
duct wall the tumor tissue can invade the adjacent blood ves-
16 Digital Diagnosis andManagement ofCholangiocarcinoma
379
sels, nerves, and lymphatic tissue and spread along within
the adjacent liver tissue. At the same time, it can form jumping metastasis along the intrahepatic duct system. Because
the inltration range of the tumor often exceeds the boundaries of the gross tumor, it is difcult to accurately identify the
actual invasion range and the optimal surgical resection
range during the operation; which is one of the important
reasons for the low rate of radical resection, easy recurrence
and poor long-term prognosis of hilar cholangiocarcinoma.
Inltration types of cholangiocarcinoma mainly include
mucosal inltration and submucosal inltration. Papillary
and well-differentiated tumors tend to inltrate along with
the mucosal layer, and microscopic inltration generally
does not exceed the general boundary of the tumor by 20mm.
Nodular, inltrating and nodular-inltrating tumors tend to
inltrate the submucosal layer. Microscopic inltration generally does not exceed the general boundary of the tumor by
10mm (Ebata etal. 2002).
Currently, commonly used clinical classication and staging systems of hilar cholangiocarcinoma mainly include the
following 4 types: Bismuth-Corlette Anatomic classication
system; Memorial Sloan-Kettering Center (MSKCC) T staging system; American Joint Committee on Cancer (AJCC)
TNM staging system; and International Cholangiocarcinoma
Group Staging System.
Bismuth-Corlette classication is the most commonly
used clinical classication method at present. The classication is based on the anatomic location and extent of the tumor
involving the bile duct and divides the tumor into four different types: type I, tumors originating from the extrahepatic
bile ducts adjacent to the bile duct conuence do not invade
the left and right hepatic ducts; type II, tumors originating
from the extrahepatic bile ducts adjacent to the bile duct conuence spread to the left and right hepatic ducts; type III a,
tumors originating from the bile duct conuence spread to
the right hepatic duct to the second-grade bile duct. Type III
b, tumors originating from the conuence of bile ducts
spread to the left hepatic duct to the second bile duct: type iv,
tumors invading the bilateral hepatic duct reaching to the
second bile duct branch or more. Bismuth-Corlette classication is of great value in the selection of surgical methods.
However, it does not cover such factors as vascular inltration, hepatic parenchymal invasion, hepatic atrophy, and
lymph node metastasis, which have an impact on the resection and prognosis of cholangiocarcinoma. In the MSKCC T
staging system, the tumor was divided into three stages
according to the extent of tumor involvement in the bile duct,
portal venous invasion, and whether there was liver lobe
atrophy: stage T1, tumor invasion at the junction of the bile
duct unilateral spreads to the secondary bile duct; In stage
T2, the tumor invades the conuence of bile ducts and
spreads to the secondary bile ducts unilaterally, and the ipsilateral portal vein is invaded or there is ipsilateral liver lobe
atrophy. In stage T3, the tumor invades the conuence of the
bile duct and spreads to the secondary bile duct bilaterally;
unilateral spread to secondary bile duct with an invasion of
the lateral portal vein; unilateral spread to secondary bile
duct with contralateral hepatic lobar atrophy, or invasion of
the main portal vein or bilateral branches. The MSKCC T
staging system is superior to Bismuth-Corlette classication
in determining resectability or prognosis, but it fails to reect
factors such as hepatic artery invasion, lymph node metastasis, and distant metastasis. The TNM staging of AJCC is a
staging system based on pathological indicators, which is
mainly based on the degree of local tumor invasion, lymph
node metastasis, and the presence or absence of distant
metastasis. At present, the TNM staging system of hilar cholangiocarcinoma in the eighth edition has been used globally
since 2018. Many large-scale and multicenter clinical studies
have shown the important value of this staging system in predicting the prognosis of patients. However, it is almost
impossible to obtain the relevant information needed for
staging, especially the status of lymph node metastasis and
distant metastasis, so the staging system has limited clinical
value in guiding preoperative resectability assessment and
intraoperative decision-making. The International
Cholangiocarcinoma Group Staging System is a new staging
system proposed in 2011. The pathological factors, such as
location and shape of cholangiocarcinoma, the involvement
of portal vein and hepatic artery, reserved liver volume, liver
parenchyma lesion, lymph node, and distant metastasis, were
evaluated and described in this stage. Although the staging
system includes almost all the risk factors that may affect the
operation and prognosis of hilar cholangiocarcinoma, the
research on resectability of the staging system for hilar cholangiocarcinoma, practical utility of surgical selection, and
prognosis judgement have not been reported in a large quantity, and its complex, diversied content is limited in practical clinical application.
16.3.1.4 Advantages of3D Visualization
inEvaluating Hilar
Cholangiocarcinoma
Because the traditional imaging evaluation of the extent of
bile duct involvement takes bile duct opening as a reference
standard (Bismuth classication) and calculates the accuracy
when the tumor has a wider range of local invasion (Bismuth
IV type), the evaluation accuracy is of little practical signicance for surgical decision-making. The cholangiotomy
limit point refers to the limit point at which the proximal
intrahepatic bile duct can be resected and reconstructed during hepatectomy. If the pathological margin of the tumor
exceeds the limit point of the hepatic duct, the involved
hepatic duct cannot be removed and reconstructed completely alone. During the right hepatectomy, the separation
limit of the left biliary tract system was located at B2 and B3,
380
the left margin of the sagittal part of the portal vein (U point).
In the case of left hepatectomy, the separation limit points of
the right biliary system were B6 and B7, near the bifurcation
of the right anterior and right posterior branches of the portal
vein (P point). Lesions exceeding both the left side of the U
point and the right side of the P point are often considered
unresectable. In addition, there are also the following
shortcomings:
• Traditional imaging data are two-dimensional images,
incapable of 3D stereoscopic display.
• It is difcult to accurately display tumor, hepatic artery,
portal vein, hepatic vein, and their relationship by traditional imaging data, let alone a 3D stereoscopic display of
the anatomic spatial relationship between the tumor and
each duct.
• None of the traditional imaging data can show the organs,
tumors, and blood vessels according to the needs of diagnosis and preoperative evaluation, with different colors
and transparency. The relationship between the tumor and
different channels cannot be shown according to clinical
needs.
• Traditional imaging methods can only be read by imaging
professionals or hepatobiliary surgeons with rich clinical
experience.
• Traditional imaging methods do not have the functionality of simulating procedures before the operation. Because
of the biological characteristics of hilar cholangiocarcinoma disease, complex anatomical spatial relationship,
and inaccurate imaging evaluation, it is difcult to obtain
satisfactory clinical results.
F. Shen et al.
Fig. 16.12 The portal bile duct morphology and its relationship with
the portal vein were constructed using the EDDA IQQA-Liver 3D
reconstruction system
In recent years, the 3D visualization technology of digital
medicine has developed rapidly and achieved clinical transformation in multiple disciplines; it has opened up a new
way for accurate surgical diagnosis and treatment of hilar
cholangiocarcinoma.
3D reconstruction software contributes to tumor resect-
ability assessment and surgical resection, mainly by threedimensional display of tumor spatial location, observing the
course, conuence and variation of portal vein, hepatic
artery, bile duct, and hepatic vein, multi-angle observation of
the relationship of tumor involved hepatic segment to peripheral vasculature, measuring the length of each incision margin and calculating the residual liver volume (Figs.16.12,
16.13 and 16.14). Combined with the invasion boundary of
the tumor, the U point, and P point can be accurately positioned on the three-dimensional image, as an important anatomical marker for the determination of resectability and
surgical method (Fig.16.15).
Fig. 16.13 3D reconstructed image shows the relationship of the
tumor to the hepatic artery, portal vein, and hepatic vein
16.3.2 3D Modelling ofHilar
Cholangiocarcinoma
16.3.2.1 High-Quality Submillimeter CT Data
Acquisition ofIntrahepatic Ducts
To construct the model, Four-phase CT scanning (plain scan,
arterial phase, hepatic vein phase, portal vein phase), of a
living subject is performed. The image data of a living human
body thus captured, is processed in an MxView workstation.
In the MxView workstation of CT, the image data with a
thickness of 5mm is processed again, and the thickness of
the slice is reduced to 0.625mm. The processed images are
16 Digital Diagnosis andManagement ofCholangiocarcinoma
Fig. 16.14 After simulating left hemihepatectomy with 3D reconstruction software, the volume of right hemihepatectomy was automatically calculated
saved in the DICOM (Digital Imaging and Communications
in Medicine) format and transmitted to the terminal server
storage disk of 3D stereo images through the internal dedicated line network. The imaging terminal server is saved
before exporting to obtain the available thin-layer original
CT image data.
Procedures used to obtain CT data with good contrast are
very important in building a 3D visualization model. Highquality data of portal vein, hepatic vein, arterial phase, and
bile duct can be obtained by increasing the concentration of
CT contrast medium, the peak of contrast agent excretion
threshold, and training the respiratory movement of the
patients. Since the greatest characteristic of hilar cholangiocarcinoma is the early tumor invasion of the portal vein, the
data of the portal phase is most important in the CT data collection of hilar cholangiocarcinoma.
16.3.2.2 3D Model Construction ofHilar
Cholangiocarcinoma
3D Reconstruction oftheLiver andIntrahepatic
Ducts
3D Reconstruction ofHilar Tumors
• The rationale for selection of original CT data for recon-
struction: Arterial phase or venous phase should be
methodically selected for tumor reconstruction, accord-
ing to the enhancement degree of lesions and surrounding
tissues in CT enhanced scan. Enhanced scanning data
with a large difference in CT threshold between tumor
381
and surrounding tissue is selected as the source of 3D
reconstruction data.
• The specic reconstruction method is the same as the
liver reconstruction method.
• For the segmentation and reconstruction of tumor images
with unclear boundaries, it is necessary to conduct multiple methods of organ reconstruction step by step, and
nally complete the three-dimensional reconstruction of
the tumor through combined functions.
3D Reconstruction ofIntrahepatic Blood Vessels
• 3D of arteries: Volume rendering reconstruction based on
Computed Tomography Angiography (CTA) data has the
advantages of fast reconstruction speed and high quality.
In the process of reconstruction, due to the need to complete operations such as the removal of bone, It may not
be possible to reconstruct some of the arterial terminal
branches in the process of adjusting the threshold, this can
be supplemented by drawing and reconstruction of the
local vascular surface, and then the effect of 3D reconstruction of the artery system can be fully displayed in a
combined form.
• 3D reconstruction of the portal vein system: The quality
of CT data of the portal vein system is generally slightly
worse than that of CTA. If 3D reconstruction of the
arterial system is used, the difference of threshold between
the blood vessel and surrounding tissue is not obvious,
and the branch of the blood vessel is reduced during the
process of adjusting the threshold. The diameter of the
blood vessel becomes thinner, which leads to an error in
the 3D reconstruction of the blood vessel. The region
growing method of surface rendering is used to complete
the blood vessel segmentation The method of surface rendering is to use the region growing method to complete
the blood vessel segmentation, which can effectively
avoid the above problems. Thus, the portal vein system
can be effectively reconstructed.
Notes
• Intrahepatic bile duct of hilar cholangiocarcinoma is generally moderately to severely dilated and needs to be differentially segmented in CT image segmentation. CT
portal phase and the low threshold value (3–7) were
adopted to enhance the density contrast between the portal vein and the biliary tract in the Glission sheath.
• The boundary of hilar cholangiocarcinoma on CT is
unclear, and the density of the tumor is uneven. Different
threshold values should be used at the boundary and in the
center of the tumor image when segmenting, and it is nec-
382
ab
F. Shen et al.
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Fig. 16.15 (a) Michel’s type I: Normal hepatic artery. Note: 1. Splenic
artery; 2. Caudal pancreatic artery; 3. Greater pancreatic artery; 4.
Transverse pancreatic artery; 5. Left renal artery; 6. Superior mesenteric artery; 7. Right gastroepiploic artery; 8. Inferior anterior pancreaticoduodenal artery; 9. Posterior inferior pancreaticoduodenal artery; 10.
Anterior superior pancreaticoduodenal artery; 11. Superior posterior
pancreaticoduodenal artery; 12. Branch of the periapical pancreatic
artery; 13. Gastroduodenal artery; 14. Dorsal pancreatic artery; 15.
Proper hepatic artery; 16. Right hepatic artery; 17. Left hepatic artery;
18. Common hepatic artery; 19. Left accessory hepatic artery; 20.
Abdominal aorta. (b) Michel’s type II: Characterized by the replaced
left hepatic artery arising from the left gastric artery, and the proper
hepatic artery only gives off the right and middle hepatic arteries. The
superior mesenteric artery is normal. The left hepatic artery is easy to
be omitted in these patients without 3D reconstruction of the artery or
celiac trunk arteriography. The left accessory hepatic artery arises from
the left gastric artery. Note: 1. Abdominal aorta; 2. Splenic artery; 3.
The great pancreatic artery; 4. Transverse pancreatic artery; 5. Left
renal artery; 6. Dorsal pancreatic artery; 7. Inferior anterior pancreaticoduodenal artery; 8. Superior mesenteric artery; 9. Posterior inferior
pancreaticoduodenal artery; 10. Anterior superior pancreaticoduodenal
artery; 11. Superior posterior pancreaticoduodenal artery; 12.
Pancreatoduodenal artery; 13. Common hepatic artery; 14. Proper
hepatic artery; 15. Right hepatic artery; 16. Celiac trunk; 17. Left
hepatic artery; 18. Left gastric artery; 19. Left accessory hepatic artery.
(c) Michel’s type II: Characterized by the replaced left hepatic artery
arising from the left gastric artery, and the proper hepatic artery only
gives off the right and middle hepatic arteries. The superior mesenteric
artery is normal. The left hepatic artery is easy to be omitted in these
patients without 3D reconstruction of the artery or celiac trunk arteriography. The left accessory hepatic artery arises from the left gastric
artery. Michel’s type III: Characterized by the replaced right hepatic
artery arising from the superior mesenteric artery. It is difcult to nd
the right hepatic artery in these patients without 3D reconstruction or
19
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13
3
4
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5
11
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10
9
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superior mesenteric arteriography. Note: 1. Abdominal aorta; 2. Left
gastric artery; 3. Splenic artery; 4. Left renal artery; 5. Superior mesenteric artery; 6. Right hepatic artery; 7. Gastroduodenal artery; 8. Left
hepatic artery; 9. Common hepatic artery. (d) Michel’s type IV: This
type has both the characteristics of Michel’s types II and III, namely the
replaced left hepatic artery arising from the left gastric artery and the
replaced right hepatic artery arising from the superior mesenteric artery.
Note: 1. Abdominal aorta; 2. Left gastric artery; 3. Splenic artery; 4.
Left renal artery; 5. Superior mesenteric artery; 6. Common hepatic
artery; 7. Gastroduodenal artery; 8. Right hepatic artery; 9. Left hepatic
artery. (e) Michel’s type V: Characterized by the replaced left hepatic
artery arising from the and left gastric artery, and the proper hepatic
artery still has three branches: the right hepatic artery, the middle
hepatic artery, and the left hepatic artery. Note: 1. Abdominal aorta; 2.
Left gastric artery; 3. Splenic artery; 4. Celiac trunk; 5. Left renal
artery; 6. Superior mesenteric artery; 7. Right renal artery; 8. Common
hepatic artery; 9. Gastroduodenal artery; 10. Proper hepatic artery. (f)
Michel’s type IX: The common hepatic artery arises from the superior
mesenteric artery and passes through the pancreatic parenchyma to give
rise to the gastroduodenal artery. Note: 1. Left gastric artery; 2. Splenic
artery; 3. The great pancreatic artery; 4. Superior mesenteric artery; 5.
Common hepatic artery; 6. Gastroduodenal artery; 7. Proper hepatic
artery; 8. Dorsal pancreatic artery; 9. Right hepatic artery; 10. Left
hepatic artery; 11. Abdominal aorta. (g) Michel’s type X: The common
hepatic artery originates from the left gastric artery; the intrahepatic
artery and the pancreaticoduodenal artery have hepatopancreatic communication branches that cross the hepatic parenchyma. Note: 1. Left
gastric artery; 2. Splenic artery; 3. Transverse pancreatic artery; 4.
Dorsal pancreatic artery; 5. Superior mesenteric artery; 6. Left renal
artery; 7. Inferior anterior pancreaticoduodenal artery; 8. Posterior inferior pancreaticoduodenal artery; 9. Right renal artery; 10. Hepatic and
pancreatic communication branch; 11. Right hepatic artery; 12. Left
hepatic artery; 13. Common hepatic artery; 14. Abdominal aorta
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g
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16 Digital Diagnosis andManagement ofCholangiocarcinoma
383
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Fig. 16.15 (continued)
384
F. Shen et al.
essary to use different thresholds in the image segmentation of the hilar cholangiocarcinoma or use multiple
segmentation methods with similar density.
• It is difcult to distinguish whether portal vein, hepatic
vein, and inferior vena cava are involved in hilar cholangiocarcinoma on CT, but a clear conclusion can be drawn
after the reconstruction of medical imaging threedimensional visualization system (MI-3DVS) and the
multidirectional rotation observation.
3D Visualization ofIndividualized Vascular
Classication
Individualized Hepatic Artery Classication The 3D
visualized hepatic artery typing was established by referring
to the Michel’s hepatic artery typing method, and the typing
was divided into 10 types (Fig.16.15):
• Type I (normal type): The proper hepatic artery divides
into the left hepatic artery, middle hepatic artery, and right
hepatic artery.
• Type II: Replaced left hepatic artery; originated from the
left gastric artery.
• Type III: Substitution of the right hepatic artery; originated from the superior mesenteric artery.
• Type IV: Replaced right hepatic artery; originated from
superior mesenteric artery +substitution of left hepatic
artery and originated from the left gastric artery.
• Type V: The accessory left hepatic artery originates from
the left gastric artery.
• Type VI: The accessory right hepatic artery originates
from a superior mesenteric artery.
• Type VII: The right accessory hepatic artery originates
from the superior mesenteric artery; the left hepatic artery
originates from the left gastric artery.
• Type VII: Replaced RHA and accessory LHA or replaced
LHA and accessory RHA.
• Type IX: The common hepatic artery originates from the
superior mesenteric artery.
• Type X: The common hepatic artery originates from the
left gastric artery.
The 3D visualized hepatic artery classication of hilar
cholangiocarcinoma was established according to the
Michel’s hepatic artery classication method, which was
mainly classied into 10 types.
Individualized Portal Vein Classication
The 3D visual-
ized portal vein classication of hilar cholangiocarcinoma
was established according to the Cheng portal vein classication method, which was mainly classied into 7 types
(Fig.16.17):
• Type I: Main portal vein (MPV) is divided into the left
portal vein (LPV) and right portal vein (RPV) at the porta
hepatis. RPV moves to the right side and is divided into
the right anterior portal vein (RAPV) and right posterior
portal vein (RPPV).
• Type II: MPV is trifurcated at the hilum and is divided
into LPV, RAPV, and RPPV.
• Type III: MPV rst sends out RPPV, and then continues to
divide into LPV and RAPV.
• Type IV: MPV rst sends out RPPV; RAPV is from LPV,
or RAPV is near umbilical point.
• Type V: LPV absence.
• Type VI: RPV absence.
• Type VII: RPV is rst issued; LPV horizontal segment is
absent; MPV continues to issue RAPV upward; RAPV
laterally changes into the LPV to the left.
Endo et al. reported that the sensitivity, specicity, and
accuracy of 3D imaging in the assessment of portal vein
invasion were 100%, 80%, and 87%, respectively, and the
sensitivity, specicity, and accuracy in the assessment of
hepatic artery invasion were 75%, 91%, and 87%, respectively. 3D visualization technique can be used to accurately
judge the locational relationship between portal vein and
lesion before operation of hilar cholangiocarcinoma, to clarify whether it is invasion or compression, to know precisely
the variation of the portal vein, and to study the pre-resected
and reserved branches of portal vein carefully. The above are
the critical issues related to the success or failure of the operation (Fig.16.16).
Individualized Hepatic Vein Classication
The 3D visu-
alized hepatic vein classication was established according
to the Nakamura portal vein classication method, which is
mainly classied into 3 types (Fig.16.17):
• The left hepatic vein (LHV) and the middle hepatic vein
(MHV) converged into the inferior vena cava (IVC). That
is, LHV and MHV co-trunk and import into ICV; LHV
and MHV were respectively imported into IVC.
• The right hepatic vein (RHV) classication: It was
divided into three subtypes according to the different
combinations of the RHV, the middle right hepatic vein
(MRHV), and the inferior right hepatic vein (IRHV).
Type I: RHV was coarse. Drainage of most of the right
lobe of the liver with small or no IRHV; Type II: The
medium size of both RHV and IRHV, type III: Drainage
of only short and small RHV of section VII; MRHV and
IRHV were coarse.
• The venous classication of hepatic segment IV can be
classied into three subtypes: Mainly originated from
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16 Digital Diagnosis andManagement ofCholangiocarcinoma
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Fig. 16.16 3D visualization of portal vein variation. (a) Type I: The
MPV is divided into the LPV and RPV at the porta hepatis. RPV moves
to the right side and is divided into the RAPV and RPPV. (b) Type II:
MPV is trifurcated at the hilum and is divided into LPV, RAPV, and
LHV, the drainage of segment IV; Type II: Hepatic IV
segment vein and umbilical vein (known as umbilical
vein along the round ligament of the liver) and type III,
the occurrence of branch IV on MHV.
RPPV. (c) Type III: MPV rst sends out RPPV, and then continues to
divide into LPV and RAPV. (d) Type IV: MPV rst sends out RPPV;
RAPV is from LPV. LP left portal vein; RA right anterior portal vein;
RP right posterior portal vein
Individualized Bile Duct Classication Bile duct variation is common, especially right hepatic duct variation.
According to the course and variation of the left and right
bile ducts, the right hepatic duct was divided into 7 types,
and the left hepatic ducts were divided into 4 types. The
Therefore, the variation of hepatic veins is diverse, and
the obstruction of venous drainage after hepatectomy is an
MRCP model of the patients could be constructed clinically
to show the variation of the bile duct.
important inuencing factor of hepatic insufciency. It is
crucial to use 3D visualization technology to clearly identify
the situation of hepatic veins and accurately classify them. It
• Right (R) hepatic duct typing was mainly based on the
right posterior lobe bile duct inux (Fig.16.18).
is recommended to establish a 3D visualized hepatic vein
classication of hilar cholangiocarcinoma concerning the
Nakamura hepatic vein classication method, which is
mainly divided into three types.
Type A (RA): Common type, in which the right posterior
lobe bile duct enters the right anterior lobe bile duct above
the portal vein to form the right hepatic duct.
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F. Shen et al.
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Fig. 16.17 3D classication of hepatic vein. (a) Type I a: left, middle,
and right hepatic veins enter the inferior vena cava separately, and no
other hepatic venules are seen. Note: 1. Left hepatic vein; 2. Middle
hepatic vein; 3. Right hepatic vein. (b) Type Ib: The left, middle, and
right hepatic veins are discharged into the inferior vena cava separately,
and the accessory middle or left hepatic vein is found, without left posterior superior and right posterior superior vein. Note: 1. Left hepatic
vein; 2. Middle hepatic vein; 3. Right hepatic vein; 4. Accessory left
hepatic vein; 5. Accessory middle hepatic vein. (c) Type Ic: The left,
middle, and right hepatic veins enter the inferior vena cava separately
and the left posterior superior or right posterior superior vein is found,
without the accessory middle or left hepatic vein. Note: 1. Left hepatic
vein; 2. Middle hepatic vein; 3. Right hepatic vein; 4. Right posterior
superior vein; 5. Right posterior inferior vein. (d) Type Id: The left,
middle, and right hepatic veins enter the inferior vena cava separately;
the accessory middle or left hepatic vein and left or right posterior supe-
rior vein are found at the same time. Note: 1. Left hepatic vein; 2.
Middle hepatic vein; 3. Right hepatic vein; 4. Right posterior superior
vein; 5. Accessory middle hepatic vein; 6. Right posterior inferior vein.
(e) Type IIa: The left and middle hepatic veins ow into the inferior
vena cava, and no other liver venules are seen. Note: 1. Left hepatic
vein; 2. Middle hepatic vein; 3. Right hepatic vein. (f) Type IIb: The left
and middle hepatic veins ow into the inferior vena cava; and accessory
middle or left hepatic veins are seen, without left or right posterior
superior vein. Note: 1. Left hepatic vein; 2. Middle hepatic vein; 3.
Right hepatic vein; 4. Accessory middle hepatic vein. (g) Type IIc: The
left and middle hepatic veins ow into the inferior vena cava; left or
right posterior superior vein are seen, without accessory middle or left
hepatic veins. Note: 1. Left hepatic vein; 2. Middle hepatic vein; 3.
Right hepatic vein; 4. Left posterior superior vein. (h) Type III: The left
and middle hepatic veins ows into the inferior vena cava. Note: 1. Left
hepatic vein; 2. Middle hepatic vein; 3. Right hepatic vein