The value of magnetic resonance DWI in Bismuth-Corlette preoperative classification of hilar cholangiocarcinoma_CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY

Authors：

HUANG Yao ^1,2,3 , YIN Peiyuan ⁴ ,  YIN Longlin ^1,2,3,4,5 , LI Xiaoyan ^2,3,5 , SUN Ju ^2,3

1. School of Medicine, University of Electronic Science and Technology of China, Chengdu 610056, P. R. China;
2. Department of Radiology, Sichuan Academy of Medical Sciences & Sichuan Provincial People’s Hospital, Chengdu 610072, P. R. China;
3. Institute of Radiological Medicine, Sichuan Academy of Medical Sciences & Sichuan Provincial People’s Hospital, Chengdu 610072, P. R. China;
4. Clinic Medical College, Southwest Medical University, Luzhou, Sichuan 646099, P. R. China;
5. School of Medical Imaging, North Sichuan Medical College, Nanchong, Sichuan 637000, P. R. China;

Corresponding author：

YIN Longlin, Email: yinlonglin@163.com

Keywords：

hilar cholangiocarcinoma; diffusion-weighted imaging; dynamic contrast-enhanced magnetic resonance imaging; magnetic resonance cholangiopancreatography; Bismuth-Corlette classification; XXXXXXXXXX

DOI：

10.7507/1007-9424.202501062

Video：

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Objective To explore the value of magnetic resonance diffusion weighted imaging (DWI) in preoperative Bismuth-Corlette classification of hilar cholangiocarcinoma (HCCA). Methods A total of 53 HCCA patients confirmed by postoperative pathology were retrospectively included. The accuracy of two sequence combinations, namely dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) + magnetic resonance cholangiopancreatography (MRCP) and DCE-MRI + MRCP + DWI, in evaluating the longitudinally involved bile duct segments and Bismuth-Corlette classification of HCCA was compared. Additionally, the correlation between apparent diffusion coefficient (ADC) values and tumor Bismuth-Corlette classification as well as degree of differentiation was analyzed. Results There were 318 bile duct segments in 53 HCCA patients. The accuracy rate of DCE-MRI + MRCP was 93.7% (298/318), the sensitivity was 91.5% (161/176), and the specificity was 96.5% (137/142); The accuracy rate of DCE-MRI + MRCP + DWI was 96.5% (307/318), the sensitivity was 96.0% (169/176), and the specificity was 97.2% (138/142). The accuracy of DCE-MRI + MRCP + DWI was higher than that of DCE-MRI + MRCP, with a statistically significant difference (χ²=275.902, P<0.001). Receiver operating characteristic (ROC) curve analysis showed that the area under the ROC curve (AUC) of DCE-MRI + MRCP + DWI was 0.966 [95%CI (0.940, 0.983), P＜0.000 1], and its diagnostic efficacy was superior to that of DCE-MRI + MRCP [AUC=0.940, 95%CI (0.908, 0.963), P＜0.000 1]. The DeLong test indicated a statistically significant difference in AUC between the two sequences (Z=2.633, P=0.008 5). The accuracy rates of preoperative Bismuth-Corlette classification of HCCA evaluated by DCE-MRI + MRCP and DCE-MRI + MRCP + DWI were 86.8% (46/53) and 94.3% (50/53), respectively. After adding the DWI sequence, the consistency between Bismuth-Corlette classification results and surgical pathological classification results (Kappa=0.922, P<0.001) was higher than that of DCE-MRI + MRCP sequence (Kappa=0.820, P<0.001), with a statistically significant difference (χ²=160.370, P<0.001). In addition, the ADC value of HCCA was negatively correlated with tumordegree of differentiation (r_s=–0.524, P<0.001), but had no significant correlation with its Bismuth-Corlette classification (r_s=–0.058, P=0.682). Conclusions DCE-MRI + MRCP + DWI sequence can effectively improve the accuracy in preoperative evaluation of the involvement of bile duct segments and Bismuth-Corlette classification of HCCA, which provides guidance for precise preoperative surgical planning in clinical practice. In addition, the ADC value can provide additional information required for non-invasive preoperative prediction of the prognosis of HCCA patients.

1.	GBD 2017 Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet, 2018, 392(10159): 1789-1858.
2.	Miranda-Filho A, Piñeros M, Ferreccio C, et al. Gallbladder and extrahepatic bile duct cancers in the Americas: incidence and mortality patterns and trends. Int J Cancer, 2020, 147(4): 978-989.
3.	Fong ZV, Brownlee SA, Qadan M, et al. The clinical management of cholangiocarcinoma in the United States and Europe: a comprehensive and evidence-based comparison of guidelines. Ann Surg Oncol, 2021, 28(5): 2660-2674.
4.	Sallinen V, Sirén J, Mäkisalo H, et al. Differences in prognostic factors and recurrence patterns after curative-intent resection of perihilar and distal cholangiocarcinomas. Scand J Surg, 2020, 109(3): 219-227.
5.	van Keulen AM, Franssen S, van der Geest LG, et al. Nationwide treatment and outcomes of perihilar cholangiocarcinoma. Liver Int, 2021, 41(8): 1945-1953.
6.	Bismuth H, Nakache R, Diamond T. Management strategies in resection for hilar cholangiocarcinoma. Ann Surg, 1992, 215(1): 31-38.
7.	Xin Y, Liu Q, Zhang J, et al. Hilar cholangiocarcinoma: value of high-resolution enhanced magnetic resonance imaging for preoperative evaluation. J Cancer Res Ther, 2020, 16(7): 1634-1640.
8.	Lee DH. Current status and recent update of imaging evaluation for peri-hilar cholangiocarcinoma. Taehan Yongsang Uihakhoe Chi, 2021, 82(2): 298-314.
9.	Yoo J, Lee JM, Kang HJ, et al. Comparison between contrast-enhanced computed tomography and contrast-enhanced magnetic resonance imaging with magnetic resonance cholangiopancreatography for resectability assessment in extrahepatic cholangiocarcinoma. Korean J Radiol, 2023, 24(10): 983-995.
10.	Wang GX, Ge XD, Zhang D, et al. MRCP combined with CT promotes the differentiation of benign and malignant distal bile duct strictures. Front Oncol, 2021, 11: 683869. doi: 10.3389/fonc.2021.683869.
11.	郑婉静, 熊美连, 陈晓丹, 等. 钆贝葡胺多期增强MRI对肿块型胆管细胞癌和不典型肝脓肿的鉴别诊断. 中国医学影像学杂志, 2022, 30(5): 474-479+489.
12.	丁薇, 成友华, 李俊余, 等. MRCP联合DWI序列诊断肝门胆管癌的应用价值. 临床和实验医学杂志, 2022, 21(15): 1671-1674.
13.	姜继华, 姜仁鸦, 汪正飞, 等. 肝门部胆管癌患者经内镜下射频消融和金属支架植入治疗后胆道感染病原菌与影响因素. 中华医院感染学杂志, 2020, 30(18): 2794-2798.
14.	Liang CY, Chen MD, Zhao XX, et al. Multiple mathematical models of diffusion-weighted magnetic resonance imaging combined with prognostic factors for assessing the response to neoadjuvant chemotherapy and radiation therapy in locally advanced rectal cancer. Eur J Radiol, 2019, 110: 249-255.
15.	Park MJ, Kim YK, Lim S, et al. Hilar cholangiocarcinoma: value of adding DW imaging to gadoxetic acid-enhanced MR imaging with MR cholangiopancreatography for preoperative evaluation. Radiology, 2014, 270(3): 768-776.
16.	Dar FS, Abbas Z, Ahmed I, et al. National guidelines for the diagnosis and treatment of hilar cholangiocarcinoma. World J Gastroenterol, 2024, 30(9): 1018-1042.
17.	Drews J, Baar LC, Schmeisl T, et al. Biliary drainage in palliative and curative intent European patients with hilar cholangiocarcinoma and malignant hilar obstruction: a retrospective single center analysis. BMC Gastroenterol, 2024, 24(1): 359. doi: 10.1186/s12876-024-03429-y.
18.	He M, Song Y, Li H, et al. Histogram analysis comparison of monoexponential, advanced diffusion-weighted imaging, and dynamic contrast-enhanced MRI for differentiating borderline from malignant epithelial ovarian tumors. J Magn Reson Imaging, 2020, 52(1): 257-268.
19.	Inchingolo R, Maino C, Gatti M, et al. Gadoxetic acid magnetic-enhanced resonance imaging in the diagnosis of cholangiocarcinoma. World J Gastroenterol, 2020, 26(29): 4261-4271.
20.	Yamada S, Morine Y, Imura S, et al. Prognostic prediction of apparent diffusion coefficient obtained by diffusion-weighted MRI in mass-forming intrahepatic cholangiocarcinoma. J Hepatobiliary Pancreat Sci, 2020, 27(7): 388-395.
21.	Raspe J, Harder FN, Rupp S, et al. Retrospective motion artifact reduction by spatial scaling of liver diffusion-weighted images. Tomography, 2023, 9(5): 1839-1856.
22.	Perucho JAU, Chiu KWH, Wong EMF, et al. Diffusion-weighted magnetic resonance imaging of primary cervical cancer in the detection of sub-centimetre metastatic lymph nodes. Cancer Imaging, 2020, 20(1): 27. doi: 10.1186/s40644-020-00303-4.
23.	Sbaraglia M, Bellan E, Dei Tos AP. The 2020 WHO classification of soft tissue tumours: news and perspectives. Pathologica, 2021, 113(2): 70-84.
24.	吴鑫, 黄新荞, 舒健, 等. 扩散加权成像评估肝外胆管癌血管生成及分化程度. 磁共振成像, 2021, 12(5): 73-76.
25.	Lu J, Li B, Li FY, et al. Long-term outcome and prognostic factors of intrahepatic cholangiocarcinoma involving the hepatic hilus versus hilar cholangiocarcinoma after curative-intent resection: Should they be recognized as perihilar cholangiocarcinoma or differentiated?. Eur J Surg Oncol, 2019, 45(11): 2173-2179.
26.	Nagino M, Ebata T, Yokoyama Y, et al. Evolution of surgical treatment for perihilar cholangiocarcinoma: a single-center 34-year review of 574 consecutive resections. Ann Surg, 2013, 258(1): 129-140.
27.	Hu HJ, Jin YW, Shrestha A, et al. Predictive factors of early recurrence after R0 resection of hilar cholangiocarcinoma: A single institution experience in China. Cancer Med, 2019, 8(4): 1567-1575.
28.	Yoo J, Kim JH, Bae JS, et al. Prediction of prognosis and resectability using MR imaging, clinical, and histopathological findings in patients with perihilar cholangiocarcinoma. Abdom Radiol (NY), 2021, 46(9): 4159-4169.
29.	Calthorpe L, Rashidian N, Cacciaguerra AB, et al. Using the comprehensive complication index to rethink the ISGLS criteria for post-hepatectomy liver failure in an international cohort of major hepatectomies. Ann Surg, 2023, 277(3): e592-e596. doi: 10.1097/SLA.0000000000005338.
30.	Lv TR, Ma WJ, Liu F, et al. Is conventional functional liver remnant volume higher than 40% still sufficient to prevent post-hepatectomy liver failure in jaundiced patients with hilar cholangiocarcinoma? A single-center experience in China. Cancer Med, 2024, 13(13): e7342. doi: 10.1002/cam4.7342.
31.	沙新杰, 夏晓亮. 磁共振成像增强扫描联合弥散加权成像评估良恶性肝脏肿瘤价值分析. 实用肝脏病杂志, 2025, 28(3): 438-441.
32.	卢灿亮, 张超, 许业传, 等. Bismuth-Corlette Ⅲ、Ⅳ型肝门部胆管癌手术治疗方式的选择. 中华肝胆外科杂志, 2022, 28(8): 597-602.

1. GBD 2017 Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet, 2018, 392(10159): 1789-1858.
2. Miranda-Filho A, Piñeros M, Ferreccio C, et al. Gallbladder and extrahepatic bile duct cancers in the Americas: incidence and mortality patterns and trends. Int J Cancer, 2020, 147(4): 978-989.
3. Fong ZV, Brownlee SA, Qadan M, et al. The clinical management of cholangiocarcinoma in the United States and Europe: a comprehensive and evidence-based comparison of guidelines. Ann Surg Oncol, 2021, 28(5): 2660-2674.
4. Sallinen V, Sirén J, Mäkisalo H, et al. Differences in prognostic factors and recurrence patterns after curative-intent resection of perihilar and distal cholangiocarcinomas. Scand J Surg, 2020, 109(3): 219-227.
5. van Keulen AM, Franssen S, van der Geest LG, et al. Nationwide treatment and outcomes of perihilar cholangiocarcinoma. Liver Int, 2021, 41(8): 1945-1953.
6. Bismuth H, Nakache R, Diamond T. Management strategies in resection for hilar cholangiocarcinoma. Ann Surg, 1992, 215(1): 31-38.
7. Xin Y, Liu Q, Zhang J, et al. Hilar cholangiocarcinoma: value of high-resolution enhanced magnetic resonance imaging for preoperative evaluation. J Cancer Res Ther, 2020, 16(7): 1634-1640.
8. Lee DH. Current status and recent update of imaging evaluation for peri-hilar cholangiocarcinoma. Taehan Yongsang Uihakhoe Chi, 2021, 82(2): 298-314.
9. Yoo J, Lee JM, Kang HJ, et al. Comparison between contrast-enhanced computed tomography and contrast-enhanced magnetic resonance imaging with magnetic resonance cholangiopancreatography for resectability assessment in extrahepatic cholangiocarcinoma. Korean J Radiol, 2023, 24(10): 983-995.
10. Wang GX, Ge XD, Zhang D, et al. MRCP combined with CT promotes the differentiation of benign and malignant distal bile duct strictures. Front Oncol, 2021, 11: 683869. doi: 10.3389/fonc.2021.683869.
11. 郑婉静, 熊美连, 陈晓丹, 等. 钆贝葡胺多期增强MRI对肿块型胆管细胞癌和不典型肝脓肿的鉴别诊断. 中国医学影像学杂志, 2022, 30(5): 474-479+489.
12. 丁薇, 成友华, 李俊余, 等. MRCP联合DWI序列诊断肝门胆管癌的应用价值. 临床和实验医学杂志, 2022, 21(15): 1671-1674.
13. 姜继华, 姜仁鸦, 汪正飞, 等. 肝门部胆管癌患者经内镜下射频消融和金属支架植入治疗后胆道感染病原菌与影响因素. 中华医院感染学杂志, 2020, 30(18): 2794-2798.
14. Liang CY, Chen MD, Zhao XX, et al. Multiple mathematical models of diffusion-weighted magnetic resonance imaging combined with prognostic factors for assessing the response to neoadjuvant chemotherapy and radiation therapy in locally advanced rectal cancer. Eur J Radiol, 2019, 110: 249-255.
15. Park MJ, Kim YK, Lim S, et al. Hilar cholangiocarcinoma: value of adding DW imaging to gadoxetic acid-enhanced MR imaging with MR cholangiopancreatography for preoperative evaluation. Radiology, 2014, 270(3): 768-776.
16. Dar FS, Abbas Z, Ahmed I, et al. National guidelines for the diagnosis and treatment of hilar cholangiocarcinoma. World J Gastroenterol, 2024, 30(9): 1018-1042.
17. Drews J, Baar LC, Schmeisl T, et al. Biliary drainage in palliative and curative intent European patients with hilar cholangiocarcinoma and malignant hilar obstruction: a retrospective single center analysis. BMC Gastroenterol, 2024, 24(1): 359. doi: 10.1186/s12876-024-03429-y.
18. He M, Song Y, Li H, et al. Histogram analysis comparison of monoexponential, advanced diffusion-weighted imaging, and dynamic contrast-enhanced MRI for differentiating borderline from malignant epithelial ovarian tumors. J Magn Reson Imaging, 2020, 52(1): 257-268.
19. Inchingolo R, Maino C, Gatti M, et al. Gadoxetic acid magnetic-enhanced resonance imaging in the diagnosis of cholangiocarcinoma. World J Gastroenterol, 2020, 26(29): 4261-4271.
20. Yamada S, Morine Y, Imura S, et al. Prognostic prediction of apparent diffusion coefficient obtained by diffusion-weighted MRI in mass-forming intrahepatic cholangiocarcinoma. J Hepatobiliary Pancreat Sci, 2020, 27(7): 388-395.
21. Raspe J, Harder FN, Rupp S, et al. Retrospective motion artifact reduction by spatial scaling of liver diffusion-weighted images. Tomography, 2023, 9(5): 1839-1856.
22. Perucho JAU, Chiu KWH, Wong EMF, et al. Diffusion-weighted magnetic resonance imaging of primary cervical cancer in the detection of sub-centimetre metastatic lymph nodes. Cancer Imaging, 2020, 20(1): 27. doi: 10.1186/s40644-020-00303-4.
23. Sbaraglia M, Bellan E, Dei Tos AP. The 2020 WHO classification of soft tissue tumours: news and perspectives. Pathologica, 2021, 113(2): 70-84.
24. 吴鑫, 黄新荞, 舒健, 等. 扩散加权成像评估肝外胆管癌血管生成及分化程度. 磁共振成像, 2021, 12(5): 73-76.
25. Lu J, Li B, Li FY, et al. Long-term outcome and prognostic factors of intrahepatic cholangiocarcinoma involving the hepatic hilus versus hilar cholangiocarcinoma after curative-intent resection: Should they be recognized as perihilar cholangiocarcinoma or differentiated?. Eur J Surg Oncol, 2019, 45(11): 2173-2179.
26. Nagino M, Ebata T, Yokoyama Y, et al. Evolution of surgical treatment for perihilar cholangiocarcinoma: a single-center 34-year review of 574 consecutive resections. Ann Surg, 2013, 258(1): 129-140.
27. Hu HJ, Jin YW, Shrestha A, et al. Predictive factors of early recurrence after R0 resection of hilar cholangiocarcinoma: A single institution experience in China. Cancer Med, 2019, 8(4): 1567-1575.
28. Yoo J, Kim JH, Bae JS, et al. Prediction of prognosis and resectability using MR imaging, clinical, and histopathological findings in patients with perihilar cholangiocarcinoma. Abdom Radiol (NY), 2021, 46(9): 4159-4169.
29. Calthorpe L, Rashidian N, Cacciaguerra AB, et al. Using the comprehensive complication index to rethink the ISGLS criteria for post-hepatectomy liver failure in an international cohort of major hepatectomies. Ann Surg, 2023, 277(3): e592-e596. doi: 10.1097/SLA.0000000000005338.
30. Lv TR, Ma WJ, Liu F, et al. Is conventional functional liver remnant volume higher than 40% still sufficient to prevent post-hepatectomy liver failure in jaundiced patients with hilar cholangiocarcinoma? A single-center experience in China. Cancer Med, 2024, 13(13): e7342. doi: 10.1002/cam4.7342.
31. 沙新杰, 夏晓亮. 磁共振成像增强扫描联合弥散加权成像评估良恶性肝脏肿瘤价值分析. 实用肝脏病杂志, 2025, 28(3): 438-441.
32. 卢灿亮, 张超, 许业传, 等. Bismuth-Corlette Ⅲ、Ⅳ型肝门部胆管癌手术治疗方式的选择. 中华肝胆外科杂志, 2022, 28(8): 597-602.

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