1988, The British Journal of Radiology, 61, 991-995 The ultrasonographic appearances of hilar cholangiocarcinoma (Klatskin tumours) By *E. Y. C. Yeung, BSc, MRCP(UK), FRCR, P. McCarthy, MRCPI, FRCR, tR. H. Gompertz, FRCS, tl. S. Benjamin, BSc, MD, FRCS, *R. N. Gibson, FRACR and P. Dawson, PhD, MRCP, FRCR Departments of Diagnostic Radiology and tSurgery, Royal Postgraduate Medical School, Hammersmith Hospital, Du Cane Road, London W12 OHS, and ^Department of Radiology, Royal Melbourne Hospital, Melbourne, Australia {Received July 1988) Abstract. The findings on ultrasound of 40 patients presenting between 1984 and 1987 who were subsequently proven patholog- ically to have hilar cholangiocarcinoma were reviewed. The sonograms of 17 other patients in whom pathological confirmation was not obtained but who were also presumed to have Klatskin tumours on clinical and radiological grounds, were also reviewed. All patients demonstrated intrahepatic bile duct dilatation with no evidence of free communication between the right and left hepatic ducts. A hilar mass was observed in 74% of the patients. Seventy-nine per cent of the hilar masses were of increased echogenicity relative to surrounding liver, 19% were of reduced echogenicity and 2% of mixed echogenicity. An intraluminal mass was seen in 21% of the patients and bile duct wall thickening was observed in 4%. The mass detection rate of different ultrasound equipment was also compared. In 15 patients the ability of ultrasound to predict the order of intrahepatic bile duct involvement was compared with cholangiography. Adenocarcinoma of the bile ducts arising at the liver hilum was described by Klatskin (1965). It is a rare tumour but has been well described in the surgical litera- ture (Skoog & Thoren, 1982; Voyles et al, 1983; Blumgart et al, 1984). There have been few reports exclusively reviewing the findings on ultrasound of Klatskin tumours (Meyer & Weinstein, 1983; Machan et al, 1986) and the numbers of patients studied are small, the largest series being 14 (Machan et al, 1986). Other authors (Dillon et al, 1981; Wheeler et al, 1981) have mentioned the ultrasound findings in proximal bile duct tumours, including hilar cholangiocarcinomas. Real-time ultrasound equipment has improved since those studies were performed and now allows better resolution of structures around the liver hilum. We therefore reviewed thefindingson ultra- sound of 40 patients with pathologically proven Klatskin tumours. Seventeen other patients in whom pathologi- cal confirmation was not obtained but who were pre- sumed to have Klatskin tumours on clinical and radiological grounds were included in the study. Subjects and methods During the period from December 1983 to October 1987, 64 patients were referred to the Hammersmith Hospital with suspected hilar cholangiocarcinoma. Patients who had afinaldiagnosis of hilar cholangiocar- cinoma and who also had an ultrasound examination were included in the study. Using these criteria the ultra- sound findings were reviewed in 57 patients. Forty of these patients had pathological confirmation of tumour by means of operative biopsy (20), fine-needle aspir- ation biopsy alone (18) and at post-mortem in two patients. In the remaining 17 patients, confirmation of malignancy was not obtained. (These patients had a *Author for correspondence. negative fine-needle aspiration biopsy and did not go to surgery.) All patients went on to have transhepatic percutaneous cholangiography with or without com- puted tomography and angiography. The patients ranged in age from 21 to 86 years (median 62.5 years). There were 41 males and 16 females. Duration of jaundice prior to presentation ranged from 2 to 26 weeks (median 7 weeks). All patients were scanned on real-time ultrasound scanners. Three patients were scanned on a Kretz Com- bison 100 Sector scanner, 11 on a Toshiba SAL 50A Linear Array, 37 on a Diasonics CV 400 Sector and six on an Acuson 128 scanner. Seventy-five per cent of the scans were performed by four experienced operators and the remainder by various other radiologists. Ultra- sound scans were performed as the first investigation and the operators were given no clinical history apart from that of obstructive jaundice. All the scans were reviewed together by two of the authors of this paper and since interpretation of scan images alone can be misleading, only the findings reported by the operators and confirmed on review of the images were recorded. The main features assessed were the presence, size, definition and echo pattern of a hilar mass, the presence of an intraluminal mass, duct wall thickening, and the presence of any other related findings. The order of Table I. Frequency of ultrasound features Confirmed Unconfirmed All pathologically pathologically (n = 57) (n = 40) (n = 17) Hilar mass Intraluminal mass Duct wall thickening 30 (75%) 8 (20%) 0 ( 0%) 12 (70%) 4 (24%) 2 (12%) 42 (74%) 12 (21%) 2 ( 4%) Vol. 61, No. 731 991
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