Biliary Tract Cancers

N Engl J Med 2000; 342:663-664March 2, 2000

Article

To the Editor:

In our opinion, the diagnostic and preoperative approaches described by de Groen et al. in their review of biliary tract cancers (Oct. 28 issue)1 are outdated. Patients with perihilar biliary tract tumors present with jaundice, and ultrasonography should be the initial imaging technique used. Ultrasonography can show intrahepatic biliary duct dilatation, with normal extrahepatic ducts, which is a useful indirect sign of perihilar cancer. However, ultrasonography rarely shows the tumor itself. Helical computed tomography (CT) should be performed to rule out liver and lymph-node metastases, as well as vascular encasement, but the proximal extent of the tumor along bile ducts is often underestimated. Therefore, magnetic resonance cholangiopancreatography should also be performed. This noninvasive technique can be used to visualize the biliary tract without the risk of inducing sepsis in patients with duc-tal obstruction.2 We disagree with the authors' statement, “Without doubt, cholangiography [both percutaneous cholangiography and endoscopic retrograde cholangiopancreatography] is currently the most important radiologic procedure for assessing the resectability of a tumor.” In our opinion, angiography and percutaneous cholangiography should be avoided, because they are invasive and can be replaced by helical CT and magnetic resonance cholangiopancreatography.

Juan Figueras, M.D.
Carles Valls, M.D.
Eduardo Jaurrieta, M.D.
Ciutat Sanitaria i Universitaria de Bellvitge, 08907 Barcelona, Spain

2 References

1
de Groen PC, Gores GJ, LaRusso NF, Gunderson LL, Nagorney DM. Biliary tract cancers. N Engl J Med 1999;341:1368-1378
Full Text | Web of Science | Medline

2
Barish MA, Yucel EK, Ferrucci JT. Magnetic resonance cholangiopancreatography. N Engl J Med 1999;341:258-264
Full Text | Web of Science | Medline

Author/Editor Response

Dr. de Groen replies:

To the Editor: Figueras et al. propose that patients with perihilar biliary tract tumors should be evaluated with the use of ultrasonography and helical CT scanning, followed by magnetic resonance cholangiopancreatography instead of endoscopic or percutaneous cholangiography. I agree that magnetic resonance cholangiography after ultrasonography and helical CT scanning is a useful alternative to invasive cholangiography, especially when performed by experienced radiologists with state-of-the-art equipment.1,2 However, in my opinion and in the opinion of others, the technique does not always provide the spatial resolution required for determining whether patients with complex perihilar tumors could benefit from an attempt at curative resection.3-5 In addition, imaging of perihilar tumors may be enhanced by distention of the biliary tree with contrast medium, which is possible only with invasive cholangiography. To decrease the risk of cholangitis and sepsis, all patients undergoing invasive cholangiography for suspected strictures should routinely receive antibiotics before and after the procedure.

Magnetic resonance cholangiography has other limitations as well: the equipment is not commonly available, the procedure cannot be performed in severely obese patients, magnetic resonance is contraindicated in the presence of magnetism-sensitive devices, respiratory motion may degrade the quality of the image, patients with claustrophobia may have difficulty undergoing the procedure, and it is not possible to obtain samples of suspicious lesions for pathological evaluation.2,3 Therefore, in my opinion, invasive cholangiography is currently the most important radiologic procedure for assessing the resectability of perihilar tumors, although I realize that other procedures, such as magnetic resonance cholangiography, may ultimately succeed invasive cholangiography.

I would like to point out an error in the legend for Figure 5: the curved arrow points to the common bile duct, not the common hepatic duct.

Piet C. de Groen, M.D.
Mayo Clinic, Rochester, MN 55905

5 References

1
Varghese JC, Farrell MA, Courtney G, Osborne H, Murray FE, Lee MJ. A prospective comparison of magnetic resonance cholangiopancreatography with endoscopic retrograde cholangiopancreatography in the evaluation of patients with suspected biliary tract disease. Clin Radiol 1999;54:513-520
CrossRef | Web of Science | Medline

2
Magnuson TH, Bender JS, Duncan MD, Ahrendt SA, Harmon JW, Regan F. Utility of magnetic resonance cholangiography in the evaluation of biliary obstruction. J Am Coll Surg 1999;189:63-71
CrossRef | Web of Science | Medline

3
Barish MA, Yucel EK, Ferrucci JT. Magnetic resonance cholangiopancreatography. N Engl J Med 1999;341:258-264
Full Text | Web of Science | Medline

4
Hatano S, Kondoh S, Akiyama T, Okita K. Evaluation of MRCP compared to ERCP in the diagnosis of biliary and pancreatic duct. Nippon Rinsho 1998;56:2874-2879
Medline

5
Mendler MH, Bouillet P, Sautereau D, et al. Value of MR cholangiography in the diagnosis of obstructive diseases of the biliary tree: a study of 58 cases. Am J Gastroenterol 1998;93:2482-2490
CrossRef | Web of Science | Medline

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