Correct answer to Q1 is: Well defined process with heterogeneous echogenicity and dilation of the peripheral bile duct.

Correct answer to Q2 is: CEUS (contrast enhanced ultrasound) to characterize the focal liver lesion previously seen.

Correct answer to Q3 is: Malignant tumor – most likely cholangiocarcinoma.

Correct answer to Q4 is: Core needle biopsy.

Discussion:

Core needle biopsy will be the next step to make the final diagnosis. Surgical resection is not performed without preoperative histological diagnosis. Fine needle biopsy cytology will rarely be sufficient for a final diagnosis. Chemotherapy can be initiated when the final diagnosis is known.

Image 4: Ultrasound – Subcostal transverse view showing biopsy needle in the lesion.

Additional Discussion

Needle biopsy showed adenocarcinoma (most likely from the bile ducts).

Conclusion

Early-stage cancers, that have not spread to other organs or tissues, can be surgically resected. However, only a small number of cholangiocarcinomas are resectable at the time of diagnosis. Hepatolithiasis is an established risk factor for cholangiocarcinoma ¹.
In our case, needle biopsy showed adenocarcinoma (most likely from the bile ducts). A PET/CT revealed a metastasis in the vertebral spine. Consequently, the patient was not eligible for surgical resection and was treated with palliative chemotherapy. Systemic chemotherapy is generally used to treat unresectable metastatic, or recurrent cholangiocarcinoma.
CEUS is a valuable tool in determining the nature of liver lesions ².

Conflicts of interest

“The authors declare no conflict of interest.”

References

1. Tyson GL, El-Serag HB. Risk Factors of Cholangiocarcinoma. Hepatology. 2011;54(1):173–184.
2. D’Onofrio M, Crosara S, De Robertis R, Canestrini S, Mucelli RP. Contrast- enhanced ultrasound of focal liver lesions. AJR Am J Roentgenol. 2015;205:W56–W66.