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Cholangiocarcinoma imaging: from diagnosis to response assessment

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Cholangiocarcinoma (CCA), a highly aggressive primary liver cancer arising from the bile duct epithelium, represents a substantial proportion of hepatobiliary malignancies, posing formidable challenges in diagnosis and treatment. Notably, the global incidence of intrahepatic CCA has seen a rise, necessitating a critical examination of diagnostic and management strategies, especially due to presence of close imaging mimics such as hepatocellular carcinoma (HCC) and combined hepatocellular carcinoma–cholangiocarcinoma (cHCC–CCA). Hence, it is imperative to understand the role of various imaging modalities such as ultrasound, computed tomography (CT), and magnetic resonance imaging (MRI), elucidating their strengths, and limitations in diagnostic precision and staging accuracy. Beyond conventional approaches, there is emerging significance of functional imaging tools including positron emission tomography (PET)–CT and diffusion-weighted (DW)-MRI, providing pivotal insights into diagnosis, therapeutic assessment, and prognostic evaluation. This comprehensive review explores the risk factors, classification, clinical features, and role of imaging in the holistic spectrum of diagnosis, staging, management, and restaging for CCA, hence serving as a valuable resource for radiologists evaluating CCA.

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Courtesy: Susanne Loomis, BS, BFA, BS, MS, FBCA, Production Supervisor, Medical and Scientific Communications, Department of Radiology, Massachusetts General Hospital, Boston

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Apparent diffusion coefficient


American Joint Committee on Cancer


Common bile duct




Intrahepatic cholangiocarcinoma


Perihilar cholangiocarcinoma


Distal or extrahepatic cholangiocarcinoma


Carcinoembryonic antigen


Contrast-enhanced ultrasound


Computed tomography


Diffusion-weighted imaging


European Association for the Study of the Liver


External beam radiotherapy


Endoscopic retrograde cholangiopancreatography


Fat fraction




Future liver remnant


Gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid


Hepatocellular carcinoma


Iodine density


Liver imaging reporting and data system


Liver venous deprivation


Multidetector CT


Magnetic resonance angiography


Magnetic resonance cholangiopancreatography


Magnetic resonance imaging


Metabolic tumor volume


Normalized iodine uptake


Positron emission tomography


Primary liver cancer


Primary sclerosing cholangitis


Portal vein embolization


Response evaluation criteria in solid tumors


Stereotactic body radiation therapy


Standardized uptake values


99mTc-labeled galactosyl human serum albumin


Total lesion glycolysis

T1WI :

T1-weighted image

T2WI :

T2-weighted image

TUE images:

True unenhanced images


Union for International Cancer Control

VUE image:

Virtual unenhanced image


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Cao, J., Srinivas-Rao, S., Mroueh, N. et al. Cholangiocarcinoma imaging: from diagnosis to response assessment. Abdom Radiol 49, 1699–1715 (2024).

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