Investigation of the accuracy of magnetic resonance cholangiography and multi-slice spiral computed tomography in the diagnosis of cholangiocarcinoma

Introduction

Cholangiocarcinoma (CCA) is a common malignant biliary tract tumor in clinical practice, and is characterized by a high degree of malignancy, unknown etiology, insidious onset, difficult treatment, and poor prognosis (1). The incidence of CCA is higher in males than females (1). Early diagnosis and therapy are essential in reducing the mortality of patients and improving the foreknowledge of observers with CCA (2). Surgical pathological diagnosis is the benchmark for the clinical diagnosis of CCA; however, it has a number of shortcomings (e.g., it carries a high risk, the operation is complex, it causes significant trauma, has high costs, and no repeated examination), which are not easily accepted by patients and their families (3). In recent years, magnetic resonance cholangiopancreatography (MRCP) has become a popular examination technique, as it clearly shows the hilar obstruction, accurately evaluates the shape of the broken end, the site of the obstruction, and the extent of obstruction, and thus enables the qualitative diagnosis of lesions (4,5). Maurea et al. (6) confirmed the diagnostic potential of MRCP in the study of the pancreatic-bile duct system. In particular, MRCP has been compared with ultrasound and multi-slice spiral computed tomography (MSCT) (6). In the study of D’Antuono et al. (7) they found that magnetic resonance imaging (MRI) with MRCP represents a valid alternative to multidetector computed tomography (MDCT) for the diagnostic evaluation of patients with CCA to establish tumor respectability providing multiplanar scanning of high-contrast imaging quality; MDCT should be preferred in uncooperative patients, in the presence of biliary stents or when MRI is absolutely contraindicated for incompatible medical devices. In addition, the MSCT comprises 2 scans (i.e., a plain scan and an enhanced scan), and has a large scanning range, provides a multi-phase enhanced scan, enables rapid examinations, and can be used to perform thin layer reconstruction (8,9). However, for lesions <10 mm in diameter, the detection rate of MSCT is low, and it is prone to misdiagnosis and missed diagnosis (10,11). In addition, the MSCT is not suitable for patients who are allergic to iodine contrast media. Conversely, the MRCP is non-traumatic, does not require the injection of contrast media, and has a fast-scanning speed and a simple operation method (12,13). The MRCP has a good development rate and a good ability to identify the human pancreas and biliary tract. The natural fluid of the patient’s pancreaticobile duct is used as a contrast agent in the examination process. Through special scanning and omnidirectional and multi-angle 3D image reconstruction, the structure, shape, scope of the obstruction site and the degree of bile duct dilation can be clearly displayed, which will not be affected by factors, such as the uneven distribution of contrast agents (14,15). To explore the accuracy of MRCP and MSCT in the diagnosis of CCA, this study examined 186 patients, who were highly suspected to have CCA and who had been admitted to the Second Affiliated Hospital of Soochow University from March 2020 to May 2022. We present this article in accordance with the STARD reporting checklist (available at https://jgo.amegroups.com/article/view/10.21037/jgo-22-1294/rc).

Methods

General information

Selection of research objects: A total of 186 patients with jaundice as the first symptom (106 males and 80 females), who were highly suspected to have CCA through computed tomography (CT) examination and who had been admitted to The Second Affiliated Hospital of Soochow University from March 2020 to May 2022 were included in this study. First, these 186 patients were examined by MSCT and MRCP. The MSCT examination was performed using the PHILIPS Ingenuity CT64 slice spiral CT. The MRCP examination was performed with the 1.5T superconducting MRI examination instrument. The patients had an average age of 57.62±6.04 years (range, 42–73 years), an average lesion diameter of 2.52±0.34 cm (range, 1.2–3.8 cm), and an average body mass index of 25.11±1.04 kg/m² (range, 22–29 kg/m²). The study conformed to the provisions of the Declaration of Helsinki (as revised in 2013). The study was approved by the ethics committee of The Second Affiliated Hospital of Soochow University (No. JD-HG-2023-20). The patients have given their consent for publication.

To be eligible for inclusion in this study, the patients had to meet the following inclusion criteria: (I) present with different degrees of fever, abdominal discomfort, abdominal pain, fatigue, and other symptoms; (II) be a male or female aged >18 years; (III) have stable vital signs, clear consciousness, and be able to cooperate with the doctor to complete the examination; and (IV) voluntarily agree to participate in this study.

Patients were excluded from the study if they met any of the following exclusion criteria: (I) had a previous history of chemoradiotherapy or surgery; (II) were participating in other research at the same time; (III) were a pregnant or lactating female; (IV) had a systemic serious infectious disease; (V) had tuberculosis or another infectious disease; (VI) had a disease of the blood or endocrine system; (VII) had other malignant tumors; (VIII) had a 2-way affective disorder, manic disorder, or other mental disorder; (IX) had abnormal kidney or liver function; and/or (X) had a cardiovascular or cerebrovascular disease.

Study methods

Multi-slice spiral computed tomography (MSCT) examination

The MSCT examination was performed using the PHILIPS Ingenuity CT64 slice spiral CT (Manufacturer: Philips, Shanghai, China). Each patient was instructed to drink 500–800 mL of warm water 20 minutes before the examination to ensure the filling of the gastrointestinal tract. The patient then underwent respiratory function training. The following parameter settings were used: tube current: a 260 mA; tube voltage: 120 kV; pitch: 3 mm; and layer thickness: 7 mm. After the plain scan, 100 mL of iohexol contrast agent was in-flooded through the ulnar vein via a high-pressure injector at an injection rate of 3 mL/s. An arterial phase scan was then undertaken within 25–30 s of the injection. A portal vein scan was performed within 50–60 s. The delay period scan was conducted within 120–180 s. Finally, the obtained image was transferred to the workstation, and maximum intensity projection (MIP), volume reproduction (VR), and multi-plane reconstruction (MPR) were used for image processing.

MRCP

The MRCP examination was performed with the 1.5T superconducting MRI examination instrument (model: Signa; manufacturer: American GE Company, USA). Each patient was told to abstain from drinking water 8–12 hours before the test. The medical staff instructed the patient to take the supine position with the head first and breathe smoothly. The fat background interference signals were removed using a fat suppression sequence, and 3-dimensional (3D) thin-layer scanning was performed using Fast recovery fast spin echo (FRFSE) with a relaxation time: re-T2-weighted single-shot fast spin aftersound sequence. The following parameter settings were used: matrix: 320×224; single layer thickness: 2.0 mm; field of vision: 380 mm; time of echo (TE): 4,000–10,000 ms; layers: 256; and time of repetition (TR): 400–800 ms. The obtained image was transferred to the workstation for MRI (MIP) reconstruction, and the coronal image was obtained by rotating the angle.

The CT and magnetic resonance imaging-diffusion weighted imaging (MRI-DWI) examinations of all the patients were performed by the same 2 radiologists, and the results were reviewed using the double-blind method. If there was any objection to the results, a 3^rd radiologist was involved in the discussion to determine the final diagnosis. Figure 1 shows the examination results of 2 women of different ages.

Figure 1 The examination results of 2 women of different ages. (A-C) The patient was a 70-year-old female. The arrows indicate the site of the tumor. The bile duct above was dilated. Pathological diagnosis: moderate-poorly differentiated cholangiocarcinoma. The type of tumor in terms of anatomic site is inter-hepatic. Tumor morphology is mass-like. (D,E) The patient was a 58-year-old female. The arrows indicate the site of the tumor with marked dilatation of the upper bile duct. Pathological diagnosis: moderate-poorly differentiated cholangiocarcinoma. The type of tumor in terms of anatomic site is extra-hepatic. Tumor morphology is nodular.

Observation indicators

The surgical pathological diagnosis results were taken as the benchmark for this study. The surgical pathological diagnosis used as benchmark for each patient. First, we compared the diagnostic accuracy, sensitivity, and specificity of MSCT and MRCP to those of the pathological diagnosis. Second, we compared the detection rates of lesions <0.5, 0.5–1.0, and >1.0 cm in diameter between MSCT and MRCP. Third, we analyzed the imaging features of CCA using the MSCT and MRCP. The following formulas were used:

Accuracy = (true negative + true positive)/(true negative + false negative + true positive + false positive) × 100.00%; Sensitivity = true positive/(false negative + true positive) × 100.00%; Specificity = true negative/(false positive + true negative) × 100.00%.

Statistical methods

SPSS26.0 software was used for the data processing. For the normally distributed measurement data, a t-test was used, and the results are expressed as the x ± s. For the enumeration data, the χ² test was used, and the results are expressed as the [n/(%)]. The consistency of the MSCT, MRCP, and measurement criteria was tested by the Kappa test. A Kappa value ≥0.75 indicated good consistency; a 0.4≤ Kappa value <0.75 indicated normal consistency; a Kappa value <0.4 indicated poor consistency. A P value <0.05 indicated a statistically significant difference.

Results

Comparison of the diagnostic efficacy of MSCT and MRCP

As Tables 1-3 show, the diagnostic accuracy (95.70%), sensitivity (95.12%), and specificity (96.15%) of MRCP were higher than those of MSCT (69.89%, 60.98%, and 76.92%, respectively; P<0.05). MSCT was in general agreement with the benchmark (Kappa value =0.527). MRCP was consistent with the benchmark (Kappa value =0.767).

Comparison of the detection rates of lesions with different diameters by MSCT and MRCP

As Table 4 shows, the detection rate of lesions <0.5 cm in diameter of MRCP (32.05%) was higher than that of MSCT (14.00%), and the P value was <0.05. The detection rate of MRCP for lesions 0.5–1.0 cm (38.46%) and >1.0 cm (29.49%) in diameter was lower than that of MSCT (50.00%, 36.00%, respectively), and the P value was >0.05.

MSCT and MRCP imaging features of CCA

A detailed description of the MSCT and MRCP imaging features of CCA is provided in Table 5.

Discussion

Human immunodeficiency virus infection, bile duct stones, primary sclerosing cholangitis, bile duct cystic dilatation, diabetes mellitus, alcoholism, and smoking are all risk factors for CCA (16,17). The incidence of CCA is high in people aged 50–70 years (16,17). The clinical symptoms of patients with CCA at the initial stage are not typical. As the disease progresses, the clinical symptoms include jaundice, upper abdominal pain, and other symptoms that can easily be ignored by patients. Most patients are at the advanced stage at the time of diagnosis, and may suffer from complications, such as shock, hepatorenal syndrome, and malignant obstructive jaundice, and thus the best opportunity for treatment is often missed (18,19). Regulation and functional models of FOSL1 in CCA were observed in the study of Vallejo et al. (18). At present, the “early diagnosis and early treatment” principle is followed in clinical practice to manage malignant tumors (20). Figure 2 shows a flow chart of treatment management and alternative therapy for hepatocellular CCA (21). Our study wants to find an accurate, reliable, sensitive, and simple diagnostic method to improve the diagnostic accuracy of CCA.

Figure 2 Therapeutic management and alternative treatments for combined hepatocellular cholangiocarcinoma. LT, liver transplantation; HCC, hepatocellular carcinoma; TACE, transarterial chemoembolization; PEI, percutaneous ethanol injection; HAIC, hepatic arterial infusion chemotherapy; CHC, combined hepatocellular-cholangiocarcinoma.

In the past, percutaneous cholangiography and B-ultrasound were used to diagnose CCA. Percutaneous cholangiography clearly shows the obstruction site and morphology of the bile duct; however, it has low acceptance among patients, as somewhat traumatic complications, such as bleeding and biliary fistula, are easily caused by this procedure (21,22). A B-ultrasound is non-invasive, inexpensive, and does not use radiation; however, it has low diagnostic accuracy and thus is mainly used in the diagnosis of biliary obstruction and bile duct dilatation and cannot meet the diagnostic needs of CCA (23,24).

The present study showed that the diagnostic accuracy (95.70%), sensitivity (95.12%), and specificity (96.15%) of MRCP were higher than those of MSCT (69.89%, 60.98%, and 76.92%, respectively; P<0.05). According to the previous study, Varghese et al. (25) reported high levels of sensitivity (91%), specificity (98%) and diagnostic accuracy (97%) for MRCP. Our results for sensitivity and diagnostic accuracy are slightly higher than those of previous study. Zhang et al. (26) found that the sensitivity and specificity of MRCP in the differential diagnosis of gallbladder lesions were 92% and 93%, respectively, which are close to the findings of this study and confirm the high clinical method efficiency of MRCP. This study showed that the detection rate of lesions <0.5 cm in diameter by MRCP (32.05%) was higher than that by MSCT (14.00%; P<0.05). Thus, the MRCP improved the detection rate of small diameter lesions, which is related to the high resolution of MRCP and 3D image reconstruction. In the study of D’Antuono et al. (7), they also confirmed that MRI with MRCP imaging represents a valuable alternative to MDCT in the diagnostic assessment of patients with CCA as it provides accurate identification and characterization of tumor lesions as well as appropriate judgement of tumor respectability.

The MRCP examination also has some shortcomings; for example, it is easily affected by volume and other factors, and the specific details of abnormal lumen masses cannot be displayed (27,28). This may be the reason why 4 cases were missed in MRCP examinations in this study. The main disadvantages of the MRCP are as follows: (I) its diagnostic costs are higher than those of MSCT; and (II) some patients and families cannot afford it. Thus, in the specific diagnosis process, clinicians should comprehensively consider each patient’s economic status and the costs of the examination and provide the best diagnostic technology for patients. Clinicians also need to combine the results of other laboratory tests to make a comprehensive judgment about each patient’s condition to reduce the rate of missed diagnosis and misdiagnosis as much as possible.

Conclusions

In conclusion, the MRCP had better diagnostic accuracy, sensitivity, and specificity than the MSCT in the diagnosis of CCA. The MRCP also provided relevant imaging feature information, which has good reference, promotion, and reference value. The MRCP examinations should be considered to maximize the diagnostic accuracy of CCA when patients are not limited by economic constraints.

Acknowledgments

Funding: This paper was supported by The Second Affiliated Hospital of Soochow University Young Staff Pre-research-Basic Research Special Project (No. SDFEYJC2112) and Suzhou High-tech Zone Medical and Health Science and Technology Plan Project (No. 2019Z016).

Footnote

Reporting Checklist: The authors have completed the STARD reporting checklist. Available at https://jgo.amegroups.com/article/view/10.21037/jgo-22-1294/rc

Data Sharing Statement: Available at https://jgo.amegroups.com/article/view/10.21037/jgo-22-1294/dss

Peer Review File: Available at https://jgo.amegroups.com/article/view/10.21037/jgo-22-1294/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jgo.amegroups.com/article/view/10.21037/jgo-22-1294/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study conformed to the provisions of the Declaration of Helsinki (as revised in 2013). The study was approved by the ethics committee of The Second Affiliated Hospital of Soochow University (No. JD-HG-2023-20). The patients have given their consent for publication.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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(English Language Editor: L. Huleatt)