Hyo Sun Kim, et al. 증례 /100 mmhg, 82 /, 20 /, 36.0 C, (Murphy s sign). 4,890/mm 3, 12.8 g/dl, 378,000/mm 3, 7.08 mg/dl, 5.54 mg/dl, AST 5

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1 Case Report The Korean Journal of Pancreas and Biliary Tract 2016;21: pissn eissn 중심부석회화를동반한간내담관암 1 예 1 한림대학교의과대학춘천성심병원내과, 2 울산대학교의과대학서울아산병원내과 김효선 1 윤재훈 1 엄정호 1 이석원 1 박태영 1 이성구 2 Intrahepatic Cholangiocarcinoma with Central Calcification Hyo Sun Kim 1, Jai Hoon Yoon 1, Jeong Ho Eom 1, Seok Won Lee 1, Tae Young Park 1, Sung Koo Lee 2 1 Department of Internal Medicine, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon; 2 Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea A 50-year-old woman complained of jaundice and dyspepsia that started 2 weeks prior to consultation. Abdomen-pelvic computed tomography showed a 3 cm mass in the right hepatic duct with central calcification, which was spreading into the second branch. Repeated biopsies through endoscopic retrograde cholangiopancreatography were needed for pathology, which was consistent with an adenocarcinoma. Imaging studies including positron emission tomography showed no evidence of distant metastasis. The patient underwent right lobectomy with bile duct resection. The final diagnosis was intrahepatic cholangiocarcinoma with central calcification. We reported a very rare case of centrally calcified mass growing in the second branch of the right hepatic duct. The possibility of intrahepatic cholangiocarcinoma with central calcification should be considered for differential diagnosis of intrahepatic calcification. Keywords: Cholangiocarcinoma, Intrahepatic, Central, Calcification Received Oct. 22, 2015 Revised Jan. 18, 2016 Accepted Jan. 20, 2016 Corresponding author : Jai Hoon Yoon Department of Internal Medicine, Hallym University Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, 77 Sakju-ro, Chuncheon 24253, Korea Tel Fax ; yoonjh@hallym.or.kr This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Copyright 2016 by The Korean Journal of Pancreas and Biliary Tract 서론 , 1. 2, (Klatskin tumor) computed tomography (CT) 15%. 3.,,,,,, Copyright 2016 by Korean Pancreatobiliary Association

Hyo Sun Kim, et al. 증례 50 2. 30. 140/100 mmhg, 82 /, 20 /, 36.0 C, (Murphy s sign). 4,890/mm 3, 12.8 g/dl, 378,000/mm 3, 7.08 mg/dl, 5.

6 IU/L, ALP 229 IU/L, GGT 310 IU/L. CA 19

2 Hyo Sun Kim, et al. 증례 /100 mmhg, 82 /, 20 /, 36.0 C, (Murphy s sign). 4,890/mm 3, 12.8 g/dl, 378,000/mm 3, 7.08 mg/dl, 5.54 mg/dl, AST 55 IU/L, ALT 116 IU/L, ALP 229 IU/L, GGT 310 IU/L. CA U/mL. CT 3 cm (Fig. 1). T2 (Fig. 2A) (Fig. 2B)., Fig. 1. Abdomen-pelvis computed tomography: About 3 cm sized heterogenous intraductal mass in right intrahepatic duct with central calcification was ingrowing to the second posterior branch of the right hepatic duct (white arrow). The tumor in right main hepatic duct (white circles) was gradually enhanced from arterial phase to portal phase. A B Fig. 2. Magnetic resonance cholangiopancreato graphy: Intraductal mass (white circle) in right main hepatic duct was hyperintense in T2 imaging (A), Intraductal tumor was in the right hepatic duct just above hilum with dilatation of both intrahepatic duct (B). 97

Cholangiocarcinoma with Intrahepatic Calcification 5. (Fig. 3). 5. (PET-CT) (FDG) 1. (Fig. 4A, B).

Endoscopic retrograde cholangiopancreatography: Biopsy was performed on intraductal hard mass in

Gross findings: About 3 cm sized intraductal polypoid mass (white circle) was located in right

The main mass was spreaded into the second branch (wihite arrow) of right hepatic duct (B).

3 Cholangiocarcinoma with Intrahepatic Calcification 5. (Fig. 3). 5. (PET-CT) (FDG) 1. (Fig. 4A, B). 13 mm (Fig. 4C)... 고찰 Fig. 3. Endoscopic retrograde cholangiopancreatography: Biopsy was performed on intraductal hard mass in right hepatic duct (white arrow). 10% 20% 8,9. 10,. 20%, , 12,,,,,, A C B Fig. 4. Gross findings: About 3 cm sized intraductal polypoid mass (white circle) was located in right intrahepatic duct (A). The main mass was spreaded into the second branch (wihite arrow) of right hepatic duct (B). Micoscopic findings (hematoxylin and eosin staining, x400): Papillary neoplasm with delicate fibrovascular core was observed in the background of mucin (yellow arrows) and central calcification (purple arrows) (C). 98

4 Hyo Sun Kim, et al. Table 1. Differential diagnosis using typical findings of CT and MRI in patients with intrahepatic calcification Diseases Intrahepatic cholangiocarcinoma (IHC) Hepatocellular carcinoma Metastatic tumors (mucin producing neoplasmas such as colon cancer) Contrast enhancement Delayed phase - contrast enhancement Arterial phase - contrast enhancement and early wash-out Typical findings of CT Hypoattenuating lesions Portal venous phase - central filling and wash-out at delayed phase Calcification Peripheral calcification - about 15% of IHC Eccentrical calcification - within a complex heterogeneous mass Central or peripheral calcification - sand-like, irregular patchy, or small punctate calcifications. Adenoma Prolonged enhancement Central calcification - MRI (gadolinum enhance) no enhancement in the center Hemangioma Progressive enhancement - peripheral central Large coarse central calcification Typical findings of MRI T2 - hypointense T1 - hyperintense T2 - isointense Ring-like enhancement T1 - hypointense T1 - hypointense Tuberculosis Various types Multiple flecked calcification T1 - hypointense CT, computed tomography; MRI, magnetic resonance imaging.. CT magnetic resonance imaging (MRI).,, CT (Table 1). 15%. MRI T2 T2. 3,12,13 CT MRI. 6,.,,.... 요약 1,. 국문색인 : 담관암, 간내, 중심부, 석회화 Conflicts of Interest The author has no conflicts to disclose. 99

5 Cholangiocarcinoma with Intrahepatic Calcification REFERENCES 1. Landis SH, Murray T, Bolden S, Wingo PA. Cancer statistics, CA: Cancer J Clin 1998;48: Khan SA, Davidson BR, Goldin RD, et al. Guidelines for the diagnosis and treatment of cholangiocarcinoma: an update. Gut 2012;61: Kitade M, Yoshiji H, Yamao J, et al. Intrahepatic cholangiocarcinoma associated with central calcification and arterio-portal shunt. Intern Med 2005;44: Paley MR, Ros PR. Hepatic calcification. Radiol Clin North Am. 1998; 36: Maeda E, Uozumi K, Kato N, et al. Magnetic resonance findings of bile duct adenoma with calcification. Radiat Med 2006;24: Chong VH, Lim KS. Hepatobiliary tuberculosis. Singapore Med J 2010; 51: Marcos LA, Terashima A, Gotuzzo E. Update on hepatobiliary flukes: fascioliasis, opisthorchiasis and clonorchiasis. Curr Opin Infect Dis 2008;21: Khan SA, Toledano MB, Taylor-Robinson SD. Epidemiology, risk factors, and pathogenesis of cholangiocarcinoma. HPB (Oxford) 2008;10: Kaczynski J, Hansson G, Wallerstedt S. Incidence, etiologic aspects and clinicopathologic features in intrahepatic cholangiocellular carcinoma--a study of 51 cases from a low-endemicity area. Acta Oncol 1998;37: Massani M, Nistri C, Ruffolo C, et al. Intrahepatic chemotherapy for unresectable cholangiocarcinoma: review of literature and personal experience. Updates Surg 2015;67: Shimada M. Highlights of topic Intrahepatic cholangiocarcinoma: recent advancements in pathogenesis, diagnosis and treatment. J Hepatobiliary Pancreat Sci 2015;22: Inoko K, Tsuchikawa T, Noji T, et al. Hilar cholangiocarcinoma with intratumoral calcification: a case report. World J Gastroenterol 2015;21: Zhou C, Li J, Wang Z. CT findings of calcified liver metastases. Zhonghua Zhong Liu Za Zhi 1998;20:

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