From question on page 1435

Close contrast enhanced ultrasound (CEU) examination using Levovist (SH U 508A; Schering, Berlin, Germany) depicted papillary masses in the cystic area (fig 2). Cytology via nasobiliary tube demonstrated class IV findings (Papanicolau), suggesting adenocarcinoma. The patient hesitated about undergoing an operation as she was symptom free. However, the tumour gradually grew and the patient recently consented to radical surgery, which is scheduled for the near future.

Cholangiocellular carcinomas are grossly characterised into three types: mass forming, periductal infiltrating, and intraductal growth.¹ The clinical manifestation of the last type shows a striking homology with the recently established entity of intraductal papillary mucinous tumour of the pancreas,^2–8 which shows a relatively better prognosis, slow growth, rarely infiltrating the surrounding parenchyma, and frequently demonstrating an adenoma to carcinoma sequence.^9,10

Diagnosis of this entity can be established by obtaining characteristic findings. As indicated in the present case, however, there are limitations to differentiation between mucin material and papillary tumours in the bile duct on endoscopic retrograde cholangiography (ERC) or magnetic resonance cholangiography. In addition, massive amounts of mucin material produced by these tumours frequently cause difficulty in sufficiently opacifying the bile duct lumen with contrast media due to retention of mucin, resulting in diagnostic problems on ERC.⁸ Using CEU, differentiation between mucin and papillary tumours and tumour along the bile duct can be diagnosed when enhancement is demonstrated within intracystic masses or in the bile duct.

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Figure 2

 Contrast enhanced ultrasound demonstrating marked enhancement of papillary projections in the cystic mass.