Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 
Print this page Email this page Users Online: 266

 
ORIGINAL ARTICLE
Ahead of print publication  

Time intensity curve in primary solid hepatic lesions: Does it provide objectivity to otherwise subjective interpretation?


1 Department of Radiology, Base Hospital, Delhi, India
2 Department of Radiology, Command Hospital Air Force, Bengaluru, Karnataka, India

Date of Submission18-Feb-2022
Date of Decision16-Sep-2022
Date of Acceptance21-Sep-2022
Date of Web Publication16-Nov-2022

Correspondence Address:
Vinay Maurya,
Department of Radiology, Base Hospital Delhi Cantt-110010, Delhi
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mjdrdypu.mjdrdypu_144_22

  Abstract 


Aims and Objectives: Magnetic resonance imaging (MRI) is able to characterize the primary solid hepatic lesions well and dynamic contrast enhanced MRI (DCE-MRI) further improves the diagnostic yield. However, the interpretation of enhancement pattern of a lesion by visual method or eyeballing is quite subjective and is prone to observer error. Time intensity curve (TIC) which plots the signal intensity values in tumor over time provides objectivity in interpretation of DCE-MRI images. Therefore, the aim of this study was to determine the pattern of TIC in primary solid hepatic lesions using DCE-MRI. Method: All cases found to have solid hepatic lesions on ultrasound from January 2017 to December 2018 were included in the study. These cases were subjected to DCE-MRI. Results: Type III-TIC was seen in 30 (93.8%) of cases of hepatocellular carcinoma (HCC), whereas only 2 (6.2%) of cases showed type II curve with χ2 = 43.9848, P < 0.01. Focal Nodular Hyperplasia (FNH) showed type II TIC in 8 (80%) of cases and type III curve in 2 (20%) of cases with χ2 = 34.0052, P < 0.01. Hemangioma showed type I TIC in 14 (93.3%) of cases and type II curve in 1 (6.7%) of cases with χ2 = 44.6185, P < 0.01. Cholangiocarcinoma showed type I TIC, χ2 values could not be determined due to inadequate sample size. Conclusion: TIC provides an objectivity by constructing a time vs signal intensity curve and is less prone to observer error. Therefore, it is recommended that TIC be included in the MRI protocol for evaluating solid hepatic lesions.

Keywords: Dynamic CEMRI, solid hepatic lesions, time intensity curve



How to cite this URL:
Maurya V, Sharma P, Bhatia M. Time intensity curve in primary solid hepatic lesions: Does it provide objectivity to otherwise subjective interpretation?. Med J DY Patil Vidyapeeth [Epub ahead of print] [cited 2022 Dec 7]. Available from: https://www.mjdrdypv.org/preprintarticle.asp?id=361287




  Introduction Top


The solid lesions in liver can be primary neoplastic lesions or secondary from elsewhere. Metastases to liver are by far the most common solid lesions. Metastatic lesions do not pose much challenge in diagnosis as the primary is identified in most of the cases elsewhere on imaging. Primary solid hepatic lesions which can be benign or malignant can be characterized on magnetic resonance imaging (MRI) due to its inherent ability to characterize the tissue on various sequences used in liver imaging. Dynamic contrast enhanced MRI (DCE-MRI) plays a major role in diagnosing a lesion of liver as its aids in characterizing the lesion due to well established facts of contrast dynamics of various lesions following contrast injection. However, the interpretation of contrast enhanced images is done by eyeballing or visual method which is subjective and prone to observer error. The time-signal intensity curve (TIC) from dynamic contrast-enhanced MRI reflects the hemodynamic features specific to a lesion. The lesion enhancement can be characterized qualitatively by evaluating the enhancement kinetics curve obtained by plotting the signal intensity values in a lesion over time after contrast injection.[1] The TIC so obtained provides objectivity in characterizing the lesions and reduces the observer error. Therefore, the aim of this study was to identify the type of time intensity curve in different primary solid hepatic lesions and determine its significance in characterizing the lesions.


  Materials and Methods Top


Setting

The study was conducted at the Department of Radiology in a tertiary care hospital.

Study design

Prospective observational study

Inclusion criteria

All cases found to have solid hepatic lesions on ultrasound from January 2017 to December 2018 were included in the study. These cases were subjected to MRI with dynamic contrast enhancement.

Exclusion criteria

  1. All cases of metastases and cystic lesions of liver were excluded from the study.
  2. Lesions with portal vein thrombosis.
  3. Cases with deranged renal function with eGFR less than 60 were also excluded from study.


Imaging parameters

All cases were done on 1.5T Siemens (Germany) Somatom symphony MRI scanner with image matrix 512 × 512.

MRI protocol included following sequences Axial and Coronal HASTE, DWI, Axial T1W, precontrast Axial T1 3D Flash (flip angle 60°) followed by Axial T1W 3D Flash Dynamic post contrast MRI (DCE-MRI). Inj Gadopentetate dimeglumine was used in the dose 0.2 ml/kg (0.1 mmol/kg) for DCE-MRI. Post processing the dynamic sequences were then categorized as

  1. Arterial phase: 20–25 seconds
  2. portal venous phase: 60–70 seconds
  3. equilibrium phase: 3 minutes
  4. hepatobiliary phase: 10 minutes
  5. hepatobiliary delayed phase: 20 minutes if indicated.


Triple phase CT was done in majority of cases suspected to have primary solid space occupying lesions (SOL) in liver. The cases with CT diagnosis of hemangioma were not subjected to fine needle aspiration cytology (FNAC) or trucut biopsy. In all other cases FNAC or trucut biopsy was done and MRI diagnosis and type of curve was correlated with histopathological examination.

Image analysis

All cases were recorded for age, sex, and presence or absence of cirrhosis. Lesion characteristics on MRI in T1W, T2W, DWI images, central scar, scar enhancement, and pseudo capsule were recorded in an excel sheet. Dynamic post contrast images were loaded in time intensity curve application software of RADIANT DICOM viewer version 4.6.9.18463. Circular ROI of 0.5 to 1.5 cm2 was placed in an area of lesion at exactly same position in different phases of examination and TIC curve was generated [Figure 1]. The area showing maximum and uniform enhancement devoid of vessels and necrosis was selected for placing the ROI. Images were stored, and type of curve was recorded.
Figure 1: (a–j) – (Screenshot of Radiant viewer) Hepatocellular carcinoma. A well- defined rounded heterogeneously hyperintense lesion on T1W & T2WI in segment V (a, b). Dynamic post contrast images (c-j) showing placement of ROI in the lesion with generation of TIC curve. The lesion shows pseudo-capsule and type III time intensity curve typical of HCC (j)

Click here to view


Type I curve – consisted of progressive enhancement with continuous increase in signal intensity.

Type II curve – showed early rise in arterial phase with plateau in portal venous phase and slow decline in equilibrium phase.

Type III curve – consisted of early peak with rapid washout in portal-venous phase and steep decline in equilibrium phase.

Statistical analysis

The data was analyzed by using Statistical packages for social sciences (version 22.0; SPSS Inc., Chicago, IL, USA). Chi-square test was used to compare the types of curves and P values less than 0.01 were considered to indicate a statistically significant difference.

Informed consent

Institutional Ethical committee approval was obtained for the study. Permission from the institution was also obtained for analyzing the data. Informed consent was obtained from patient and Identity of patients was kept confidential.


  Results Top


During the study period, ranging from January 2017 to December 2018, 86 cases were diagnosed to have solid hepatic space occupying lesions on ultrasound. Out of 86 cases, 59 cases met our inclusion criteria and were subjected to DCE-MRI. About 44 cases were males and 15 cases were females. Hepatocellular carcinoma (HCC) was the most common solid tumor found in 32 (54.2%) patients with M: F ratio of 7:1. The HCC was found most in 60–70 age group in 34.4% of cases. Focal Nodular Hyperplasia (FNH) was found in 10 (17%) patients with M:F ratio of 2:3. Most common affected age group was 40–50 years with 60% of cases occurring in this age group. Hemangioma was seen in 15 (25.4%) cases with M: F ratio of 2:1. It was seen most in 40–50 year age group with 60% of cases falling in this age group. Intrahepatic mass forming cholangiocarcinoma (IHCC) was seen in only 2 (3.4%) cases, both the cases were elderly males. About 81.2% cases of HCC, 80% cases of FNH, 86.7% cases of hemangiomas, and all the cases of cholangiocarcinoma were hypointense on T1WI [Table 1]. About 96.8% cases of HCC, 90% cases of FNH, 100% cases of hemangioma, and 100% cases of cholangiocarcinoma were hyperintense on T2WI [Table 1]. Pseudocapsule was seen in 18 (56.3%) cases of HCC and 30% of cases of FNH [Table 1]. None of the cases of hemangioma and cholangiocarcinoma showed Pseudocapsule. Central scar was seen in 18.8% cases of HCC, 90% cases of FNH, and 13.3% cases of hemangioma [Table 1]. Delayed enhancement of central scar was seen in 9.4% cases of HCC, 90% cases of FNH, and 6.7% cases of hemangioma [Table 1]. Type III-time intensity curve (TIC) was seen in 30 (93.8%) of cases of HCC [Figure 2] whereas only 2 (6.2%) cases showed type II curve with χ2 = 43.9848, P < 0.01, none of the cases of HCC showed type I curve [Table 2]. FNH showed type II TIC in 8 (80%) cases [Figure 3] and type III curve in 2 (20%) of cases with χ2 = 34.0052, P < 0.01, none of the cases of FNH showed type I curve. Hemangioma showed type I TIC in 14 (93.3%) of cases [Figure 4] and type II curve in 1 (6.7%) of cases with χ2 = 44.6185, P < 0.01, none of the cases showed type III curve. There were only 2 cases of cholangiocarcinoma both of which showed type I curve [Figure 5] and χ2 values could not be determined due to inadequate sample size. However, Fisher exact test statistic value was 0.0701 with P > 0.01.
Figure 2: (a–f) – Hepatocellular carcinoma. On T1WI (a) the lesion is hypointense and heterogeneously hyperintense on T2WI (b). Post contrast the lesion shows early heterogeneous enhancement in arterial phase (c) with rapid washout in portal venous phase (d). Note the prominent pseudocapsule is seen in equilibrium phase (e). The lesion shows a type III time intensity curve with steep up slope in arterial phase and rapid fall in portal venous phase (f)

Click here to view
Figure 3: (a–f) – Focal Nodular hyperplasia. A well-defined rounded hypointense lesion with central scar is seen in right lobe of liver on T1WI (a). The lesion is hyperintense on T2WI with a central T2 hyperintense scar (b). The lesion shows early heterogeneous enhancement in arterial phase (c) with plateau in portal venous phase slow wash out in equilibrium phase (d). The central scar shows enhancement in delayed phase at 15 min (e). The lesion shows type II time intensity curve with early rise followed by plateau and slow decline as seen in image (f)

Click here to view
Figure 4: (a–f) – Hemangioma. A well-defined T1W hypointense lesion is seen in segment VII (a) which is hyperintense on T2WI (b) also note the central T2 hyperintense scar. Post contrast the lesion shows peripheral nodular enhancement in arterial phase (c) with progressive centripetal filling in equilibrium (d) and delayed phase (e) with intensity of enhancement equal to blood pool. The central scar does not enhance in delayed phase. The lesion shows progressive enhancement with increase in signal intensity typical of type I curve (f)

Click here to view
Figure 5: (a–f) – Intrahepatic cholangiocarcinoma. Mass forming IHCC is seen is segment IV which is heterogeneously hypointense on T1WI and iso to hyperintense on T2WI (a & b). On dynamic CEMRI there is minimal peripheral enhancement on arterial phase (c), with gradual heterogeneous enhancement in equilibrium and delayed phase (d, e). The lesion shows type I-time intensity curve (f). Note dilated intrahepatic biliary radicals associated with IHCC

Click here to view
Table 1: MRI features of lesions

Click here to view
Table 2: Type of time intensity curve

Click here to view



  Discussion Top


Solid hepatic lesions in liver can be primary or metastatic lesions. Metastases to liver are more common than primary lesions but they do not pose serious challenge on imaging as they are multiple and in most cases a primary can be identified elsewhere. Primary solid hepatic lesions can be benign and malignant. The common benign lesions are hemangioma, fibronodular hyperplasia (FNH), and hepatic adenoma. Other benign lesions are regenerating nodules and lipomatous lesions. The common malignant lesions are hepatocellular carcinoma and intrahepatic cholangiocarcinoma. Primary sarcomas and lymphomas of liver are rare.

It is important to diagnose and characterize the liver lesion early as it has direct bearing on the management of the patient. Ultrasound has high sensitivity in detecting a lesion but has low specificity in characterizing a lesion unless contrast enhanced ultrasound is done. Triple phase CT is excellent in characterizing some lesions such as hemangiomas and hepatocellular carcinomas. But there are times when CT is unable to give a definite answer. MRI has emerged as a problem-solving tool and has high specificity in characterizing a solid hepatic lesion. The various sequences used in MRI for liver imaging are T1W, T2W, DWI, in and opp phase, T2W with longer TE.[2] The DCE-MRI provides vital information about the contrast dynamics of a lesion such as the wash in and wash out which is used in interpreting these images and helps in characterizing a lesion. However, the pattern of contrast enhancement of a solid lesion is currently assessed by visual method or eyeballing which is prone to error in interpretation and can lead to erroneous diagnosis. Physiology of time intensity curve depends on flow of contrast medium from the blood pool into the tissues, the signal intensity on a T1WI during and after the injection varies according to a pattern which is depends on the vascularity and the viability of the tissue. This time dependent signal intensity in the tissues is recorded and forms the basis of time intensity curve (TIC). TIC has been used extensively in breast imaging,[1] but has not been widely used in liver imaging and there are few studies which have dealt with this topic. Three types of curves have been defined in breast imaging. Type I curve which typically shows a continuous increase in signal intensity with time, type II curve shows initial uptake followed by the plateau phase with increasing time, and type III curve has early uptake and rapid wash out of contrast with time.[1] Time intensity curve can be modified for liver imaging and the types of curve which can be defined are Type I curve of progressive enhancement with continuous increase in signal intensity. Type II curve showing early rise in arterial phase with plateau in portal venous phase and slow decline in equilibrium phase. Type III curve of early peak in arterial phase with rapid washout in portal-venous phase and steep decline in equilibrium phase.

HCCs have variable appearances on MRI but usually they are hypointense on T1WI and mild to moderately hyperintense on T2WI.[3] In this study, 81.2% of cases of HCC were hypointense on T1WI and 96.8% of cases were hyperintense on T2WI [Table 1]. Majority of HCCs have a pseudocapsule consisting of compressed liver parenchyma that usually enhances on the delayed images. Pseudocapsule was seen [Figure 1] and [Figure 2]e in 56.3% of cases in this study [Table 1]. Central scar in HCC is seen in Fibrolamellar HCC. The central scar of Fibrolamellar HCC is typically hypointense on all sequences but can sometimes be hyperintense on T2W and can mimic FNH. Central scar in this study was seen in 6 (18.8%) cases of HCC out of which 2 (6.25%) cases showed delayed scar enhancement. No enhancement of central scar was seen in remaining 4 (12.5%) cases [Figure 6]. Contrast enhancement in central scar of HCC has been found to be quite variable. Earlier studies reported that central scar in fibrolamellar HCC did not show delayed enhancement, but recent literature suggests contrast enhancement of central scar can also be seen in fibrolamellar HCC.[4] But lack of definite central scar enhancement favors the diagnosis of HCC over FNH. On DCE-MRI, type III time intensity curve was seen in 93.8% cases of HCC [Figure 1] and [Figure 2] and type II curve was seen in 6.2% cases, none of the HCC showed type I curve [Table 2] with χ2 = 43.9848, P < 0.01. This observation is significant and provides objectivity to the already established fact that HCCs show early enhancement and rapid wash out in portal-venous phase. L Wang and Van den Bos et al.[5] in their study found that HCCs typically showed type III enhancement curve as seen in this study. Jingjing Chen et al.[6] in their study have described four type of time intensity curves with malignant lesions following type I curves which was similar to type III curve described in this study.
Figure 6: (a–f) – Fibrolamellar HCC. A well- defined rounded T1W hypointense lesion with central hypointense scar in Segment VIII (a). The lesion is hyperintense on T2WI with central hyperintense scar (b). The lesion shows early arterial enhancement (c) with wash out in portal venous phase (d). There is no enhancement of central scar even after 20 min delay (e). The lesion shows typical type III time intensity curve of HCC (f). Note the pseudocapsule in portal venous phase and delayed phase (d, e)

Click here to view


FNH is the second most common benign hepatic tumor after hemangioma and has been shown to constitute about 8% of primary hepatic tumors. On MRI, FNH are considered classic when they are homogeneously iso to hyperintense on T2WI and hypointense on T1WI and show central stellate scar which is hyperintense on T2W. In this study 80% of the FNH were hypointense on T1WI and 90% cases were hyperintense on T2WI. A Pseudocapsule was seen in 30% of cases which is considered an atypical feature of FNH [Table 1]. On DCE-MRI, the FNH shows type II TIC which is marked by early homogeneous enhancement during arterial phase and washed out during portal venous phase with slow decline during the equilibrium and delayed phase [Figure 3]. However, type III TIC can also be seen in some FNH as was seen in 20% [Table 2] of the cases in this study [Figure 7]. The enhancement of central stellate scar in delayed phase is typical of FNH and helps in differentiating it from Fibrolamellar HCC [Figure 3] and [Figure 6]. There are few studies in literature which have studied the pattern of time intensity curve of FNH, Wang et al.[5] in their study have mentioned that even though FNH are benign lesions but they show type III curve similar to HCC. However, TIC curve modified to liver imaging will show a type II curve for FNH which will be considered as showing features of arterialization (steep enhancement) in the initial part of the curve and later showing features of hepatization that is plateau or slow wash out/decline in equilibrium phase and delayed phase. In this study, 8 (80%) cases of FNH showed type II curve [Figure 3] with χ2 = 34.0052 and P < 0.01, which is a significant finding and can be used for differentiating HCC or fibrolamellar HCC from FNH as both show early enhancement and central scar on MR imaging.
Figure 7: (a–f) – Fibronodular hyperplasia. A well-defined rounded lesion in segment VIII which is hypointense on T1WI (a), isointense on T2WI with central hyperintense scar on T2WI (b). On DCEMRI the lesion shows early homogeneous enhancement in arterial phase (c) with washout in portal venous phase and steep slope in equilibrium and delayed phase (d). The lesion shows type III time intensity curve unlike FNH (f). However, note the dot like enhancement of central scar on delayed image (d)

Click here to view


Hepatic hemangioma is the most common primary liver tumor with the incidence of up to 20% in the general population.[7] Hemangiomas typically appear as low-density masses with well-defined lobulated margins on non-contrast computed tomography (NCCT) imaging. In Multiphasic CT, during the arterial phase, hemangiomas demonstrate an initial peripheral nodular enhancement; this enhancement is isodense with the aorta and progresses centripetally with time. On delayed scans, the lesion becomes iso to hyperdense compared with normal liver parenchyma.[8] Multiphasic CT imaging of a typical hemangioma is so classical that there is no requirement of any other investigation to confirm the diagnosis. This could be the main reason the number of cases of hemangiomas were less than HCC in this study even though hemangioma is the most common solid lesion to be found in liver. On MRI hemangiomas are most commonly seen as hypointense lesion on T1WI and homogeneously hyperintense lesion on T2WI.[2] In this study, hemangiomas were hypointense in 86.7% of cases and isointense in 13.3% of cases on T1WI. All the cases of hemangiomas in this study were hyperintense on T2WI. Central scar was seen in 2 (13.3%) cases with scar enhancement in 1 (6.7%) case in delayed scan. On DCE-MRI, a classical hemangioma shows early peripheral nodular enhancement with centripetal fill in on delayed phases which is equal to blood pool phase in all phases. In this study, 14 (93.3%) cases of hemangioma showed type I enhancement [Figure 4] and only 1 (6.7%) case showed type II enhancement curve with χ2 = 44.6185, P < 0.01. The finding is significant and it can be used for differentiating lesions based on this observation. Wang et al. in their review article also found that vast majority of hemangiomas showed classical enhancement pattern with type I enhancement curve as was seen in this study.[5]

Cholangiocarcinoma is a primary malignant tumor arising from the bile duct epithelium and comprises 10–25% of all liver and biliary tract cancers. Liver cancer study group of Japan have proposed a new classification for intrahepatic Cholangiocarcinoma (IHCC) as mass-forming, periductal-infiltrating, or intraductal-growing based on their growth characteristics.[9] It is Intrahepatic mass forming type cholangiocarcinoma which is seen as solid lesion on imaging and has to be differentiated from other solid lesions on imaging. On NCCT, IHCC are hypodense and on post contrast imaging demonstrate heterogeneous mild peripheral enhancement with gradual centripetal enhancement in delayed scans. The lesion may show mild haphazard dilatation of the adjacent biliary radicles and if the lesion is close to capsule, may also show capsular retraction.[10] MRI features of mass-forming IHCC are similar to its CT features. On MRI, the IHCC is iso to hypointense on T1WI and hyperintense on T2WI which can be mild to marked depending upon the fibrous and mucin contents. Only 2 cases were diagnosed as IHCC in this study and both were hypointense on T1WI and hyperintense on T2WI. On DCE-MRI, minimal or mild incomplete enhancement is seen at the tumor periphery in early phases, whereas progressive central contrast-enhancement is seen in delayed images. In this study, both the cases of IHCC showed mild peripheral enhancement in portal venous phase and delayed centripetal enhancement on delayed scans [Figure 5] and both the cases showed type I curve post processing [Table 2]. However, the sample size was inadequate to determine the significance of this finding.

The limitation of this study was an inadequate sample size of Intrahepatic cholangiocarcinoma, FNH, and absence of cases of hepatic adenoma which also present as solid hepatic masses. There was no blinding of the data which may have resulted in some observer error. More multicentric studies by other authors with greater number of cases if done will strengthen the findings this study.


  Conclusion Top


DCE-MRI helps in characterizing a solid hepatic lesion by studying the contrast dynamic of the lesion such as wash in and wash out or persistence of contrast in a lesion. This interpretation is presently subjective and is done by visual method which may lead to ambiguity in interpreting a lesion. The Time intensity curve provides an objectivity to DCE-MRI by constructing a time vs signal intensity curve and aids in better interpretation of the lesion. Therefore, it is suggested that TIC be included in the MRI protocol for evaluating primary solid hepatic lesions in all cases.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Cheng L, Li X. Breast magnetic resonance imaging: Kinetic curve assessment. Gland Surg 2013;2:50–3.  Back to cited text no. 1
    
2.
Maniam S, Szklaruk J. Magnetic resonance imaging: Review of imaging techniques and overview of liver imaging. World J Radiol 2010;2:309-22.  Back to cited text no. 2
    
3.
Choi BI, Lee JM. Advancement in HCC imaging: Diagnosis, staging and treatment efficacy assessments: Imaging diagnosis and staging of hepatocellular carcinoma. J Hepatobiliary Pancreat Sci 2010;17:369-73.  Back to cited text no. 3
    
4.
Corrigan K, Semelka RC. Dynamic contrast enhanced MR imaging of fibrolamellar hepatocellular carcinoma. Abdominal Imaging 1995;20:122-5.  Back to cited text no. 4
    
5.
Wang L, Van den Bos I C, Hussain S M, Pattynama PM, Vogel MW, Krestin GP. Post-processing of dynamic gadolinium-enhanced magnetic resonance imaging exams of the liver: Explanation and potential clinical applications for color-coded qualitative and quantitative analysis. Acta Radiol 2008;49:6-18.  Back to cited text no. 5
    
6.
Chen J, Si Y, Zhao K, Shi X, Bi W, Liu S, et al. Evaluation of quantitative parameters of dynamic contrast-enhanced magnetic resonance imaging in qualitative diagnosis of hepatic masses. BioMed Central Medical Imaging 2018;18:56.  Back to cited text no. 6
    
7.
Albiin N. MRI of focal liver lesions. Curr Med Imaging Rev 2012;8:107–16.  Back to cited text no. 7
    
8.
Yamashita Y, Ogata I, Urata J, Takahashi M. Cavernous hemangioma of the liver: Pathologic correlation with dynamic CT findings. Radiology 1997;203:121-5.  Back to cited text no. 8
    
9.
Liver Cancer Study Group of Japan. The General Rules for the Clinical and Pathological Study of Primary Liver Cancer. 4th ed. Kanehara, Tokyo, 2000.  Back to cited text no. 9
    
10.
Chung YE, Kim MJ, Park YN, Choi JY, Pyo JY, Kim YC, et al. Varying appearances of cholangiocarcinoma: Radiologic-pathologic correlation. Radiographics 2009;29:683-700.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
 
 
    Tables

  [Table 1], [Table 2]



 

 
Top
 
 
  Search
 
     Search Pubmed for
 
    -  Maurya V
    -  Sharma P
    -  Bhatia M
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
   Abstract
  Introduction
   Materials and Me...
  Results
  Discussion
  Conclusion
   References
   Article Figures
   Article Tables

 Article Access Statistics
    Viewed111    
    PDF Downloaded5    

Recommend this journal