[70-72] The accuracy of CT and MRI with MRCP for prediction of the extent of ductal involvement, hepatic arterial invasion, portal vein invasion, and lymph node metastasis is in the range of 84–91%, 83–93%, 86–98%, and 74–84%, respectively.[73, 74] Although PET

combined with CT (PET/CT) has been recommended to evaluate the metastasis of many intra-abdominal malignancies, it is premature BMS-354825 manufacturer to state the routine use of PET/CT in HCCA. The sensitivity rate of detecting non-nodal distant metastases by PET and PET/CT in patients with CCA was in the range of 70–100%, while the sensitivity of regional lymph node metastases was only about 12%.[75, 76] 10. Endoscopic ultrasonography (EUS) with FNA in combination with other modalities may improve the diagnostic accuracy for HCCA. Level of agreement: a—47%, b—35%, 12%, d—6%, e—0% Quality of evidence: II-2 Classification of recommendation: B Although CT and MRI are the standard imaging tools to evaluate the presence and resectability of CCA, they may miss some small lesions.[70, 77, 78] EUS has been Carfilzomib supplier proven to detect those small lesions and may help to predict

the unresectability of CCA.[79] However, its sensitivity is significantly higher in distal CCA than in HCCA.[79] Although it is technically difficult due to the tumor’s anatomical position, EUS-FNA in brush-negative HCCA patients has been practiced in many advanced endoscopy centers.[80-82] Original reports in suspected HCCA patients with an inconclusive tissue diagnosis demonstrated that the overall diagnostic accuracy, sensitivity, specificity, PPV, and negative predictive value for EUS-FNA in diagnosing HCCA were 91%, 89%, 100%, 100%, and 67%, respectively.[80-82] Therefore, EUS may be considered, where available, to confirm HCCA diagnosis and to evaluate the Tolmetin resectability in those with inconclusive results after the standard evaluation. 11. EUS has a limited role in local staging of HCCA but may be useful in detecting nodal disease. Level of agreement: a—42%, b—42%, c—16%, d—0%, e—0% Quality of evidence: II-2 Classification of recommendation: B

Complete staging of HCCA with EUS is challenging because of the limited depth of visualization and T staging may be inadequate. EUS is able to detect locoregional lymph nodes in the hepatic hilum and in the coeliac axis, as well as para-aortic lymph nodes.[83] In a study of 47 patients, EUS correctly identified lymph nodes in all the patients and confirmation of malignancy by FNA precluded liver transplantation in 17%, implying that EUS-FNA for regional lymph node staging should be further considered in all resectable HCCA patients predicted by CT or MRI to avoid unnecessary surgery.[84] Intraductal ultrasonography (IDUS) is useful in the evaluation of CCA from inside out. IDUS was found to be superior to EUS for T staging (78% vs 54%).