Can an elevated liver stiffness on liver elastography (liver elastography) be a sign of cholangiocarcinoma (bile duct cancer)?

From the Guidelines

Elevated liver stiffness on liver elastography can be a sign of cholangiocarcinoma, but it is not specific and should prompt further diagnostic evaluation. Liver elastography measures the stiffness of liver tissue, which typically increases when there is fibrosis, inflammation, or tumor infiltration. In cholangiocarcinoma, the cancer can cause obstruction of bile ducts leading to cholestasis (bile buildup), inflammation, and fibrosis, all of which can increase liver stiffness values. Additionally, direct tumor infiltration into the liver parenchyma can also increase stiffness measurements.

According to the study by 1, liver stiffness measurements on elastography can be influenced not only by fibrosis but also by edema, inflammation, extrahepatic cholestasis, and passive congestion. The study also notes that patients undergoing US elastography should be fasting.

The European Society of Gastrointestinal Endoscopy (ESGE) and European Association for the Study of the Liver (EASL) clinical guideline, as mentioned in 1, recommends that cholangiocarcinoma should be suspected in any patient with worsening cholestasis, weight loss, raised serum CA19-9, and/or new or progressive dominant stricture, particularly with an associated enhancing mass lesion.

However, elevated liver stiffness is not specific to cholangiocarcinoma and can occur in many other liver conditions including viral hepatitis, alcoholic liver disease, non-alcoholic fatty liver disease, primary sclerosing cholangitis, and other malignancies. Therefore, while an abnormally high liver stiffness measurement might raise suspicion for cholangiocarcinoma in the appropriate clinical context (especially with other concerning symptoms like jaundice, weight loss, or abdominal pain), it should prompt further diagnostic evaluation with blood tests, imaging studies like MRI with MRCP (magnetic resonance cholangiopancreatography), and possibly biopsy for definitive diagnosis rather than being used as a standalone diagnostic tool for bile duct cancer.

Some key points to consider when interpreting liver stiffness measurements include:

• The presence of other liver conditions that can cause elevated liver stiffness
• The clinical context, including symptoms and laboratory results
• The need for further diagnostic evaluation to confirm the diagnosis of cholangiocarcinoma. As noted in 1, US elastography, including shear-wave elastography and strain elastography, can quantify elasticity and help predict the histologic stage of hepatic fibrosis. However, it is essential to consider the limitations of US elastography, including its operator dependence and potential for unreliable examinations in patients with obesity or ascites.

In summary, elevated liver stiffness on liver elastography should be interpreted with caution and in the context of the patient's overall clinical presentation, and further diagnostic evaluation should be pursued to confirm the diagnosis of cholangiocarcinoma.

From the Research

Elevated Liver Stiffness and Cholangiocarcinoma

Elevated liver stiffness on liver elastography can be associated with various liver conditions, including cholangiocarcinoma (bile duct cancer). The following points summarize the relationship between elevated liver stiffness and cholangiocarcinoma:

• A study published in 2008 2 found that malignant liver tumors, including cholangiocarcinoma, had significantly greater mean shear stiffness than benign tumors and normal liver parenchyma.
• Another study published in 2019 3 found that cholangiocarcinoma was associated with a raised enhanced liver fibrosis score, independent of primary sclerosing cholangitis.
• Liver elastography, including transient elastography and MR elastography, has emerged as a non-invasive imaging technique for assessing liver fibrosis and stiffness 4, 5.
• Elevated liver stiffness values have been linked to various risk factors, including metabolic syndrome and harmful alcohol use 6.

Key Findings

• Elevated liver stiffness can be a sign of cholangiocarcinoma, as well as other liver conditions such as fibrosis and cirrhosis.
• Liver elastography is a useful tool for assessing liver stiffness and fibrosis, and can help identify patients at risk of cholangiocarcinoma.
• Further research is needed to fully understand the relationship between elevated liver stiffness and cholangiocarcinoma, and to develop effective screening and diagnostic strategies.

Liver Elastography Techniques

• Transient elastography (TE) is a non-invasive technique that uses ultrasound to measure liver stiffness.
• MR elastography (MRE) is a non-invasive technique that uses magnetic resonance imaging to measure liver stiffness.
• Both TE and MRE have been shown to be effective in assessing liver fibrosis and stiffness, and can help identify patients at risk of cholangiocarcinoma 2, 5.