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Radiologic imaging findings of preneoplastic lesions of cholangiocarcinoma; Biliary intraepithelial neoplasia (BilIN), Mucinous cystic neoplasm (MCN), Intraductal papillary neoplasm (IPNB), Intraductal tubulopapillary neoplasm Premalignant lesions of CCA: Microscopic Biliary intraepithelial neoplasia (BilIN) Macroscopic Mucinous cystic neoplasm (MCN) Intraductal papillary neoplasm (IPNB) Intraductal tubulopapillary neoplasm (ITPN) Biliary Intraepithelial Neoplasia (BilIN): Flat or micropapillary growth of atypical biliary epithelium : Pan-IN Previously ‘‘atypical biliary epithelia’’ or ‘‘biliary dysplasia’’ a/w hepatolithiasis, biliary cysts, flukes, PSC Grossly invisible, subtle (mucosal thickening) Secondary change of underlying disease on imaging Mucinous cystic neoplasm (MCN): Cuboidal/columnar, variably mucin-producing epithelium Ovarian-like stroma, women, more common in Lt liver Noncommunicating with bile ducts, well-demarcated Multilocular, small cyst at wall, papillary projection Low/intermediate dysplasia is more common than high-grade or invasive Intraductal papillary neoplasm of the bile ducts (IPNB): Grossly visible, intraductal papillary or villous growth of biliary-type epithelium Fibrovascular core and frequent mucin overproduction a/w hepatolithiasis, choledochal cysts; (x) PSC Transform to colloid (favorable prognosis) or tubular adenocarcinoma Type 1: Similar to IPMN pancreas, intrahepatic bile duct Type 2: Irregular papillary branching/tubular component, extrahepatic BD Imaging Patterns of IPNB: Diffuse duct ectasia with grossly visible papillary lesions Diffuse duct ectasia without grossly visible mass Localized duct dilatation with mural nodule Intraductal cast with mildly dilated duct Focal stricture with proximal dilation Intraductal tubulopapillary neoplasm (ITPN) Cuboidal or columnar cell without mucin production Tubular architecture & solid sheet without papilla formation Invasive carcinoma in 70 – 80% (IPNB, 60%) Less aggressive behavior than IPNB Summary: Premalignant lesions of CCA: Imaging plays important role to identify & differentiate premalignant lesions BilIN is mostly depicted with focal stenosis with signs of underlying disease MCN is seen with smoothly outlined cyst with internal septa and mural cysts IPNB shows various imaging patterns with different potential of invasiveness Imaging findings are useful for predicting invasive lesion and outcome ITPN shows intraductal cast-like lesion with minimally dilated duct