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Page 2 of 14 Afyouni et al. Hepatoma Res 2023;9:28 https://dx.doi.org/10.20517/2394-5079.2023.29

[3,4]
thorotrast, and certain metabolic disorders .

Clinical presentation and prognosis
ICC often presents at an advanced stage due to its asymptomatic nature in the early stages of the disease.
Patients may experience nonspecific symptoms such as abdominal pain, weight loss, fatigue, and jaundice.
The presence of these symptoms is usually indicative of advanced disease, and patients may already have
[5]
liver dysfunction or metastases at the time of diagnosis . Therefore, the prognosis associated with ICC is
generally poor, with a 5-year survival of approximately 10%-15% .
[6]
Importance of early and accurate diagnosis
Early and accurate diagnosis of ICC is essential to improve patient outcomes, as it allows for timely
initiation of appropriate treatments. Early-stage tumors may be amenable to surgical resection, which offers
the best chance of long-term survival. In contrast, advanced-stage tumors are usually not amenable to
surgical resection; in turn, patients with advanced disease are often only eligible for non-curative treatment
options such as chemotherapy, radiation therapy, or targeted therapies . Precise diagnosis is also crucial to
[5]
differentiate ICC from other hepatic malignancies, such as hepatocellular carcinoma (HCC), as the
management strategies and prognoses for these tumors differ significantly . This review aims to summarize
[7]
the current literature regarding the role of diagnostic radiology in the management of ICC, and prospects
for research and clinical practice in the management of ICC.

The role of radiology in the diagnosis
The diagnosis of ICC primarily relies on imaging studies and biopsy. Conventional imaging methods such
as ultrasound, computed tomography (CT), magnetic resonance imaging (MRI), and Positron Emission
Tomography (PET) [Figure 1] are commonly used to identify and characterize liver lesions. Distinguishing
ICC from other primary liver cancers, such as HCC, combined hepatocellular cholangiocarcinoma (cHCC-
CCA) [Figure 2], and secondary liver tumors (e.g., metastases from colorectal cancer) can be challenging,
however, due to overlapping imaging features and nonspecific clinical presentation , precise
[8,9]
differentiation is essential as management strategies and prognoses for these tumors differ significantly.

MRI generally outperforms CT and Ultrasound in the diagnosis of hepatic tumors. This is because MRI
allows for the comparison of conventional T2-W and T1-W data with functional DWI and DCE-MRI data
in a single protocol. Granata et al. evaluated MR features of patients with ICC and compared the
radiographic features with control groups, including colorectal hepatic metastases (group A), peribiliary
metastases (group B), HCC (group C), cHCC-CCA (group D), and hemangioma (group E). Of note, T1 and
T2 W signal intensity (SI), restricted diffusion, (transitional phase) TP, and (hepatobiliary phase) HP
appearance was able to differentiate ICCs from mimickers; the arterial phase (AP) appearance differentiated
the study group from the control groups C and D. Portal phase and washout appearance distinguished ICC
[10]
tumors from control groups A, C, and D .
Conventional MRI sequence characteristics can distinguish HCC and cHCC-CCA. The radiologist should
suspect cHCC-CCA if the lesion has satellite nodules, a hyperintense signal on T2-W, restricted diffusion,
[11]
and no capsule in a nodule with peripheral and increasing contrast enhancement .
MRI with diffusion-weighted imaging (DWI) provides quantifiable functional parameters for measuring the
mobility of water ions in the tissue microstructure. Viscosity, vascularity, and tissue cell density are all
connected to water diffusion mobility. Numerous researchers have examined the role of DWI in ICC with a
specific focus on how DWI affects the capability to distinguish between IMCC and HCC. A study by Park
et al. employed the target appearance (TA) on the DWI to differentiate small ICC from HCC [12,13] , and