Bile Duct and GB Cancer

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Transcript of Bile Duct and GB Cancer

  • Mazen Hassanain

  • Bile duct CancerAverage age 60 years

    Ulcerative colitis is a common associated condition

    Subtypes: (1) periductal infiltrating, (2) papillary or intraductal, and (3) mass forming-nodular

    Location: 85% extrahepatic

  • Risk FactorsDefinite risk factors Primary sclerosing cholangitis (1% per year)Liver fluke infection (Opisthorchis viverrini) Hepatolithiasis (10%)Biliary malformation (10% choledochal cysts, Caroli's)Thorotrast Probable risk factors Hepatitis C Cirrhosis Toxins (dioxin, polyvinyl chloride) Biliary-enteric drainage procedures

  • Staging

  • T1: Tumor involving biliary confluence unilateral extension to 2 biliary radicles T2 Tumor involving biliary confluence unilateral extension to 2 biliary radicles AND Ipsilateral portal vein involvement ipsilateral hepatic lobe atrophy T3 Tumor involving biliary confluence + bilateral extension to 2 biliary radicles OR Unilateral extension to 2 biliary radicles with contralateral portal vein involvement OR Unilateral extension to 2 biliary radicles with contralateral hepatic lobe atrophy OR Main or bilateral portal venous involvement

  • PresentationObstructive jaundice

    Cholangitis (10%)

    Palpable mass

    Liver cirrhosis

    Cachexia

  • DiagnosisBlood work

    CA19-9: Its sensitivity and specificity for detection of CCA in PSC are 79% and 98%, respectively, at a cutoff value of 129 U/mL.

    Imaging (US, CT, MRI/MRCP, ERCP, PTC, EUS, PET/CT)

  • Treatment and prognosisSurgical resection Adjuvant and neoadjuvant treatmentsMayo Protocol

    The average patient with adenocarcinoma of the bile duct survives less than a year. The overall 5-year survival rate is 15%. Following a thorough radical operation, 5-year survival is about 40%. Biliary cirrhosis

  • Surgery

    Local lymph node metastases (N1) are not an absolute contraindication to surgical treatment, because they do not significantly influence outcomes in hilar CCA

  • GB cancerPredominantly in the elderly

    Incidentally diagnosed at an early stage after cholecystectomy for cholelithiasis (1%)

    Approximately 90% of patients have gallstones. The 20-year risk of developing cancer for patients with gallstones is less than 0.5% for the overall population and 1.5% for high-risk groups

  • Risk FactorsLarger stones (3 cm) tenfold increased risk The risk is higher in patients with symptomatic pts

    Polypoid lesions, particularly in polyps >10mm

    The calcified "porcelain" gallbladder (20%) selective mucosal calcification (7%)

    Choledochal cysts have an increased risk of developing cancer anywhere in the biliary tree, but the incidence is highest in the gallbladder.

  • Other Risk FactorsAnomalous pancreatobiliary duct junction Obesity and pregnancyChronic inflammatory bowel disease Polyposis coli Mirizzi syndrome Bacterial and Salmonella infections Industrial exposure to carcinogens Familial tendency

  • PathologyAdenocarcinomas 90% . Squamous cell, adenosquamous, oat cell,

    Papillary (10%), nodular, and tubular

    Lymphatics are present in the subserosal layer only. Therefore cancers invading but growing through the muscular layer have minimal risk of nodal disease

    40% have distant metastasis at Dx

  • PresentationAbdominal discomfort, right upper quadrant pain, nausea, and vomiting.

    Jaundice, weight loss, anorexia, ascites, and mass

    Blood work

    Imaging (UD, CT, MRI/MRCP, ERCP, PTC, PET/CT)

  • AJCC stagingStage 0: Carcinoma in situ Stage I: T1/2 N0 M0: invades lamina propria, muscle layer, perimuscular connective tissue Stage II: T3 N0/1 M0 T3: perforates the serosa and/or directly invades the liver and/or one adjacent organ Stage III: T4: invades any main vesselStage IV: M1: distant metastases, including metastases in lymph nodes at the pancreatic body and tail

  • Treatment and prognosisSurgeryAdjuvant therapyThe 5-year survival rate of all patients is less than 5%, median survival of 6 months.T1 treated with cholecystectomy 90% 5-year survival T2 lesions treated with an extended cholecystectomy and lymphadenectomy is over 70% Advanced but resectable gallbladder cancer are reported to have 5-year survival rates of 20 to 50%.

  • Surgery

    Lap vs. open

    Post Lap Choly