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