Bile Duct Cancer Health Article

Diagnosis

Certain laboratory tests of the blood may aid in the diagnosis. The most important one is the test for elevated bilirubin levels in the bloodstream. Levels of alkaline phosphatase and CA 19-9 may also be elevated.

When symptoms, physical signs, and blood tests point toward an abnormality of the biliary tract, then the next step involves radiographic tests. Ultrasound and computed tomography (CT scan) are noninvasive and rapid. These tests can often detect the actual tumor as well as dilatation of the obstructed biliary tract. If these tests indicate the presence of a tumor, then cholangiography is required. This procedure involves injecting dye into the biliary tract to obtain anatomic images of the bile ducts and the tumor. The specialist that performs this test can also insert small tubes, or stents, into a partially obstructed portion of the bile duct to prevent further obstruction by growth of the tumor. This is vitally important since it may be the only intervention that is possible in certain patients. Cholangiography is an invasive test that carries a small risk of infection of the biliary tract. The objective of these radiological tests is to determine the size and location of the tumor, as well as the extent of spread to nearby structures.

The treatment of bile duct tumors is usually not affected by the specific type of cancer cells that comprise the tumor. For this reason, some physicians forego biopsy of the tumor.

Treatment team

The treatment team may include the patient's primary physician, a surgeon, and a gastroenterologist who specializes in the stenting technique described above for palliation of bile duct strictures.

Clinical staging, treatments, and prognosis

Staging

Bile duct tumors are staged according to the tumor-node-metastasis (TNM) system of the American Joint Commission on Cancer. This staging scheme assesses the invasiveness of the tumor, the involvement of nearby lymph nodes, and the extent of distant metastasis.

• Stage I tumors are confined to the bile duct itself.
• Stage II tumors extend to the immediately adjacent tissues.
• Stage III tumors have spread to associated lymph nodes.
• Stage IV tumors have invaded local structures or have metastasized to distant structures.

A higher stage signifies worse prognosis.

Treatment

The only hope for cure lies with surgical resection (removal) of the tumor and all involved structures. Unfortunately, sometimes the cancer has already spread too far when the diagnosis is made. Thus, in the treatment of bile duct cancer, the first question to answer is if the tumor may be safely resected by surgery with reasonable benefit to the patient. If the cancer involves certain blood vessels or has spread widely throughout the liver, then resection may not be possible. Sometimes further invasive testing is required.

Angiography can determine if the blood vessels are involved. Laparoscopy is a surgical procedure that allows the surgeon to directly assess the tumor and nearby lymph nodes without making a large incision in the abdomen. Only about 45% of bile duct cancers are ultimately resectable.

If the tumor is resectable, and the patient is healthy enough to tolerate the operation, then the specific type of surgery performed depends on the location of the tumor. For tumors within the liver or high up in the biliary tract, resection of part of the liver may be required. Tumors in the middle portion of the biliary tract can be removed alone. Tumors of the lower end of the biliary tract may require extensive resection of part of the pancreas, small intestine, and stomach to ensure complete resection.

Unfortunately, sometimes the cancer appears resectable by all the radiological and invasive tests, but is found to be unresectable during surgery. In this scenario, a bypass operation can relieve the biliary tract obstruction, but does not remove the tumor itself. This does not produce a cure but it can offer a better quality of life for the patient.

Chemotherapy and radiation therapy have not been proven effective in the treatment of bile duct cancer.

Prognosis

Prognosis depends on the stage and resectability of the tumor. If the patient cannot undergo surgical resection, then survival is expected to be less than one year. If the tumor is resected, survival improves but is still dismal. Only 20% of these patients survive past five years.