Bile duct cancer treatment
Bile duct cancer (cholangiocarcinoma) is a rare malignant disease that affects the bile ducts and the gallbladder. Currently, there are sufficient treatments for cholangiocarcinoma: surgery, chemotherapy, radiation therapy, targeted therapy, interventional radiology methods, radiotherapy, ablation and photodynamic therapy.
Bile duct cancer (also called cholangiocarcinoma) originates from the epithelium of the mucous membrane of the biliary tract. The tumour develops when malignant (cancerous) cells occur in one of the ducts that transport bile from the liver to the duodenum.
It includes three types, classified according to their origin and location. We distinguish between:
- The bile ducts inside the liver (intrahepatic cholangiocarcinoma);
- Those outsides of the liver (extrahepatic cholangiocarcinoma);
- Gallbladder cancer.
Cancers of the bile ducts are relatively rare and usually only appear in old age. It happens mainly in people over 50. While more women are affected by gallbladder cancer, men are more likely to be affected by bile duct cancer.
What are the causes of malignant bile duct tumours?
This type of cancer goes through several stages of development. Beginning with individual gene changes (mutations) and ending with cancer over several intermediate steps. There are risk factors leading to DNA damage and increasing the risk of developing bile duct cancer:
- Inflammatory conditions. Patients with chronic inflammatory bowel diseases, such as ulcerative colitis, are at increased risk. People who have primary sclerosing cholangitis, an inflammatory disease that affects the bile ducts, are also at increased risk of cholangiocarcinoma;
- Anomalies of the development of bile ducts. People born with congenital abnormalities such as a choledochal cyst (sac-like enlargement of the bile duct) have a higher risk of developing cancer;
- Infection. A large number of patients had parasitic infections before getting diagnosed with cholangiocarcinoma;
- Cirrhosis. Alcoholic liver damage leads to cirrhosis and bile duct cancer;
- Toxins. Effects on the body of chemical agents (for example, thorium dioxide);
- Age. Although cholangiocarcinoma can occur in young people, more than two-thirds of it occurs in people over 65.
The most common signs
The exact symptoms depend on tumour localisation. For example, cholangiocarcinoma can block bile flow from the liver to the intestine. As a result, bile enters the blood and tissues, causing yellowing of the skin, mucous membranes, and whites of the eyes (jaundice). Most patients decide to visit the doctor after these signs. It also causes dark yellow urine and pale stools.
The other symptoms are:
- Indigestion, especially of fats;
- Itching of the skin;
- Light-coloured stools;
- Nausea and vomiting;
- Right upper abdominal pain;
- Weight loss.
Many other reasons besides bile duct cancer can cause these symptoms, but it is essential to check with a doctor.
Bile duct cancer diagnosis
The diagnosis of cholangiocarcinoma begins with a comprehensive medical examination, during which the patient must describe his symptoms and medical history. The following examinations are commonly used to diagnose the disease:
Traditional blood tests can be very informative for preliminary screening. Liver function tests are blood tests to study the functional state of the liver. For example, examining unique proteins can detect disorders of the gallbladder and bile ducts. Tumour marker tests are methods of diagnosing blood or urine for the presence of markers that indicate bile duct cancer.
Abdominal ultrasound is the primary imaging method used to diagnose bile duct cancer. With the help of ultrasound, specialist detects changes in the liver, gallbladder, bile ducts, and pancreas. Doctors can find a bile duct tumour during regular CT or MRI scans of the abdomen.
Magnetic resonance cholangiopancreatography (MRCP) is a special and very accurate method of diagnosis that allows the doctor to examine the condition of the liver, gallbladder and bile ducts in detail.
Endoscopic retrograde cholangiopancreatography (ERCP) helps examine the inside of the bile and pancreatic ducts. First, a special device is inserted into the pharynx. Next, the doctor carefully passes it through the oesophagus, stomach and duodenum. Finally, the device reaches the place where the bile duct and the duct of the pancreas are connected to investigate the presence of suspicious changes.
Percutaneous transhepatic cholangiography (PTC) is based on the use of Х-ray radiation similar to ERCP. The difference is that the doctor performs a puncture and inserts a special needle directly into the ducts. As a result, the method has high reliability and informativeness.
A biopsy is prescribed to confirm and establish the stage of the bile duct cancer. The doctor takes a sample of the affected tissue and examines it under a microscope (so-called histological examination). As a result, doctors can precisely determine the type of malignant cells.
After getting the results of histological examination, the oncologist classifies bile duct cancer by stages:
- I - a single small tumour within one bile duct or gallbladder without damaging vessels and surrounding tissue;
- II - a single large tumour or several small, without vascular damage and metastasis;
- III - several malignant neoplasms that can penetrate blood vessels and surrounding organs but do not metastasise;
- IV - several different-sized tumours that can affect vessels and organs and metastasise.
The latest treatment options for bile duct cancer
The treatment plan depends on cancer's location and size, whether it has spread beyond the bile ducts, and how much it affects your overall health. In some cases, the goal of treatment is to relieve symptoms. However, removing the cancerous tumour is the primary treatment for bile duct cancer.
Surgical treatment - in the case of gallbladder cancer, surgeons remove the gallbladder and sometimes part of the bile ducts and the liver (partial hepatectomy) as part of an operation. In case of spreading cholangiocarcinoma to the pancreas, doctors perform Whipple surgery. This complex operation involves the removal of the head of the pancreas, part of the small intestine (duodenum), gallbladder, and the bile ducts. Liver transplantation is effective in the initial stages and if a donor presents. And if it's untreated cancer, only palliative surgery will help reduce symptoms and pain.
Chemotherapy - during chemotherapy, doctors use potent cell toxins, the cytostatics. As a result, chemotherapy slows down cancer cells' growth, preventing cell division and killing them. There are several locally advanced chemotherapy options: Transarterial chemoembolisation - the doctor uses tiny beads to block the blood supply to the tumour and destroy it with chemo drugs. Transarterial chemoperfusion - chemo drugs are injected directly into the tumour artery.
Immunotherapy - the method aims to activate your immune system against foreign malignant cells in the gallbladder and bile ducts. Target therapy - the technique of cholangiocarcinoma treatment, in which antitumor drugs target specific damaged enzymes of bile ducts. So it works on the cause and doesn't affect healthy cells.
Ablation therapy (RFA, MWA, Ethanol) - ablation therapy is the method of bile duct cancer treatment. A doctor can use radio waves (radiofrequency ablation, RFA), microwaves (microwave ablation), or alcohol (ethanol ablation).
Radioembolization - is an effective and breakthrough method for treating malignant neoplasms. It is based on destroying cancer cells with the help of radioactive substances delivered through arterial vessels. They block the blood flow to the tumour tissues and lead to the destruction of bile ducts cancer.
Radiation therapy - the method works with high-energy X-rays. Radiotherapy can stop the tumour from growing but cannot eliminate it. Therefore, radiotherapy is usually performed after (adjuvant) or before (neoadjuvant) the surgery to reduce possible relapse. Brachytherapy (internal radiotherapy) - the method of contact internal radiotherapy for cholangiocarcinoma uses the installation of radioactive drugs directly into the tumour. The most advanced radiotherapy option is proton beams. Proton therapy - is the type of radiation therapy for cholangiocarcinoma without damaging surrounding organs. In addition, it makes proton therapy more precise than conventional radiotherapy.
Photodynamic therapy (PDT) - first, doctors administer a substance that makes the cancerous tissue sensitive to laser beams, a so-called photosensitiser. Then, laser light is introduced into the bile duct via an endoscope, which destroys the tumour tissue. Healthy tissue is largely spared.
What can patients with a bile duct tumour expect?
Despite many modern treatment options, the prognosis is not very satisfactory. The 5-year survival of such patients ranges from 10 to 15%. It applies to cases where the malignant process does not go beyond the bile ducts. But in the case of spreading to vessels and surrounding tissues and metastases, the 5-year survival level is only 2%.
The main difficulties with biliary system tumours are the late diagnosis and fast spreading. Therefore, doctors rarely diagnose patients in the early stages. However, when the condition is appropriately and timely diagnosed, patients can expect a cure in localized cases and effective disease control in advanced cancer.
How fast does the bile duct tumour spread?
Compared to liver cancer, bile duct cancer grows much faster. In short, the tumour spreads beyond the ducts and grows into blood vessels and surrounding tissues. Cholangiocarcinoma also tends to metastasise actively and requires immediate treatment.
How to cure bile duct cancer?
Treatment depends on the tumour's size, number and location, the degree of its malignancy, and the presence of metastases and comorbidities. Accordingly, the doctor chooses the necessary complex treatment. That may include surgery, chemotherapy, radiation therapy, targeted therapy, local chemotherapy, interventional radiotherapy, ablation and photodynamic therapy.
What type of surgeon operates on bile duct cancer?
The extent of surgery in treating bile duct cancer depends on the prevalence. It can be the removal of only the bile ducts and gallbladder. If the process has spread to the liver, surgeons perform a partial hepatectomy. There is also a complex operation (Whipple surgery) to remove the head of the pancreas, duodenum, gallbladder and bile ducts. Another type of surgery is a liver transplant. Due to that, the type of surgeons operating on bile duct cancer includes surgical oncologists, abdominal surgeons, hepatobiliary surgeons and transplant surgeons.
How aggressive is bile duct cancer?
Bile duct malignancy is a very aggressive disease. The danger is that the condition does not manifest itself in the early stages but spreads very quickly and affects distant organs.
What is the life expectancy of bile duct neoplasm?
The average 5-year survival of patients with bile duct cancer ranges from 10 to 15%. However, this figure can reach 18% if the disease is diagnosed early. At the same time, the 5-year survival rate of patients with widespread metastases drops to only 2%.
Where can I get Bile duct cancer treatment?
What are the best clinics for Bile duct cancer treatment?
Who are the best doctors for Bile duct cancer?
Prof. Dr. med. Roland Ladurner from Academic Hospital Martha-Maria Munich
Prof. Dr. med Harald-Robert Bruch, MSc, PhD from Oncological and Haematological Praxis Clinic Bonn
Prof. Dr. med. Roland M. Schmid from University Hospital Rechts der Isar Munich
Prof. Dr. med. Florian Bassermann from University Hospital Rechts der Isar Munich
Prof. Dr. med. Helmut Friess from University Hospital Rechts der Isar Munich