Staging Perihilar Extrahepatic Cholangiocarcinoma

Curative Treatments for Cholangiocarcinoma

Potentially curative surgery:

When imaging tests or the results of earlier surgeries show there’s a good chance that the surgeon can remove all of the cancer. Doctors use the term resectable to describe cancers they believe can be removed completely (by potentially curative surgery) and unresectable to describe those they think have spread too far or are in too difficult a place to be entirely removed by surgery. Unfortunately, only a small portion of bile duct cancers are resectable when they are first found.

If potentially curative surgery is being considered, you may want to get a second opinion or even be referred to a large cancer center. Nearly all doctors agree that surgery offers the only realistic chance for curing people with bile duct cancer. But there are differences of opinion about how advanced a bile duct cancer can be and still be treatable with surgery. The surgery needed for bile duct cancer is often complex and requires an experienced surgeon. These operations are most often done at major cancer centers.

If your surgical team is planning curative surgery, they first may do a laparoscopy (a type of minor surgery) to look for any spread of the cancer that could make curative surgery impossible. During the laparoscopy, the surgeon can look for areas of cancer that were not detected with imaging tests. If the cancer is still resectable, laparoscopy can also help plan the operation to remove it.

Surgery for resectable cancers:

    • Intrahepatic bile duct cancer:
      These cancers have started in bile ducts within the liver. To treat these cancers, the surgeon cuts out the part of the liver containing the cancer. Removing part of the liver is called a partial hepatectomy. Sometimes this means that a whole lobe (right or left part) of the liver must be removed. This is called hepatic lobectomy. It is a complicated operation and requires an experienced team of surgeons and assistants. If the amount of liver removed is not too great, the liver will still function normally because it has some ability to grow back.
       

    • Perihilar bile duct cancer:
      These cancers begin where the branches of the bile duct first leave the liver. Surgery for these cancers requires great skill, as the operation is quite extensive. Usually part of the liver is removed, along with the bile duct, gallbladder, nearby lymph nodes, and sometimes part of the pancreas and small intestine. Then the surgeon connects the remaining ducts to the small intestine. This is a complex operation that can even have life threatening complications for some patients.

    • Distal bile duct cancer:
      These cancers are further down the bile duct near the pancreas and small intestine. Along with the bile duct and nearby lymph nodes, in most cases the surgeon must remove part of the pancreas and small intestine, an operation called a Whipple procedure. Like the other operations, this is a complex procedure that requires an experienced surgical team.

Surgery for unresectable cancer:

 Liver transplant:
For some people with unresectable intrahepatic or perihilar bile duct cancers, removing the liver and bile ducts and then transplanting a donor liver may be an option. In some cases it might even cure the cancer.

But even for people who are eligible for a transplant, getting a new liver may not be easy. Not many centers accept patients with bile duct cancer into their transplant programs. Also, few livers are available for patients with cancer because they are generally used for more curable diseases. People needing a transplant must wait until a liver is available, which can take too long for some people with bile duct cancer.

One option might be having a living donor (often a close relative) give a part of their liver for transplant. This can be successful, but it carries risks for the donor. Another option might be to treat the cancer first with chemotherapy and radiation. This is followed by a transplant when a liver becomes available.

Possible risks and side effects of surgery:
The risks and side effects of surgery depend on the extent of the operation and a person’s general health. All surgery carries some risk, including the possibility of bleeding, blood clots, infections, complications from anesthesia, pneumonia, and even death in rare cases. People will have some pain from the incision for some time after the operation, but this can usually be controlled with medicines.

Surgery for bile duct cancer is a major operation that might mean removing parts of several organs. This can significantly affect a person’s recovery and health after the surgery. Serious problems soon after surgery can include bile leakage into the abdomen, infections, and liver failure. Because most of the organs removed are involved in digestion, eating and nutrition problems can be side effects of surgery for this cancer.

Chemotherapy for Cholangiocarcinoma:
Chemotherapy (chemo) is treatment with anti-cancer drugs that are usually given into a vein or taken by mouth. These drugs enter the bloodstream and reach all areas of the body, making this treatment useful for some cancers that have spread to organs beyond the bile duct. Because the drugs reach all the areas of the body, this is known as a systemic treatment. Chemo can help some people with bile duct cancer, but so far its effects against this type of cancer have been found to be limited.

For resectable bile duct cancers (cancers that can be removed completely), chemo may be used after surgery (often along with radiation therapy) to try to lower the risk that the cancer will return. This is known as adjuvant chemo. Some doctors may use it before surgery for borderline resectable cancers to try to improve the odds that surgery will be successful. This is called neoadjuvant treatment.

Chemo can also be used (sometimes with radiation therapy) for more advanced cancers. Chemo does not cure these cancers, but it might shrink or slow the growth of tumors for a time. This can help relieve symptoms from the cancer, and may help people live longer.

Doctors give chemo in cycles, with each period of treatment followed by a rest period to give the body time to recover. Chemo cycles generally last about 3 to 4 weeks. Chemo is often not recommended for patients in poor health, but advanced age by itself is not a barrier to getting chemotherapy.

Hepatic artery infusion (HAI):
Because giving chemo into a vein is not always helpful for bile duct cancer, doctors have tried giving the drugs directly into the main artery going into the liver, called the hepatic artery. Since the hepatic artery also supplies most bile duct tumors, more chemo goes to the tumor. The healthy liver then removes most of the remaining drug before it can reach the rest of the body. HAI may help some people whose cancer was not removable by surgery live longer, but more research is needed. This technique may not be useful for some people because it often requires surgery to insert a catheter into the hepatic artery, an operation that many bile duct cancer patients might not tolerate well.

Drugs used to treat bile duct cancer
Several drugs can be used to treat bile duct cancer. In some cases, 2 or more of these drugs may be combined to try to make them more effective. The drugs used most often to treat bile duct cancer include:

    • 5-fluorouracil (5-FU)
    • Gemcitabine (Gemzar®)
    • Cisplatin Capecitabine
    • (Xeloda®)
    • Oxaliplatin (Eloxatin®)

Possible side effects of chemotherapy:
Chemo drugs attack cells that are dividing quickly, which is why they work against cancer cells. But other cells in the body, such as those in the bone marrow (where new blood cells are made), the lining of the mouth and intestines, and the hair follicles, also divide quickly. These cells can also be affected by chemo, which can lead to side effects.

The side effects of chemo depend on the type and dose of drugs given and the length of time they are taken. Side effects can include:

    • Hair Loss 
    • Mouth sores
    • Loss of appetite 
    • Nausea and vomiting 
    • Diarrhea
    • Nerve damage
    • Increased chance of infections
    • Easy Bruising
    • bleeding 
    • Fatigue

These side effects are usually short-term and go away after treatment is finished. There are often ways to lessen these side effects. For example, drugs can be given to help prevent or reduce nausea and vomiting. Be sure to ask your doctor or nurse about medicines to help reduce side effects, and let them know when you do have side effects so they can be managed effectively.

Radiation Therapy for Cholangiocarcinoma:
Radiation therapy uses high-energy rays or particles to destroy cancer cells. Radiation can be used in different settings to treat bile duct cancer.

    • After surgery for resectable cancers:This is known as adjuvant therapy. It is meant to kill any tiny deposits of cancer cells that remain after surgery (but are too small to see). Some doctors believe adjuvant radiation therapy is helpful, but more research is needed to confirm this.

    • Before surgery for borderline resectable cancers:
      Some doctors may use radiation therapy before surgery for certain cancers that are thought to be resectable. This is done to try to shrink the cancer and make the operation easier and is known as neoadjuvant therapy. It’s not clear how helpful this is.


    • As part of the main therapy for some advanced cancers: 
      Radiation therapy can also be used as a main therapy for some patients whose cancer has not spread widely throughout the body, but is not resectable. While treatment in this case does not offer a cure, it may help patients live longer.


    • External beam radiation therapy (EBRT):
      This type of radiation therapy uses x-rays from a machine outside the patient's body to kill cancer cells. Before your treatments start, the radiation team will take careful measurements to determine the correct angles for aiming the radiation beams and the proper dose of radiation. The treatment is much like getting an x-ray, but the radiation is much stronger. The procedure itself is painless. Each treatment lasts only a few minutes, but the setup time – getting you into place for treatment – usually takes longer. Most often, radiation treatments are given 5 days a week for several weeks.

      Newer radiation techniques now let doctors more accurately treat bile duct cancers while reducing the radiation exposure to nearby healthy tissues. This may increase the success rate and help reduce side effects.

    • Three-dimensional conformal radiation therapy (3D-CRT):
      This type of radiation therapy uses special computers to precisely map the location of the tumor(s). Radiation beams are then shaped and aimed at the tumor(s) from several directions, which makes it less likely to damage normal tissues.

    • Intensity-modulated radiation therapy (IMRT):
      This type of radiation therapy is an advanced form of 3D therapy. It uses a computer-driven machine that moves around you as it delivers radiation. Along with shaping the beams and aiming them at the cancer from several angles, the intensity (strength) of the beams can be adjusted to limit the dose reaching the most sensitive normal tissues. This lets doctors deliver an even higher dose to the cancer areas.

    • Stereotactic body radiotherapy (SBRT):
      This type of radiation uses the techniques of 3D-CRT and IMRT, but gives the radiation over fewer sessions. A course of SBRT may take less than a week, while a course of radiation using these other techniques often takes place over 3 to 6 weeks.

EBRT side effects:
Side effects of EBRT depend on the area of the body being treated. Some common side effects include:

    • Skin changes, ranging from redness to blistering and peeling.
    • Nausea and vomiting
    • Diarrhea
    •  Fatigue (tiredness) 
    • Hair loss (on the skin in the area being treated)
    • Low blood cell counts

Brachytherapy (internal radiation therapy):
This type of treatment uses small pellets of radioactive material placed next to or directly into the cancer. The radiation travels a very short distance, so it affects the cancer without causing much harm to nearby healthy body tissues. For bile duct cancer, brachytherapy is sometimes done by placing the pellets in a tube, which is inserted into the bile duct for a short time.