Palliative Treatment

Palliative Treatment for Cholangiocarcinoma

Palliative therapy for bile duct cancer:
is treatment given to help control or reduce symptoms caused by advanced cholangiocarcinoma. It is not meant to cure the cancer. If the cancer has spread too far to be removed by surgery, doctors may focus on palliative operations, radiation, or other treatments to help make you feel better or to help prevent possible complications from the cancer. Because these cancers tend to advance quickly, doctors try to use palliative therapies that are less likely to have unpleasant short-term side effects, when possible.

Palliative surgery:
Palliative surgery: In some cases a doctor may think that a cancer is resectable based on the information available (imaging tests, laparoscopy, etc.), but once surgery is started it becomes clear that the cancer is too advanced to be removed completely. In these cases, the surgeon might still try to prevent or relieve symptoms using a different approach.

    •  Biliary bypass:
      There are several different biliary bypass operations, and the decision on which one to use is based on the location of the blockage. In these procedures, the surgeon creates a bypass around the tumor blocking the bile duct by connecting part of the bile duct before the blockage with a part of the duct that lies past the blockage, or with the intestine itself.

      This option is more likely to be used if a patient is already having surgery to try to cure the cancer, but it turns out to be unresectable. While a bypass is clearly more invasive than placing a stent or catheter, it has some advantages in that the effects may last longer and infection is less likely to be a problem.

    • Stent or biliary catheter placement:
      If a bypass can’t be done, the surgeon may place a plastic or expandable metal tube (called a stent) inside the bile duct to keep it open (stenting). In some cases the doctor will place a thin flexible tube (catheter) into the bile duct to allow the bile to drain. This may be done as part of a cholangiography procedure such as ERCP or, in some cases, during surgery.

    • A stent is a small metal or plastic tube that keeps the duct open to allow the bile to drain into the small intestine.

    • A catheter is a thin, flexible tube. One end of the tube is placed into a bile duct to allow bile to drain into a bag outside the body through a small hole in the skin of the abdomen. The bag can be emptied when needed. If you have a catheter, your doctor or nurse will teach you how to care for it.

These procedures are often done to help prevent or relieve symptoms from more advanced cancers, but they can also be done to help relieve jaundice before potentially curative surgery is done. This helps lower the risk of complications from the surgeryThe stent or catheter may need to be replaced every few months if it becomes clogged and to reduce the risk of infection and gallbladder inflammation.

Palliative radiation therapy:
Radiation therapy uses high-energy rays or particles to destroy cancer cells. Radiation can be used in different settings to treat bile duct cancer. This therapy is often used to palliate (relieve) symptoms when a cancer is too advanced to be cured. It can help relieve pain or other symptoms by shrinking tumors that block passageways for blood or bile, or press on nerves.

Radiation therapy may be used to help relieve pain and other symptoms by killing some cancer cells that are causing blockage of the bile duct or are pressing on nerves.

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 vomitingDiarrheaFatigue (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.

Tumor ablation (radiofrequency ablation or cryosurgery):
Tumors in the liver that can’t be resected can sometimes be destroyed (ablated) by placing a long metal probe through the skin and into the tumor. The tip of the probe is then heated (in radiofrequency ablation) or frozen (in cryotherapy) to kill the cancer cells.

Photodynamic therapy (PDT):
For this technique, a light-activated drug is injected into a vein. The drug is more likely to collect in cancer cells than in normal cells. A few days later, an endoscope (a long, flexible tube that can be used to look inside the body) is passed down the throat, through the stomach and intestine, and into the bile ducts. A special red light on the end of the endoscope is aimed at the tumor, causing the cells to die. The combination of PDT and stenting can be helpful for patients with bile duct cancer whose tumors aren’t resectable.

This drug can also collect in normal cells in the body, making a person very sensitive to sunlight or strong indoor lights. You will likely need to stay out of any strong light for several weeks after the injection.

Alcohol injection:
To relieve pain, doctors may deaden the nerves that convey sensations of pain from the bile duct and intestinal area to the brain by injecting these nerves with alcohol. This can be done during surgery or by guiding a long, hollow needle into place with the help of a CT scan.