Bile Duct Cancer
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Extrahepatic bile duct cancer is a rare disease in which malignant
(cancer) cells form in the part of bile duct that is outside the liver.
A network of bile ducts (tubes) connects the
liver and the gallbladder to the small intestine. This network begins in
the liver where many small ducts collect bile, a fluid made by the liver
to break down fats during digestion. The small ducts come together to form
the right and left hepatic bile ducts, which lead out of the liver. The two
ducts join outside the liver to become the common hepatic duct. The part
of the common hepatic duct that is outside the liver is called the extrahepatic
bile duct. The extrahepatic bile duct is joined by a duct from the gallbladder
(which stores bile) to form the common bile duct. Bile is released from the
gallbladder through the common bile duct into the small intestine when food
is being digested.
Having colitis or certain liver diseases can affect the risk of developing
extrahepatic bile duct cancer.
Risk factors include having any of the following
- Primary sclerosing cholangitis.
- Chronic ulcerative colitis.
- Choledochal cysts.
- Infection with a Chinese liver fluke parasite.
Possible signs of extrahepatic bile duct cancer include jaundice and
These and other symptoms may be caused by extrahepatic
bile duct cancer or by other conditions. A doctor should be consulted if
any of the following problems occur:
- Jaundice (yellowing of the skin or whites of the eyes).
- Pain in the abdomen.
- Itchy skin.
Tests that examine the bile duct and liver are used to detect (find)
and diagnose extrahepatic bile duct cancer.
The following tests and procedures may be used:
- Physical exam and history: An exam of the body to check general signs
of health, including checking for signs of disease, such as lumps or anything
else that seems unusual. A history of the patientís health habits and past
illnesses and treatments will also be taken.
- Ultrasound: A procedure in which high-energy sound waves (ultrasound)
are bounced off internal tissues or organs and make echoes. The echoes form
a picture of body tissues called a sonogram.
- CT scan (CAT scan): A procedure that makes a series of detailed pictures
of areas inside the body, taken from different angles. The pictures are
made by a computer linked to an x-ray machine. A dye may be injected into
a vein or swallowed to help the organs or tissues show up more clearly.
This procedure is also called computed tomography, computerized tomography,
or computerized axial tomography. A spiral or helical CT scan makes detailed
pictures of areas inside the body using an x-ray machine that scans the
body in a spiral path.
- MRI (magnetic resonance imaging): A procedure that uses a magnet, radio
waves, and a computer to make a series of detailed pictures of areas inside
the body. This procedure is also called nuclear magnetic resonance imaging
- ERCP (endoscopic retrograde cholangiopancreatography): A procedure used
to x-ray the ducts (tubes) that carry bile from the liver to the gallbladder
and from the gallbladder to the small intestine. Sometimes bile duct cancer
causes these ducts to narrow and block or slow the flow of bile, causing
jaundice. An endoscope (a thin, lighted tube) is passed through the mouth,
esophagus, and stomach into the first part of the small intestine. A catheter
(a smaller tube) is then inserted through the endoscope into the pancreatic
ducts. A dye is injected through the catheter into the ducts and an x-ray
is taken. If the ducts are blocked by a tumor, a fine tube may be inserted
into the duct to unblock it. This tube (or stent) may be left in place to
keep the duct open. Tissue samples may also be taken.
- PTC (percutaneous transhepatic cholangiography): A procedure used to x-ray
the liver and bile ducts. A thin needle is inserted through the skin below
the ribs and into the liver. Dye is injected into the liver or bile ducts
and an x-ray is taken. If a blockage is found, a thin, flexible tube called
a stent is sometimes left in the liver to drain bile into the small intestine
or a collection bag outside the body.
- Biopsy: The removal of cells or tissues so they can be viewed under a
microscope to check for signs of cancer. The sample may be taken using a
fine needle inserted into the duct during an x-ray or ultrasound. This is
called needle biopsy or fine-needle aspiration biopsy. The biopsy is usually
done during PTC or ERCP. Tissue may also be removed during surgery.
- Liver function tests: A procedure in which a blood sample is checked to
measure the amounts of certain substances released into the blood by the
liver. A higher than normal amount of a substance can be a sign of liver
disease that may be caused by extrahepatic bile duct cancer.
Certain factors affect prognosis (chance of recovery) and treatment
The prognosis (chance of recovery) and treatment
options depend on the following:
- The stage of the cancer (whether it affects only the bile duct
or has spread to other places in the body).
- Whether the tumor can be completely removed by surgery.
- Whether the tumor is in the upper or lower part of the duct.
- Whether the cancer has just been diagnosed or has recurred (come back).
Treatment options may also depend on the symptoms
caused by the tumor. Extrahepatic bile duct cancer is usually found after
it has spread and can rarely be removed completely by surgery. Palliative
therapy may relieve symptoms and improve the patient's quality of life.
After extrahepatic bile duct cancer has been diagnosed, tests are
done to find out if cancer cells have spread within the bile duct or to other
parts of the body.
The process used to find out if cancer has spread
within the extrahepatic bile duct or to other parts of the body is called
staging. The information gathered from the staging process determines the
stage of the disease. It is important to know the stage in order to plan
Extrahepatic bile duct cancer is usually staged
following a laparotomy. A surgical incision is made in the wall of the abdomen
to check the inside of the abdomen for signs of disease and to remove tissue
and fluid for examination under a microscope. The results of the diagnostic
imaging tests, laparotomy, and biopsy are viewed together to determine the
stage of the cancer. Sometimes, a laparoscopy will be done before the laparotomy
to see if the cancer has spread. If the cancer has spread and cannot be removed
by surgery, the surgeon may decide not to do a laparotomy.
Stage 0 (Carcinoma in Situ)
In stage 0, cancer is found only in the innermost
layer of cells lining the extrahepatic bile duct. Stage 0 cancer is also
called carcinoma in situ.
Stage I is divided into stage IA and stage IB.
- Stage IA: Cancer is found in the bile duct only.
- Stage IB: Cancer has spread through the wall of the bile duct.
Stage II is divided into stage IIA and stage
- Stage IIA: Cancer has spread to the liver, gallbladder, pancreas, and/or
to either the right or left branches of the hepatic artery or to right or
left branches of the portal vein.
- Stage IIB: Cancer has spread to nearby lymph nodes and:
- is found in the bile duct; or
- has spread through the wall of the bile duct; or
- has spread to the liver, gallbladder, pancreas, and/or the right or
left branches of the hepatic artery or portal vein.
In stage III, cancer has spread:
- to the portal vein or to both right and left branches of the
portal vein; or
- to the hepatic artery; or
- to other nearby organs or tissues, such as the colon, stomach, small intestine,
or abdominal wall.
Cancer may have spread to nearby lymph nodes
In stage IV, cancer has spread to lymph nodes
and/or organs far away from the extrahepatic bile duct.
Extrahepatic bile duct cancer can also be grouped according to how
the cancer may be treated. There are two treatment groups:
Localized (and resectable)
The cancer is in an area where it can be removed
completely by surgery.
The cancer cannot be removed completely by surgery.
The cancer may have spread to nearby blood vessels, the liver, the common
bile duct, nearby lymph nodes, or other parts of the abdominal cavity.
Treatment of localized extrahepatic bile duct
cancer may include the following:
- Stent placement or biliary bypass to relieve blockage of the
bile duct may be done before surgery to relieve jaundice.
- Surgery, with or without external-beam radiation therapy.
Treatment of unresectable extrahepatic bile
duct cancer may include the following:
- Stent placement or biliary bypass with or without internal or
external radiation therapy, as palliative treatment to relieve symptoms
and improve the quality of life.
- A clinical trial of hyperthermia therapy, radiosensitizers, chemotherapy, or
This summary section refers to specific treatments
under study in clinical trials, but it may not mention every new treatment
Treatment of recurrent extrahepatic bile duct
cancer may include the following:
- Palliative treatment to relieve symptoms and improve quality
- A clinical trial.
There are different types of treatment for patients with extrahepatic
bile duct cancer.
Different types of treatment are available for
patients with extrahepatic bile duct cancer. Some treatments are standard
(the currently used treatment), and some are being tested in clinical trials.
Before starting treatment, patients may want to think about taking part in
a clinical trial. A treatment clinical trial is a research study meant to
help improve current treatments or obtain information on new treatments for
patients with cancer. When clinical trials show that a new treatment is better
than the standard treatment, the new treatment may become the standard treatment.
Choosing the most appropriate cancer treatment
is a decision that ideally involves the patient, family, and health care
The following types of surgery are used to treat
extrahepatic bile duct cancer:
- Removal of the bile duct: If the tumor is small and only in the bile duct,
the entire bile duct may be removed. A new duct is made by connecting the
duct openings in the liver to the intestine. Lymph nodes are removed and
viewed under a microscope to see if they contain cancer.
- Partial hepatectomy: Removal of the part of the liver where cancer is
found. The part removed may be a wedge of tissue, an entire lobe, or a larger
part of the liver, along with some normal tissue around it.
- Whipple procedure: A surgical procedure in which the head of the pancreas,
the gallbladder, part of the stomach, part of the small intestine, and the
bile duct are removed. Enough of the pancreas is left to produce digestive
juices and insulin.
- Surgical biliary bypass: If the tumor cannot be removed but is blocking
the small intestine and causing bile to build up in the gallbladder, a biliary
bypass may be done. During this operation, the gallbladder or bile duct
will be cut and sewn to the small intestine to create a new pathway around
the blocked area. This procedure helps to relieve jaundice caused by the
build-up of bile.
- Stent placement: If the tumor is blocking the bile duct, a stent (a thin
tube) may be placed in the duct to drain bile that has built up in the area.
The stent may drain to the outside of the body or it may go around the blocked
area and drain the bile into the small intestine. The doctor may place the
stent during surgery or PTC, or with an endoscope.
Radiation therapy is a cancer treatment that
uses high-energy x-rays or other types of radiation to kill cancer cells.
There are two types of radiation therapy. External radiation therapy uses
a machine outside the body to send radiation toward the cancer. Internal
radiation therapy uses a radioactive substance sealed in needles, seeds,
wires, or catheters that are placed directly into or near the cancer. The
way the radiation therapy is given depends on the type and stage of the cancer
Other types of treatment are being tested in clinical trials. These
include the following:
Clinical trials are studying ways to improve
the effect of radiation therapy on tumor cells, including the following:
- Hyperthermia therapy: A treatment in which body tissue is exposed to high
temperatures to damage and kill cancer cells or to make cancer cells more
sensitive to the effects of radiation therapy and certain anticancer drugs.
- Radiosensitizers: Drugs that make tumor cells more sensitive to radiation
therapy. Combining radiation therapy with radiosensitizers may kill more
Chemotherapy is a cancer treatment that uses
drugs to stop the growth of cancer cells, either by killing the cells or
by stopping the cells from dividing. When chemotherapy is taken by mouth
or injected into a vein or muscle, the drugs enter the bloodstream and can
reach cancer cells throughout the body (systemic chemotherapy). When chemotherapy
is placed directly into the spinal column, an organ, or a body cavity such
as the abdomen, the drugs mainly affect cancer cells in those areas (regional
chemotherapy). The way the chemotherapy is given depends on the type and
stage of the cancer being treated.
Biologic therapy is a treatment that uses
the patient's immune system to fight cancer. Substances made by the body
or made in a laboratory are used to boost, direct, or restore the body's
natural defenses against cancer. This type of cancer treatment is also called
biotherapy or immunotherapy.