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Biliary tract cancer
- 1. Biliary Tract Cancer PresentedBy : Dr Ankit Lalchandani Moderated By : Dr MP Singh
- 2. GB Cancer • Highprevalence in north India • Incidence increases with age • Women > men • Risk Factor : chronic inflammation due to gall stones • Gall stone present in 70-90% patients • But only 0.5-3 % patients with gall stones develop GB cancer
- 3. • Others : •Porcelain GB • Adenomatous polyps • S. Typhi infection • Radon exposure • APBDJ
- 4. • Abnormal PancreaticobiliaryDuct Junction • Long common channel and increased tone of Sphincter of Oddi • Reflux of pancreatic secretions into CBD chronic inflammation • Carcinoma occur at a younger age • Not associated with cholelithiasis
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- 6. • Histology • Adenocarcinoma( 80%) • Small cell • Squamous cell CA • Lymphoma • Morphology • Infiltrative : diffuse growth, difficult to recognize on imaging, metastasize early • Papillary : Project into the lumen, less likely to metastasize , best prognosis
- 7. Clinical Presentation anddiagnosis • Symptoms • Early : asymptomatic / mild abdominal pain, anorexia, nausea • Advanced : weight loss, hepatomegaly, ascites • Blood investigations • Suggest obstructive jaundice • Tumor markers CEA/ CA 19-9 may be elevated ( low sensitivity and specificity)
- 8. Diagnostic Imaging • USGabdomen • Asymmetrical wall thickening • GB mass • Loss of normal GB- liver interface
- 9. • CECT Abdomen •To assess local invasion • Vascular invasion • Lymph node involvement • Distant Metastasis • MRI/MRCP • Delineates invasion into porta hepatis
- 10. • ERCP/PTC : •used primarily for palliation or preoperative management of obstructive jaundice • FNAC/ Biopsy : • Contraindicated if imaging features suggestive of resectable disease
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- 13. Surgical Management • Macroscopicallycomplete surgical resection with negative margin (R0) remains the only curative treatment T1a • Tumors confined to lamina propria • Incidental finding post cholecystectomy • Simple cholecystectomy alone is definitive ( 5yr survival 97-99%, Recurrence 0.6-3.4 %)
- 14. T1b • Tumors invademuscularis propria • Rates of residual disease in GB fossa after simple cholecystectomy ~10% • Rate of lymph node positivity ~15% • Extended cholecystectomy with en bloc resection of adjacent liver parenchyma to include segment IVb and V + Regional LN dissection • Bile duct resection only if cystic duct margin is positive
- 15. T2 • Tumors extendthrough perimuscular connective tissue • Nodal positivity rate 39-46% • Recommended Tx : same as T1b • Simple cholecystectomy is done in subserosal plane, increased risk of residual disease • If diagnosed postcholecystectomy : Re exploration and radical resection and re excision of all port sites
- 16. T3 • Tumors invadeGB serosa and/or invade liver or an adjacent organ • Major hepatic resections may provide survival advantage if disease is limited to periportal lymph nodes • 5 yr survival 16-39% • As GB fossa bridges IVb and V , extended right hepatectomy may be required
- 17. T4 • Tumors invade2 or more adjacent organs or invade main portal vein/hepatic artery • Unresectable Lymph Node dissection : • Portal LN dissection recommended for T1b –T4 (porta hepatis, gastrohepatic ligament, retroduodenal) • AHPBA recommends at least 6 LN to be dissected • N2 disease ( celiac, retropancreatic, inter aortocaval) is unresectable
- 18. Staging Laparoscopy: • Identifiesthose with unresectable disease when imaging studies are equivocal • High yield in T3 disease (30-50%) Adjuvant Therapy : • EBRT +/- 5 FU is associated with low rates of local recurrence • Not standard recommendation
- 19. Palliation • Goals : •Relieve pain : Opioid analgesics • Biliary obstruction : ERCP and stenting/ PTBD • Bowel obstruction : Endoscopic Duodenal stenting • Chemotherapy : Gemcitabine + cisplatin ( ABC-02 trial)
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- 21. Cholangiocarcinoma • Involves intrahepaticand extrahepatic biliary channels • Incidence men > women • Risk Factors • Primary Sclerosing cholangitis • Liver flukes (Opisthorchis and chlonorchis) • Choledochal cyst • Carolis disease • Hepatolithiasis • Thorotrast • Hepatitis C
- 22. • 90% areadenocarcinomas • Morphology : • Sclerosing : intense desmoplastic reaction, highly invasive, low resectability • Nodular : constriction annular lesions, low resectability • Papillary : rare, bulky masses projecting into the lumen, cause jaundice early, high resectability • Location : • Intrahepatic (10%) • Perihilar (65%) • Distal ( 25%)
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- 24. Clinical Presentation • Intrahepatic •Present with non specific symptoms • May have Increased ALP with normal bilirubin • Extrahepatic • Present with painless obstructive jaundice • Unilobar bile duct obstruction may present with unilobar atrophy with compensatory contralateral hypertrophy • Tumors arising at or below the bifurcation present early • CEA/CA 19-9 have low sensitivity and specificity, not routinely used as diagnostic tool • May be used for surveillance among patients with PSC
- 25. Diagnosis • CECT • Siteand extent of the primary • Vascular invasion • Lymph node involvement • Distant metastasis • Unilobar Liver atrophy with contralateral hypertrophy ( s/o unilobar bile duct infiltration by tumor)
- 26. • Cholangiography • PTC: for intrahepatic and perihilar tumors • ERCP : For distally located tumors • MRCP : non invasive, no ionic contrast used, can visualize bile ducts both proximal and distal to stricture • Cytology • Indicated for stricture in PSC to rule out malignancy • ERCP guided brush cytology EUS guided FNA
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- 30. Surgical Management Intrahepatic Cholangiocarcinoma •Major hepatic resection with negative margins is curative ( +/- EHBD, vascular resction) • 5 yr survival in R0(39%) vs R1(4.7%) • Surgery recommended only if R0 possible
- 31. • Contraindications: • Involvementof inflow and outflow bilaterally • Multiple intrahepatic tumors • Metastatic disease • Lymph node dissection • No therapeutic value • May help in staging and prognosis
- 32. Perihilar Cholangiocarcinoma • R0resection may require partial hepatectomy along with EHBD resection • Include resection of caudate lobe for tumors involving confluence • Frozen section should be performed to ensure negative margins • Secondary R0 resection vs primary R0 • Survival is equivalent • Increased incidence of biliary fistula after additional resection • After R0, 5 yr survival (20-40%, median 36 months) with high recurrence rates (68% within 24 months)
- 33. • Contraindications • Hepaticduct involvement with tumor extension bilaterally to second order radilcles • Encasement of main portal vein • Lobar atrophy with tumor involvement of contralateral second order biliary radicles • Lobar atrophy with tumor involvement of contralateral portal vein branches • Distant metastasis • Lymph Node dissection • Include nodes along hepatoduodenal ligament • Inclusion of lymph nodes along common hepatic or coeliac axis is not recommended • For accurate staging, at least seven LN recommended
- 34. Distal Cholangiocarcinoma • Mostcommonly along the pancreatic portion • High rates of lymph node (63%) and pancreatic invasion (87%) • Resection involves pancreaticoduodenectomy and lymphadenectomy • After R0, 5 yr survival ( 27-44%), median survival 18 months
- 35. Palliation • Goal :Relieve biliary obstruction • Biliary stenting • Percutaneous : proximal tumors • Endoscopic : Distal tumors • Bismuth Type 1 require single stent while others may require two or more • Plastic stents patency (3-6 months) vs metal stents ( 8-12 mo) • Chemotherapy : Gemicitabine + cisplatin
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