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Cancer of the bile ducts: Cholangiocarcinoma

Cancer of the bile ducts: Cholangiocarcinoma

Cancer of the bile ducts: Cholangiocarcinoma

Patient’s information

How the bile ducts work:  Bile is a green colored fluid produced by the liver cells. It is collected within the bile ducts and is transported to the gall bladder for storage. The bile from liver mix up with the food from stomach and helps to absorb vitamins (like vitamin D and E) and is required for the process of breaking down fats from our diet.

The presence of food within the first part of small intestine (duodenum) stimulate the gall bladder to contract and squeeze bile out of the gall bladder, into the duodenum. Here it helps to digest and absorb the fats in the food.

Bile contains bile salts and bile pigments, most of which are recycled and the excessive ones are passed out of the body through urine and feces. The blockage of the bile duct system leads to dark urine and pale stools.

Human body is made up of millions of cells. These cells have different shape and function in different parts of the human body. The routine wear & tear of the body cells is controlled by a process called cell cycle. This process is strictly regulated by the body’s control mechanisms. In cancers the cells reproduce in an uncontrolled fashion which can lead to the formation of growth or tumor. The cancer cells develop the ability to invade and destroy surrounding cells by a process called invasion and eventually can spread to the other parts of the body (a process called metastases). Some of the cells that form a lump are malignant (cancerous); others are benign (non-cancerous). The cells which do not spread to other parts of the body (benign tumors) may cause symptoms as they grow by pressing on the surrounding organs. A lump can be diagnosed as benign or malignant with help of different investigations; such as blood tests, x-rays, ultrasound and CT scans. Examination of the affected cells under a microscope can confirm the diagnosis of cancer. The special stains & techniques can also help to determine the origin of the cancer.

Cancer that starts anywhere within the biliary system is called cholangiocarcinoma. “Cholangio” means bile duct and “carcinoma” means cancer. The bile duct cancer is a very uncommon cancer and not much is known about its cause. The presence of choledochal (bile duct) cysts, primary sclerosing cholangitis (a disease of the bile ducts within the liver) and gallstones leading to chronic bile duct irritation has been associated with the increased incidence of the bile duct cancer. The bile duct cancer usually is a slow growing cancer and can spread to other parts of the body in the later stages of the disease. Its incidence is about 20 per million population and affects both men and women equally. Usually it is more common in people over 65 years of age; however recently young patients in their 4th decade of life are being diagnosed with bile duct cancer in Pakistan.

Symptoms of the bile duct cancer: The general symptoms are non-specific and includes: weight loss, lethargy/tiredness, loss of appetite, indigestion and abdominal pain.

Once the cancer causes a blockage of the bile ducts symptoms include; pale feces, dark urine, itching and jaundice.

Clinical evaluation by the doctor to look for the presence of jaundice (yellowness of skin and eyes) or presence of scar marks (due to itching)  and presence of any lumps in the tummy.

Blood tests including LFT’s (bilirubin level in your blood will be high due to the blockage of the bile duct).

Hemoglobin (Hb level) can be low

Tumor markers. These are substances normally seen in the blood, however, in people with a cancer they may be high. In bile duct cancer, the tumor marker that has been associated with it is Ca19.9.

Ultrasound scan

CT scan

MRI (magnetic resonance imaging)

Endoscopic Retrograde Cholangio-Pancreatography (ERCP)

Endoscopic ultrasound (EUS)

You may undergo one or more of the scans in order to help identify the tumor and assess your suitability for the various treatments.

Histology/cytology: All of the previously mentioned tests may lead the doctor to diagnose bile duct cancer. However the only definite way to confirm this diagnosis is to examine some of the abnormal tissue (cancer cells) under a microscope. Some cells may be taken during the ERCP procedure (theses are called brushings). These cells are taken to the laboratory for cytology examination. However, the results of cytology do not always produce a diagnosis and may give a negative result, despite a cancer existing. If a larger sample of tissue is required we may perform a biopsy. This is when a needle is passed through your skin, into the affected area. If your doctor is planning to treat your cancer with surgery, you may not undergo a biopsy, as tissue confirmation can be obtained after the operation, by the laboratory.

Treatment: Complete surgical removal of the cancer is the main stay of bile duct cancer treatment. The aim of the treatment is to treat the cancer and any symptoms it may cause. Treatment of the bile duct cancer depends on the stage of the cancer and may differ from person to person because of:

Location of the cancer: The bile duct cancer can occur anywhere within the bile duct system. There are bile ducts throughout the liver – these are called intra (within) hepatic (liver) bile ducts, some of which may run alongside major vessels that supply blood to or return blood from the liver.

There are also bile ducts that run from the liver to the gall bladder, and then from the gall bladder to the duodenum – these are called extra (outside) hepatic ducts.

Size of the cancer: The bile duct cancers can grow to a relatively large size causing any symptoms. Some cancers may be too small to identify on scanning tests.

Spread of the cancer: CT scans can detect whether the cancer has spread to any other part of the body – including the lymph glands. As the lymph system runs throughout the body, cancer that may have spread to the lymph system can increase the risk of further cancer spread (metastases) or increase the risk of cancer recurrence where the main cancer has been already surgically removed.

Age of the patient: Age can affect how well your body works, however, when deciding on which treatment is the best for each individual, it is important to assess each person’s actual health, rather than expected health for someone of that age.

Associated medical problems:  Are you well despite having another illness or does you have other medical problem limiting your lifestyle or life expectancy? Curable or palliative (may alleviate symptoms) therapies may be offered to you, depending on the factors mentioned above. The clinical team caring for you will discuss, with you, the different treatments and therapies available. They will assist and support you in making decisions and choices about what is right for you.

Surgery: Surgery may be offered as a potentially curable or palliative treatment. At present complete surgical removal of the cancer offers the only possible cure.

Surgery to remove an intra-hepatic bile duct cancer will involve removing part of the liver. A normal working liver can continue to function effectively, even if up to 80% of the liver is removed. The part of the liver that would remain after surgery will be assessed to ensure that it is function is normal. However, if the liver function is compromised, removing even a small part of it may lead to liver failure and/or death.

Surgery to remove an extra-hepatic bile duct cancer may involve removing part or all of any tissue or organ next to it. As an example, if the cancer is within the gall bladder it may be necessary to remove a small part of the liver, as the gall bladder is attached to the undersurface of the liver. If it is near the lower part of the bile duct system, then part of the duodenum (small intestine) may need to be removed. After surgery, patient are monitored in a dedicated Liver Intensive Care Unit for 24-48 hours. After smooth ICU recovery you will be moved to a ward.

Stenting: The insertion of a plastic or metal tube into the blocked bile duct, in order to keep it open is called stenting. It helps to restore the flow of bile in to the intestine and can alleviate jaundice. The stent can be inserted by a procedure called Endoscopic Retrograde Cholangio-Pancreatogram (ERCP) and it’s done by gastroenterologists/ hepatologists. This is preferred way of stent placement as it is more convenient for the patient. In case of failed ERCP; the other way to insert the stent is called Percutaneous Transhepatic CholangioPancreatogram (PTC) and this procedure is done by specialist doctors called as interventional radiologists

If the cancer is causing a narrowing of the small intestine (duodenum) this can cause problems with your ability to eat and drink and leads to vomiting after meals. A stent, larger than that used for the bile ducts, can be used and inserted into the duodenum to allow you to eat and drink, without nausea and/or vomiting.

Chemotherapy:  The treatment of cancer with drugs is called chemotherapy). This treatment may be offered as a palliative treatment, where surgery is not possible, or as an add-on to surgical treatment. The aim of the palliative it to potentially slow down and/or shrink the cancer. As an “add-on” (adjuvant) treatment, it is offered to treat any cancer that may remain after surgery. Each dose of chemotherapy (single or combination) is called a cycle, each cycle is usually separated by a 2-3 weeks of a recovery period. This allows your body to receive the treatment, react/respond and recover.

Unfortunately, with bile duct cancer, it is very difficult to predict whether it will respond to chemotherapy. However, in some people, even if a response is not achieved, they may find it can alleviate their symptoms and may prolong their life expectancy.

Palliative care: If after a detailed discussion of the treatment options you and your family decide rather not to receive any active treatment for your condition, or we feel that active treatment would not help you; the team will refer you for palliative care (supportive care to alleviate symptoms, not a curative treatment) near your home. Supportive care can also be offered to you if you are undergoing treatment such as chemotherapy, which is not expected to offer you a cure.

If you have any further questions or worries please feel free to ask the staff on your ward, your surgical team or your clinical nurse specialist.

 

Patient Help Line (PHL) is a service that offers support, information and assistance to patients, relatives and visitors. They can also provide help and advice if you have a concerns.

The PHL office is located on the ground 6th floor of the “Quaid e Azam International Hospital”, Islamabad our staff will be happy to help and assist you.

Transplant coordinator:

Mr. Touseef Ahmed 0333-1027353

Transplant Coordinator: (for post-transplant follow up patients):

M. Zaheen Hashmi 0333-1027354

Hepatobiliary & Pancreatic Surgery Services:

Muhammad Asif 0341-0543883

24 Hours Patients emergency Helpline: 0333-1027356

Email: info@faisaldar.com

Counselling service: The counselling service offers free and confidential sessions to our inpatients, outpatients, their relatives and friends. If you would like to meet with one our counsellors you can contact us on 0333-1027356

New Life Health Services at Quaid e Azam International Hospital”, Islamabad, Pakistan

Transplant coordinator:

Mr. Touseef Ahmed 0333-1027353

Transplant Coordinator: (for post-transplant follow up patients):

M. Zaheen Hashmi 0333-1027354

Hepatobiliary & Pancreatic Surgery Services:

Muhammad Asif 0341-0543883

24 Hours Patients emergency Helpline: 0333-1027356

Email: info@faisaldar.com

Website: www.faisaldar.com

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