Choosing the right treatment for bile duct cancer depends upon the disease stage, the patient’s physical condition and tumor characteristics. Our treatment approach is individualized for every patient.
At UofL Health – Brown Cancer Center, our experts from our Multidisciplinary Gastrointestinal Cancer Clinic team have years of experience treating bile duct cancer with surgery, radiation and chemotherapy.
Bile duct cancer is relatively uncommon in the United States. About 10,000 cases are diagnosed each year, mostly in people over the age of 70. Most bile duct cancers are diagnosed in more advanced stages.
- Bile duct cancer is a rare disease in which malignant (cancer) cells form in the bile ducts.
- Having colitis or certain liver diseases can increase the risk of bile duct cancer.
- Signs of bile duct cancer include jaundice and pain in the abdomen.
- Tests that examine the bile ducts and nearby organs are used to detect (find), diagnose and stage bile duct cancer.
- Different procedures may be used to obtain a sample of tissue and diagnose bile duct cancer.
- Certain factors affect prognosis (chance of recovery) and treatment options.
A network of tubes, called ducts, connects the liver, gallbladder and 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 ducts, which lead out of the liver. The two ducts join outside the liver and form the common hepatic duct. The cystic duct connects the gallbladder to the common hepatic duct. Bile from the liver passes through the hepatic ducts, common hepatic duct, and cystic duct and is stored in the gallbladder.
When food is being digested, bile stored in the gallbladder is released and passes through the cystic duct to the common bile duct and into the small intestine. Bile duct cancer is also called cholangiocarcinoma.
There are two types of bile duct cancer:
Intrahepatic bile duct cancer: This type of cancer forms in the bile ducts inside the liver. Only a small number of bile duct cancers are intrahepatic. Intrahepatic bile duct cancers are also called intrahepatic cholangiocarcinomas.
Intrahepatic bile ducts are a network of small tubes that carry bile inside the liver. The smallest ducts, called ductules, come together to form the right hepatic bile duct and the left hepatic bile duct, which drain bile from the liver. Bile is stored in the gallbladder and is released when food is being digested.
Extrahepatic bile duct cancer: The extrahepatic bile duct is made up of the hilum region and the distal region. Cancer can form in either region:
- Perihilar bile duct cancer: This type of cancer is found in the hilum region, the area where the right and left bile ducts exit the liver and join to form the common hepatic duct. Perihilar bile duct cancer is also called a Klatskin tumor or perihilar cholangiocarcinoma.
- Distal extrahepatic bile duct cancer: This type of cancer is found in the distal region. The distal region is made up of the common bile duct which passes through the pancreas and ends in the small intestine. Distal extrahepatic bile duct cancer is also called extrahepatic cholangiocarcinoma.
Extrahepatic bile ducts are small tubes that carry bile outside of the liver. They are made up of the common hepatic duct (hilum region) and the common bile duct (distal region). Bile is made in the liver and flows through the common hepatic duct and the cystic duct to the gallbladder, where it is stored. Bile is released from the gallbladder when food is being digested.
Having colitis or certain liver diseases can increase the risk of bile duct cancer.
Risk factors for bile duct cancer include the following:
- Primary sclerosing cholangitis (a progressive disease in which the bile ducts become blocked by inflammation and scarring)
- Chronic ulcerative colitis
- Cysts in the bile ducts (cysts block the flow of bile and can cause swollen bile ducts, inflammation, and infection)
- Infection with a Chinese liver fluke parasite.
Signs of bile duct cancer include jaundice and pain in the abdomen.
These and other signs and symptoms may be caused by bile duct cancer or by other conditions. Check with your doctor if you have any of the following:
- Jaundice (yellowing of the skin or whites of the eyes)
- Dark urine
- Clay-colored stool
- Pain in the abdomen
- Itchy skin
- Nausea and vomiting
- Weight loss for an unknown reason
Tests that examine the bile ducts and nearby organs are used to detect, diagnose and stage bile duct cancer.
Procedures that make pictures of the bile ducts and the nearby area help diagnose bile duct cancer and show how far the cancer has spread. The process used to find out if cancer cells have spread within and around the bile ducts or to distant parts of the body is called staging.
In order to plan treatment, it is important to know if the bile duct cancer can be removed by surgery. Tests and procedures to detect, diagnose and stage bile duct cancer are usually done at the same time.
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 patient’s health habits and past illnesses and treatments will also be taken.
- Liver function tests: A procedure in which a blood sample is checked to measure the amounts of bilirubin and alkaline phosphatase released into the blood by the liver. A higher than normal amount of these substances can be a sign of liver disease that may be caused by bile duct cancer.
- Laboratory tests: Medical procedures that test samples of tissue, blood, urine or other substances in the body. These tests help to diagnose disease, plan and check treatment, or monitor the disease over time.
- Carcinoembryonic antigen (CEA) and CA 19-9 tumor marker test: A procedure in which a sample of blood, urine, or tissue is checked to measure the amounts of certain substances made by organs, tissues or tumor cells in the body. Certain substances are linked to specific types of cancer when found in increased levels in the body. These are called tumor markers. Higher than normal levels of carcinoembryonic antigen (CEA) and CA 19-9 may mean there is bile duct cancer.
- Ultrasound exam: A procedure in which high-energy sound waves (ultrasound) are bounced off internal tissues or organs, such as the abdomen, and make echoes. The echoes form a picture of body tissues called a sonogram. The picture can be printed to be looked at later.
- CT scan (CAT scan): A procedure that makes a series of detailed pictures of areas inside the body, such as the abdomen, 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.
- 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.
- MRCP (magnetic resonance cholangiopancreatography): A procedure that uses a magnet, radio waves and a computer to make a series of detailed pictures of areas inside the body such as the liver, bile ducts, gallbladder, pancreas and pancreatic duct.
Different procedures may be used to obtain a sample of tissue and diagnose bile duct cancer.
Cells and tissues are removed during a biopsy so they can be viewed under a microscope by a pathologist to check for signs of cancer. Different procedures may be used to obtain the sample of cells and tissue. The type of procedure used depends on whether the patient is well enough to have surgery.
Types of biopsy procedures include the following:
- Laparoscopy: A surgical procedure to look at the organs inside the abdomen, such as the bile ducts and liver, to check for signs of cancer. Small incisions (cuts) are made in the wall of the abdomen and a laparoscope (a thin, lighted tube) is inserted into one of the incisions. Other instruments may be inserted through the same or other incisions to perform procedures such as taking tissue samples to be checked for signs of cancer.
- Percutaneous transhepatic cholangiography (PTC): 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. A sample of tissue is removed and checked for signs of cancer. If the bile duct is blocked, a thin, flexible tube called a stent may be left in the liver to drain bile into the small intestine or a collection bag outside the body. This procedure may be used when a patient cannot have surgery.
- Endoscopic retrograde cholangiopancreatography (ERCP): 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 is passed through the mouth and stomach and into the small intestine. Dye is injected through the endoscope (thin, tube-like instrument with a light and a lens for viewing) into the bile ducts and an X-ray is taken. A sample of tissue is removed and checked for signs of cancer. If the bile duct is blocked, a thin tube may be inserted into the duct to unblock it. This tube (or stent) may be left in place to keep the duct open. This procedure may be used when a patient cannot have surgery.
Certain factors affect the prognosis (chance of recovery) and treatment options, including:
- The cancer is in the upper or lower part of the bile duct system
- The cancer has spread to nearby nerves or veins
- The cancer can be completely removed by surgery
- The patient has other conditions, such as primary sclerosing cholangitis
- The cancer has just been diagnosed or has recurred (come back)
- It also depends on the stage of cancer (whether it affects only the bile ducts or has spread to the liver, lymph nodes or other places in the body)
Treatment options may also depend on the symptoms caused by the cancer. Bile duct cancer is usually found after it has spread and can rarely be completely removed by surgery. Palliative therapy may relieve symptoms and improve the patient's quality of life. There are different types of treatment for patients with bile duct cancer.
Three types of standard treatment are used:
- Radiation therapy