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    Biliary Tract Cancer: Presented By: DR Ankit Lalchandani Moderated By: DR MP Singh

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    Ankit Lalchandani
    This document summarizes biliary tract cancers including gallbladder cancer and cholangiocarcinoma. It discusses risk factors, pathogenesis, clinical presentation, diagnostic imaging, staging, surgical management including extent of resection needed based on tumor stage, palliative options, and chemotherapy regimens. Complete surgical resection with negative margins offers the only potential for cure but has low 5-year survival rates even with resection due to high recurrence risks. Location of the tumor determines palliative approach to relieve biliary obstruction.

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    Biliary Tract Cancer: Presented By: DR Ankit Lalchandani Moderated By: DR MP Singh

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    Ankit Lalchandani
    50 views36 pages
    This document summarizes biliary tract cancers including gallbladder cancer and cholangiocarcinoma. It discusses risk factors, pathogenesis, clinical presentation, diagnostic imaging, staging, surgical management including extent of resection needed based on tumor stage, palliative options, and chemotherapy regimens. Complete surgical resection with negative margins offers the only potential for cure but has low 5-year survival rates even with resection due to high recurrence risks. Location of the tumor determines palliative approach to relieve biliary obstruction.

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    Biliary Tract Cancer

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    This document summarizes biliary tract cancers including gallbladder cancer and cholangiocarcinoma. It discusses risk factors, pathogenesis, clinical presentation, diagnostic imaging, staging, surgical management including extent of resection needed based on tumor stage, palliative options, and chemotherapy regimens. Complete surgical resection with negative margins offers the only potential for cure but has low 5-year survival rates even with resection due to high recurrence risks. Location of the tumor determines palliative approach to relieve biliary obstruction.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    50 views36 pages

    Biliary Tract Cancer: Presented By: DR Ankit Lalchandani Moderated By: DR MP Singh

    Uploaded by

    Ankit Lalchandani
    This document summarizes biliary tract cancers including gallbladder cancer and cholangiocarcinoma. It discusses risk factors, pathogenesis, clinical presentation, diagnostic imaging, staging, surgical management including extent of resection needed based on tumor stage, palliative options, and chemotherapy regimens. Complete surgical resection with negative margins offers the only potential for cure but has low 5-year survival rates even with resection due to high recurrence risks. Location of the tumor determines palliative approach to relieve biliary obstruction.

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    © All Rights Reserved
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    of 36

    Biliary Tract Cancer

    Presented By : Dr Ankit Lalchandani


    Moderated By : Dr MP Singh
    GB Cancer
    • High prevalence 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
    • Others :

    • Porcelain GB

    • Adenomatous polyps

    • S. Typhi infection

    • Radon exposure

    • APBDJ
    • Abnormal Pancreaticobiliary Duct 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


    Pathogenesis

    p53
    Gall
    Stone
    Chronic
    Dysplasia CIS Carcinoma
    inflammation

    APBDJ

    K ras
    • 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
    Clinical Presentation and diagnosis
    • 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)
    Diagnostic Imaging
    • USG abdomen

    • Asymmetrical wall thickening

    • GB mass

    • Loss of normal GB- liver interface


    • CECT Abdomen
    • To assess local invasion
    • Vascular invasion
    • Lymph node involvement
    • Distant Metastasis

    • MRI/MRCP
    • Delineates invasion into porta hepatis
    • ERCP/PTC :

    • used primarily for palliation or preoperative management of obstructive


    jaundice

    • FNAC/ Biopsy :

    • Contraindicated if imaging features suggestive of resectable disease


    AJCC Staging
    Surgical Management
    • Macroscopically complete 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 %)
    T1b

    • Tumors invade muscularis 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


    T2

    • Tumors extend through 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
    T3

    • Tumors invade GB 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
    T4

    • Tumors invade 2 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
    Staging Laparoscopy:
    • Identifies those 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
    Palliation

    • Goals :
    • Relieve pain : Opioid analgesics
    • Biliary obstruction : ERCP and stenting/ PTBD
    • Bowel obstruction : Endoscopic Duodenal stenting

    • Chemotherapy : Gemcitabine + cisplatin ( ABC-02 trial)


    Summary

    Cholecystectomy
    Extended
    Chole.
    Major hepatic
    resection

    Palliation
    Cholangiocarcinoma
    • Involves intrahepatic and extrahepatic biliary channels
    • Incidence men > women
    • Risk Factors
    • Primary Sclerosing cholangitis
    • Liver flukes (Opisthorchis and chlonorchis)
    • Choledochal cyst
    • Carolis disease
    • Hepatolithiasis
    • Thorotrast
    • Hepatitis C
    • 90% are adenocarcinomas

    • 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%)
    • Bismuth classification
    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
    Diagnosis

    • CECT
    • Site and 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)
    • 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
    AJCC Staging
    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


    • Contraindications:
    • Involvement of inflow and outflow bilaterally
    • Multiple intrahepatic tumors
    • Metastatic disease

    • Lymph node dissection


    • No therapeutic value
    • May help in staging and prognosis
    Perihilar Cholangiocarcinoma

    • R0 resection 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)
    • Contraindications
    • Hepatic duct 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
    Distal Cholangiocarcinoma

    • Most commonly 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


    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
    THANK YOU

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