Bile duct cancer, including gallbladder, intrahepatic bile duct cancer, hilar bile duct cancer and distal bile duct cancer. Its treatment varies depending on the staging and staging. This article summarizes the diagnosis, staging and treatment of cholangiocarcinoma with ESMO guidelines.
Diagnosis
Radiological examination: magnetic resonance imaging (MRI), computed tomography (CT) scan
Pathological diagnosis: from biopsy, fine needle aspiration, biliary brushings
Staging evaluation items include complete history and physical examination, blood count, liver function tests, chest radiograph, abdominal ultrasound and CT or MRI, retrograde endoscopy or percutaneous hepatic aspiration angiography, which may also include ultrasound endoscopy, cholangioscopy and laparoscopy. Patients with isolated intrahepatic masses must undergo upper and lower gastrointestinal endoscopy.
Staging of gallbladder cancer, intrahepatic cholangiocarcinoma, hilar cholangiocarcinoma and distal cholangiocarcinoma is based on the 2010 TNM system. Hepatoportal cholangiocarcinoma (Klatskin tumor) is clinically staged according to the BismuthCCorlette staging of the bile ducts involved.
Treatment
Treatment of accidental detection of gallbladder cancer
Complete resection is highly recommended for unexpected gallbladder cancers of stage T1b (invasion of the muscularis) or larger that are shown to be resectable after an examination including laparoscopy. patients with stage T1a (invasion of the lamina propria) who have already had a complete gallbladder resection do not benefit from re-excision and should only be kept under observation.
If unexpected gallbladder cancer is found intraoperatively, a simultaneous staging evaluation should be performed during surgery and the decision to perform extended cholecystectomy (total hepatectomy + lymphatic dissection with ± bile duct resection) should be made based on resectability and physician opinion.
Treatment of resectable tumors
Complete surgical resection is the only possible curative treatment.
Cholecystectomy includes extended cholecystectomy, including partial hepatectomy and lymphatic drainage (hilar, hepatogastric ligament, post duodenal) with or without bile duct resection. Major hepatic resections including caudate lobectomy, such as extended right lobe resection with hilar resection, have improved resectability and cure rates for stage 3 and 4 hilar cholangiocarcinoma, extending patient survival by 5 years.
Preoperative transarterial or venous embolization increases the volume of the residual liver in patients with an expected postoperative residual volume of <25% and may reduce postoperative liver dysfunction. Indications for biliary drainage should be systematically discussed preoperatively with an experienced surgeon. Even when patients receive aggressive surgical treatment, the 5-year survival rate is only 5-10% for gallbladder cancer and 10-40% for bile duct cancer.
Adjuvant therapy
Chemotherapy with 5-Fu provides a small postoperative survival benefit for patients receiving non-radical gallbladder cancer. The postoperative treatment of nonradical resection of bile duct cancer remains controversial, with both supportive therapy and palliative chemotherapy and/or radiation therapy.
Local adjuvant therapy should be considered due to the 52% local recurrence rate of postoperative gallbladder and biliary tract tumors. Retrospective studies have shown that adjuvant and, more recently, neoadjuvant chemotherapy may provide a survival benefit for gallbladder and biliary tract tumors, and that postoperative radiotherapy may be considered an option.
5-Fu is most commonly used in radiotherapy for cholangiocarcinoma, and gemcitabine in combination with or without oxaliplatin may be used in radiotherapy for this disease.
Treatment of unresectable tumors
Relief of jaundice can be performed by endoscopic or percutaneous biliary stenting or bile-intestinal bypass. Emergency biliary drainage and broad-spectrum antibiotics are essential for patients with obstructive jaundice causing cholecystitis.
Studies have shown that palliative chemotherapy increases survival time and quality of life in patients with advanced cancer, but the overall survival benefit of chemotherapy is not yet clear, and gemcitabine combined with cisplatin therapy may have a significant survival advantage .
In cases of cisplatin intolerance, oxaliplatin may be an option for gemcitabine combination therapy, and several phase II trials have demonstrated antitumor activity and good tolerability of gemcitabine in combination with oxaliplatin. 5-Fu or gemcitabine monotherapy should be administered when neither gemcitabine in combination with cisplatin or oxaliplatin is available. The limiting toxicity of cisplatin may be renal or neurotoxicity, bone marrow suppression, or ototoxicity, while sensory neuropathy may limit the use of oxaliplatin.
The biologic agent erlotinib showed clinical activity in a phase II trial with bevacizumab, an epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor, and a vascular endothelial growth factor (VEGF) inhibitor. Because patients with this disease rarely experience grade 3 to 4 side effects, bevacizumab in combination with erlotinib may be a treatment option for cytostatic therapy.
Simultaneous radiotherapy is an additional treatment option. After years of 5-Fu-based radiotherapy, gemcitabine and oxaliplatin have shown the feasibility of combined chemotherapy (see adjuvant therapy). High-dose iridium-19 radiotherapy may improve local control of the disease compared to 3-dimensional conformal radiotherapy, and emphasized radiotherapy (IMRT) has recently been shown to increase the safe dose to higher levels, and later trials will test the efficacy of this approach.
Neoadjuvant therapy is not a routine treatment option for biliary tract tumors. However, surgical resection should be considered if re-staging evaluation of patients with locally advanced cancer shows potentially resectable tumors.
Efficacy evaluation
Clinical evaluation, subjective symptom evaluation, blood tests, and repeat radiologic or ultrasound examinations that initially showed abnormalities are performed 2 or 3 cycles (8 to 12 weeks) after chemotherapy.
There is no evidence that regular follow-up after initial treatment affects outcomes. Follow-up of patients after complete resection should take into account symptoms, nutrition and psychological issues with only some history taking and physical examination.