Bile Duct Cancer

Bile duct cancers are of three main types:

Extrahepatic bile duct cancer: It is the cancer of the bile duct that originates outside the liver. The cancer may be in the ducts where they meet the small intestine or as they exit the liver. It is the commonest variant of cholangiocarcinoma. Hilar cholangiocarcinoma is a subtype of extrahepatic cholangiocarcinoma. It originates outside the liver, usually in the hilum, an area where the bile ducts and some vital blood vessels join with the liver.

Intrahepatic bile duct cancer: This type of bile duct cancer originates outside the liver.

Following are some conditions that make the person more susceptible to developing cholangiocarcinoma:

• Choledochal cyst disease or bile duct stones
• Abnormalities at the area where the pancreatic duct and bile duct meet
• Liver cirrhosis
• Chronic ulcerative colitis
• Clonorchiasis
• Human immunodeficiency virus (HIV).
• Hepatitis B or Hepatitis C.
• Non-alcohol related fatty liver disease.
• Inflammatory bowel disease (IBD).
• Primary sclerosing cholangitis (scarring and inflammation obstruct the bile ducts).
• Apart from these, diabetes, alcohol use disorder, smoking, obesity, and exposure to toxins increases the chances of developing bile duct cancer.

The exact cause of cholangiocarcinoma is not known. It is believed that medical conditions that cause chronic bile duct inflammation may play a part in the progression of this cancer. Persistent problems such as inflammation may also cause changes in DNA, which might affect the way certain cells grow, behave, and multiply. These changes are not necessarily inherited, which indicates that they are not passed down to the generations. Instead, those probably occur during the lifetime of a person.

The symptoms of bile duct cancer include dark urine, abdominal pain, itchy skin, fever, light-coloured stool, jaundice, nausea and vomiting, and sudden unexplained weight loss.

Your symptoms will be evaluated by your healthcare provider, medical history will be reviewed, and a complete physical examination will be conducted. Following are some tests to be performed for diagnosing cholangiocarcinoma:

• Tumour marker tests
  These tests are performed to check your urine or blood for proteins and other substances that indicate cancer.
• Liver function tests
  The liver function tests are performed on the blood to check for high levels of certain substances that may suggest that the liver is not functioning properly or that there might be an obstruction of bile ducts.
• Abdominal ultrasound
  An abdominal ultrasound employs sound waves to produce highly detailed images of your gallbladder, pancreas, and liver. It is usually the first imaging test to be done if your healthcare provider suspects you have cancer of the bile duct.
• Magnetic resonance cholangiopancreatography (MRCP)
  It is a specialised investigation that involves an MRI machine. It produces detailed images of the bile ducts, liver, pancreas, gallbladder, and pancreatic duct.
• Endoscopic retrograde cholangiopancreatography (ERCP)
  During this procedure, an endoscope and a catheter is employed to examine your bile ducts. The endoscope is introduced via the mouth and it is passed down to the small intestine. A contrast dye is delivered via the catheter to outline the shape of your bile ducts and make those visible on X-rays. If you are having an obstruction of the bile ducts, a stent can be introduced during an ERCP in the obstruction bile duct so that it opens up.
• Percutaneous transhepatic cholangiography (PTC)
  During this procedure, an X-ray of the bile ducts is created just like in case of an ERCP. However, instead of a catheter and endoscope, the contrast dye is delivered by introducing a needle directly into the liver and the bile ducts. A percutaneous transhepatic cholangiography is usually reserved for patients who are not fit to undergo ERCP.

If the laboratory tests and imaging indicate cancer, a biopsy will be performed by your healthcare provider. During biopsy, a sample of tissue is taken from your body, which is then examined under the microscope by a pathologist to look for any sign of malignancy. The samples can be taken during a PTC, ERCP, or by inserting a small needle via the skin.

A biopsy not only helps the healthcare provider to determine whether or not the person has cancer, it also allows them to stage the cancer. During staging, the extent of cancer in the body is also determined. This helps the healthcare provider plan treatment accordingly. As far as bile duct cancer is concerned, staging is done based on the size of the tumour and on the extent of spread. The doctors try to find out whether the tumour has spread to the blood vessels, organs surrounding the bile ducts like gallbladder or liver, lymph nodes and lymph vessels, and distant organs like bones, lungs, or abdominal cavity.

The treatment plan for bile duct cancer depends on its location and extent of spread. Early bile duct cancers that haven’t metastasized can be treated surgically but most bile duct cancers have already metastasized at the time of diagnosis. In such cases, a combination of multiple treatment modalities may be preferred.

Following are some options for bile duct cancer surgery:

• Removal of the bile duct to get rid of the bile duct part if the tumour hasn’t undergone metastasis
• Partial hepatectomy to remove sections of the liver and part of the bile duct
• Whipple procedure so that the gallbladder, bile duct, and part of the stomach, pancreas, and small intestine are removed.
• Liver transplant so that the liver can be replaced by a donor liver, though it only works for early stage cancers and finding a donor is quite difficult
• Palliative surgery to ease cancer symptoms by removing bile duct blockages. The doctor may introduce a stent in the bile duct so that it drains into the small intestine or he may keep a drain in place that is attached to a bag outside the body.

During radiation therapy, powerful radiation beams are used to damage tumours. You might also be given radiation therapy to damage any remaining cancer cells. Sometimes, radiation therapy is given before surgery to shrink tumours before they can be removed.

Radiation is also given via transarterial radioembolization (TARE) that employs a catheter to place tiny radiation beads in blood vessels supplying the tumour. The vessel is blocked by the beads and the blood doesn’t reach the tumour. The beads also release radiation so that the tumour is shrinked.

During chemotherapy, drugs are used to damage a tumour. Systemic chemotherapy due to which the drug goes through the entire body can be used to shrink the tumour so that surgery is easily possible. If the cancer can’t be surgically removed, chemotherapy can still prolong life and help reduce the unpleasant symptoms of a tumour. Some procedures can also be done to introduce the chemo drug directly into the bile duct. Those include:

• Transarterial chemoembolization (TACE)
  It is a procedure during which a catheter is employed to implant tiny beads of chemotherapy drugs in the blood vessels that supply a tumour. The beads also deliver some chemoradiation to shrink the tumour.

Although there is no way to completely eliminate the risk of developing bile duct cancer, there are some measures you can take including:

• Getting vaccinated against Hepatitis B
• Avoiding exposure to viruses like Hepatitis C, Hepatitis B, and HIV
• Maintaining a healthy body weight
• Limiting the amount of alcohol you consume
• Quit smoking, if you are a smoker

In nutshell, bile duct is the cancer of the bile ducts. It is more commonly seen in older people and the risk for the cancer is more if you have chronic inflammation or certain viruses in your liver or bile duct. A combination of different treatment modalities medications including surgery, chemotherapy, and radiation therapy is required to treat this cancer.

The Centre for Cancer at Kokilaben Dhirubhai Ambani Hospital, Indore offers comprehensive diagnostic, preventive and therapeutic services for a diverse range of bile duct cancers. Our oncologists assess complex forms of such cancers and offer tailored treatment plans for the same.

Apart from being equipped with all the basic amenities required for modern oncological care, the centre boasts advanced laboratories for diagnosing complex forms of bile duct cancers. We are front-runners in the field of oncological care and offer optimised treatment plans for a wide range of cancers under one roof.