Lecture Notes: Cholangiocarcinoma and Gallbladder Cancer

Dr. Stanley Kim, Guam Regional Medical City
Date: [Insert Date]

Introduction

• Discussion on cholangiocarcinoma, a cancer of the bile duct.
• Incidence of intrahepatic cholangiocarcinoma is rising.
• Limited treatment options historically, but recent advancements have improved diagnosis and treatment.

Definitions

• Cholangiocarcinoma:
  • Cancer arising from bile ducts.
  • More common in men.
• Gallbladder Cancer:
  • Arises from gallbladder and cystic duct; classified as gallbladder cancer.
  • More common in women.
• Incidence: 1-2 cases per 100,000 in the U.S., higher in Native Americans and South Americans.
• Age of onset: 50-70 years; younger in cases linked to primary sclerosing cholangitis.

Risk Factors

Cholangiocarcinoma

• Primary sclerosing cholangitis
• Choledochal cyst
• Hepatolithiasis
• Gallstone disease
• Alcohol and smoking
• Hepatitis C
• Liver cirrhosis
• Genetic predispositions (Lynch syndrome, hereditary hemochromatosis, cystic fibrosis)
• Liver flukes (common in Southeast Asia)
• HIV infection, diabetes, obesity, contraceptives.

Gallbladder Cancer

• Gallstones:
  • Present in 80% of gallbladder cancer cases but only a minority develop cancer.
• Porcelain Gallbladder:
  • 2-3% develop gallbladder cancer, warranting cholecystectomy.
• Large gallbladder polyps (≥1 cm) require cholecystectomy due to a 20-30% association with cancer.

Anatomy of the Biliary System

• Bile produced in the liver drains through bile ducts into the duodenum.
• Cholangiocarcinoma classifications:
  • Intrahepatic cholangiocarcinoma
  • Extrahepatic cholangiocarcinoma (divided into perihilar and distal types).

Clinical Manifestations

Intrahepatic Cholangiocarcinoma

• Symptoms include abdominal pain, weight loss, and less frequently jaundice.

Extrahepatic Cholangiocarcinoma

• Symptoms primarily due to biliary obstruction: jaundice, itching, dark urine, and abdominal pain.

Gallbladder Cancer

• Often asymptomatic; diagnosed during or after cholecystectomy.
• Symptoms include abdominal pain, nausea, vomiting, and anorexia.

Imaging Studies

• Important for diagnosis and management:
  • Ultrasound
  • CT scan (multi-phasic, multi-detector)
  • MRI and MRCP
  • ERCP (Endoscopic retrograde cholangiopancreatography)
  • Endoscopic ultrasound
  • Percutaneous transhepatic angiography

Tumor Markers

• CA19-9, CEA, Alpha-fetoprotein (AFP)
• Elevated CA19-9 in about 80% of cholangiocarcinoma cases.
• False negatives in Lewis blood group negative patients.

Staging

• Cholangiocarcinoma:
  • TNM staging varies depending on the location (intrahepatic, perihilar, distal).
• Gallbladder Cancer:
  • Staging based on depth of invasion and lymph node involvement.

Surgical Resection

• Cholangiocarcinoma:
  • Surgical resection is the only curative treatment.
  • Contraindications include metastatic disease or major vascular invasion.
• Gallbladder Cancer:
  • Requires assessment for resectability.
  • Resection is more complex if found during cholecystectomy.

Treatment Post-Surgery

• Adjuvant chemotherapy and radiation for positive margins or lymph nodes.
• Protocols depend on cancer type (intrahepatic vs. extrahepatic).

Advanced and Metastatic Disease

• Combination therapies using cisplatin and gemcitabine show improved survival.
• New targeted therapies and immunotherapy options available.

Conclusion

• Survival rates for cholangiocarcinoma and gallbladder cancer are improving with advances in treatment.
• Continuous follow-up and assessment for resectability are crucial.

Inspirational Note

• Dr. Kim shares a personal reflection about hope and peace for cancer patients, quoting John 14:27.