Bile Duct Cancer

Pathology

admin — Tue, 24 Jul 2007 08:34:29 +0000

Blockage of the bile duct by a cancer, gallstones, or scarring from injury prevents the bile from being transported to the intestine and the active ingredient in the bile (bilirubin) instead accumulates in the blood. This condition is called jaundice and the skin and eyes become yellow from the bilirubin in the blood. This condition also causes severe itchiness from the bilirubin deposited in the tissues. In certain types of jaundice, the urine will be noticeably darker, and the stools will be much paler than usual. This is caused by the bilirubin all going to the bloodstream and being filtered into the urine by the kidneys, instead of some being lost in the stools through the ampulla of Vater.Jaundice is commonly caused by conditions such as pancreatic cancer, which causes blockage of the bile duct passing through the cancerous portion of the pancreas; cholangiocarcinoma, cancer of the bile ducts; blockage by a stone in patients with gallstones; and from scarring after injury to the bile duct during gallbladder removal.

Share This

Suitability Of Hepatopancreatoduodenectomy

admin — Tue, 24 Jul 2007 08:33:15 +0000

Abstract:We aimed to determine whether bile duct cancer (BDC) or gallbladder cancer (GBC) was a better candidate for hepatopancreatoduodenectomy (HPD). Ten patients with BDC and ten with GBC were treated by HPD with major hepatectomy between 1994 and 2004 and compared, in terms of surgical outcome and survival. In the BDC patients, the International Union Against Cancer (UICC) stage was I in three patients; II in four; III in one; and IV in two; of the GBC patients, one was stage II; four were stage III; and five were stage IV. The reasons for choosing HPD for BDC were: superficial spreading, in three patients; intramural wide invasion, in five; and hepatoduodenal ligament (HDL) invasion, in two; and for GBC, extrahepatic bile duct invasion, in seven; and HDL invasion, in three. The morbidity and mortality rates for BDC and GBC were 40% and 60%, and 0% and 30%, respectively. All three of the GBC patients who died in hospital had undergone a right trisectionectomy with caudate lobectomy. The cumulative 5-year survival rate of the BDC patients was 64%; the 1-year survival rate for the GBC patients was only 20%, and none survived for over 2 years (P < 0.001). Of the patterns of BDC cancer invasion, the superficial-spreading type appeared to have a better prognosis than the others, but the difference was not statistically significant. HPD is indicated for any type of BDC, but HPD did not show any survival benefits in treating patients with GBC with obstructive jaundice.

Share This

How To Improve Survival With Photodynamic Therapy

admin — Tue, 24 Jul 2007 08:31:19 +0000

According to a study published in the American Journal of Gastroenterology, treatment of nonresectable bile duct cancer with photodynamic therapy results in improved patient survival.

The bile ducts connect the liver and the gallbladder to the small intestine. Roughly two-thirds of patients with bile duct cancer have cancer that cannot be surgically removed (nonresectable) and is therefore incurable. Thus, patients are treated to relieve symptoms and improve survival. Patients with nonresectable bile duct cancer often experience bile duct obstruction; in these cases, treatment involves the placement of stents or other procedures to improve bile duct drainage.

A new treatment being explored for nonresectable bile duct cancer is photodynamic therapy. With this approach, a photosensitizing agent (an agent that makes cells sensitive to light) is applied to cancer cells. A laser light with a specific wave length can then be used to destroy the cells.

In order to evaluate the benefit of photodynamic therapy for patients with nonresectable bile duct cancer, researchers in

Germany conducted a randomized clinical trial among 32 patients. Half the patients were treated with photodynamic therapy and bile duct drainage, and half were treated with bile duct drainage alone.

Survival was significantly longer in the patients treated with photodynamic therapy; these patients survived for a median of 21 months, compared to seven months for those treated with bile duct drainage alone. Adverse effects of photodynamic therapy included infections, which occurred in four of the 16 treated patients.

The researchers conclude that photodynamic therapy has the potential to greatly improve the survival of patients with nonresectable bile duct cancer. Larger studies are needed to confirm the benefit observed in this study of 32 patients.

Patients with bile duct cancer may wish to talk with their doctor about the risks and benefits of participating in a clinical trial further evaluating therapeutic options. Two sources of information regarding ongoing clinical trials include the National Cancer Institute (www.cancer.gov) and www.cancerconsultants.com

Share This

Coping Skills

admin — Tue, 24 Jul 2007 08:29:39 +0000

Learning you have any life-threatening illness can be devastating. But coping with a diagnosis of biliary tract cancer can be especially difficult. The more advanced the disease when it’s discovered, the less likely the chance of real recovery. As a result you may feel especially overwhelmed just when you need to make crucial decisions. Although there are no easy answers for people dealing with biliary tract cancer, some of the following suggestions may help:

§ Learn all you can about your illness. Learn everything you can about gallbladder and bile duct cancer — how the disease progresses, your prognosis and your treatment options, including both experimental and standard treatments and their side effects. Be sure you understand whether a particular approach is used to treat cancer or provide palliative care. Don’t be afraid to seek a second opinion and to explore treatments available through clinical trials. You will have many decisions to make in the weeks and months ahead. The more you know, the more active a role you can take in the decision-making process.

In addition to talking to your medical team, look for information in books and reputable sources on the Internet. The National Cancer Institute offers a toll-free information line called the Cancer Information Service. It provides access to trained counselors and accurate, up-to-date information on all aspects of living with cancer. You can reach the Cancer Information Service 24 hours a day at (800) 4-CANCER, or (800) 422-6237.

§ Maintain a strong support system. More and more studies show that strong relationships are crucial in dealing with life-threatening illnesses. Although friends and family can be your best allies, in some cases they may have trouble dealing with your illness. Or you may not have a large social network. If so, a counselor, medical social worker, religious counselor or even a formal support group can be helpful.

If you’re interested in learning more about support groups, talk to a doctor, nurse, social worker or psychologist. They may be able to put you in touch with a group in your area. Or check your local phone book, library or a cancer organization. The National Cancer Institute also can provide a list of support groups. After deciding to participate in a group, try it out a few times. If it doesn’t seem useful or comfortable, you don’t have to continue.

§ Come to terms with your illness. Coming to terms with your illness may be the hardest thing you’ve ever done. For some people, having a strong faith or a sense of something greater than themselves makes this process easier. Others seek counseling from someone who understands life-threatening illnesses, such as a medical social worker, psychologist or chaplain. Many people also take steps to ensure that their end-of-life wishes are known and respected.

In fact, the greatest fear of many people with a life-threatening illness is being subjected to treatments they don’t want or spending their last weeks or months in a hospital away from loved ones and familiar surroundings. But many more choices now exist for people with a terminal illness.

Hospice care, for example, provides a special course of treatment to terminally ill people. This allows family and friends — with the aid of nurses, social workers and trained volunteers — to care for a loved one themselves. It also provides emotional, social and spiritual support for people who are ill and those closest to them. Although most people under hospice care remain in their own homes, the program is available anywhere — including nursing homes and assisted-living centers. For those who stay in a hospital, palliative care specialists can provide comfort, compassionate care and dignity.

It’s also important to discuss end-of-life issues with your family and medical team. Part of this discussion will likely involve advance directives — a general term for oral and written instructions you give concerning your medical care should you become unable to speak for yourself.

One type of advance directive is known as a durable power of attorney (POA) for health care. In this case, you sign a legal document authorizing a person you respect and trust to make legally binding medical decisions for you if you’re unable to do so. A POA is often recommended because the appointed person can make decisions in situations not covered in a regular advance directive. Whatever you decide, it’s important to put your wishes in writing. Laws regarding advance directives and POAs vary from state to state, but a written document is more likely to be respected.

Share This

Factors Affecting Prognosis and Treatment Options.

admin — Tue, 24 Jul 2007 08:28:09 +0000

The prognosis (chance of recovery) and treatment options depend on the following:

The stage of the cancer (whether it affects only the bile duct or has spread to other places in the body).
Whether the tumor can be completely removed by surgery.
Whether the tumor is in the upper or lower part of the duct.
Whether the cancer has just been diagnosed or has recurred (come back).

Treatment options may also depend on the symptoms caused by the tumor. Extrahepatic bile duct cancer is usually found after it has spread and can rarely be removed completely by surgery. Palliative therapy may relieve symptoms and improve the patient’s quality of life.

Does stress cause cancer?

Psychological stress can have a number of different effects on the body and its function, including effects on the immune response. Stress can worsen the symptoms of most medical conditions. Nevertheless, at this time there is little proof that stress alone is actually a cause of medical problems or cancer. Cancer is a complex disease that results from a combination of hereditary (inherited) and environmental factors.

Although some epidemiologic studies have suggested an association between lifestyle stress and cancer, most studies fail to confirm this association. Stress is known to affect the functioning of the immune system, and it is known that compromised immune function may play a role in the development of cancers. However, there has been no scientific proof that stress can increase cancer risk.

Share This

Asking Questions To The Doctor?

admin — Tue, 24 Jul 2007 08:26:52 +0000

The Commission for Health Improvement has produced a guide for all cancer patients to help you get the best care and information from your treatment team. It is called Getting the best from your cancer services. It covers diagnosis, treatment and care, and palliative care.You might like to ask your doctor/surgeon/consultant/nurse specialist…

How advanced is my cancer, and has it spread to other parts of my body?
How big is the tumour?
What are my treatment options, and what are the risks and benefits of each?
What is the chance of a cure?
Which treatment do you recommend, and why?
If I don’t have treatment, what will happen?
Are there any clinical trials that I might be able to enter?
Where will I go for my treatment?
How long will I have to wait for my treatment to start?
Will I have to stay in hospital? For how long?
When will you be able to tell me how successful my treatment has been?
How long will it take me to feel better after treatment?
What will life be like for me after treatment?
What can I do to help myself, during and after treatment?
What follow up checks will I need?

What are the chances of this cancer coming back?

Share This

Expected Duration & Prevention

admin — Tue, 24 Jul 2007 08:25:11 +0000

Expected DurationTo treat a gallstone blockage and infection, doctors first prescribe antibiotics. After the infection subsides, a surgeon removes the gallbladder. Symptoms caused by a scar (stricture) may improve rapidly after treatment restores the duct’s drainage.Symptoms of primary biliary cirrhosis and primary sclerosing cholangitis may steadily get worse and lead to cirrhosis and liver failure after years of damage. When liver failure develops, a liver transplant can improve survival. However, primary sclerosing cholangitis and primary biliary cirrhosis can return after transplant. PreventionIf you have gallstones, you can prevent bile duct blockage and serious infection (ascending cholangitis or cholecystitis) by having your gallbladder removed. This is done using small incisions in the abdomen, in a surgery called laparoscopic cholecystectomy.If you are overweight or have high cholesterol, you are at higher risk of developing gallstone. To avoid trouble, work toward a healthy weight through diet and exercise. Women who take birth control pills or hormone replacement therapy are at higher risk of gallstones and may factor this risk in their decision to use these medications.Although cholangiocarcinoma is uncommon, risks associated with developing it include smoking, eating a high carbohydrate diet and having gallstones. Certain parasite infections (Clonorchis sinensis and Opisthorchis viverrini, also known as Chinese liver fluke) can increase the risk of bile duct infections and cancers. If you travel to

Southeast Asia, eat fish only if it is well cooked. If you do eat undercooked fish while traveling in this area, ask your doctor for a stool parasite test, especially if you have symptoms of weight loss or diarrhea.

Share This

Correlation Of Bile Duct Obstruction With Ductal Cancer

admin — Tue, 24 Jul 2007 08:23:52 +0000

When bile duct cancer cells were placed in the liver of animals with bile duct obstruction, they grew more rapidly than identical cells placed in animals without bile duct obstruction. In fact, half of the total liver mass of the rats with bile duct obstruction became replaced by cancer cells within three weeks compared to only 16 percent of that of animals without bile duct obstruction.

Perhaps even more important, the cancers metastized outside the liver (as they frequently do in human patients with advanced bile duct cancer) only in the animals with bile duct obstruction.

The bile ducts are tubes that carry bile (a liquid secreted by the liver that contains cholesterol, bile salts, and waste products) from the liver to the gallbladder and small intestine. Bile duct obstruction has long been known to be present in both malignant and nonmalignant liver disease (jaundice, for example), but before the study by Dr. Sirica and his colleagues the direct effect of such obstruction on bile duct cancer cell growth and aggressiveness had not been previously investigated.

These new findings are highly significant for two reasons, says Dr. Sirica.

First, they establish an important correlation between bile duct obstruction and bile duct cancer, suggesting growth regulatory mechanisms that could be highly significant in the progression of the cancer and that could become good molecular targets for drug therapy.

Second, they establish a unique preclinical model of how bile duct cancer in liver progresses that can be used to rapidly test and evaluate novel molecular treatment strategies.

Such strategies are badly needed for this understudied cancer, adds Dr. Sirica. The incidence and mortality of cholangiocarcinoma, the primary cancer of the bile ducts, is increasing worldwide. Some 3,500 new cases are now diagnosed annually in the

United States. Survival rates remain dismally low because most patients have advanced disease at the time of diagnosis and thus are poor candidates for the current best treatment, surgical resection. Although there are some known risk factors for the disease (such as primary sclerosing cholangitis), the cause of most cases remain unknown and the cellular and molecular changes that accompany the disease have not been well understood.

This study is part of ongoing work in Dr. Sirica’s laboratory aimed at identifying altered growth factor signaling pathways in cholangiocarcinoma that may be exploited as potential molecular targets for therapy. Dr. Sirica’s co-authors for the Experimental Biology 2007 presentation are Dr. Zichen Zhang, Dr. Toru Asano, Dr. Xue-Ning Shen, Deanna J. Ward and Dr. Arvind Mahatme. Support for the work came from the National Cancer Institute, National Institutes of Health.

Share This

Staging Of Bile Duct Cancer

admin — Tue, 24 Jul 2007 08:21:43 +0000

From a clinical and practical point of view, extrahepatic bile duct cancers can be considered to be localized (resectable) or unresectable. This has obvious prognostic importance. Localized extrahepatic bile duct cancerPatients with localized extrahepatic bile duct cancer have cancer that can be completely removed by the surgeon. These patients represent a very small minority of cases of bile duct cancer and usually are those with a lesion of the distal common bile duct where 5-year survival rate of 25% may be achieved. Extended resections of hepatic duct bifurcation tumors (Klatskin’s tumors) to include adjacent liver, either by lobectomy or removal of portions of segments 4 and 5 of the liver, may be performed. There has been no randomized trial of adjuvant therapy for patients with localized disease. Radiation therapy (external-beam radiation with or without brachytherapy), however, has been reported to improve local control. [1] [2][Level of evidence: 3iiiDii]

Unresectable extrahepatic bile duct cancer

Patients with unresectable extrahepatic bile duct cancer have cancer that cannot be completely removed by the surgeon. These patients represent the majority of patients with bile duct cancer. Often the cancer invades directly into the portal vein, the adjacent liver or along the common bile duct, and to adjacent lymph nodes. Spread to distant parts of the body is uncommon but intra-abdominal metastases, particularly peritoneal metastases, do occur. At this stage patient management is directed at palliation.

The TNM staging system should be used when staging the disease of a patient with extrahepatic bile duct cancer. Most cancers are staged following surgery and pathologic examination of the resected specimen. Evaluation of the extent of disease at laparotomy is most important for staging.

Staging depends on imaging, which often defines the limits of the tumor, and surgical exploration with pathologic examination of the resected specimen. In many cases, it may be difficult to completely resect the primary tumor.

The American Joint Committee on Cancer (AJCC) has designated staging by TNM classification. [3] Stages defined by TNM classification apply to all primary carcinomas arising in the extrahepatic bile duct or in the cystic duct and do not apply to intrahepatic cholangiocarcinomas, sarcomas, or carcinoid tumors. [3]

TNM definitions

Primary tumor (T)

TX: Primary tumor cannot be assessed
T0: No evidence of primary tumor
Tis: Carcinoma in situ
T1: Tumor confined to the bile duct histologically
T2: Tumor invades beyond the wall of the bile duct
T3: Tumor invades the liver, gallbladder, pancreas, and/or unilateral branches of the portal vein (right or left) or hepatic artery (right or left)
T4: Tumor invades any of the following: main portal vein or its branches bilaterally, common hepatic artery, or other adjacent structures, such as the colon, stomach, duodenum, or abdominal wall

Regional lymph nodes (N)

NX: Regional lymph nodes cannot be assessed
N0: No regional lymph node metastasis
N1: Regional lymph node metastasis

Distant metastasis (M)

MX: Distant metastasis cannot be assessed
M0: No distant metastasis
M1: Distant metastasis

AJCC stage groupings

Stage 0
Tis, N0, M0
Stage IA
T1, N0, M0
Stage IB
T2, N0, M0
Stage IIA
T3, N0, M0
Stage IIB
T1, N1, M0
T2, N1, M0
T3, N1, M0
Stage III
T4, any N, M0
Stage IV

Any T, any N, M1

Share This

What To Do After Treatment

admin — Tue, 24 Jul 2007 08:01:54 +0000

Coordinated treatment and care by a multidisciplinary team of clinician-researchers, with experience and expertise in treating cancer and its related symptoms, can help ensure quality of life for longer periods than have been possible in the past.

Follow-Up Care

Regular follow-up care after the initial course of treatment is very important. You should never hesitate to let members of your cancer care team know if you experience any symptoms, changes, or treatment-related problems.

Symptom Management

In many hepatobiliary cancers, symptom control is just as important as treatment aimed at controlling the disease. When the tumor can not be surgically removed, palliative surgery may help prevent blockage of bile ducts and relieve symptoms, such as jaundice, itching of the skin, nausea, vomiting, and fever. In most cases, these symptoms are controlled with biliary drainage.

Other Support Services

To help patients manage some of the other issues that may come up following treatment, Memorial Sloan-Kettering offers a wide range of programs, including the following:

Our Counseling Center offers individual and family counseling sessions to help cancer survivors and their families address the problems that they may encounter in adjusting to life during and after treatment. (by

Sloan-Kettering

Counseling

Center)

· Integrative Medicine Service

Our Integrative Medicine Service is designed to enhance quality of life through healing regimens that address the body, mind, and spirit. Beneficial complementary therapies include various types of massage, acupuncture, hypnotherapy, meditation, visualization and other mind-body therapies, music therapy, and nutritional counseling, as well as classes such as yoga, t’ai chi, and chair aerobics. Patients may benefit from some of these services in the hospital, while others are better suited to recovering or recovered patients after discharge.

Share This