Bile Duct Cancer Flashcards
cholangiocarcinoma is rising worldwide and is now the second most common primary cancer of the liver behind
hepatocellular carcinoma
How it is devided ?
> > perihilar and intrahepatic lesions, known as proximal lesions
> > periampullary region, known as distal disease.
> > More than two thirds of all cholangiocarcinomas involve the proximal biliary tree near the bifurcation, known as a Klatskin tumor.
RF ?
- Chronic Inflammation
- PSC
- Choledochal Cyst
- Recurrent pyogenic cholangitis
- Liver Cirrhosis
- Toxins ( Asbestos, Thorotrast, OCP, Cigarrete )
PSC Risk for Cancer increase with What ?
IBD
Three distinct pathologic subtypes
- sclerosing
- nodular
- papillary cholangiocarcinoma
Sclerosing , papillary and nodular
> > Sclerosing cholangiocarcinoma tends to occur in the proximal bile ducts, causing periductal fibrosis in a concentric pattern and a circumferential duct occlusion.
> > The papillary and nodular subtypes tend to occur in distal cholangiocarcinomas and are manifested with intraluminal growths
The papillary Vs nodular
Nodular :
- Firm mass, on the Duct wall, grown intraluminal
Papillary :
- Polypoidal mass , Less periductal fibrosis , and
» BETTER PROGNOSIS
Which Ts have better prognosis
> > Tumors confined to the bile duct (T1)
> > those extending outside the bile duct but not invading adjacent structures such as the hepatic artery or portal vein (T2)
The two pathologic factors most influencing prognosis after resection are
> > complete (R0) resection to negative margins
absence of lymph node metastases.
Presentation
Depends on the location
> > Unilobar obstruction of a bile duct may present with unilateral lobar atrophy and subsequent contralateral lobar hypertrophy
> > cholangiocarcinoma causing obstruction at or below the hepatic bifurcation tends to be manifested at earlier stages than intrahepatic cholangiocarcinoma
Labs ?
- Tbil
- ALP
- CEA + CA 19-9»_space; Unreliable
Imaging ?
US :
» intrahepatic biliary ductal dilation
> > hilar cholangiocarcinomas :
the gallbladder and visualized extrahepatic biliary tree are usually decompressed
> > distal lesions will have extrahepatic biliary ductal dilation and gallbladder distention.
CT ?
> > Can asses Respectability
Asses mets
Vascular involvement , segmental lobe Involvement
CT only ?
NO
» MRCP
» PTC
» ERCP
They determine the proximal extent of resection
contraindications to resection
> > Bilobar intrahepatic metastases
any extrahepatic disease
involvement of bilateral secondary biliary radicals.
encasement of the main portal vein
bilateral hepatic lobar artery involvement
lobar atrophy with involvement of the contralateral portal vein or biliary radicals.
Do you need Tissue Bx ?
NO
Does a negative brush cytology rule out Cancer?
NO
When is Bx Important ?
Establishment of a tissue diagnosis is important only when the patient is not a surgical candidate.
Preop Biliary Drianage ?
> > For distal cholangiocarcinoma, preoperative biliary drainage increases the rate of infectious complications of resection but is generally useful for
those with preoperative hyperbilirubinemia (bilirubin level >10 mg/dL)
and
those with a prolonged time interval between presentation and resection.
For patients with hilar cholangiocarcinoma, what needs to be resected ?
> > hepatic resection remains an important feature of the operative strategy
> > In the setting of complete biliary obstruction, hepatic resection carries an additional risk of bleeding, sepsis, and hepatic failure.
What can enhance the post resection hypertrophy of the remaining liver
- Drainage of the obstructed but unaffected segments can enhance the postresection hypertrophy of the remaining liver
> > but may increase perioperative infectious complications
What can you do as part of Staging? Before Laparotomy ?
> > Staging laparoscopy can also be an important initial step at the time of resection to reduce the incidence of nontherapeutic laparotomy
Distal cholangiocarcinoma Tx ?
> > Distal cholangiocarcinoma is managed by pancreaticoduodenectomy.
> > Because these lesions tend to grow in a submucosal plane, a frozen section of the proximal bile duct margin helps ensure an R0 resection
Proximal cholangiocarcinoma tx ?
> > resection of regional nodal tissue and en bloc resection of the CBD with hepatic parenchyma
