Biliary Tract and GB Cancer

Question 1

• Cholangiocarcinomas account for approximately____ of gastrointestinal malignancies
• Typical age of diagnosis: _____

Answer 1

3%

50-70

Question 2

What would cause ealier onset of cholangiocarcinoma then 50-70?

Answer 2

 earlier in Primary Sclerosing Cholangitis (PSC ) and biliary cysts

Question 3

Cholangiocarcinoma risk factors

Answer 3

• PSC (up to 30% of patients with cholangiocarcinomas)
• biliary cysts
• biliary parasitosis (Clonorchis and Opisthorchis)
• thorotrast

Question 4

How do you diagnose PSC?

Answer 4

Need to to holiangiography to enter the GB and see if there is blockage; don’t have healthy looking biliary tree

PSC are fibrotic strictures, they are benign

Question 5

What does primary sclerosing cholangitis look like on histology

Answer 5

Scar tissue forms around and obstructs the lumen; get onion skinning

Question 6

Biliary Cysts:

• Type I: 50-85%
• ______ only

Answer 6

Extrahepatic

Question 7

• Type _____
• Multiple cysts
• Extrahepatic +/- intrahepatic

Answer 7

IV: 15-35%

Question 8

• Type _____
• Intrahepatic only
• Caroli’s disease

Answer 8

V: 20%

Question 9

Clonorchis sinensis (Chinese liver fluke)
• Far East and far eastern Russia
• Asymptomatic, cholangitis
• Chronic infection associated with cholangiocarcinoma
• Treatment with anti-helminthic therapy

Answer 9

BILIARY PARASITOSIS

Question 10

BILIARY PARASITOSIS
•________ (liver fluke of cats, dogs, and fish-eating mammals)
 Southeast Asia and in Central and Eastern Europe
 Similar presentation as Clonorchis sinensis

Answer 10

Opisthorchiasis

Question 11

What types of biliary cysts predispose you to cholangiocarcinoma?

Answer 11

Type I, II, IV

Question 12

leads to obstruction or severe narrowing of bile duct

See elevated conjugated bilirubin

Type of malignancy

Answer 12

Cholangiocarcinoma

(PSC is benign stricture)

Question 13

When looking at histology of cholangiocarcinoma, what type is most common?

Answer 13

• Adenocarcinoma (> 90%)
• Squamous cell carcinoma and others

Question 15

Preceptor tells you your patient has cholangiocarcinoma with the following symptoms;
 Jaundice, abdominal pain, pruritus, weight loss, fever

Where is the location of the stricture?

What do the labs look like?

Answer 15

• Extrahepatic: symptomatic from biliary obstruction

more likely labs to be elevated than if intrahepatic

Question 16

Pt has cholangiocarcinoma and presents with abdominal pain and weight loss but no jaundice, where is the cancer?

Answer 16

Intrahepatic

Question 17

CHOLANGIOCARCINOMA: DIAGNOSIS
• Lab testing
 _________ of limited valuedue to false positives and negatives

Answer 17

Carbonic Anhydrase (CA) 19-9

Question 18

What imaging do we get to diagnose cholangiocarcinoma?

Answer 18

• Imaging
 Computed tomography (CT)
 Magnetic resonance imaging (MRI)
 Endoscopic Retrograde Cholangio Pancreatigraphy (ERCP); MOST IMPORTANT

Question 19

What is the treatement of Cholangiocarcinoma

Answer 19

Curative surgery like Whipple, perihiliar, intrahilar

OR

liver translpant for hilar cholangiocarcinoma

5% 5 yr survival if you do nothing

Question 20

Describe Whipple procedure

Answer 20

Resect piece of bile duct

piece of pancrease

piece of small intesting and liver

Attach pancrease to jejunum and bypass duodenum

Question 21

Most common GB cancer in US

who is more at risk, men or women?

Answer 21

• Adenocarcinoma; 75% of cases
• Uncommon (< 5,000 cases/year in the United States) and highly fatal
• Women affected 2-6 times more than men

Question 22

What are risks for GB cancer?

Answer 22

• Porcelain gallbladder
• Gallbladder polyps
• Cholelithiasis
 0.5-3% incidence
 70-90% of patients with gallbladder cancer
have cholelithiasis

Question 23

Chronic cholecystitis with intramural
calcification of the gallbladder wall

Answer 23

PORCELAIN GALLBLADDER

risk factor for GB cancer

Question 24

Porcelain GB:

Is this common? geneder preferance? Affect rate of GB cancer?

Answer 24

uncommon, more in females (6:1)

• Increased risk of gallbladder cancer (0-62%)
 Incomplete calcification of gallbladder wall associated with higher risk than complete calcification

Question 25

Three causes of GB polpys

Answer 25

Cholesterol; deposits of TG, cholesterol

Inflammatory: granulation +fibrous tissue

Adenomas = bening glandular tumor (can become maligant) once larger then 12 mm

Question 26

What exsists in 70% of PSC patients?

Answer 26

Inflammatory Bowel Disease (esp ulcerative colitis) 70% of time

Question 27

Features of PSC clinically

Answer 27

progressive fatigue, pruitis, jaundice

Question 28

What do labs look like for PSC?

Answer 28

Persistantly elevated ALK PHOS with AMA+ antibodies

Question 29

SEe florid duct lesion adn loss of small ducts

serology:

AMA+ (95%)

ANA+ (20%)

ANCA (40%)

Answer 29

Primary biliary cirrhosis

Question 30

What is the most common way GB cancer is discovered?

Answer 30

Incidentally: on imaging, intraoperatively during cholecystecomy or during a pathological exam

Question 31

What are the symptoms for GB cancer?

Answer 31

pain, anorexia, nausea,
vomiting, jaundice from biliary obstruction

Question 32

What is the prognosis and treament like for GB Cancer?

Answer 32

Generally poor prognosis, better outcomes if you find it early, but often wont have symptoms till much later

Surgery is the only option for cure

**GB is in close proximity to lots of structures so it spreads very easily