cholangioca

Question 1

definition of cholangioca

Answer 1

primary adenocarcinoma of the biliary tree

usually slow growing - most are distal extra-hepatic or perihilar

Question 2

aetiology and RF of cholangioca

Answer 2

unknown

associations and RF:

• UC
• PSC screening by CA19–9 may be helpful,
• choledochal cysts
• Caroli’s disease
• parasitic infections of the biliary tract eg clonorchis sinensis liver flukes
• HBV
• HCV
• DM
• N-nitroso toxins

Question 3

pathology of cholangioca

Answer 3

micro: adenocarcinoma arising from biliary tract, papillary, nodular or sclerosing types. Usually moderately differentiated and slow growing
macro: described according to location of hilar, mid-duct, distal and diffuse

bismuth:

• classification of hilar tumours into types 1-5 based on location in relation to the confluence of hepatic ducts
• klatskin tumours are cholangiocarcinomas arising at the confluence of the L and R hepatic ducts

staging: TNM

Question 4

epidemiology of cholangioca

Answer 4

rare

0.2-0.3% cancer

more males

more in developing world - parasites

Question 5

sx of cholangioca

Answer 5

obstructive jaundice - yellow skin and sclera, pale stools, dark urine, pruritus

abdo fullness/pain

symptoms of malignancy: weight loss, malaise

fever

Question 6

signs of cholangioca

Answer 6

• ascites
• malaise
• raided BR, ALP
• jaundice
• palpable gallbladder - Courvoisier’s law states that, in the presence of jaundice, an enlarged gallbladder is unlikely to be due to gallstones; i.e. carcinoma of the pancreas or the lower biliary tree is more likely
• epigastric/RUQ mass
• hepatomegaly

Question 7

Ix for cholangioca

Answer 7

bloods

• FBC, UE, LFT (BR, alkphos and y-GT raised)
• clotting
• tumour markers (CA19-9 raised in cholangiocarcinomas) and pancreatic carcinomas

endoscopy - ERCP enables bile cytology, tumour biopsy if accessible and interventions to relieve obstructive jaundice

US - varying sensitivity, will show biliary duct dilation

CT, MRI, MRCO, bone scan - stage tumour and visualise any regional spread

arteriogram (invasive or MR) - important when considering surgery to show any involvement of surrounding vascular structures

Question 8

Mx of chanlangioca

Answer 8

rfefer to 2WW if upper R quad mass
* surgery if resectablke +- chemo, immuno, radio
* unresectable: liver transplant

Question 9

monitoring for cholangioca

Answer 9

Imaging regularly every 6mo initially then every 12mo - determine if further obstruction after rx

Question 10

complications of cholangioca

Answer 10

• cholangitis
• biliary leak
• biliary obstruction
• complications from immunotherapy

Question 11

complications from immunotherapy

Answer 11

anaemia
fatigue
dysphagia
neutropenia
lymphopenia
hypertension
elevated lipase