Cholangiocarcinoma

Question 1

ESSENCE

Answer 1

Type of cancer that originates in bile ducts

Question 2

What is the histology

Answer 2

• Majority are adenocarcinomas

Question 3

What is usual site

Answer 3

• Can affect bile ducts inside liver (intrahepatic ducts) or outside (extrahepatic ducts)
• Most common site is perihilar region

Question 4

AETIOLOGY

Risk factors

Answer 4

• Key risk factors
  
  • Primary sclerosing cholangitis - worth knowing patients with ulcerative colitis at risk of this
  • Liver flukes (a parasite infection)

Question 5

CLINICAL FEATURES

Presentation

Answer 5

• Obstructive jaundice key feature to remember, also associated with
  
  • Pale stools
  • Dark urine
  • Generalised itching
• Other non-specific signs and symptoms
  
  • Unexplained weight loss
  • Right upper quadrant pain
  • Palpable gallbladder
  • Hepatomegaly

Question 6

What does Couvoisier’s law state

Answer 6

Palpable gallbladder along with jaundice is unlikely to be gallstones, cause is usually cholangiocarcinoma or pancreatic cancer

Question 7

What should painless jaundice make you think of

Answer 7

Cholangiocarcinoma or cancer at head of pancreas (pancreatic cancer most common)

Question 8

INVESTIGATIONS

First choice

Answer 8

• Diagnosis based on imaging (CT or MRI) plus histology from biopsy
• Staging CT scan - thorax, abdomen, pelvis (CTTAP)
• Ca19-9
• MRCP can be used to assess for obstruction of biliary tree
• ERCP can be used to put in stent to relieve obstruction

Question 9

What tumour marker is raised

Answer 9

CA19-9

Question 10

MANAGEMENT

General principles

Answer 10

• MDT
• Curative surgery maybe in early cases
  
  • Chemotherapy and radiotherapy
• In most cases palliative therapy

Question 11

MANAGEMENT

What does palliative therapy involve

Answer 11

• Stents to relive biliary obstruction
• Surgery to improve symptoms (eg bypassing obstruction)
• Palliative chemotherapy
• Palliative radiotherapy
• End of life care with symptom control