Cholangiocarcinoma

Question 1

Define cholangiocarcinoma

Answer 1

Malignancy arising from the bile duct epithelium – mostly adenocarcinomas

Question 2

What are the causes/risk factors of cholangiocarcinoma?

Answer 2

• Age >50 years
• Gallstones/ cholangitis
• Structural disorder of the biliary tree
• Primary sclerosing cholangitis
• Liver disease
• Ulcerative cholitis
• HBV/HCV infection

Question 3

What are the symptoms of cholangiocarcinoma?

Answer 3

• Weight loss
• Jaundice
• Abdominal pain
• Pruritus

Question 4

What are the signs of cholangiocarcinoma?

Answer 4

• Jaundice

* Hepatomegaly

Question 5

What investigations are carried out for cholangiocarcinoma?

Answer 5

• FBC - normal
• LFTs - Obstructive picture: Elevated ALP and GGT. Mildly elevated ALT and AST –higher in intrahepatic cholangiocarcinoma cases. High BR (BR-C) and Low Albumin
• Clotting Screen - prolonged PT/INR –due to reduced absorption of fat-soluble vitamin K
• Serum CEA (carcinoembryonic antigen) - elevated; may be elevated in IBD and other tumours as well
• Serum CA 19-9 - elevated; very useful in patients with PSC to detect cholangiocarcinoma.
*serum CA 19-9 + (40 times CEA) equation used to calculate the likelihood of a tumour progression. Positive predictive value of 100% in predicting progression to cholangiocarcinoma.
>40 kilo-units/L
• Liver USS - diagnosis suspected when intrahepatic ducts are dilated; intrahepatic cholangiocarcinoma may be seen as a mass lesion
• ERCP - a filling defect or narrowing may be seen at tumour location
• MRCP - can show extent of duct involvement above and below the obstruction
• CT/ MRI - intrahepatic mass lesion, dilated intrahepatic ducts, and localised lymphadenopathy may be seen. Useful for staging
• MR-Angiography - useful for staging.
• PET Scan - shows hot nodules in areas of metastases; useful for staging
• Immunostaining - to distinguish intrahepatic cholangiocarcinoma from mixed hepatocellular cholangiocarcinoma
• Shifting dullness - ascites