Cholangiocarcinoma

Question 1

Define cholangiocarcinoma and what is the most common histology

Answer 1

Cancer arising from the bile duct epithelium. Either intrahepatic or extrahepatic (perihilar and distal)

> 95% are adenocarcinomas (infiltrating nodular or diffusely infiltrating)

Question 2

What are Klatskin’s tumours

Answer 2

Perihilar tumours involving the bifurcation of the ducts

Question 3

Aetiology of cholangiocarcinoma

Answer 3

Association with infection and inflammation
CLD due to Hep B or C -> cirrhosis
Alcoholic liver disease
Cirrhosis
Bile duct disease (adenoma, papilllomatosis, Caroli’s)
Chloledocholithiasis + cholelithiasis + cholangitis
UC
HIV
PSC

Point mutation of K-ras and beta-catenin Proto-oncogenes + p53, p16, APC, DPC4 alterations

Question 4

Symptoms of cholangiocarcinoma

Answer 4

Painless jaundice 
Dark urine, pale stools 
Weight loss 
Abdominal pain (RUQ)
Pruritus 

Charcot’s triad: fever + RUQ pain + jaundice (cholangitis - cause)

Question 5

Signs of cholangiocarcinoma on examination

Answer 5

Palpable gall bladder
Hepatomegaly
Dark urine + pale stools

Question 6

Investigations for cholangiocarcinoma

Answer 6

Abdominal CT: extent and visualisation of tumour, dilated intrahepatic ducts, localised lymphadenopathy

LFTs + enzymes: alk phos + GGT markedly elevated, Bilirubin raised, ALT/AST raised
Clotting: PT prolonged
Cancer markers: CA 19-9 elevated (+ CEA, CA-125)

Abdominal USS: intrahepatic duct dilation, mass lesion
Abdominal MRI: extent of tumour, liver mets
ERCP: Filling defect or area of narrowing
MRCP: extent of duct involvement
Immunostaining: distinguishes between intrahepatic and mixed

Percutaneous transhepatic catheterisation: dilated ducts + irregular filling defects