General surgery (7) (GI cancers) Flashcards
colorectal cancer (bowel)
Common cancer- cancer of the colon or rectum. Small bowel and anal cancers less common
aetiology of bowel cancer
- Adenocarcinomas (rarer types inc lymphoma, carcinoid and sarcoma)
- Adenomas may be present for 10 years before becoming cancerous
bowel cancer DD
Differentials: IBD, haemarrhoids
risk factors for bowel cancer
- Family history of bowel cancer
- Familial adenomatous polyposis (FAP)
- Hereditary nonpolyposis colorectal cancer (HNPCC), also known as Lynch syndrome
- Inflammatory bowel disease (Crohn’s or ulcerative colitis)
- Increased age
- Diet (high in red and processed meat and low in fibre)
- Obesity and sedentary lifestyle
- Smoking
- Alcohol
presentation of bowel cancer
- Change in bowel habit (usually to more loose and frequent stools)
- Unexplained weight loss
- Rectal bleeding
- Unexplained abdominal pain
- Iron deficiency anaemia (microcytic anaemia with low ferritin)
- Abdominal or rectal mass on examination
- Presenting with obstruction
- Tumour blocks passage through bowel- surgical emergency
- Right side colon cancer: abdominal pai, iron def anaemia, palpable mass in RIF or on PR exam
- Left side colon cancer: rectal bleeding, change in bowel habit, tenesmus, palpable mass in LIF
bowel cancer refferal
- Over 40 years with abdominal pain and unexplained weight loss
- Over 50 years with unexplained rectal bleeding
- Over 60 years with a change in bowel habit or iron deficiency anaemia
investigations for bowel cancer
- Bloods- FBC (microcytic – iron def anaemia), LFTs, clotting, carcinoembryonic antigen (CEA)- tumour marker
- Colonoscopy with biopsy- gold standard- biopsy if lesion found
- Sigmoidoscopy (if only features of rectal bleeding)
- CT colonography- pts less fit for colonoscopy- less detailed doesn’t allow for biopsy
-
Staging CT scan
- CT thorax, abdomen and pelvis (CT TAP)
Familial adenomatous polyposis (FAP)
- Autosomal dominant condition involving malfunctioning of the tumour suppressor genes called adenomatous polyposis coli (APC).
- It results in many polyps (adenomas) developing along the large intestine.
- These polyps have the potential to become cancerous (usually before the age of 40).
- Patients have their entire large intestine removed prophylactically to prevent the development of bowel cance (panproctocolectomy).
which gene is involved in FAP
malfunctioning of the tumour suppressor genes called adenomatous polyposis coli (APC).
Hereditary nonpolyposis colorectal cancer (HNPCC)
- Lynch syndrome.
- Autosomal dominant condition that results from mutations in DNA mismatch repair (MMR) genes.
- Patients are at a higher risk of a number of cancers, but particularly colorectal cancer.
- Unlikely FAP, it does not cause adenomas and tumours develop in isolation.
patients with FAP or HNPCC
These patients offered FIT screening at regular intervals
management of bowel cancer
Management
-
MDT approach
- Surgeons
- Oncologists
- Radiologists
- Histopathology
- Specialist nurse
-
Choice of managed depends on
- Clinical condition
- General health
- Stage
- Histology
- Patient wishes
- Options (in any combination)
- Surgical resection
- Chemotherapy
- Radiotherapy
- Palliative care
surgical resection for bowel cancer
Ideal to surgically remove entire tumour – potentially curative. Can also be used palliatively- reduce size of tumour and improve symptoms
- Laparoscopic surgery gives better recovery and few complications than open surgery
- Robotic surgery used increasingly
-
Surgery involves
- Identify tumour (may have been tattooed in endoscopy)
- Remove section of bowel containing tumour
- Creating an end-to- end anastomosis (sewing the remaining ends back together)
- Creating a stoma if end to end not possible
*
complications of surgical resection for bowel cancer
There is a long list of potential complications of surgery for bowel cancer:
- Bleeding, infection and pain
- Damage to nerves, bladder, ureter or bowel
- Post-operative ileus
- Anaesthetic risks
- Laparoscopic surgery converted during the operation to open surgery (laparotomy)
- Leakage or failure of the anastomosis
- Requirement for a stoma
- Failure to remove the tumour
- Change in bowel habit
- Venous thromboembolism (DVT and PE)
- Incisional hernias
- Intra-abdominal adhesions
Faecal Immunochemical Test (FIT) and Bower Cancer Screening
-
Faecal immunochemical tests (FIT) look very specifically for the amount of human haemoglobin in the stool.
- FIT replaced the older stool test called the faecal occult blood(FOB) test, which detected blood in the stool but could give false positives by detecting blood in food (e.g., from red meats).
- Used for bowel cancer screening in UK
- Ages 60-74yo every 2 years
- If results positive à colonscopy
- FIT tests can be used as a test in general practice to help assess for bowel cancer in specific patients who do not meet the criteria for a two week wait referral, for example:
- Over 50 with unexplained weight loss and no other symptoms
- Under 60 with a change in bowel habit
classification of bowel cancer using
Dukes classification and TNM classification
Dukes’ Classification
Dukes’ classification is the system previously used for bowel cancer. It has now been replaced in clinical practice by the TNM classification, but you may come across it in older textbooks or question banks. A brief summary is:
- Dukes A – confined to mucosa and part of the muscle of the bowel wall
- Dukes B – extending through the muscle of the bowel wall
- Dukes C – lymph node involvement
- Dukes D – metastatic disease
TNM classification
T for Tumour:
- TX – unable to assess size
- T1 – submucosa involvement
- T2 – involvement of muscularis propria (muscle layer)
- T3 – involvement of the subserosa and serosa (outer layer), but not through the serosa
- T4 – spread through the serosa (4a) reaching other tissues or organs (4b)
N for Nodes:
- NX – unable to assess nodes
- N0 – no nodal spread
- N1 – spread to 1-3 nodes
- N2 – spread to more than 3 nodes
M for Metastasis:
- M0 – no metastasis
- M1 – metastasis
operations for colorectal cancer
- Right hemicolectomy involves removal of the caecum, ascending and proximal transverse colon.
- Left hemicolectomy involves removal of the distal transverse and descending colon.
- High anterior resection involves removing the sigmoid colon (may be called a sigmoid colectomy).
- Low anterior resection involves removing the sigmoid colon and upper rectum but sparing the lower rectum and anus.
- Abdomino-perineal resection (APR) involves removing the rectum and anus (plus or minus the sigmoid colon) and suturing over the anus. It leaves the patient with a permanent colostomy.
- Hartmann’s procedure is usually an emergency procedure that involves the removal of the rectosigmoid colon and creation of an colostomy. The rectal stump is sutured closed. The colostomy may be permanent or reversed at a later date. Common indications are acute obstruction by a tumour, or significant diverticular disease.
Low Anterior Resection Syndrome
Low anterior resection syndrome may occur after resection of a portion of bowel from the rectum, with anastomosis between the colon and rectum. It can result in a number of symptoms, including:
- Urgency and frequency of bowel movements
- Faecal incontinence
- Difficulty controlling flatulence
follow up after bowel cancer resection
Follow-Up
Patients will be followed up for a period of time (e.g., 3 years) following curative surgery. This includes:
- Serum carcinoembryonic antigen (CEA)
- CT thorax, abdomen and pelvis
stomach cancer
Majority of gastric cancers arise from gastric mucosa as adenocarcinomas. The rest are a mixture of connective tissue, lymphoid or neuroendocrine malignancies
DD for stomach cancer
- Peptic ulcer disease
- GORD
- Gallstone
- Pancreatic cancer
RF for gastric cancer
(rate has improved in the west due to H.pylori eradication therapy and improved diet)
- H.pylori
- Male
- Age
- Smoking
- Alcohol
- Positive family history
- Pernicious anaemia
presentation of gastric cancer
- Vague and non-specific – pts present at advanced stage
- Dyspepsia
- Dysphagia
- Early satiety
- Vomiting (haematemesis
- Melaena
- Non-specific cancer SYMPTOMS
- ANOREXIA
- WEIGHT LOSS
- ANAEMIA
- Clinical signs usually absent
- Epigastric mass in late disease
- Troisiers sign- palpable left supraclavicular node (Virchow node)- metastatic abdominal malignancy
- Metastatic signs
- Hepatomegaly
- Ascites
- Jaundice
- Acanthosis nigricans (hyper pigmentation of skin creases e.g. axilla
Troisiers sign
- palpable left supraclavicular node (Virchow node)- metastatic abdominal malignancy
investigations for gastric cancer
- Bloods: FBC, LFT
- Imaging
- Urgent upper GI endoscopy (OGD)- any patients presenting with new-onset dysphagia or aged >55 years presenting with weight loss and either upper abdominal pain, reflux, or dyspepsia.- signet ring cells
- Biopsy
- Histology- neoplasia
- CLO test- H.pylori
- HER2/neu protein expression (targeted monoclonal therapies)
- Staging- CT chest-abdomen-pelvis and staging laparoscopy (looking for peritoneal metastases)- TNM staging
which cells may be found in a biopsy after OGD in gastric cancer
signet ring cells
Helicobacter Pylori
- The most important modifiable risk factor identified in developing gastric cancer is infection of the stomach mucosa by Helicobacter Pylori.
- H. Pylori is a Gram negative helical bacterium that produces the urease enzyme, acting to break down urea into CO2 and ammonia.
- The ammonia neutralises stomach acid, allowing the bacterium to create an alkaline microenvironment.
- It subsequently sets off a cycle of repeated damage to the epithelial cells, leading to inflammation, ulceration, and ultimately gastric neoplasia.
Helicobacter Pylori eradication therapy
- (x7-14 days)
- PPI
- X2 antibiotics
- Amoxicillin
- Metronidazole
management of gastric cancer
- MDT approach
- Adequate nutrition
- NG, RIG may be needed
- Curative treatment- surgery
- Peri-operative chemotherapy
- 3 cycles neoadjuvant and 3 cycles adjuvant
- Surgery
- Peri-operative chemotherapy
- Palliative care
gastrectomy
The aim of surgery is to achieve loco-regional control by removing the tumour and its local lymph nodes. The type of operation performed depends on the region of the malignancy:
- Proximal gastric cancers – total gastrectomy
- Distal gastric cancers (antrum or pylorus) – subtotal gastrectomy
reconstruction after gastrectomy
The most commonly used method in reconstructing the alimentary anatomy is the Roux-en-Y reconstruction as it gives the best functional result, in particular with less bile reflux.
Post-gastrectomy, distal oesophagus is end-to-end anastomosed directly to the small bowel, and the proximal small bowel is end-to-side anastomosed also to the small bowel
endoscope mucosal resection (EMR) and gastric cancer
Patients with early T1a tumours (tumours confined to the muscularis mucosa) may be offered an Endoscopic Mucosal Resection (EMR). This has the advantage of a greatly reduced morbidity, mortality, and quality of life impact, however is only used in early tumours therefore current use in clinical practice is rare.
complications of gastrectomy
- Death
- Anastomotic leak
- Re-operation
- Dumping syndrome
- Vitamin B12 def
palliative management fo gastric cancer
Most patients will be offered only a palliative approach due to the extent of disease at time of presentation. This may include :
- Chemotherapy
- Best supportive care,
- Stenting (for patients who have gastric outlet obstruction secondary to an obstructing cancer).
Palliative surgery (usually distal gastrectomy or bypass surgery (a gastro-jejunostomy)) can be used when stenting fails or is not available. It can also be used cautiously in the palliation of bleeding gastric tumours.
pancreatic cancer
Diagnosed late and very poor prognosis due to late presentation
- Vast majority adenocarcinomas
- Most occur in head of pancreas (as opposed to body or tail)
- Once large enough will press on bile duct- obstructive jaundice
-
Prognosis
- Spreads and metastasises early
- Liver
- Peritoneum
- Lungs
- Bones
- 6 months average survival
- Spreads and metastasises early
RF for pancreatic cancer
- Age
- Male
- Race
- Smoking
- Obesity, diet, alcohol
- Diabetes
- Fx
presentation of pancreatic cancer
Painless obstructive jaundice is a key presenting feature that should make you immediately consider pancreatic cancer (the key differential is cholangiocarcinoma)
- Yellow skin and sclera
- Pale stools
- Dark urine
- Generalised itching
The other presenting features for pancreatic cancer can be vague:
- Non-specific upper abdominal or back pain
- Unintentional weight loss
- Palpable mass in the epigastric region
- Change in bowel habit
- Nausea or vomiting
- New‑onset diabetes or worsening of type 2 diabetes
investigations for pancreatic cancer
-
Staging CT- CT TAP
- Looks for metastasis and other cancers
- CA 19-9 (carbohydrate antigen) is a tumour maker raised in pancreatic cancer (also raised in cholangiocarcinoma)
- Magnetic resonance cholangial pancreatography (MRCP)- assess biliary system
- Endoscopic retrograde cholangial-pancreatography (ERCP)- stent to relieve obstruction and biopsy tumour
-
Biopsy
- Through skin under US OR CT guidance
referral for pancreatic cancer
The NICE guidelines on suspected cancer (last updated January 2021) give the criteria for when to refer for suspected pancreatic cancer:
- Over 40 with jaundice – referred on a 2 week wait referral
- Over 60 with weight loss plus an additional symptom (see below) – referred for a direct access CT abdomen
The NICE guidelines suggest a GP referral for a direct access CT abdomen (or ultrasound if not available) to assess for pancreatic cancer if a patient has weight loss plus any of:
- Diarrhoea
- Back pain
- Abdominal pain
- Nausea
- Vomiting
- Constipation
- New‑onset diabetes
names signs for pancreatic cancer
courvoisiers law
trousseau’s sign of malignancy
Courvoisier’s law
states that a palpable gallbladder along with jaundice is unlikely to be gallstones. The cause is usually cholangiocarcinoma or pancreatic cancer.
trousseaus sign
-
Trousseau’s sign of malignancy refers to migratory thrombophlebitis as a sign of malignancy, particularly pancreatic adenocarcinoma.
- Thrombophlebitis is where blood vessels become inflamed with an associated blood clot (thrombus) in that area.
- Migratory refers to the thrombophlebitis reoccurring in different locations over time.
management of pancreatic cancer
- HPB MDT meeting
-
Surgery
- More likely to be considered with small tumours isolated in the head of the pancreas
- Total pancreatectomy
- Distal pancreatectomy
- Pylorus-preserving pancreaticoduodenectomy (PPPD) (modified Whipple procedure)
- Radical pancreaticoduodenectomy (Whipple procedure)
- More likely to be considered with small tumours isolated in the head of the pancreas
-
Palliative treatment (mostly curative surgery not possible)
- Stents inserted to relieve the biliary obstruction
- Surgery to improve symptoms (e.g., bypassing the biliary obstruction)
- Palliative chemotherapy (to improve symptoms and extend life)
- Palliative radiotherapy (to improve symptoms and extend life)
- End of life care with symptom control
whipple procedure
A Whipple procedure (pancreaticoduodenectomy) is a surgical operation to remove a tumour of the head of the pancreas that has not spread. A Whipple procedure is a massive operation so patients need to be in good baseline health. It involves the removal of the:
- Head of the pancreas
- Pylorus of the stomach
- Duodenum
- Gallbladder
- Bile duct
- Relevant lymph nodes
oesophageal canceer types
- Squamous cell carcinoma
- More common in developing world
- Middle and upper thirds of the oesophagus
- Adenocarcinoma
- More common in developed world
- Lower third of oesophagus
- Consequence of metaplastic epithelium (Barretts oesophagus)
RF for oesophageal cancer
- Male
- Squamous cell carcinoma
- Smoking
- Excessive alcohol consumption
- Chronical achalasia
- Low vitamin A
-
Adenocarcinoma
- Barretts oesophagus
- GORD
obesity - High fat intake
presentation of oesophageal cancer
- Early stage lacks well defined symptoms
- Dysphagia – progressive in nature
- Weight loss
- Odynophagia
- Hoarseness
- Weight loss or cachexia
- Dehydration
- Supraclavicular lymphadenopathy
- Metastatic disease signs
investigations for oesophageal cancer
- Upper GI endoscopy- (OGD) within 2 weeks – biopsy and sent for histology
- CT CAP and PET-CT scan to investigate metastases
- Endoscopic US (measure penetration into oesophageal wall)
- Staging laparoscopy- intra peritoneal metastases
- Fine needle aspiration of palpable cervical lymph nodes
- Bronchoscopy for hoarseness or haemoptysis
prognosis of oesophageal cancer
poor due to late presentation (five year survival is 5-10%)
hiatus/s in the diaphragm
- Vena cava (T8)
- 8 letters
- Oesophagus (T10)
- 10 letters
- Aortic hiatus (T12)
- 12 letters
Criteria for Upper GI Endoscopy
Current NICE guidance states the red-flag symptoms for a suspected oesophageal malignancy requiring urgent endoscopy are:
- Any patient with dysphagia
- Any patient >55yrs with weight loss and upper abdominal pain, dyspepsia, or reflux
Dysphagia DD
- Neuromuscular
management of oesophageal cancer
- MDT approach
- CPEX test for fitness for surgery
- Mostly treated palliatively due to late presentation
- may stent for symptoms
- Curative management
- Depends on
- Tumour type,
- Site
- Patient factors e.g. patient co-morbidities
- Inc surgery with or without neoadjuvant chemotherapy or chemoradiotherapy
-
Squamous cell carcinoma- upper oesophagus is difficult to operate on.
- Definitive chemo-radiotherapy is treatment of choice
-
Adenocarcinoma- neoadjuvant chemotherapy or chemoradiotherapy
- Oesophageal resection = definitive treatment
-
Squamous cell carcinoma- upper oesophagus is difficult to operate on.
- Depends on
oesophagectomy approaches
- Removal of tumour, top of stomach, surrounding lymph nodes
- Stomach is then made into a tube (conduit) and brought up into the chest to replace the oesophagus
- Specific approaches include
- Right thoracotomy (a surgical procedure in which a cut is made between the ribs to see and reach the lungs or other organs in the chest or thorax) with laparotomy (termed an Ivor-Lewis procedure)
- Right thoracotomy with abdominal and neck incision (termed a McKeown procedure)
- Left thoracotomy with or without neck incision
- Left thoraco-abdominal incision (one large incision starting above the umbilicus and extending round the back to below the left shoulder blade)
most common procedure for oesophagectomy
ivor lewis
- Right thoracotomy (a surgical procedure in which a cut is made between the ribs to see and reach the lungs or other organs in the chest or thorax) with laparotomy (termed an Ivor-Lewis procedure)
early cancer/high grade barretts
- Right thoracotomy (a surgical procedure in which a cut is made between the ribs to see and reach the lungs or other organs in the chest or thorax) with laparotomy (termed an Ivor-Lewis procedure)
complications of oesophagectomy
- Anastomotic leak
- High rate- any deterioration in an oesophagectomy pt should be considered an anastomotic leak until proven otherwise
- Re-operation
- Pneumonia
- Death
Post-operative nutrition
- Major problem for these patients as they lose the reservoir function of the stomach.
- Many centres will routinely insert a feeding tube into the small bowel (a “feeding jejunostomy”) to aid nutrition.
- However, most patients will need to eat 5-6 small meals per day to meet their nutritional requirement
Palliative management of oesophageal cancer
Pts too unfit or unsuitable fo curative therapy
- Oesophageal stent (if difficulty swallowing)
- Radiotherapy/and or chemo
- To reduce tumour size and bleeding
- Nutritional support
- Thickened fluids
- Nutritional supplements
- Radiologically inserted gastrotomy (RIG) if dysphage too bad to tolerate enteral feeds
liver cancer can either be
Can either be metastatic (90%) or primary (10%)
what type of cancer is liver cancer
- hepatocellular carcinoma
- Due to chronic inflammation in the liver
RF for liver cancer
- Viral hepatitis
- Hepatitis B virus and Hepatitis C virus are the most common causative organisms
- High alcohol intake
- Smoking
- Advanced age (>70yrs)
- Aflatoxin exposure
- Hereditary haemochromatosis
presentation of liver cancer
- Liver cirrhosis
- Fatigue
- Fever
- Weight loss
- Lethargy
- Dull ache in right upper quadrant
- Ascites
- Jaundice
- One examination
- Irregular enlarged, craggy and tender liver
staging of liver cancer
Barcelona clinic liver cancer staging system (BCLC)
Barcelona clinic liver cancer staging system (BCLC)
Provides guidance on which treatment is most suitable
- Tumour stage
- Liver function
- Physical status
- Cancer related symptoms
risk assessment scores of liver cancer
-
Child-Pugh
- Uses serum bilirubin, albumin, INR, degree of ascites, evidence of encephalopathy
- Calculates prognosis of patient with liver cirrhosis
-
MELD score- better predictor or morality
- Creatinine, bilirubin, INR, sodium and use of dialysis
- Used to predict likelihood of patient tolerating potential liver transplant
investigations for liver cancer
- Bloods
- Liver function test (ALP, ALT, AST, bilirubin)
- *If AST:ALT ratio >2, likely alcoholic liver disease; if AST:ALT around 1, likely viral hepatitis
- Low platelets
- Prolonged clotting
-
Alphafetoproetin (AFP)
- Also used to monitor treatment response and recurrence
- Liver function test (ALP, ALT, AST, bilirubin)
- Imaging
- US
- If mass >2cm found with AFT- virtually diagnostic
- Staging CT
- Patients with rising AFP and suggestive US nodules – MRI liver scanning
- US
- If diagnosis still in doubt- biopsy or percutaneous fine-needle aspiration
AST:ALT ratio for alcoholic liver disease
ratio >2
AST:ALT ratio for viral hepaitits
AST:ALT around 1
prognosis for Hepatocellular carcinoma
depends on cirrhosis. Median survival time form diagnosis 6 months
management of HCC: surgical management
- Resection
- Treatment of choice in pt without cirrhosis and with good baseline health status
- High recurrence rate 50-60%
- Transplantation
- Can be considered in pt that fulfils Milan Criteria
- One lesion is smaller than 5cm or three lesions smaller than 3cm
- No extrahepatic manifestation
- No vascular infiltration
- Can be considered in pt that fulfils Milan Criteria
management of HCC: non-surgical management
- Image-guided ablation
- For early HCC
- US probes are placed in the tumour mass to induce necrosis
- Alcohol ablation
- Transarterial chemoembolization (TACE)
- High conc of chemo are injected directly into hepatic artery and an embolising agent is then added to induce ischaemia
- Radiology used to visualise hepatic artery supplying tumour- preserving majority of liver
secondary liver malignancy
Most common underlying cause of death in patients with cancer
secondary liver malignancy causes
- Bowel (via portal circulation)
- Breast
- Pancreas
- Stomach and lung
secondary liver malignancy presentation
- Hepatomegaly
- Ascites
- Jaundice upper
- Abdominal pain
secondary liver malignancy investigations
- Similar to HCC
- Bloods
- Derangement of LFTS (ALPs most raised)
- Imaging
- US imaging of choice
- Staging
- CT
- Biopsy not advice if tumour is operable- needle tract may lead to seeding of tumour
Management metastatic liver malignancy
- Due to nature of metastasis surgery is more diff and less useful- resection not particularly useful
- Surgery may be considered if metastasis confined to the liver and the primary tumour is under control
- Oncological and palliative input important
- Alternatives
- Transarterial chemoembolization
- Selective interval radiotherapy
Cholangiocarcinoma
Cancer originating in bile duct
Where?
- Intrahepatic ducts (bile ducts in the liver)
- Extrahepatic (outside liver)
- Most common sit= perihilar region – where the right and left hepatic ducts have joined to become the common hepatic duct just after leaving the liver
what type of cancer is cholangiocarcinoma
- Adenocarcinoma
RF for cholagiocarcinoma
- Primary sclerosing cholangitis (pt with UC at risk)
- Liver flukes (parasitic infection)
presentation of cholagiocarcinoma
- Obstructive jaundice
- Pale stools
- Dark urine
- Generalise itching
- Non-specific signs and symptoms
- Unexplained weight loss
- Right upp quadrant pain
- Palpable gallbladder
- Hepatomegaly
-
Courvoisiers law states that a palpable gallbladder along with jaundice is unlikely to be gallstone
- Cholangiocarcinoma
- Pancreatic cancer
Courvoisiers law
-
states that a palpable gallbladder along with jaundice is unlikely to be gallstone
- Cholangiocarcinoma
- Pancreatic cancer
investigations for cholagiocarcinoma
- Diagnosis is based on imaging (CT or MRI) plus histology from a biopsy.
- Staging CT scan involves a full CT thorax, abdomen and pelvis (CT TAP). This is used to look for metastasis and other cancers.
- CA 19-9 (carbohydrate antigen) is a tumour marker that may be raised in cholangiocarcinoma. It is also raised in pancreatic cancer and a number of other malignant and non-malignant conditions.
- Magnetic resonance cholangio-pancreatography (MRCP) may be used to assess the biliary system in detail to assess the obstruction.
- Endoscopic retrograde cholangio-pancreatography (ERCP) can be used to put a stent in and relieve the obstruction, and also obtain a biopsy from the tumour.
tumour marker for cholangiocarcinoma
CA 19-9 (carbohydrate antigen)
also raised in pancreatic cancer
management of cholangiocarcinoma
- MDT meeting
- Curative surgery (may be possible in early cases) +- radio and chemo
- Normally palliative care
- Stents inserted to relieve the biliary obstruction
- Surgery to improve symptoms (e.g., bypassing the biliary obstruction
- Palliative chemotherapy
- Palliative radiotherapy
- End of life care with symptom control
