Biliary cancer is a relatively rare type of aggressive cancer that originates from the bile duct cells. Bile duct is the “pipe” that carries bile juice being produced by the liver into the small bowel to help with digestion. There are several forms of biliary tract cancer and each type has slightly different clinical presentation, histopathology, treatment, and overall prognosis. Biliary duct cancer that occurs inside the liver is called intrahepatic cholangiocarcinoma. Bile duct cancer that occurs at the junction of right and left bile duct is called perihilar cholangiocarcinoma or Klatskin tumor. Chronic inflammatory state of the biliary tract such as seen in patients with primary sclerosing cholangitis, liver flukes/parasite in Asia, and chronic biliary obstruction/sepsis is a predisposing factor for development of biliary duct cancer. Clinical presentation of biliary cancer depends on the location of the tumor within the biliary tree. For the purpose of this blog, we will limit the discussion for intrahepatic cholangiocarcinoma.
Intrahepatic cholangiocarcinoma is a malignant type of biliary tract cancer that often presents as a liver tumor, seen on CT scan on MRI. Many patients do not have any symptoms until the cancer reaches an advanced stage or even metastatic stage. For patients with symptoms, nausea, upper abdominal pain/discomfort, unintentional weight loss, and jaundice (yellowing of skin and eyes) are the most common findings leading to cancer diagnosis. The tumor can be as big as 20 cm in size prior to diagnosis. Large tumors can create mechanical compression to the adjacent main biliary tract causing a complete biliary obstruction and subsequently biliary sepsis. Patients with any suspicion of having biliary cancer need to see a liver surgeon immediately. Early diagnosis and treatment are keys to improve biliary cancer prognosis. The treatment of biliary tract cancer falls into the specialty of liver surgeon, since the treatment of biliary tract cancer often involve liver resection (minor or major).
Once bile duct cancer is diagnosed using a combination of blood work, imaging, and sometimes liver biopsy, treatment plan should be formulated. Tumor size, location, proximity to major vascular structures (artery and vein), obstruction of bile duct, background liver function, and presence of spread to other organs determine course of action. The gold standard treatment in biliary tract cancer is surgical resection, whenever possible. Liver/bile duct resection is the only hope to achieve cure in biliary tract cancer. Systemic chemotherapy has a poor response to bile duct cancer (only up to 50% response rate) even to date.
Placement of biliary drain is sometimes necessary to resolve the jaundice prior to surgical liver resection. This can be achieved by agastroenterologist or interventional radiologist. In patients with marginal liver function, preoperative induction of liver growth via portal vein embolization or portal vein ligation may be needed. An experienced liver surgeon develops an accurate treatment plan in order to avoid postoperative liver failure, especially in patients who require extended liver resection removing up to 70% of the liver volume. Dr. Sucandy and his team have an extensive experience in treating patients with biliary tract cancers in Tampa Bay Area, including those who need an extended liver resection to achieve clean margins.
Our liver surgery team performs biliary tract cancer operation routinely, via ‘open’ or minimally invasive robotic technique. Minimally invasive robotic technique for biliary tract cancer is a novel approach with lower postoperative complications when compared to the ‘open’ surgical resection. Only a few major centers in the country can offer this technique. It is quite common for Dr. Sucandy and his team to remove intrahepatic biliary tract tumors with size more than 10 cm. Regional lymph nodes are also removed during this operation. Many patients require postoperative chemotherapy to achieve best long-term overall survival. Biliary cancer prognosis can be maximized with combination of complete surgical resection and postoperative chemotherapy. Many patients from around the Tampa Bay Area and various cities in the state of Florida came to seek treatment of biliary tract cancer in our program since 2017. Please to not hesitate to call your doctor regarding treatment of biliary duct cancer since it is important to receive treatment from the high volume liver/bile duct surgeons.