ERCP is a diagnostic procedure used to study the bile ducts, pancreatic duct, and gallbladder.

Liver transplantation is often used for cancer that occurs within the liver. But the University of Michigan is one of a small number of centers around the country to offer a transplant for cancer of the bile duct. The procedure offers hope for some patients who have no other effective options.

Treatment Options Based on the Extent of Bile Duct Cancer
The extent of bile duct cancer is an important factor in deciding on treatment options. Whenever possible, surgery is the main treatment for bile duct cancers. It offers the only realistic chance for a cure. Because of this, doctors generally divide bile duct cancers into:

Resectable cancers, those that doctors believe can be removed completely by surgery, based on the results of imaging tests and other tests.
Unresectable cancers, those that have spread too far or are in too difficult a place to be removed entirely by surgery.
Most bile duct cancers are unresectable by the time they're found.

Resectable bile duct cancers
Most stage 0, I, and II cancers and possibly some stage III cancers are potentially resectable -- it might be possible to completely take out the cancer with surgery. But other factors can impact whether this is a good option, such as where the cancer is and whether the patient is healthy enough to have major surgery.

Surgery to remove the cancer completely is the preferred treatment if it's possible. If surgery is being considered, a staging laparoscopy may be done first. This allows the doctor to look inside the abdomen (belly) for any spread of the cancer that could make it unresectable. (Laparoscopy is described in Tests for Bile Duct Cancer)

Types of surgery
The type of surgery done to remove the cancer depends on the location and extent of the cancer. (See Surgery for bile duct cancer for more details.)

Other treatments that may be used with surgery
If the patient has jaundice (yellowing of the skin and eyes) before surgery, a stent or catheter may be put in the bile duct first. This allows the bile to flow the way it should. It can help relieve symptoms over a few days and might help make a person healthy enough to have the operation.

Radiation therapy and/or chemotherapy (chemo) may be given after surgery to try to lower the risk that the cancer will come back. This is called adjuvant therapy. Doctors aren’t sure how helpful adjuvant therapy is. It's more likely to be used if there’s a higher chance that the cancer wasn’t removed completely (based on looking at and testing the tissue removed during surgery). If it's clear that some cancer was left behind, a second surgery to take out more tissue may also be an option in some cases.

Sometimes it isn’t clear from imaging or other tests whether the cancer can be removed completely. These cancers may be called borderline resectable tumors. Some doctors may recommend treatment with radiation and/or chemo before surgery to try to shrink the tumor. (This is called neoadjuvant treatment.) Then, if the cancer shrinks, surgery can be done to try to remove all of it.

Unresectable bile duct cancers
These cancers cannot be removed with surgery, which includes most stage III and IV cancers. It may also include earlier stage cancers if a person isn’t healthy enough for surgery.

Trying surgery
As noted above, in cases where it isn’t clear if a cancer is resectable, chemotherapy and/or radiation therapy may be used first to try to shrink the cancer and make it able to be removed. Surgery could then be done to try to remove the cancer completely.

In some cases, the doctor might think that a cancer is resectable, but once the operation starts it becomes clear that it can’t be removed completely. For example, the cancer may turn out to have spread farther than was seen on the imaging tests done before surgery. It doesn't help to remove only part of the cancer, and surgery could still cause major side effects, so this part of the operation is stopped. But while the doctor can see the area, a biliary bypass may be done to relieve any bile duct blockage or to try to keep it from happening in the future. Putting stents in the bile ducts to keep them open may also be an option.

Liver transplant
For some unresectable intrahepatic or perihilar bile duct cancers, a liver transplant (after complete removal of the liver and bile ducts) may be an option. Chemo and radiation may be given first. It's often hard to find a compatible liver donor, but a liver transplant can provide a chance for a cure.

Other options
For most bile duct cancers, it’s clear from imaging tests and/or laparoscopy when they're not resectable. For these cancers, treatment is aimed at trying to control the growth of the cancer for as long as possible and to relieve any symptoms it's causing.

Radiation and/or chemo: Radiation therapy and/or chemo may shrink or slow the growth of the cancer for a time. When chemo is given alone (without radiation) the drugs cisplatin and gemcitabine (Gemzar) are often used. When chemo is given with radiation, 5-FU is the drug most often used.

Targeted therapy: For bile duct cancers within the liver that have the FGFR2 gene mutation (change) and have grown after at least one chemotherapy treatment, the targeted therapy drug Pemigatinib (Pemazyre) might be an option.

Janet Beard was looking forward to spending Thanksgiving with her family last year when a cancer diagnosis canceled her plans.

The retired pharmacist from Wichita Falls says she first became worried when her son noticed something was wrong. He could see it in her eyes: an unnatural yellow tint.

Over the next few days, the jaundice got worse and spread throughout her body. Janet’s symptoms brought her to the office of Edward Cho, MD, hepatobiliary surgeon on the medical staff at Methodist Richardson Medical Center.

“The workup revealed that Janet had a mass in the head of her pancreas,” Dr. Cho says, “and 90% of the time that usually turns out to be cancer.”

In Janet’s case, it was a rare type of bile duct carcinoma known as distal cholangiocarcinoma.

What Is Bile Duct Cancer?
Cancer starts when cells in the body start to grow out of control. Cells in nearly any part of the body can become cancer, and can spread to other areas of the body. To learn more about how cancers start and spread, see What Is Cancer?

Bile duct cancer starts in a bile duct. To understand this cancer, it helps to know about the bile ducts and what they normally do.

About the bile ducts

color illustration of the digestive system which shows the location of the esophagus, stomach, pancreas, rectum, colon, small intestine, gallbladder and liver
The bile ducts are a series of thin tubes that go from the liver to the small intestine. Their major job is to move a fluid called bile from the liver and gallbladder into the small intestine, where it helps digest the fats in food.


illustration showing the location of the common bile duct, liver, pancreas, pancreatic duct, ampula of vater, duodenum, gallbladder, cystic duct, right hepatic duct, left hepatic duct and common hepatic duct
Different parts of the bile duct system have different names. In the liver it begins as many tiny tubes (called ductules) where bile collects from the liver cells. The ductules come together to form tubes called small ducts. These merge into larger ducts and then the left and right hepatic ducts. All of these ducts within the liver are called intrahepatic bile ducts.

The left and right hepatic ducts exit the liver and join to form the common hepatic duct in an area called the hilum. Lower down, the gallbladder (a small organ that stores bile) is joined to the common hepatic duct by a small duct called the cystic duct. This combined duct is called the common bile duct. The common bile duct passes through part of the pancreas before it joins with the pancreatic duct and empties into the first part of the small intestine (the duodenum) at the ampulla of Vater.

Types of bile duct cancers by location
Cancer can start in any part of the bile duct system. Based on where the cancers are (see the picture below), they're grouped into 3 types:

Intrahepatic bile duct cancers
Perihilar (also called hilar) bile duct cancers
Distal bile duct cancers
Another name for bile duct cancer is cholangiocarcinoma.


illustration showing the location of the common bile duct, intrahepatic bile ducts, perihilar bile ducts and distal bile ducts in relation to the liver, pancreas, gallbladder and duodenum (intestine)
Cholangiocarcinomas in these different groups cause different symptoms.

Intrahepatic bile duct cancers
These cancers start in the smaller bile duct branches inside the liver. Sometimes they're confused with cancers that start in the liver cells, which are called hepatocellular carcinomas , which are often treated the same way.

Perihilar (also called hilar) bile duct cancers
These cancers start at the hilum, where the left and right hepatic ducts have joined and are just leaving the liver. These are also called Klatskin tumors. These cancers are grouped with distal bile duct cancers as extrahepatic bile duct cancers.

Distal bile duct cancers
These cancers are found further down the bile duct, closer to the small intestine. Like perihilar cancers, these are extrahepatic bile duct cancers because they start outside of the liver.

Types of bile duct cancer by cell type
Bile duct cancers can also be divided into types based on how the cancer cells look under the microscope.

Nearly all bile duct cancers or cholangiocarcinomas are adenocarcinomas, which are cancers that start in glandular cells. Bile duct adenocarcinomas start in the mucous gland cells that line the inside of the ducts.

Other types of bile duct cancers are much less common. These include sarcomas, lymphomas, and small cell cancers. Our information does not cover these other types of bile duct cancer.

Benign bile duct tumors
Not all bile duct tumors are cancer. Bile duct hamartomas and bile duct adenomas are examples of benign (non-cancer) tumors.

Other cancers in the liver
The most common type of cancer that starts in the liver – much more common than cholangiosarcoma – is hepatocellular carcinoma, which starts in cells that form the liver.

Cancers that start in other organs can spread to the liver. These are called liver metastases or metastatic cancer to the liver. Their outlook and treatment are not the same as cancer that starts in the liver (such as hepatocellular carcinoma) or bile ducts (like cholangiocarcinoma), but instead depend on where the cancer started. For this reason, it’s important to know whether a tumor in the liver started in bile ducts (is a cholangiocarcinoma), or whether it's made up of cancer cells that started in another organ (like the colon) and spread to the liver (is metastatic cancer).