Biliary Tract Cancer I Case 1:Risk / treatment I Case 2: Treatment by stage I Case 3: Risk / Therapy

Case 1 parts 1&2
The highest gallbladder cancer incidence rates worldwide were reported for women in Delhi, India (21.5/100,000), South Karachi, Pakistan (13.8/100,000) and Quito, Ecuador (12.9/100,000). Female‐to‐male incidence ratios were generally around 3. History of gallstones was the strongest risk factor for gallbladder cancer. Other risk factors are obesity, multiparity and chronic infections like Salmonella typhi and S. paratyphi and Helicobacter bilis and H. pylori.
If Gallbladder adenocarcinoma is found incidentally on a cholecystectomy specimen and the patient is ruled out for metastatic disease, he/she should undergo an en bloc hepatic resection + lymphadenectomy +/- bile duct excision for malignant involvement.
Hepatic resection should be performed to obtain clear margins, which usually consists of removing segments IVB and V. Lymphadenectomy should be performed to clear all lymph nodes in the porta hepatis.
This patient has a T2 lesion which has up to a 40% chance of harboring lymph node metastasis. This patient needs a definitive surgery.
Reference: Randi G et al. Gallbladder cancer worldwide: geographical distribution and risk factors. Int J Cancer 2006;118(7):1591-602
Reference: http://www.nccn.org/profession....als/physician_gls/pd

Case 2:
If T1a (lamina propria) gallbladder adenocarcinoma is found and there are negative margins, no more surgery may be needed as long-term survival rates approaching 100%.. However, anything with a higher stage/T score should be offered more definitive/radical surgery.
If a patient is found to incidentally have a T1b or greater gallbladder cancer and if not metastatic disease is seen, then when should offer hepatic resection + lymphadenectomy +/- bile duct excision for malignant involvement.
Reference: http://www.nccn.org/profession....als/physician_gls/pd

Case 3 parts 1&2:
HCV confers a higher risk than HBV for cholangiocarcinoma. Case-controlled studies from Asian and Western countries have reported hepatitis C infection as a significant risk factor for the development of intrahepatic cholangiocarcinoma.
Other risk factors for cholangiocarcinoma includes diabetes, obesity, cirrhosis, NAFLD, alcohol drinking, chronic calculi of the bile duct and smoking.
Ulcerative colitis/IBD increases the risk of sclerosing cholangitis which in turn can lead to Cholangiocarcinoma.
if margins are positive and further surgery is not possible, consider chemoradiation.
Of note, adjuvant chemotherapy (5-FU based or Gemcitabine based) or Chemotherapy (5-FU based or Gemcitabine-based) followed by 5-FU based chemoradiation) or Chemoradiation (5-FU based) followed by chemotherapy (5-FU based or Gemcitabine-based) would also have been acceptable options for this patient.
Post-operative chemoradiation for patients with biliary cancers who have R1 disease improves RFS.
The role of adjuvant therapy for patients with R0 disease is undefined. However, data was presented at ASCO 2017 (BILCAP Study) that showed that Capecitabine may play a role in this clinical situation.
Reference: Tyson GL et al. Risk factors for cholangiocarcinoma. Hepatology 2011;54(1):173-84
Reference: http://www.nccn.org/profession....als/physician_gls/pd

• Category

  Bile Duct Cancer (Cholangiocarcinoma)