Treatment Options Based on the Extent of Bile Duct Cancer

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.

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