Treatment for Bile duct cancer (cholangiocarcinoma)

The type of treatment that you are given will depend on a number of factors, including your general health, the position and size of the cancer in the bile duct and whether the cancer has spread beyond the bile duct.

Surgery

Surgery may be used to remove the cancer if it has not spread beyond the bile duct. It is not always possible to carry out surgery, as bile duct cancer is in a difficult position and it may be impossible to remove the cancer completely. The decision about whether surgery is possible or not depends on the results of the tests described above. If surgery is recommended then you will be referred to a surgeon with a special interest in this rare cancer.

There are different operations depending upon how big the cancer is and whether it has begun to spread into nearby tissues.

Removal of the bile ducts If the cancer is small and contained within the ducts, then just the bile ducts containing the cancer are removed and the remaining ducts in the liver are joined to the small bowel, allowing the bile to flow again.

Partial liver resection If the cancer has begun to spread into the liver, the affected part of the liver is removed, along with the bile ducts.

Whipple's If the cancer is larger and has spread into nearby structures, then the bile ducts, part of the stomach, part of the duodenum (small bowel), the pancreas, gall bladder and the surrounding lymph nodes are all removed.

After your operation you may stay in an intensive-care ward for the first couple of days. You will then be moved to a general ward until you recover. Most people need to be in hospital for up to two weeks after this type of operation.

Bypass surgery Sometimes it isn't possible to remove the tumour and other procedures may be performed to relieve the blockage and allow the bile to go into the intestine. The jaundice will then clear up.

The surgical method of dealing with blockage (obstruction) of the bile duct involves joining the gall bladder (or the bile duct) to part of your small bowel (the duodenum or jejunum). This bypasses the blocked part of the bile duct and allows the bile to flow from the liver into the intestine. This operation is called a cholecysto-jejunostomy or cholecysto-duodenostomy if the gall bladder is used. It is called a hepatico-jejunostomy if the bile duct is used.

Another type of operation may be necessary if the duodenum is also blocked. This is called a gastrojejunostomy and involves connecting a piece of the small bowel (the jejunum) to the stomach to bypass the duodenum. This will stop the persistent vomiting that can occasionally happen if the cancer blocks the duodenum.

Stent insertion

There are two ways in which it may be possible to relieve jaundice without a surgical operation. These use the ERCP or PTC procedures described below.

The ERCP method involves the insertion of a tube, called a stent into the blocked bile duct. The stent is about as thick as a ball-point pen refill and about 5–10cm long (2–4 inches). The stent clears a passage through the bile duct to allow the bile to drain away. The preparation and procedure is the same as for ERCP described above. By looking at the x-ray image the doctor will be able to see the narrowing in the bile duct. The narrowing can be stretched using dilators (small inflatable balloons), and the stent can then be inserted through the endoscope to enable the bile to drain.

The tube usually needs to be replaced every three to four months to prevent it becoming blocked. If the tube does block, recurrent high temperatures and/or return of the jaundice will occur. It is important to tell your specialist about these symptoms as early as possible. Antibiotic treatment may be needed and your specialist may advise that the stent is exchanged for a new one. This procedure can be done relatively easily for most people.

During the PTC method, the procedure and the preparation you will need is as described in the section about PTC. A temporary wire is passed to the area of blockage and the stent is guided along the wire. Sometimes a drainage tube (catheter) is left in the bile duct. One end of the catheter is in the bile duct and the other lies outside the body connected to a bag, which collects the bile. This is to help with the insertion of the stent or, sometimes, to enable x-rays to be taken to check the position of the stent after it has been put in place. It is usually left in for a few days. Once the catheter is removed the hole heals over within two days. You will be given antibiotics before and after the procedure to help prevent any infection. It is likely that you will stay in hospital for a few days.

Sometimes, if the bile duct cannot be opened easily from the small intestine during ERCP, a combination of ERCP and PTC may be used.

Radiotherapy

is occasionally used. Radiotherapy treats cancer by using high-energy x-rays to destroy cancer cells while doing as little harm as possible to normal cells. It may be given either externally from a radiotherapy machine, or internally by placing radioactive material close to the tumour.

Chemotherapy

is the use of anti-cancer (cytotoxic) drugs to destroy the cancer cells. They work by disrupting the growth of cancer cells. Occasionally, chemotherapy may be given in combination with radiotherapy for cancers that cannot be removed surgically. Researchers are still looking into how effective chemotherapy is for the treatment of bile duct cancer.

Photodynamic Therapy (PDT)

uses a combination of laser light of a specific wavelength and a light-sensitive drug to destroy cancer cells. In bile duct cancer it is used to help relieve symptoms.

The light-sensitive drug (a photosensitising agent) is injected into a vein. It circulates in the bloodstream and enters cells throughout the body. The drug enters more cancer cells than healthy cells. It does not do anything until it is exposed to laser light of a particular wavelength. When a laser is shone on to the cancer, the drug becomes active and destroys the cancer cells.