Treatments for Bile Duct Cancer (Cholangiocarcinoma)

Executive Summary

The different types of standard treatments for bile duct cancer are explained in detail. Standard treatments are used along with the integration of effective treatment planning. Clinical trials are used as an innovative treatment approach that combines different therapies and drugs for treating bile duct cancer. Surgery is used as it integrates the complete excision in the initial stages of bile duct cancer. A liver transplant is also done for treating perihilar bile duct cancer. Hepatectomy is removed in case of intrahepatic bile duct cancer. The bile duct, gallbladder, part of the pancreas, duodenum, and part of the stomach (Whipple surgery) are all removed to treat distal bile duct cancer. Other treatment methods for bile duct cancer include chemotherapy following surgery and radiation therapy. Unresectable treatment involves treating bile ducts cancer symptoms such as jaundice, cholangitis, abdominal discomfort, palliative surgery or procedures, and modification in bile flow. Chemotherapy, radiation therapy, and liver transplantation are other unresectable treatments for bile duct cancer. The localized treatment for bile duct cancer includes the treatment for intrahepatic bile duct carcinoma with the integration of chemoembolization, embolization, radiofrequency ablation, and microwave ablation. Surgery, chemotherapy, chemoradiation, resection of the bile duct, resection of liver, liver transplant, palliative surgery, biliary bypass surgery, brachytherapy and follow-ups along with following up appointments.

Treatment of Bile Duct Cancer

The Treatments for Bile Duct Cancer will be based on your health as well as specific cancer facts. Your healthcare team will evaluate the following factors when selecting which therapies to offer for bile duct cancer: whether the tumor can be removed with surgery (is resectable) or cannot be removed entirely (is unresectable).

General well-being

Complete excision of the tumor with surgery is the only treatment that offers a cure in the early stages of bile duct cancer ^​1​. However, in most cases, surgery will not altogether remove the tumor at this time. Chemotherapy and chemoradiation are two treatments that can decrease the progression of cancer and extend life. Palliative care might also help to alleviate discomfort. Cancers of the intrahepatic bile duct are treated similarly to liver cancer ^​2,3​.

Resectable Treatments for Bile Duct Cancer

The term “resectable” refers to cancer that can be eradicated through surgery. Surgery can generally eliminate stage 1 and stage 2 bile duct tumors. Your healthcare team will provide recommendations based on your specific needs and collaborate with you to create a treatment plan.

The therapy options for resectable bile duct cancer are as follows. Surgery is the chosen treatment option since it provides the best results.

Surgery

The primary treatment for resectable bile duct carcinoma is surgery ^​4​. The sort of surgery you have is determined by the location, size, and spread of cancer throughout your body. These types of operations are possible:

• The bile duct is resected to treat extrahepatic bile duct carcinoma.
• For perihilar bile duct carcinoma, the bile duct and a portion of the liver (partial hepatectomy) are removed.
• A liver transplant is an option for perihilar bile duct cancer but not for intrahepatic bile duct cancer.
• The bile duct, gallbladder, part of the pancreas, the first part of the small intestine (duodenum), and part of the stomach (Whipple surgery) are all removed to treat distal bile duct tumors.
• For resectable intrahepatic bile duct tumors, the tumor plus a portion of the liver (hepatectomy) are removed.

Chemotherapy

Chemotherapy is administered following surgery (called adjuvant therapy) ^​5​. Compared to having simple radiation therapy following surgery, chemotherapy or chemoradiation after surgery has improved outcomes. If cancer cannot be eliminated with surgery or spread, adjuvant therapy may be beneficial.

Radiation therapy 

Radiation therapy damages or eliminates cancer cells by using high-energy rays or particles, such as x-rays or gamma rays. External beam radiation therapy treats bile duct cancer. Radiation is delivered to the tumor and some surrounding tissue through the skin using a machine ^​6​.

People with bile duct cancer can participate in several clinical studies in Canada. Clinical trials examine new approaches to cancer prevention, detection, and treatment. To learn more about clinical trials, go here.

Unresectable Treatments for Bile Duct Cancer

Unresectable cancer cannot be completely removed through surgery. Your healthcare team will provide recommendations based on your specific needs and collaborate with you to create a treatment plan.

Surgery cannot wholly remove most stage 3 and all stage 4 bile duct tumors. This is because cancer has gone too far outside the bile duct or to a location where surgery would be challenging to eradicate. Consider the following scenario:

• Cancer has spread to the liver’s blood vessels (vascular invasion) and cannot be removed entirely.
• Metastasis.

Unresectable bile duct carcinoma has several therapy options.

Procedures or surgery for palliative care

If you are not well enough to have surgery or if your doctor believes cancer cannot be entirely removed with surgery, you may be treated for the following bile duct cancer symptoms:

• jaundice
• The bile ducts are inflamed and cause pain (cholangitis)
• abdominal discomfort
• The following are examples of palliative surgery or procedures:
• To keep the bile duct open and allow bile to flow, a tiny wire or plastic tube (stent) is placed.
• a tube (catheter) is inserted to help remove bile
• To modify the flow of bile, a biliary bypass is performed.

Chemotherapy for Bile Duct Cancer

If they are healthy enough, persons with unresectable or metastatic bile duct cancer are treated with chemotherapy.

Radiation therapy 

Radiation therapy damages or eliminates cancer cells by using high-energy rays or particles, such as x-rays or gamma rays. Radiation is delivered to the tumor and some surrounding tissue through the skin using a machine.

Chemoradiation

To treat advanced unresectable bile duct carcinoma, external beam radiation therapy may be given simultaneously with chemotherapy.

Transplantation of the liver for Bile Duct Cancer

The removal of the liver (total hepatectomy) and a liver transplant may be an option for some persons with unresectable perihilar bile duct carcinoma that has progressed to the liver. A liver transplant is only performed if the malignancy has not gone to other organs or lymph nodes.

Localized Treatments for Bile Duct Cancer

Treatments for Bile Duct Cancer provided near to or directly into the tumor are known as locoregional therapy. These could be used to treat intrahepatic bile duct carcinoma resistant to surgery (which is unresectable). Chemoembolization, embolization, radiofrequency ablation, and microwave ablation are among them.

If you are unable or unwilling to get cancer therapy, you may wish to pursue a sort of care that may help you feel better without really treating the illness. This could be because cancer treatments are no longer effective, are unlikely to improve your condition, or are associated with unpleasant side effects. There may be additional reasons why you are unable or unwilling to get cancer therapy.

People with bile duct cancer can participate in several clinical studies in Canada. Clinical trials examine new approaches to cancer prevention, detection, and treatment.

Procedures or surgery for palliative care

To treat the signs and symptoms of advanced bile duct cancer, such as jaundice, palliative surgery or procedures are used.

• The bile ducts are inflamed and cause pain (cholangitis)
• abdominal discomfort
• If the bile duct is blocked, you may have these symptoms. The following techniques or palliative surgery may be used to remove the block:
• keeping the bile duct open and draining the liver using a thin wire or plastic tube (stent)
• Bile is drained by a tube (catheter).

To modify the flow of bile, a biliary bypass is performed.

Chemotherapy

Recurrent bile duct carcinoma is treated with chemotherapy. To treat recurrent bile duct cancer, you may receive a single chemotherapy treatment or a combination of chemotherapy agents.

Also Read: What is chemotherapy?

Chemoradiation

Chemoradiation is one of the Treatments for Bile Duct Cancer that combines radiation therapy and chemotherapy to kill cancer cells more efficiently. It may be used to treat pain and other symptoms associated with advanced bile duct cancer. If the person has previously received radiation therapy, it is possible that they will not receive it in the same treatment area. Because the tissues can only handle a limited quantity of radiation therapy, this is the case.

The surgeon seeks to remove the tumor and a layer of tissue at the tumor’s perimeter that is free of cancer cells (a negative margin). However, the majority of people with bile duct cancer are diagnosed at a late stage, when surgery to remove cancer altogether is not possible, such as when cancer has spread too far into the liver, into significant blood vessels in the area, to the lining of the abdominal cavity (peritoneum), and organs far from the bile duct (metastatic cancer)

The surgeon will review the test findings before surgery to determine if the malignancy can be removed through surgery—some persons have jaundice. Bile duct cancer is treated with the following forms of surgery. Other therapies may be necessary before or after surgery.

Resection of the bile duct

The cancer is still in its early stages, with only a tiny portion of the bile duct affected. This operation may be utilized when cancer is found in a section of the bile duct outside the liver (extrahepatic). By linking the remaining duct opening to the small intestine, a new bile channel is created. Lymph nodes in the surrounding area may be removed to test if they contain malignancy. Because bile duct cancer is rarely detected in its early stages, this procedure is seldom performed.

Resection of the liver

A liver resection (also known as a partial hepatectomy) involves the surgical removal of a portion of the liver along with a healthy liver tissue area. It may treat bile duct cancer near the liver (perihilar) or cancer of the liver itself (intrahepatic).

The various blood arteries (portal vein and hepatic artery) and hepatic ducts in the liver make this surgery difficult. The abdomen is sliced by the doctor (belly). The procedure is determined by the tumor’s size and location and how far it has gone to the liver. It also depends on the liver’s ability to function correctly. It’s possible that a piece of the liver or an entire lobe will need to be removed. The remaining bile duct is connected to the liver by the surgeon.

Procedure of Whipple

Extrahepatic distal bile duct cancer is treated with a Whipple technique (pancreaticoduodenectomy). Parts of the bile duct and pancreas, the gallbladder, and parts of the small intestine (duodenum) and stomach, as well as the surrounding lymph nodes, are removed during a Whipple procedure. The surgeon joins the remaining bile duct to the small intestine to drain bile from the liver after removing these organs.

Transplantation of the liver

Treatments for Bile Duct Cancer Most bile duct cancer patients do not qualify for a liver transplant, and it is not a conventional treatment. Because intrahepatic bile duct carcinoma has a high incidence of recurrence following treatment, a liver transplant is rarely used (recurrence). Finding a qualified liver donor is tough. 

In perihilar cholangiocarcinoma, a liver transplant is a possibility. This procedure may be used when a tumor cannot be entirely removed by surgery but has not spread beyond the liver. Chemoradiation is given before a transplant if one is scheduled. It is sometimes administered after the person has had the transplant. A liver transplant will not be performed if the malignancy has progressed to other organs.

Palliative surgery and procedures are used to help people when bile duct cancer cannot be eliminated surgically or is too extensive; palliative surgery is used. These techniques help to alleviate symptoms such as jaundice and pain while also preventing infection. Jaundice can develop if a tumor blocks the bile duct, preventing the bile from flowing normally and accumulating. Biliary drainage improves bile flow and soothes symptoms, but it is not a cancer treatment. It has the potential to improve your quality of life.

Stents are tiny metal or plastic tubes that are inserted into the bile duct. Expandable wire mesh is used in the majority of biliary stents. The bile duct stent keeps it open, allowing bile to pass into the small intestine. A stent can be inserted into the bile duct in numerous ways:

Endoscopy is the most common method for inserting a stent. During an ERCP, the stent is implanted (endoscopic retrograde cholangiopancreatography).

Stents can also be implanted during surgery. However, this is less often than endoscopy. During a PTC, doctors can also implant a stent through the belly with the help of an x-ray (percutaneous transhepatic cholangiography). 

Catheter

A tube (catheter) can sometimes be used to drain bile from around a blockage. The bile is emptied into a bag outside the body or into the small intestine via the catheter. A stitch is frequently used to secure the catheter to the skin (suture). A PTC is commonly used to introduce a biliary catheter in the same way that a stent is.

Biliary bypass surgery

A biliary bypass is a procedure that allows bile to move through an obstruction. It alters the flow of bile so that it can bypass the tumor. Depending on the location of the blockage, many types of biliary bypass surgeries may be performed.

A choledochojejunostomy connects the common bile duct to the small intestine’s jejunum.

A hepatic jejunostomy connects the common hepatic duct and the jejunum.

People with advanced extrahepatic bile duct cancer may be offered a biliary bypass.

Negative effects

Any sort of Treatments for Bile Duct Cancer might have side effects, but everyone’s experience is different. Some folks have a slew of adverse side effects. Others have only a few minor adverse effects. Side effects might occur during surgery, immediately afterwards, or a few days or weeks later. Late side effects can appear months or even years after surgery. The majority of adverse effects will go away on their own or can be managed, but some will linger or become permanent. The sort of surgery you have and your overall health will determine the extent of your surgery’s side effects. You may experience common surgical side effects, such as pain, nausea, vomiting, or infection. Surgery for bile duct cancer can result in bleeding, lung issues, and the following potential complications:

• Deep vein thrombosis is a blood clot in the leg (DVT). Because the person is not moving around much following bile duct surgery, it can happen right away. Several other reasons cause DVT. Pulmonary embolism is a blood clot that breaks free and travels to the lungs (called a pulmonary embolism). This results in shortness of breath and impairs the blood’s ability to absorb oxygen from the lungs. Shortness of breath, as well as any redness, swelling, soreness, or cramps in the calf the leg, should be reported to your doctor or healthcare provider.
• People with extrahepatic bile duct surgery may experience diarrhoea or have more frequent bowel movements, significantly if bile is rerouted to flow straight into the small intestine. In addition, the stool tends to stay in the gut for a shorter time.
• Cholangitis is a condition in which the bile ducts become inflamed. When bile does not drain adequately, an infection develops. Antibiotics may be prescribed, and a clogged biliary stent or catheter may be replaced.
• After extrahepatic bile duct surgery, a bile leak or bile duct injury might occur. It has the potential to cause abdominal pain. An ERCP may be performed to determine the leak’s source and implant a stent to aid bile drainage. In some cases, surgery is required to correct a bile duct leak or injury.
• An anastomosis is a surgical connection of the residual bile duct to another structure, such as the small intestine. Bile may flow into the abdomen if the stitches holding the two ends together fail or come apart. This is known as an anastomotic leak, and the surgeon must repair it.
• After a Whipple procedure, you may experience digestive issues. The pancreas produces digestive enzymes, and removing a portion of the pancreas might reduce enzyme production. About one-third of persons who have had Whipple surgery require enzymes to aid digestion.
• You may not feel like eating after surgery, or you may feel bloated or full more quickly. Smaller meals throughout the day may be more convenient than three huge meals each day. Snacking in between meals can also aid digestion and reduce bloating and a sense of being overly full.
• When a portion of the pancreas is removed during a Whipple procedure, problems with blood sugar levels can occur. Insulin is produced by the pancreas and is required for blood sugar regulation. If part or all of your pancreas is removed, you may get diabetes. If you had blood sugar problems before surgery, your chances of acquiring diabetes are higher. The medical team will monitor the blood sugar level. Controlling high blood sugar may include dietary and medication changes.

Tell your doctor if you’re experiencing any of these or additional adverse effects that you suspect are related to surgery. The sooner you inform them of any issues, the sooner they can recommend solutions to assist you. For bile duct carcinoma, radiation therapy is used.

To kill cancer cells, radiation therapy uses high-energy photons or particles. It’s frequently used to treat cancers of the bile ducts outside of the liver. When planning the type and amount of radiation and when and how it is delivered, your healthcare team will consider your unique needs. Other therapies may be given to you. In the Treatments for Bile Duct Cancer, radiation therapy is frequently coupled with chemotherapy. Chemoradiation is the term for this process. Both therapies are administered at the same time. Radiation therapy is issued for a variety of reasons. Radiation therapy or chemoradiation may be used to: destroy cancer cells that may persist after the tumor has been surgically removed.

If surgery is unable to remove the tumor, ease pain, or control the symptoms of advanced bile duct cancer, destroy as many cancer cells as feasible (called palliative therapy)

Radiation therapy is beneficial in treating extrahepatic bile duct cancer after surgery, according to a few studies. It’s unclear whether this treatment extends people’s lives. Due to the rarity of extrahepatic bile duct cancer, few people have had radiation therapy in these instances, making it challenging to assess thoroughly.

As a result, there are no established radiation therapy guidelines for the Treatments for Bile Duct Cancer. It could be utilized to treat malignancies of the bile ducts that start outside the liver (extrahepatic). Chemoradiation is a treatment that combines radiation therapy and chemotherapy to treat unresectable extrahepatic bile duct tumors. If an extrahepatic bile duct tumor presses on nerves, it might block the bile duct and produce jaundice or discomfort. Palliative radiation, also known as chemoradiation, can help reduce a tumor and relieve symptoms.

If cancer cells are discovered in the surgical margins, chemoradiation therapy may be used. Radiation therapy is rarely utilized to treat malignancies of the bile ducts in the liver (intrahepatic). To treat bile duct cancer, the following methods of radiation therapy may be employed—radiation treatment given during surgery. During surgery, radiation is delivered directly to the area where the tumor was removed. Special devices are used to provide a single strong dosage of radiation.

Radiation therapy using an external beam

A machine transmits radiation through the skin to the tumor and some surrounding tissue during external beam radiation therapy.

Brachytherapy

Internal radiation therapy is known as brachytherapy. It makes use of a radioactive isotope, which is a type of radioactive substance. It’s inserted into the tumor or extremely close to it. In the location where the tumor was excised, radioactive elements can potentially be used. Over time, the radiation kills the cancer cells.

Negative effects

Any sort of Treatments for Bile Duct Cancer might have side effects, but everyone’s experience is different. Some folks have a slew of adverse side effects. Others have few, if any, at all.

The healthcare staff strives to safeguard healthy cells in the treated area as much as possible during radiation therapy. However, damage to healthy cells might occur, resulting in adverse effects. Radiation therapy can cause side effects during, immediately after, or a few days or weeks after that. Late side effects can appear months or years after radiation treatment.

Most adverse effects fade away on their own or maybe managed, but some can remain for a long time or become permanent. The size of the area being treated, the specific area or organs being treated, the overall radiation dose, and the treatment schedule will all influence the adverse effects of radiation therapy. When chemotherapy is combined with radiation therapy, the side effects can be more severe. You may get negative effects from the chemotherapeutic medicine used during chemoradiation.

The following are some of the most prevalent side effects of bile duct cancer radiation therapy:

• Problems with the skin
• vomiting and nausea
• indigestion and a loss of appetite
• diarrhoea\fatigue

Cholangitis is a condition in which the bile ducts become inflamed. Radiation therapy for extrahepatic bile duct cancer patients might cause mild to severe cholangitis. When brachytherapy (intraluminal radiation therapy) is performed, this is more likely to happen. Fever, jaundice, and pain in the upper-right portion of the abdomen are all symptoms of cholangitis. The doctor may prescribe antibiotics and anti-inflammatory medications to treat this illness. Let your doctor know if you’re experiencing any of these or additional adverse effects following radiation therapy. The sooner you inform them of any issues, the sooner they can recommend solutions to assist you.

Bile Duct Cancer Chemotherapy

Anticancer (cytotoxic) medicines are used in chemotherapy to kill cancer cells. It’s mainly used to treat cancer of the bile duct. When planning chemotherapy medicines, doses, and timings, your healthcare team will consider your unique needs. Other therapies may be given to you.

In the Treatments for Bile Duct Cancer, chemotherapy is frequently coupled with radiation therapy. Chemoradiation is the term for this process. Both therapies are administered at the same time.

Chemotherapy is used for a variety of reasons. Chemotherapy or chemoradiation may be used to: eliminate cancer cells left behind after surgery; and lower the likelihood of cancer returning (recurrence) (called adjuvant chemotherapy or chemoradiation). As a treatment for extrahepatic bile duct cancer that has returned, palliative chemotherapy or chemoradiation is used to reduce discomfort or manage symptoms of advanced bile duct cancer (also known as chemoradiation) ^​7​.

Chemotherapy is frequently administered as a whole-body treatment. This implies that the medications travel via the bloodstream to reach and eliminate cancer cells all over the body, even those that have broken away from the initial bile duct tumor. Chemotherapy can also be administered to a specific part of the body as a localized therapy. Chemoembolization may be used to treat intrahepatic bile duct cancers.

Gemcitabine (Gemzar), capecitabine (Xeloda), and cisplatin are the most popular chemotherapy medicines used to treat bile duct cancer (Platinol AQ)

Gemcitabine and cisplatin are the most popular chemotherapy medication combinations used to treat bile duct cancer.

Negative effects

Any sort of Treatments for Bile Duct Cancer might have side effects, but everyone’s experience is different. Some folks have a slew of adverse side effects. Others have few, if any, at all.

Chemotherapy can have adverse effects since it kills cancer cells while also harming healthy cells. Side effects can occur during, soon following, or a few days or weeks after chemotherapy. Late side effects might appear months or even years after chemotherapy. Most adverse effects fade away on their own or may be managed, but some can remain for a long time or become permanent. Chemotherapy side effects are determined mainly by the type of medicine, the amount, the method of administration, and your overall health. When chemotherapy is combined with radiation therapy, the side effects can be more severe.

The following are some of the adverse effects of bile duct cancer chemotherapy drugs:

• a low number of blood cells
• a decrease in appetite
• nausea and vomiting
• mouth ache
• diarrhoea
• renal failure
• Problems with the skin
• Symptoms of the flu
• hair thinning

Numbness and tingling (pins and needles) or a burning sensation in the hands or feet can be caused by almost all medications used to treat extrahepatic bile duct cancer. This could indicate peripheral nerve injury (peripheral neuropathy). Cisplatin can induce ringing in the ears or hearing loss in certain people. It can also create problems with balance or walking, both of which are symptoms of neurotoxicity. The dose of chemotherapeutic medicine provided is frequently linked to nerve damage. The majority of people have transient nervous system issues. Nervous system damage can be a long-term issue for a few people. Damage to the nervous system can occur months or years after treatment and can take months to heal.

Follow-up

Following up on Treatments for Bile Duct Cancer is an essential element of cancer treatment. Follow-up for bile duct cancer is frequently shared by cancer experts and your primary care physician. Your healthcare team will work with you to choose the best course of action for you.

Don’t put off reporting any new or persistent symptoms until your next scheduled appointment. If you have any of the following symptoms, tell your doctor:

• Jaundice
• abdominal discomfort (belly)

Within the first few years, the chances of bile duct cancer returning (recurring) are incredibly high; hence close monitoring is required during this time. Make appointments for follow-up visits. Each person’s post-treatment follow-up is unique. If you have surgery, you should have regular follow-ups because bile duct cancer frequently recurs after surgery. After bile duct cancer surgery, follow-up appointments may be planned every three months for the first two years.

During follow-up appointments

During a follow-up visit, your healthcare team will typically inquire about the treatment’s side effects and how you’re dealing with them. They might also ask about your weight, appetite, and digestion. A physical exam by your doctor may include looking for pain or an increase in pain in the abdomen, as well as examining for jaundice and a bulge in the belly.

Follow-up care frequently includes tests. Imaging tests, such as an ultrasound, CT scan, or MRI, may be used to determine if cancer has returned or if the tumor has grown in size. Liver function may also be assessed by blood testing. If your cancer has returned, you and your healthcare team will discuss your treatment options for Bile Duct Cancer and follow-up care.

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