Advances in diagnosis, treatment and palliation of cholangiocarcinoma: 1990-2009

Abstract

Several advances in diagnosis, treatment and palliation of cholangiocarcinoma (CC) have occurred in the last decades. A multidisciplinary approach to this disease is therefore recommended. CC is a relatively rare tumor and the main risk factors are: chronic inflammation, genetic predisposition and congenital abnormalities of the biliary tree. While the incidence of intra-hepatic CC is increasing, the incidence of extra-hepatic CC is trending down. The only curative treatment for CC is surgical resection with negative margins. Liver transplantation has been proposed only for selected patients with hilar CC that cannot be resected who have no metastatic disease after a period of neoadjuvant chemo-radiation therapy. Magnetic resonance imaging/magnetic resonance cholangiopancreatography, positron emission tomography scan, endoscopic ultrasound and computed tomography scans are the most frequently used modalities for diagnosis and tumor staging. Adjuvant therapy, palliative chemotherapy and radiotherapy have been relatively ineffective for inoperable CC. For most of these patients biliary stenting provides effective palliation. Photodynamic therapy is an emerging palliative treatment that seems to provide pain relief, improve biliary patency and increase survival. The clinical utility of other emerging therapies such as transarterial chemoembolization, hepatic arterial chemoinfusion and high intensity intraductal ultrasound needs further study.

Figure 1

Bismuth’s classification of cholangiocarcinomas. Type I: Cholangiocarcinoma is confined to the common hepatic duct; Type II: Cholangiocarcinoma involves the common hepatic duct bifurcation; Type IIIa: Cholangiocarcinoma affects the hepatic duct bifurcation and the right hepatic duct; Type IIIb: Cholangiocarcinoma affects the hepatic duct bifurcation and the left hepatic duct; Type IV: Cholangiocarcinoma is either located at the biliary confluence with both the right and left hepatic ducts involvement or has multifocal distribution.

Figure 2

Anatomical presentation of cholangiocarcinomas. The majority of cholangiocarcinomas (60%-70%) present in the area of the biliary duct bifurcation and are called Klatskin tumors. The extra-hepatic bile duct is involved in 20%-30% of cases while intrahepatic cholangiocarcinomas represent 5%-10% of the tumors originating from the biliary system.