bile duct and gb cancer
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Mazen Hassanain
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Bile duct CancerAverage age 60 years
Ulcerative colitis is a common associated condition
Subtypes: (1) periductal infiltrating, (2) papillary or intraductal, and (3) mass forming-nodular
Location: 85% extrahepatic
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Risk FactorsDefinite risk factors
Primary sclerosing cholangitis (1% per year) Liver fluke infection (Opisthorchis viverrini) Hepatolithiasis (10%) Biliary malformation (10% choledochal cysts,
Caroli's) Thorotrast
Probable risk factors Hepatitis C Cirrhosis Toxins (dioxin, polyvinyl chloride) Biliary-enteric drainage procedures
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Staging
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T1: Tumor involving biliary confluence ± unilateral extension to 2° biliary radicles
T2 Tumor involving biliary confluence ± unilateral extension to 2° biliary radicles AND Ipsilateral portal vein involvement ± ipsilateral hepatic lobe atrophy
T3 Tumor involving biliary confluence + bilateral extension to 2° biliary radicles OR Unilateral extension to 2° biliary radicles with
contralateral portal vein involvement OR Unilateral extension to 2° biliary radicles with
contralateral hepatic lobe atrophy OR Main or bilateral portal venous involvement
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PresentationObstructive jaundice
Cholangitis (10%)
Palpable mass
Liver cirrhosis
Cachexia
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DiagnosisBlood work
CA19-9: Its sensitivity and specificity for detection of CCA in PSC are 79% and 98%, respectively, at a cutoff value of 129 U/mL.
Imaging (US, CT, MRI/MRCP, ERCP, PTC, EUS, PET/CT)
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Treatment and prognosisSurgical resection Adjuvant and neoadjuvant treatmentsMayo Protocol
The average patient with adenocarcinoma of the bile duct survives less than a year. The overall 5-year survival rate is 15%.
Following a thorough radical operation, 5-year survival is about 40%. Biliary cirrhosis
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Surgery
Local lymph node metastases (N1) are not an absolute contraindication to surgical treatment, because they do not significantly influence outcomes in hilar CCA
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GB cancerPredominantly in the elderly
Incidentally diagnosed at an early stage after cholecystectomy for cholelithiasis (1%)
Approximately 90% of patients have gallstones. The 20-year risk of developing cancer for
patients with gallstones is less than 0.5% for the overall population and 1.5% for high-risk groups
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Risk FactorsLarger stones (3 cm) tenfold increased risk
The risk is higher in patients with symptomatic pts
Polypoid lesions, particularly in polyps >10mm
The calcified "porcelain" gallbladder (20%) selective mucosal calcification (7%)
Choledochal cysts have an increased risk of developing cancer anywhere in the biliary tree, but the incidence is highest in the gallbladder.
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Other Risk FactorsAnomalous pancreatobiliary duct junction Obesity and pregnancyChronic inflammatory bowel disease Polyposis coli Mirizzi syndrome Bacterial and Salmonella infections Industrial exposure to carcinogens Familial tendency
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PathologyAdenocarcinomas 90% .
Squamous cell, adenosquamous, oat cell, …
Papillary (10%), nodular, and tubular
Lymphatics are present in the subserosal layer only. Therefore cancers invading but growing through the muscular layer have minimal risk of nodal disease
40% have distant metastasis at Dx
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PresentationAbdominal discomfort, right upper quadrant
pain, nausea, and vomiting.
Jaundice, weight loss, anorexia, ascites, and mass
Blood work
Imaging (UD, CT, MRI/MRCP, ERCP, PTC, PET/CT)
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AJCC stagingStage 0: Carcinoma in situ Stage I: T1/2 N0 M0: invades lamina propria,
muscle layer, perimuscular connective tissue Stage II: T3 N0/1 M0 T3: perforates the
serosa and/or directly invades the liver and/or one adjacent organ
Stage III: T4: invades any main vesselStage IV: M1: distant metastases, including
metastases in lymph nodes at the pancreatic body and tail
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Treatment and prognosisSurgeryAdjuvant therapyThe 5-year survival rate of all patients is less than
5%, median survival of 6 months.T1 treated with cholecystectomy 90% 5-year
survival T2 lesions treated with an extended
cholecystectomy and lymphadenectomy is over 70% Advanced but resectable gallbladder cancer are
reported to have 5-year survival rates of 20 to 50%.
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Surgery
Lap vs. open
Post Lap Choly