Risk Factors

When a person is diagnosed with bile duct cancer, it's natural to wonder what may have caused the disease. Doctors can't always explain why one person gets bile duct cancer and another doesn't.

However, certain risk factors make a person more likely than others to develop bile duct cancer. A risk factor is something that may increase the chance of getting a disease.

Having a risk factor does not mean that a person will get bile duct cancer. Many people who get bile duct cancer have none of these risk factors, and many people who have known risk factors never get cancer. A person with one or more of these risk factors should talk with his or her doctor about cancer risk.

Risk factors for bile duct cancer include these disorders:

• Primary sclerosing cholangitis
• Chronic ulcerative colitis
• Choledochal cysts
• Infection with a Chinese liver fluke parasite

Symptoms

Bile duct cancer may cause these common symptoms:

• Fever
• Itchy skin
• Jaundice (yellowing of skin or eyes)
• Pain in the abdomen

Most often, these symptoms are not due to cancer. A person with these symptoms should tell his or her doctor so any health problems can be diagnosed and treated as early as possible.

Screening and Diagnosis

If symptoms suggest bile duct cancer, the doctor will try to find out what's causing the problems. The doctor may order one or more of the following tests:

• Physical exam: The doctor feels the abdomen for fluid, swelling, or other changes. The doctor will also check for swollen lymph nodes.
• Ultrasound test: This test uses high-energy sound waves that bounce off internal organs and tissues. The sound waves produce a pattern of echoes, and a computer creates a picture from the echoes. Tumors may produce echoes that are different from the echoes made by healthy tissues.
• CT scan: An x-ray machine linked to a computer takes a series of detailed pictures of the inside of the body. The patient may receive contrast material by mouth or by injection into a blood vessel. The contrast material makes abnormal areas easier to see.
• MRI: A large machine with a strong magnet linked to a computer is used to make detailed pictures of areas inside the body. Sometimes contrast material is given by injection into a blood vessel. The contrast material makes abnormal areas show up more clearly on the picture.
• ERCP: The doctor uses an x-ray to see if there is any blockage in the bile ducts. Sometimes bile duct cancer causes these ducts to narrow and block the flow of bile, causing jaundice. A thin lighted tube-like instrument (endoscope) is passed through the mouth, esophagus, and stomach into the small intestine. A smaller tube (catheter) is inserted through the endoscope into the pancreatic ducts. A dye is put into the catheter into the ducts and an x-ray is taken.
• PTC: The doctor inserts a thin needle through the skin below the ribs and into the liver. Dye is injected into the liver or bile ducts and an x-ray is taken. If a blockage is found, a thin, flexible tube called a stent is left in the liver to drain bile into the small intestine or a collection bag outside the body.
• Biopsy: The doctor removes cells or tissues from the bile duct. Tissue samples may be taken during surgery. The tissue samples are sent to the lab and viewed under a microscope to check for cancer cells. The removal of tissue to look for cancer cells is called a biopsy. In most cases, a biopsy is the only sure way to tell whether cancer is present. How much tissue is removed and how the biopsy is done depends on what part of the body is being tested for cancer. The doctor may obtain tissue in one of several ways:
  • A needle through the skin: The doctor inserts a thin needle into the bile duct to remove a small amount of tissue. CT or ultrasound may be used to guide the needle.
  • Open surgery: The surgeon can remove tissue from the bile duct through a large incision.
• Liver function tests: The doctor sends blood to the lab to measure the amounts of certain substances released into the blood by the liver. A higher than normal amount of a substance can be a sign of liver disease that may be caused by bile duct cancer.

Staging

If bile duct cancer is diagnosed, the doctor needs to learn the extent (stage) of the disease to help choose the best treatment.

Staging is a careful attempt to find out the following:

• Whether the tumor has invaded the bile duct
• Whether the tumor has invaded nearby tissues
• Whether the cancer has spread, and if so, to what parts of the body

Stages of bile duct cancer

Stage 0: Cancer cells are found in the innermost layer of the tissue lining the bile duct.

Stage I: The cancer is found in the wall of the bile duct or the bile duct only.

Stage II: The cancer has spread to the liver, gallbladder, pancreas and/or the hepatic artery or portal vein. Cancer may have also spread to nearby lymph nodes.

Stage III: The cancer has spread to the portal vein, hepatic artery, or other organs and tissues such as the colon, stomach, small intestine, or abdominal wall.

Stage IV: The cancer has spread to lymph nodes, and/or organs far away from the bile duct.

Treatment

At Huntsman Cancer Institute, bile duct cancer is treated by a team of specialists including surgeons, medical oncologists (doctors who treat cancer with medicine), radiation oncologists (doctors who treat cancer with radiation), gastroenterologists (doctors who treat diseases of the digestive system), nurses, dietitians, and social workers.

Common treatment options for bile duct cancer include the following:

• Surgery
• Radiation therapy
• Clinical trials

A patient may have a combination of treatments. The treatment that's right for each patient depends on many factors:

• The location of the cancer
• Whether the cancer is removable by surgery (resectable)
• The patient's overall health
• Side effects of the treatment

The health care team can describe all of the treatment choices, the expected results of each, and the possible side effects. Because cancer therapy often damages healthy cells and tissues, side effects are common. Side effects may not be the same for each person, and they may even change from one treatment session to the next.

Surgery

There are different types of surgery for bile duct cancer. The type depends mainly on where the cancer is located and how large the tumor is.

Common types of surgery for bile duct cancer include the following:

• Removal of the bile duct: If the tumor is small enough and only in the bile duct, the doctor may remove the entire bile duct.
• Partial hepatectomy: The doctor removes part of the liver where cancer is present.
• Whipple procedure: A surgeon removes the head of the pancreas, the gallbladder, part of the stomach, part of the small intestine and the bile duct. The doctor leaves enough of the pancreas to make digestive juices and insulin.
• Surgical biliary bypass: If a tumor cannot be removed, but is blocking the small intestine and causing bile buildup in the gallbladder, a biliary bypass may be done. A surgeon will cut out the gallbladder or bile duct and sew it to the small intestine to create a new pathway around the blocked area. This surgery helps relieve jaundice caused by the buildup of bile.
• Biliary stent: A stent (a thin tube) is placed in the duct to drain bile that has built up in the area. The stent may drain to the outside of the body or it may go around the blocked area and drain the bile into the small intestine. The doctor may place the stent during surgery or PTC, or with an endoscope.

Radiation therapy

Radiation therapy uses high-energy rays to kill cancer cells. Radiation therapy only affects cells in the treated area.

There are two types of radiation therapy that doctors may use to treat bile duct cancer:

• External radiation: The radiation comes from a large machine outside the body. The machine aims beams of radiation at the cancer. Patients go to a hospital or clinic for treatment. This type of treatment uses computers to closely target the cancer, which protects healthy tissue near the bile duct.
• Internal radiation therapy (brachytherapy): The radiation comes from radioactive material usually contained in very small implants called seeds. The seeds are put near or directly into the cancer, using thin plastic tubes.

Clinical trials

These studies discover and evaluate new and improved cancer treatments. Patients are encouraged to talk with their doctors about participating in a clinical trial or any questions regarding research studies. For more information, also visit HCI's clinical trials website.

Support

When you or someone you love is diagnosed with cancer, concerns about treatments and side effects, hospital stays, and medical bills are common. You may also worry about caring for your family, work, or normal daily life.

There are several places you can go for support:

• Your health care team can answer your questions and talk to you about your concerns. They can help you with any side effects and keep you informed of all your treatments, test results, and future doctor visits.
• The Cancer Learning Center has hundreds of free brochures and over 3,000 books, DVDs, and CDs available for checkout. Talk one-on-one with trained and caring staff, or send an e-mail for answers to your cancer questions.
• Our Patient and Family Support Services offer emotional support and resources for coping with cancer and its impact on daily life to Huntsman Cancer Institute (HCI) patients and their families.
• The Linda B. and Robert B. Wiggins Wellness-Survivorship Center offers many programs to increase the quality of life and well-being of HCI patients and their families.