What is the treatment of Bile duct cancer?
Many years of treating cancer patients and testing treatments in clinical trials has helped doctors know what is likely to work for a particular type and stage of cancer. You will be advised on the best treatment for your cancer. This will depend on the type of cancer you have, where it is and how far it has spread and your general health.
Surgery For Bile duct cancer
If the tumor is resectable, surgery is usually the main type of treatment for bile duct cancer, as it offers the only reasonable chance to cure the cancer. Radiation therapy and/or chemotherapy may be added after surgery in some cases, or they may be used instead of surgery if the cancer cannot be entirely removed.
Though cancer surgeries are extensive and take longer hours; with advanced medical care, surgeries have become safer and better equipments are now available to perform surgeries. Improved techniques of anaesthesia and post-operative monitoring have significantly contributed to overall safety of surgical procedures for cancers.
There are 2 general types of surgical treatment for bile duct cancer — potentially curative surgery and palliative surgery.
- Potentially curative surgery is used when imaging tests indicate a good chance that the surgeon will be able to remove all of the cancer. Doctors may use the term resectable to describe cancers they believe can be removed completely (by potentially curative surgery) and unresectable to describe those they think have spread too far or are in too difficult a place to be entirely removed by surgery. Unfortunately, only a small portion of bile duct cancers are resectable at the time they are first found.
- Palliative surgery may be performed to relieve symptoms or treat (or even prevent) complications, such as blockage of the bile ducts. This type of surgery is performed when the tumor is too widespread to be completely removed. Palliative surgery is not expected to cure the cancer, but it can sometimes help someone feel better and sometimes can even help them live longer.
SURGERY FOR RESECTABLE CANCERS
For resectable cancers, the type of operation depends on the location of the cancer.
- Intrahepatic bile duct cancer: These cancers have started in bile ducts within the liver. To treat these cancers, the surgeon cuts out the part of the liver containing the cancer. Removing part of the liver is called a partial hepatectomy. Sometimes this means that a whole lobe of the liver must be removed. This is called hepatic lobectomy. As much as 70 percent of the liver may be removed if the remaining liver is healthy. The remaining healthy liver can then take care of the body functions. Also, the liver can re-grow some of the missing part. The new cells grow over several weeks.
- Hilar bile duct cancer (Hilar Cholangiocarcinoma): These cancers begin where the branches of the bile duct first exit the liver. Surgery for these cancers requires great skill, as the operation is quite extensive. Usually part of the liver must be removed along with the entire bile duct, gallbladder and nearby lymph nodes. Then the surgeon must connect the remaining ducts to the small intestine. (It becomes important for the patient to understand that a major portion of the liver needs to be removed as the bile duct system is connected to that lobe of the liver. So for the patient this is an extensive liver surgery).
- Distal bile duct cancer: These cancers are further down the bile duct near the pancreas and small intestine. Along with the bile duct and nearby lymph nodes, in most cases the surgeon must remove part of the pancreas and small intestine. The procedure is same as that performed for a pancreatic cancer (Whipple’s operation). See treatment of pancreatic cancer.
SURGERY FOR UNRESECTABLE CANCERS
Liver transplant: The surgeon may sometimes remove the whole liver. If the whole liver is removed, it is replaced with healthy liver tissue from a donor. Such type of surgery is called Liver Transplant. To have a liver transplant you need a liver from a donor. It can sometimes take months to find a donated liver that closely matches yours. During this delay, the cancer may continue to grow and you may need to have other treatment to try to control it. Moreover there are strict criteria as to which patient can undergo liver transplant in the setting of cancers. Also after a liver transplant, you have to take drugs to stop your body rejecting the donated liver. These drugs damp down the activity of your immune system and reduce its ability to control the cancer.
Cytoreduction (Debulking) Surgery
Palliative therapy is treatment that is given to help control or reduce symptoms caused by advanced cancer. It is not meant to be a curative treatment. If the cancer has spread too far to be completely removed by surgery, doctors may focus on palliative operations, palliative radiation, and other palliative therapies. Because these cancers tend to advance quickly, doctors try to use palliative therapies that are less likely to affect a person’s quality of life, when possible.
- Palliative surgery: In some cases a doctor may think that a cancer is resectable based on the information available (imaging tests, laparoscopy, etc.), but once the surgery is started it becomes clear that the cancer is too advanced to be removed completely. At this point the surgeon may do a biliary bypass to allow the bile to flow into the intestines to reduce symptoms such as jaundice or itching.
- In this palliative procedure, the surgeon creates a bypass around the tumor blocking the bile duct by connecting part of the bile duct before the blockage with a part of the intestine.
- If a bypass can’t be done, the surgeon may simply ask for a plastic or expandable metal tube (called a stent) to be placed through the bile duct to keep it open.
- Biliary stent or biliary catheter: If cancer is blocking the bile duct, the doctor may insert a small tube (called a stent or catheter) into the duct to help keep it open. This may be done as part of a cholangiography procedure such as PTC or ERCP.
- A stent opens the duct to allow the bile to drain into the small intestine, while a catheter drains into a bag outside the body that can be emptied when needed. The stent or catheter may need to be replaced every few months if it becomes clogged and to reduce the risk of infection and gallbladder inflammation.
For bile duct cancers that are resectable, chemotherapy may be used after surgery (often along with radiation therapy) to try to lower the risk that the cancer will return. This is known as adjuvant chemo. Some doctors may use it before surgery for borderline resectable cancers to try to improve the odds that surgery will be successful. This is called neoadjuvant treatment. Chemotherapy may also be used (with or without radiation therapy) for more advanced cancers. By and large there are very few responses to chemotherapy for Bile duct cancers.
Radiation therapy is treatment with high-energy rays or particles that destroy cancer cells. There are different kinds of radiation therapy.
External beam radiation therapy (EBRT): This type of radiation therapy uses x-rays from a machine outside the patient’s body to kill cancer cells. It is the most common form of radiation therapy for bile duct cancer. The treatment is much like getting an x-ray, but the radiation is more intense. The procedure itself is painless. Before your treatments start, the radiation team will take careful measurements to determine the correct angles for aiming the radiation beams and the proper dose of radiation. Each treatment lasts only a few minutes, but the setup time — getting you into place for treatment — usually takes longer. Most often, radiation treatments are given 5 days a week for several weeks.
Three-dimensional conformal radiation therapy (3D-CRT) uses special computers to precisely map the location of the tumor(s). Radiation beams are shaped and aimed at the tumor(s) from several directions, which makes it less likely to damage normal tissues. Most doctors now recommend using 3D-CRT when it is available.
Brachytherapy (internal radiation therapy)
This type of treatment uses small pellets of radioactive material placed next to or directly into the cancer. The radiation travels a very short distance, so it affects the cancer without causing much harm to nearby healthy body tissues. Brachytherapy is sometimes used in treating people with bile duct cancer by placing the pellets in a tube, which is inserted into the bile duct for a short time.