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home - Biliary - Biliary Cancers - Cholangiocarcinoma Diagnosis Written by Dr Sebastian Zeki

Knows the epidemiology pathology and clinical presentation of bile
duct tumours

Can recognise the presentation of biliary tumours arising de novo or
in the context of PSC Can plan programme of investigations
including detailed staging

Understands treatment options including surgery chemotherapy and
endoscopic management

Aware of the treatment options including biliary drainage
chemotherapy radiotherapy photodynamic therapy or surgery

Understands rationale for selection of particular therapy in individual

Awareness of the diagnostic modalities including CT MRI scanning
brush cytology intra ductal cholangioscopy and biopsy

Understands importance of multidisciplinary team of oncologist
surgeon radiologist histopathologist in decision making

Discusses cases with the specialist MDT

Cholangiocarcinoma Diagnosis

=Where the common bile duct lies posterior to the duodenum Classified according to the pattern of involvement of the hepatic ducts (the Bismuth-Corlette classific-tion) Tumour Markers: CEA — Can be elevated in any acute or chronic inflammatory state.CA 19-9 — ≥400 U/mL is suspicious for cholangioca in PSC.Combined CEA and CA 19-9 — CEA >5.2 ng/mL and CA 19-9 >180 U/mL, gives sen 100% spec 78%. Staging laparoscopy Resectability can be determined only by operative evaluation.Laparoscopy can identify the majority of patients with unresectable hilar and distal cholangiocarcinoma, thereby reducing the number of unnecessary laparotomies. Modes of Radiographic presentation Diagnostic Tests For Cholangiocarcinoma Arise from: Small intrahepatic ductules (peripheral cholangiocarci-nomas) ORLarge intrahepatic ducts proximal to the bifurcation of the right and left hepatic ducts. Classification Endoscopic ultrasound For distal bile duct lesions this is good for T and N stag-ing.EUS+ FNA has greater sensitivity than ERCP+ brushings.EUS is better than CT for detection of cholangioca and 3. Ductal dilatationIf in both hepatic lobes with a contracted gallbladder or nonunion of the right and left hepatic ducts with or without a visibly thickened wall suggests a Klatskin tumor. 2. Intrahepatic mass lesion 1. One hepatic lobe atrophied, the adjacent lobe hypertrophied- suggests portal vein invasion. Radiological diagnosisFor anatomical relationships CT> MRI.For benign vs malignant contrast CT>MRI.MRCP- gives info re disease extent and potential resectability-On MRCP, T1: Hypointense lesions T2: Hyperintense sometimes with central hypointensity (fibrosis). On MRCP, contrast fills from periphery inwards.Pooling of contrast on MRCP delayed images is suggestive of a peripheral cholangiocarcinoma.Cholangiography shows +ve cytology in 30%- more if biopsies or brushings taken.PET scan can detect nodular cholan-giocarcinomas as small as 1 cm but is less helpful for infiltrating tumors. It can also dentify occult mets. Intrahepatic Perihilar extrahepatic Distal extrahepatic >5.2 ng/mL in PSC has a sen of 68% and spec of 82%Biliary levels of CEA are elevated x5 in cholangioca Written by Dr Sebastian Zeki Type I Type II Type Type IIIb Type IV

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