Tumors of the bile ducts

Gallbladder cancer Fifth most frequent GI cancer 2/3 women 75% >65 ani 70-90% associated to litiasis ETIOLOGY Gallbladder litiasis Abnormal bilio-pancreatic junction Porcelain gallbladder Cyst of the main bile duct Sclerozng cholangitis

Gallbladder cancer Pathology 90% adenocarcinoma Scquamous cell with small cells, mostly undifferentiated At diagnosis 25% limited to the wall 35% loco-regional metastasis 40% distant metastasis 1% incidentally found on apparently normal gallbladders after cholecystectomy Spread Lymph – cystic ln – ln near main bile duct – retropancreatic ln – intercavoaortic ln; retroportal ln; coeliac ln. Direct into the liver Angiolymphatic along portal tracts Hematogeneous

TNM Staging for Gallbladder Cancer T1 Tumor invades lamina propria (T1a) or muscular (T1b) layer T2 Tumor invades perimuscular connective tissue, no extension beyond the serosa or into the liver T3 Tumor perforates the serosa (visceral peritoneum) and/or directly invades into liver and/or one other adjacent organ or structure such as the stomach, duodenum, colon, pancreas, omentum, or extrahepatic bile ducts T4 Tumor invades main portal vein or hepatic artery or invades multiple extrahepatic organs and/or structures N0 No lymph node metastases N1 Regional lymph node metastases M0 No distant metastases M1 Distant metastases StageStage Grouping IA T1 N0 M0 IB T2 N0 M0 IIA T3 N0 M0 IIB T1 N1 M0  T2 N1 M0  T3 N1 M0 III T4 Any N M0 IV Any T Any N M1

Gallbladder cancer CLINICAL Can resemble: Chronic cholecystitis – 40-45% Acute cholecystitis – 15-20% Jaundice – 30-35% Weight loss – 25-30% Other GI symptoms (upper GI bleeding, bowel obstruction) <5%

Gallbladder cancer US CT, MRI Echoendoscopy ERCP Guided biopsy

Gallbladder cancer TREATMENT T1 - cholecystectomy >T2 - cholecystectomy+lymphadenectomy+hepatectomy with 3-5 cm margin Unresectable: Palliative care Endoscopic or percutaneous stent placing Radio and chemotherapy – weak chances PROGNOSIS 85% die within the first year 5 year survival T1a – 100% T1b – 75% Std IIa 28-63% Std IIb 19-25% Std IV – 1-3 luni

CHOLANGIOCARCINOMA Rare W:M=1:1 95% adenocarcinoma Intra- or extrahepatic Klatskin tumors ETIOLOGY Primary sclerotizing cholangitis Parasites – Clonorchis sinesis Liver litiasis – 5-10% Coledoco-duodenal anastomosis

CHOLANGIOCARCINOMA Symptoms Variable depending on site and stage Jaundice Abdominal pain Fever, chills Pruritus General signs of neoplasia Palpable gallbaldder Courvoisier sign

CHOLANGIOCARCINOMA Diagnosis Lab Imaging Positive cholestasis tests CEA, CA 19-9 positive – 40% of patients Alfa-fetoprotein increased < CH Imaging US CT, MRI

ERCP

brushing

Echoendoscopy

Transhepatic percutaneous cholangiography

Treatment Surgical Periferal tumor hepatectomy

Tumor in the hilum Bile ducts resection + hepatectomy

Tumor of the extrahepatic bile ducts located halfway between the hilum and the papila Bile duct resection

Tumor of the extrahepatic bile ducts located distally Bile duct resection + duodenopancreatectomy

Endoscopicaly Percutaneously Palliative treatment Stent placing

CHOLANGIOCARCINOMA TREATMENT Photodynamic therapy Radiotherapy Unresectable tumors Chemotherapy Weak results PROGNOSIS 5 year survival hepatic tumors– 30-40% perihilar tumors– 10-20% distale tumors– 40-45% Unresectable tumors– 5-8 months