1. Mazen Hassanain

2. Bile duct Cancer Average 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

3. Risk Factors Definite 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 T oxins (dioxin, polyvinyl chloride) Biliary-enteric drainage procedures

4. Staging

5. 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

6. Presentation Obstructive jaundice Cholangitis (10%) Palpable mass Liver cirrhosis Cachexia

7. Diagnosis Blood 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)

8. Treatment and prognosis Surgical resection Adjuvant and neoadjuvant treatments Mayo 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

9. Surgery Local lymph node metastases (N1) are not an absolute contraindication to surgical treatment, because they do not significantly influence outcomes in hilar CCA

10. GB cancer Predominantly 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

11. Risk Factors Larger 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.

12. Other Risk Factors Anomalous pancreatobiliary duct junction Obesity and pregnancy Chronic inflammatory bowel disease Polyposis coli Mirizzi syndrome Bacterial and Salmonella infections Industrial exposure to carcinogens Familial tendency

13. Pathology Adenocarcinomas 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

14. Presentation Abdominal 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)

15. AJCC staging Stage 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 vessel Stage IV: M1: distant metastases, including metastases in lymph nodes at the pancreatic body and tail

16. Treatment and prognosis Surgery Adjuvant therapy The 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%.

17. Surgery Lap vs. open Post Lap Choly