Biliary+Tract

Primary liver and bile duct cancers are the 5th most common cause of cancer death in men and 9th in women. 1 Incidence rates have increased in people of all races and in both sexes. Men are more than twice as likely as women to develop and die from liver and bile duct cancers. African Americans and Hispanics are almost twice as likely to develop these cancers as whites. || - Closely associated with hepatitis virus infections, especially hepatitis B 1 - Almost all cases of liver cancer in the U.S. occur in people who 1st had cirrhosis, usually resulting from hepatitis B or C or from heavy alcohol use - Ingestion of foods contaminated with aflatoxin and obesity may also increase liver cancer risk || More than 90% of patients present with jaundice. Jaundice usually occurs late in the course of the disease. Less common clinical features are: 2 The initial radiographic evaluation consists of either an abdominal ultrasonography or computed tomography (CT) scan. If a bile duct dilation is documented, a cholangiography is performed either through percutaneous, transhepatic or endoscopic retrograde routes. Endoscopic retrograde cholangiopancreatography (ERCP), magnetic resonance cholangiopancreatography, MRI angiography, and conventional angiography can be done to evaluate vascular involvement. 2 || There are several histologic types, the most common of which are adenocarcinoma, papillary carcinoma, and mucinous carcinoma. 3 They are best classified into three broad groups: interhepatic, perhilar, and distal. This classification correlates with anatomic distribution and implies the preferred treatment for each site. 4 || Primary lymphatic drainage of the biliary tract is to nodes within the porta hepatis and pancreaticoduodenal groups. 3 || Metastatic Biliary Tract cancer can spread to nearby blood vessels, the liver, the common bile duct, nearby lymph nodes, other parts of the abdominal cavity, or to distant parts of the body. 5 || Grading refers to the appearance of cancer cells under a microscope. 6 Low grade means that the cancer cells look very much like normal cells. They are usually slow growing and are less likely to spread. High grade means the cells look very abnormal and are likely to grow and spread more quickly. || The following is TNM staging for Bilalry Tumors: 7 **Primary tumor (T):** extrahepatic bile duct The side effects for treating bilary tumors with radiation is much the same as pancreatic tumors. The most common side effects are nausea and vomiting. 8 This is mainly due to where the area of interest is located in the abdomen. These side effects are usually resolved with antiemtics (antinausea). 8 Other side effects include damge to the liver such as hepatitis or liver failure. 8 However, doses high enough to cause these side effects are rarely used. || There are several factors that influence the prognosis of biliary tract cancer such as location of the disease, complete or partial resection and the patient’s general health status. 9 It is important to identify that because bile duct cancer is rare, the statistics represent a small number of patients compared with other cancer diagnoses. The 5 year survival rates for intrahepatic and extrahepatic bile duct cancers are divided into 3 categories: localized, regional, and distant. The localized stage survival rate is 15% for intrahepatic and 30% for extrahepatic. 9 This prognosis is for patients who have a gross tumor with no other nodal or organ involvement and no metastasis. For patients with regional disease, the survival rate for intrahepatic and extrahepatic is 6% and 24% respectively. 9 These patients have regional lymph node or other partial organ involvement located in close proximity to the primary lesion. Finally, patients with intrahepatic and extrahepatic distant disease have a 5 year survival rate of 2%. 9 These patients are diagnosed with most advanced stages of bile duct cancer and have metasteses located throughout the body. || Surgical resection is the best treatment option for patients with this type of cancer. Whether or not the surgeon is able to completely resect the tumor plays an integral part in the patient’s prognosis. Usually patients with stage 0, 1, or 2 disease have an accurate chance at complete resection with negative margins. 9 Adjuvant radiation therapy and/or chemotherapy are options for patients after surgery to prevent recurrence. If a patient is given chemotherapy drugs, they most often use cisplatin and gemcitabine or 5-FU to further treat cancer cells. 9 Patients treated with post-operation radiation therapy are usually given 40-50Gy. 9 This prescription may be compromised on a case to case basis because of critical structure proximity. If the patient is not a good candidate for total resection, they may be given neoadjuvant chemotherapy or radiation therapy to shrink the tumor and produce better results for surgery. 9 || Tissue dose associated with 5% injury rate within 5 years 10,11
 * **Epidemiolgy:** || Lindsey
 * **Etiology:** || Lindsey
 * **Signs & Symptoms:** || Kevin T
 * Pruritus
 * Fever
 * Mild abdominal pain
 * Fatigue
 * Anorexia
 * Weight loss
 * Cholangitis (not frequent, but develops commonly after cholangiography) ||
 * **Diagnostic Procedures:** || Kevin T
 * **Histology:** || Jenn
 * **Lymph node drainage:** || Jenn
 * **Metastatic spread:** || Rachel
 * **Grading:** || Rachel
 * **Staging:** || Brandon
 * TX: Primary tumor cannot be assessed
 * T0: No evidence of primary tumor
 * Tis: Carcinoma in situ
 * T1: Tumor invades subepithelial connective tissue or fibromuscular layer
 * T1a: Tumor invades subepithelial connective tissue
 * T1b: Tumor invades fibromuscular layer
 * T2: Tumor invades perifibromuscular connective tissue
 * T3: Tumor invades adjacent structures: liver, pancreas, duodenum, gallbladder, colon, stomach
 * Lymph Nodes (N) **
 * NX: Regional lymph nodes cannot be assessed
 * N0: No regional lymph node metastasis
 * N1: Metastasis in cystic duct, pericholedochal and/or hilar nodes
 * N2: Posterior pancreaticodoudenal lymph nodes
 * Metastasis (M) **
 * MX: Distant metastasis cannot be assessed
 * M0: No distant metastasis
 * M1: Distant metastasis ||
 * **Radiation side effects:** || Brandon
 * **Prognosis:** || Ashley
 * **Treatments:** || Ashley
 * **TD 5/5:** || Amanuel
 * Liver: 3000cGy [Acute and chronic hepatitis]
 * Stomach: 5500cGy [Ulceration/perforation]
 * Small bowel: 4500cGy [Obstruction/perforation] ||
 * **References:** || Amanuel.
 * 1) National Cancer Institute Web Site. [] . Accessed June12, 2013.
 * 2) Lenhard RE, Osteen R, Gansler T. The American Cancer Society’s Clinical Oncology. Williston, VT: Blackwell Publishing, Inc; 2001.
 * 3) Chao KS, Perez CA, Brady LW. Radiation Oncology Management Decisions. 3rd . Philadelphia, PA: Lippincott Williams & Wilkins; 2011: 433.
 * 4) Redlich PN, Ahrendt SA, Pitt HA. Tumor of the Pancreas, Gallbladder, and Bile Ducts. In. //The American Cancer Society’s Clinical Oncology. // Atlanta, Georgia: 2001; 373-392.
 * 5) Bile Duct Cancer Treatment. National Cancer Institute. []. Accessed June 13, 2013.
 * 6) Bile Duct Cancer. Macmillan Cancer Support Web Site. []. Accessed June 13, 2013.
 * 7) Chao K, Perez C, Brady L. //Radiation Oncology Management Decisions //. 2nd ed. Philadelphia, PA: Lippincott, Williams & Wilkins; 2002: 348.
 * 8) Washington C, Leaver D. //Principles and Practice of Radiation Oncology. // 3rd ed. St. Louis, MO: Mosby Elsevier; 2010:891-892
 * 9) Bile Duct Cancer. American Cancer Society Web site. [|www.cancer.org/bile-duct-cancer-pdf] <span style="color: #008000; font-family: Arial,sans-serif; line-height: 1.5;">. Updated June 12, 2012. Accessed June 12, 2013.
 * 10) <span style="background-color: #ffffff; color: #ff7100; font-family: Arial,sans-serif; line-height: 1.5;">Washington CM, Leaver D. Principles and Practice of Radiation Therapy. 3rd ed. St. Louis, MO: Mosby-Elsevier; 2010
 * 11) <span style="background-color: #ffffff; color: #ff7100; font-family: Arial,sans-serif; line-height: 1.5;">Clifford C, Perez C, Brady LW. Radiation Oncology Management Decisions. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins;2011. ||

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