If you or a loved one is dealing with a diagnosis of hepatobiliary cancer (bile duct, gallbladder or liver), our multidisciplinary team of gastrointestinal cancer specialists at West Cancer Center & Research Institute is here to surround you with the latest treatments and technology to design a personalized treatment plan specific for your disease. Our goal is to also provide resources and information to better help you understand and manage your disease.
What is Hepatobiliary Cancer?
The hepatobiliary system includes the liver, gallbladder and bile duct. These organs work together to make bile. Bile helps you digest food in the small intestine, specifically fats. The liver makes the bile. The bile duct is a tube that passes bile from the liver to the gallbladder and small intestine. The bile is stored in the gallbladder. Hepatobiliary cancers include:
- Liver cancer
- Gallbladder cancer
- Bile duct cancer
The body is programmed to routinely replenish cells in different organs. As normal cells age or get damaged, they die off. New cells take their place. Abnormal cell growth refers to a buildup of extra cells. This happens when:
- New cells form even though the body doesn’t need them or
- Old, damaged cells don’t die off.
These extra cells slowly accumulate to form a tissue mass, lump or growth called a tumor. These abnormal cells can destroy normal body tissue and spread through the bloodstream and lymphatic system.
Types of Hepatobiliary Cancer
Liver cancer beings in the football shaped organ that sits in the upper right portion of your abdomen and the most common type is hepatocellular carcinoma (affecting the main type of liver cell-hepatocyte)
Gallbladder cancer is uncommon and difficult to diagnose due to no specific signs or symptoms; therefore, it is often discovered at a late stage. The gallbladder is a small, pear-shaped organ located on the right side of your abdomen that stores digestive fluid (bile) produced by your liver.
BILE DUCT CARCINOMA
The bile ducts within the liver join into a main bile duct(common hepatic duct) that carries bile to the small intestine. The cystic duct connects the gallbladder to the common hepatic duct and combines to form the common bile duct. Bile duct tumors, called cholangiocarcinomas can occur in the main bile duct within the liver (intrahepatic) or outside the liver (extrahepatic)
Stages of Hepatabiliary Cancer
The Barcelona Clinic Liver Cancer Staging System may be used to stage adult primary liver cancer.
There are several staging systems for liver cancer. The Barcelona Clinic Liver Cancer (BCLC) Staging System is widely used and is described below. This system is used to predict the patient’s chance of recovery and to plan treatment, based on the following:
- Whether the cancer has spread within the liver or to other parts of the body.
- How well the liver is working.
- The general health and wellness of the patient.
- The symptoms caused by the cancer.
The BCLC staging system has five stages:
- Stage 0: Very early
- Stage A: Early
- Stage B: Intermediate
- Stage C: Advanced
- Stage D: End-stage
Bile Duct Cancer
Intrahepatic bile duct cancer
In Stage 0 intrahepatic bile duct cancer, abnormal cells are found in the innermost layer of tissue lining the intrahepatic bile duct. These abnormal cells may become cancer and spread into nearby normal tissue. Stage 0 is also called carcinoma in situ.
Cancer has formed:
- In an intrahepatic bile duct and the tumor is 5 centimeters or smaller; or
- In an intrahepatic bile duct and the tumor is larger than 5 centimeters.
In Stage II intrahepatic bile duct cancer, either of the following is found:
- The tumor has spread through the wall of an intrahepatic bile duct and into a blood vessel; or
- More than one tumor has formed in the intrahepatic bile duct and may have spread into a blood vessel.
The tumor has spread:
- Through the capsule (outer lining) of the liver; or
- To organs or tissues near the liver, such as the duodenum, colon, stomach, common bile duct, abdominal wall, diaphragm, or the part of the vena cava behind the liver, or the cancer has spread to nearby lymph nodes.
In stage IV intrahepatic bile duct cancer, cancer has spread to other parts of the body, such as the bone, lungs, distant lymph nodes, or tissue lining the wall of the abdomen and most organs in the abdomen.
Perihilar Bile Duct Cancer
In stage 0 perihilar bile duct cancer, abnormal cells are found in the innermost layer of tissue lining the perihilar bile duct. These abnormal cells may become cancer and spread into nearby normal tissue. Stage 0 is also called carcinoma in situ or high-grade dysplasia.
In Stage I, perihilar bile duct cancer, cancer has formed in the innermost layer of tissue lining the perihilar bile duct and has spread into the muscle layer or fibrous tissue layer of the perihilar bile duct wall.
In stage II perihilar bile duct cancer, cancer has spread through the wall of the perihilar bile duct to nearby fatty tissue or to liver tissue.
Cancer has spread
- To branches on one side of the hepatic artery or of the portal vein; or
- To one or more of the following:
- The main part of the portal vein or its branches on both sides;
- The common hepatic artery;
- The right hepatic duct and the left branch of the hepatic artery or of the portal vein;
- The left hepatic duct and the right branch of the hepatic artery or of the portal vein; or
- Or to 1 to 3 nearby lymph nodes.
Cancer has spread:
- To 4 or more nearby lymph nodes.
- To other parts of the body, such as the liver, lung, bone, brain, skin, distant lymph nodes, or tissue lining the wall of the abdomen and most organs in the abdomen.
Distal Extrahepatic Bile Duct
In stage 0 distal extrahepatic bile duct cancer, abnormal cells are found in the innermost layer of tissue lining the distal extrahepatic bile duct. These abnormal cells may become cancer and spread into nearby normal tissue. Stage 0 is also called carcinoma in situ or high-grade dysplasia.
In Stage I, distal extrahepatic bile duct cancer, cancer has formed and spread fewer than 5 millimeters into the wall of the distal extrahepatic bile duct.
Cancer has spread:
- Fewer than 5 millimeters into the wall of the distal extrahepatic bile duct and has spread to 1 to 3 nearby lymph nodes; or
- 5 to 12 millimeters into the wall of the distal extrahepatic bile duct.
- 5 millimeters or more into the wall of the distal extrahepatic bile duct.
- Cancer may have spread to 1 to 3 nearby lymph nodes.
Cancer has spread
- Into the wall of the distal extrahepatic bile duct and to 4 or more nearby lymph nodes.
- To the large vessels that carry blood to the organs in the abdomen.
- May have spread to 1 or more nearby lymph nodes.
In Stage IV, distal extrahepatic bile duct cancer, cancer has spread to other parts of the body, such as the liver, lungs, or tissue lining the wall of the abdomen and most organs in the abdomen.
Stage 0 (Carcinoma in Situ)
In Stage 0, abnormal cells are found in the mucosa (innermost layer) of the gallbladder wall. These abnormal cells may become cancer and spread into nearby normal tissue. Stage 0 is also called carcinoma in situ.
In stage I, cancer has formed in the mucosa (innermost layer) of the gallbladder wall and may have spread to the muscle layer of the gallbladder wall.
Cancer has spread
- Through the muscle layer to the connective tissue layer of the gallbladder wall on the side of the gallbladder that is not near the liver; or
- Through the muscle layer o the connective tissue layer of the gallbladder wall on the same side as the liver.
- Cancer has not spread to the liver.
Cancer has spread
- Through the connective tissue layer of the gallbladder wall and one or more of the following is true:
- Cancer has spread to the serosa (layer of tissue that covers the gallbladder).
- Cancer has spread to the liver.
- Cancer has spread to one nearby organ or structure (such as the stomach, small intestine, colon, pancreas, or the bile ducts outside the liver)
- Cancer formed in the mucosa (innermost layer) of the gallbladder wall and may have spread to the muscle, connective tissue, or serosa (layer of tissue that covers the gallbladder) and may have also spread to the liver or to one nearby organ or structure (such as the stomach, small intestine, colon, pancreas, or the bile ducts outside the liver).
- Cancer has spread to one to three nearby lymph nodes.
Cancer has spread
- To the portal vein or hepatic artery or to two or more organs or structures other than the liver.
- To one to three nearby lymph nodes.
- To nearby organs or structures.
- To four or more nearby lymph nodes; or
- To other parts of the body, such as the peritoneum and liver.
Symptoms of Hepatobiliary Cancer
If you are experiencing any of these symptoms, we urge you to speak to your provider as soon as possible for further examination.
- Losing weight without trying
- Loss of appetite
- Upper abdominal pain
- Nausea and vomiting
- General weakness and fatigue
- Abdominal swelling
- Yellow discoloration of your skin and the whites of your eyes (jaundice)
- Dark colored urine and light colored stool
- Swelling of the legs
How to Diagnose Hepatobiliary Cancer
If your provider would like to further investigate the possibility of hepatobiliary cancer, one or more of the following diagnostic procedures may be performed:
BIOPSY (FINE NEEDLE)
This image guided procedure is usually performed by an interventional radiologist to remove a small tissue or fluid sample for evaluation.
Several blood test may be done to correctly diagnose your cancer.
• Your blood may be analyzed to check for an elevated bilirubin (a chemical that gives bile its yellow color and leads to jaundice) level.
• Your alkaline phosphatase level may be checked to see if your bile ducts are blocked.
• Test may be done to detect and analyze tumor markers (proteins in the blood when certain cancers are present)
A long, narrow scope with a camera is inserted into your mouth to examine the bile ducts and obtain a biopsy.
MAGNETIC RESONANCE CHOLANGIOPANCREATOGRAPHY (MRCP)
MPCP reveals the extent of tumor growth within your gallbladder or bile ducts to help determine if a tumor can be surgically removed. Additional MRI may be necessary to see if the tumor has spread to the liver or other organs.
Sometimes the tumor may be too small for a biopsy and has to be removed surgically to confirm the diagnosis.
This imaging technique helps your physician determine the extent of your disease by providing images of the liver, bile ducts, and nearby lymph nodes during three different phases of blood flow through the liver.
Ultrasound is used to detect the location and number of tumors and determine if they involve your main blood vessels. (Tumors located near blood vessels may be more difficult to remove). Ultrasound also can be used to distinguish a cancerous mass from benign (noncancerous) gallstone disease. Unlike CT and MRI, ultrasound does not use radiation.
POSITRON EMISSION TOMOGRAPHY (PET)
This technique is used to identify metastases (tumors that have spread from the gallbladder or bile ducts to other tissues or organs). PET and CT scans can be used in combination to pinpoint the exact location of tumors.
Types of Hepatobiliary Cancer Treatments
Your hepatobiliary cancer treatment plan will vary depending on multiple factors including, but not limited to, your stage of diagnosis, as well as the location of your cancer. Your dedicated team of cancer experts will discuss your treatment options and plan with you, allowing you and your loved ones to consider all possible treatment options for your diagnosis.
BILE DUCT SURGERY
An open surgical approach removes the bile duct and regional lymph nodes.
This minimally invasive approach creates a new pathway around the tumors that are blocking the flow of bile by connecting the gallbladder or bile duct directly to the small intestine.
CHEMOTHERAPY WITH HEPATIC ARTERIAL INFUSION (HAI)
A new chemotherapy technique called HAI is a treatment of your gallbladder and bile duct cancer that has been shown to extend survival in patients with liver cancer and involves delivering a high dose of chemotherapy drugs directly to the liver through a tiny pump implanted under the skin in the lower abdomen. Additional chemotherapy medicine is injected into the pump, as needed, on an outpatient basis. HAI therapy may be used to shrink tumors before surgery or, after surgery, to prevent recurrence.
A procedure where the gallbladder, lymph nodes, a margin of surrounding tissue and possibly part of the liver are surgically removed.
Ask your physician if you are a candidate for a clinical trial.
A probe that contains liquid nitrogen can be inserted into your liver tumors with ultrasound guidance and destroyed with extreme cold.
This is an option for a small percentage of people with early-stage liver cancer where your diseased liver is replaced with a healthy donor liver.
When large bile duct tumors are found inside the liver (intrahepatic peripheral tumors), a portion of the liver and margin of healthy tissue is surgically removed.
WHIPPLE PROCEDURE (PANCREATODUODENECTOMY)
Whipple Procedure (Pancreatoduodenectomy) If your bile duct tumor is outside the liver (extrahepatic), your gallbladder, part of your stomach, part of your small intestine, your bile ducts and the right section of your pancreas is surgically removed.
This targeted therapy assist your immune system to find and eliminate the tumor cells. Late stage hepatabiliary cancer with MMR (DNA mismatch repair) deficiency or high MSI (microsatellite instability) are approved for immunotherapy.
NEUROLYTIC CELIAC PLEXUS BLOCK (NCPB)
To relieve debilitating pain if your disease is too advanced for surgery, a local anesthetic can be injected into your celiac plexus (a cluster of nerves near the liver) to block pain signals. This procedure can be performed through the skin with x-ray guidance, laparoscopically or with endoscopic ultrasound(EUS) guidance through your mouth and into your stomach.
Radiation may be administered alone or in combination with chemotherapy or other treatments.
EXTERNAL BEAM RADIATION
External beam radiation, used alone or in combination with a radiosensitizer (a drug that makes the tissue more sensitive to radiation), is the most common type of radiotherapy used to treat gallbladder and bile duct cancer. Radiation may be administered in the area where the gallbladder once lay or in the nearby lymph nodes to destroy tumor cells that may remain following surgery. Radiation also is occasionally used to shrink a tumor, either to increase the chance that it may be surgically removed or to relieve symptoms.
IMAGE-GUIDED RADIATION THERAPY (IGRT)
Image-guided radiation therapy (IGRT) and respiratory gating are two approaches that have the potential to reduce toxicity (damage) to normal tissue during radiation therapy for bile duct cancer and, less commonly, gallbladder cancer. IGRT targets tumors with greater precision than conventional radiation therapy. Using highly sophisticated computer software and 3-D images from CT scans, your radiation oncologist can develop an individualized treatment plan that delivers high doses of radiation to cancerous tissue while sparing surrounding organs and reducing the risk of injury to healthy tissue.
With ultrasound or CT guidance, electric current is used to heat and destroy your cancer cells
A small drainage tube (stent) is inserted to relieve a blocked bile duct and allows bile to flow across the blockage to the small intestine. The stent can either be placed through an endoscope (a thin, tube-like instrument inserted through the mouth) or percutaneously (with a needle) through the liver