Cholangiocarcinoma is serious illness and is relatively rare. It is essential that patients are cared for by knowledgeable specialists so that they are properly assessed and offered the right treatment and management for their particular situation.
For information on requesting a referral for a further opinion to ensure a diagnosis is correct, and for reassurance that the treatments suggested are the best options available, click here
Treatment of cholangiocarcinoma will depend on the position and size of the cancer and whether it has spread beyond the bile duct, as well as on general health. The main options are:
Surgery to completely remove the cancer is currently the only potentially curative treatment for cholangiocarcinoma. This involves a major operation and, often, because the disease is too far advanced, or the patient is already too poorly, surgery is not possible. The decision about whether an operation to remove the cancer can be done depends on the results of the diagnostic tests, and on the patient’s general health.
If surgery is possible, the patient must be referred to a surgeon who specialises in biliary tract cancer surgery. The type of operation that is done depends on the size of the cancer and whether it has begun to spread into nearby tissues.
- Removal of the bile ducts
- Partial liver resection
- Whipple procedure
- Surgery to relieve obstruction (blockage)
- Liver transplantation
- Stent Insertion
May 2017: Following the positive outcome of the BILCAP trial*, it is expected that Capecitabine chemotherapy will be offered to all patients following a resection for cholangiocarcinoma.
*The result of the BILCAP trial showed that three year survival improved by almost a quarter (23 per cent) in patients who were given Capecitabine, and the average survival was increased to 53 months from 36 months compared to those who only had surgery. For more information, go to: https://ammf.org.uk/2017/05/18/bilcap-results-show-chemo-improves-survival.Read More
One of the frequent symptoms of cholangiocarcinoma is jaundice. This happens because the bile duct or ducts become blocked, preventing the normal flow of bile from the liver to the intestines. To allow the bile to flow again, a stent (usually a metal stent) will be inserted into the bile duct to hold it open. This will relieve the symptoms of jaundice, the patient’s general health will then improve and they are able to digest food again normally. (If chemotherapy has been recommended, it is essential this happens before it can begin.)
A stent usually needs to be replaced every 3-4 months as they can become blocked, and cause a biliary tract infection (cholangitis), which can rapidly become serious. Symptoms of a blocked stent/infection include:
- high temperature/fever
- chills, shivering
If these symptoms develop, it is important to contact the doctor or CNS (Clinical Nurse Specialist) for advice, as antibiotic treatment may be needed and the stent may need to be replaced.Read More
Chemotherapy is the use of anti-cancer (cytotoxic) drugs to destroy cancer cells. There are now a number of chemotherapies used for those with cholangiocarcinoma.
Gemcitabine and Cisplatin (Gem/Cis)
First line standard of care chemotherapy treatment for those with inoperable cholangiocarcinoma is usually a combination of Gemcitabine (Gemzar®) and Cisplatin.
This standard of care chemotherapy combination was adopted worldwide following the results of the UK’s ABC-02 trial in 2010. Although a number of clinical trials have been carried out since that time, this has not yet been improved on.
For a Patient Information Sheet on the Gemcitabine/Cisplatin chemotherapy, click here
Dr John Bridgewater of UCL talks about cholangiocarcinoma (bile duct cancer) and the Gemcitabine/Cisplatin study (the ABC-02 trial).
The chemotherapy capecitabine is now offered to patients following surgical resection for their cholangiocarcinoma.
The results of the long running BILCAP showed that this improved survival. For more information see: https://ammf.org.uk/2017/05/18/bilcap-results-show-chemo-improves-survival.
For a Patient Information Sheet on Capecitabine, click here
A second line treatment, the combination of folinic acid, fluorouracil and oxaliplatin (FOLFOX) may be offered to those patients with advanced or metastatic cholangiocarcinoma who have already received first line treatment with the combination chemotherapy Gemcitabine/Cisplatin.
For a Patient Information Sheet on FOLFOX, click here
Other chemotherapies your oncologist may advise for you include:
CAPOX (Capecitabine and oxaliplatin):
For a Patient Information Sheet on CAPOX, click here
Gemcitabine (given alone):
For a Patient Information Sheet on Gemcitabine, click here
Clinical trials continue to investigate ways to better, more effective treatments. For more information on current trials, click here
Radiotherapy, which uses high energy x-rays to destroy cancer cells, is not routinely used to treat cholangiocarcinoma, although there may be occasions when it is used palliatively (to reduce symptoms).
However, there have been major advances in this technology, and SIRT, the first treatment to be made available to NHS patients in England through Commissioning through Evaluation (CtE) – a new NHS initiative to permit access to innovative therapies – is now available through the NHS in England and Scotland for certain eligible patients with cholangiocarcinoma (bile duct cancer) in whom routine chemotherapy has been tried or has not been well tolerated.
See below for more details on SIRT.
Please note: NHS England funding for SIRT, which had been available for patients with intrahepatic cholangiocarcinoma through the CtE (Commissioning through Evaluation) programme ceased on 31st March, 2017.
However, for those meeting the eligibility criteria, it is still available privately. SIRT may also accessed in a clinical trial setting, or by making an application for its use under exceptional circumstances.
SIRT (Selective Internal Radiation Therapy, also known as radio-embolisation) is a special type of internal radiotherapy that targets liver tumours inside the body with high doses of radiation.
SIRT involves injecting millions of tiny radioactive ‘beads’ called microspheres into the main blood vessel of the liver through a long thin tube (catheter). The microspheres travel through the blood to the liver and lodge themselves in the very small blood vessels in and around the liver tumours, where they give off high doses of radiation. As the microspheres only give off radiation to a small area, they target the liver tumour while doing little damage to the surrounding healthy liver tissue. The action of the radiation destroys the liver tumour cells causing the tumours to shrink.Read More
SBRT (Stereotactic body radiotherapy)
SBRT gives radiotherapy from several different positions around the body, with the beams meeting at the tumour. In this way, the tumour receives a high dose of radiation, but the tissues around it receive only a low dose, which lowers the risk of side effects. SBRT is only suitable for those whose cancer has not spread to others parts of the body.
A clinical trial, ABC-07, using a combination of SBRT and Gemcitabine/Cisplatin chemotherapy for eligible biliary tract cancer patients is now open. For more information, click here
The Cyberknife is an advanced radiotherapy technology and works very differently from conventional radiotherapy machines. The robotic arm and image sensors can track a moving target allowing for hundreds of beams of radiation from a wide variety of angles to be delivered with pinpoint accuracy.
This equipment is now being installed in several private and NHS locations in the UK and there are plans for it to be available for patients with hard-to-treat tumours in the prostate, pancreas, lung, spinal cord, head and neck, and liver. We await news on whether this will be generally available to suitable cholangiocarcinoma patients in the UK.
(For details on private Cyberknife treatment, go to: http://www.cyberknifeservice.com/)
Photodynamic therapy (PDT)
PDT uses a combination of laser light of a specific wavelength and a light-sensitive drug to destroy cancer cells. However, following the findings of the Photostent-02 trial, this therapy is no longer recommended for cholangiocarcinoma patients.
23.07.18: The findings of the PHOTOSTENT-02 trial have now been published, and can be seen here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6069917
Progress in treatments for cholangiocarcinoma
Current scientific advances mean that cancer treatments are moving towards those more specifically targeting the tumour ‘drivers’, and ways to inhibit these drivers. Progress is beginning to be made in the understanding of cholangiocarcinoma, with studies being carried out to find target agents, and also genomic profiling, in the search for better and more effective treatments.
For information on getting a referral or a second opinion for diagnosis or treatment, click here