Gallbladder/ bile duct carcinoma

Within the tumours of the biliary system, we differentiate between tumours of the gallbladder and the bile ducts. Tumours of the bile ducts can also be divided into tumours of the bile ducts inside and outside the liver. Malignant tumours of the opening of the bile duct into the duodenum (papillary tumours) are usually classified as pancreatic tumours due to their close proximity, but formally belong to the group of bile duct tumours.

Malignant tumours of the biliary tract and gallbladder (biliary system) are generally rare diseases with an annual incidence of around 5 cases per 100,000 inhabitants.

While malignant tumours of the biliary tract occur more frequently in men than in women, gallbladder carcinomas are more common in women (ratio 2:1), which can primarily be explained by the more frequent occurrence of gallbladder stones in women. Gallstones are found in almost all patients (74-92%) with gallbladder carcinoma, but only very few patients with gallbladder stones develop gallbladder carcinoma in the course of their lives. However, in the presence of gallbladder stones with typical symptoms (symptomatic gallstones), the risk of a carcinoma forming appears to be increased; patients with symptomatic gallstones are usually operated on for other reasons.

In the course of gallbladder operations, gallbladder carcinoma is diagnosed in approx. 1% of cases during tissue work-up.

Other diseases that are considered a risk factor for gallbladder carcinomas are chronic inflammation of the gallbladder. Malignant tumours can also develop from polyps in the gallbladder, although this primarily applies to polyps that are observed to grow larger than 10 mm.

The risk factors for carcinomas of the bile ducts are known to a lesser extent. In addition to inflammatory diseases such as "primary sclerosing cholangitis (PSC)", a moderately increased risk of disease is assumed in chronic smokers.

There are no characteristic early symptoms. Yellowing of the skin and eyes (jaundice) often occurs during the course of the disease, which is caused by a tumour-related lack of drainage of bile into the intestine. While this jaundice in gallbladder carcinoma usually indicates an advanced stage, smaller carcinomas of the bile ducts can also lead to an obstruction and thus to the development of this yellow colouration. Many patients with gallbladder carcinoma also report pressing pain in the right upper abdomen, although this does not specifically indicate malignant tumour disease of the gallbladder.

A number of examination procedures are used to diagnose and determine the treatment for cancers of the gallbladder and bile ducts. In addition to actually confirming the diagnosis, the main purpose of diagnostics is to distinguish malignant tumours of the gallbladder or bile ducts that can be operated on with the prospect of cure from tumours where patients do not benefit from an operation. In particular, we want to use these examinations to obtain information on how deeply the tumours infiltrate the wall of the gallbladder or bile ducts and whether there are metastases in lymph nodes and other organs.

The following examinations are available to us in individual cases:

Medical history and physical examination

In a detailed discussion, all complaints and previous illnesses (including family hereditary diseases) are asked about and documented. This is followed by a thorough physical examination.

Laboratory

By analysing your blood, we obtain information about your general condition and certain organ functions. In addition to the blood count, frequent changes include laboratory values that indicate a delayed or absent outflow of bile.

Tumour markers are only of secondary importance in the case of tumours of the gallbladder or bile ducts and are used, for example, in patients who present for follow-up care after complete surgical removal of the tumour.

Upper abdominal sonography (ultrasound)

Due to its wide availability, simple handling and lack of radiation exposure, ultrasound is usually the first procedure used. Bile stasis in particular, the most common complication of biliary tumours, can be reliably detected with the aid of ultrasound. However, direct visualisation of smaller tumours of the bile ducts is often not possible.

Under sonographic guidance, material can also be taken from enlarged lymph nodes, metastases on other organs or the tumours themselves for fine tissue analysis.

Gastro-oesophagoscopy-duodenoscopy

Gastro-oesophago-duodenoscopy alone is a decisive diagnostic tool for tumours that are located in the area where they open into the duodenum. Infiltration into the duodenum or a constriction from the outside can also be detected and any complications, such as bleeding, can be treated.

Endosonography

Endosonography provides a good indication of the local extent of the tumour and the involvement of regional lymph nodes, particularly for carcinomas located close to the duodenum (distal bile duct tumours). This information is crucial for deciding whether an operation is possible.

This method can also be used to biopsy the tumour or, in particular, enlarged lymph nodes under sonographic guidance.

Endoscopic retrograde cholangiopancreatography (ERCP)

This method enables precise visualisation of the bile ducts and therefore tumour localisation.

One advantage is the option of simultaneously performing a diagnostic removal of tumour tissue and a therapeutic removal of the bile duct obstruction. A disadvantage of this invasive procedure is the possible occurrence of complications, such as inflammation of the pancreas or injuries to the gastrointestinal tract. The procedure is also not suitable for all patients.

If ERCP is not possible or if a purely diagnostic examination is planned, magnetic resonance cholangiopancreaticography (MRCP) can be considered as an alternative.

Computer tomography

Depending on the location of the tumour, computer tomography provides information about possible metastases of the tumour in other organs or lymph nodes. As with ultrasound, however, it is often not possible to visualise smaller tumours in the bile ducts. The disadvantage is a certain radiation exposure.

The tumour stage can be determined using the diagnostics mentioned above. This is necessary to determine the best possible therapy. However, a more precise assessment of the tumour stage is often only possible after surgery.

The TNM classification is usually used for this purpose, where T stands for the size and extent of the primary tumour, N for the number of affected lymph nodes and M for the occurrence of tumour metastases in other organs.

The TNM classification can be used to differentiate between different tumour stages with different treatment objectives. The tumour stage also allows the prognosis to be estimated to a certain extent.

Basic principles

Treatment aimed at curing the tumour is only possible through complete surgical removal (R0 resection).

With further extension of the tumour (higher stage), the prognosis of the disease worsens.

An urgent goal for every patient is to ensure the drainage of bile

The appropriate therapy must be selected with the patient based on the stage of the tumour AND the patient's general condition. The following treatment methods are available:

Surgery

In the case of small tumours with no evidence of metastases in lymph nodes or distant metastases, surgical removal of the tumour is the treatment of choice if there are no other reasons (e.g. unfavourable location of the tumour or diseases of the heart and lungs) that speak against surgery. The type and extent of the operation depend primarily on the location of the tumour. In some cases, additional follow-up treatment with radiotherapy and/or chemotherapy may be useful. A complete (R0) resection is the only way to treat tumours of the gallbladder and bile ducts with the aim of curing them.

Radiotherapy

Several studies have shown an advantage for radiotherapy (radiotherapy) in addition to surgery. In patients with a moderate to high risk of tumour recurrence, radiotherapy and / or chemotherapy can be carried out after surgery.

Local therapy methods

In a further study, photodynamic therapy with subsequent stent insertion was shown to have a good effect in non-curable patients in terms of improving bile drainage, quality of life and survival. There is also the option of intraductal radiofrequency thermal ablation (RFTA) to prevent obstruction of the bile ducts.

Chemotherapy

Optimal supportive therapy is the basis of any therapy.
Carcinomas of the biliary system often show a high resistance to chemotherapy. The standard therapy in this situation is gemcitabine and cisplatin. In recent years, however, several treatment options have also been introduced here, so that in individual cases several lines of chemotherapy are possible.
We are constantly endeavouring to improve the treatment of patients through current studies. Current studies can be found here.

Supportive therapy methods

The aims of supportive therapy for tumour diseases of the gallbladder and bile ducts are Ensuring the drainage of bile and thereby preventing / treating infections in the bile ducts. Reduction/elimination of itching (caused by bile deposits in the skin). Pain relief

Bile drainage (biliary drainage)

To treat bile stasis, the primary aim is to "bridge" the tumour with drainage via an ERC. Only if endoscopic access via the duodenum is not possible should external access via a PTCD be considered. PTCD (percutaneous transhepatic cholangiodrainage) is a drainage of the bile through a puncture from the outside. This method is used if an ERCP is unsuccessful, e.g. after certain operations on the stomach or a tumour that cannot be bridged.

If bile stasis with jaundice is present in tumours of the biliary system, an attempt is first made to bridge the tumour-related constriction with a plastic prosthesis (stent), which, however, has to be changed repeatedly due to possible blockage by deposits in the lumen. In individual cases, a metal mesh stent can be inserted to prolong the time the stent remains open. Frequent complications of a bile blockage are infections, which can be accompanied by high fever. Icterus (jaundice due to congestion of the bile) or dark urine can be early symptoms of an obstruction of the bile duct.

Pain therapy

Satisfactory pain control is usually possible with sufficient painkillers. If pain relief cannot be achieved despite adequate drug therapy, radiotherapy or local blockade of a nerve plexus (coeliac plexus) can be attempted.

If a recurrence (recurrence of the tumour in the former tumour area) occurs, treatment should be repeated, whereby the limitations of the treatment described also apply here.