Treatment

Resection:

• surgery with curative intent must guarantee the complete excision of the tumour with negative margins. Potentially curative resection may include aggressive surgery (partial hepatectomy)
  • prognosis is strongly related to radical surgery and complete resection is the most effective therapy; the location within the biliary tree (proximal versus distal) has no impact on survival when a complete resection is achieved despite the fact the rate of resectability is up to 70% in case of distal cancer and 15-20% for high bile ducts tumours

Palliation:

• surgical:
  • bypass - e.g. anastomosis of jejunum to third segment duct in left lobe to bypass hilar cholangiocarcinoma
  • intubation of stricture with trans-hepatic tubes
• stents placed across the stricture by ERCP or PTC; may become blocked or infected, and require replacement

Of little proven value:

• internal and external beam radiotherapy
  • prognosis of cholangiocarcinoma remains poor even with aggressive surgical therapy because of the high incidence of local or regional recurrence and distant metastasis. The main purpose of adjuvant radiotherapy is to sterilize the surgical margins and reduce local failure
• chemotherapy
  • evidence of systemic chemotherapy in cholangiocarcinoma is limited because it is essentially based on small phase I/II trials performed in variable patient groups, which may also include patients with gallbladder cancer
• hepatic transplantation - high rate of recurrence of tumour
  • liver transplantation as a primary treatment for hilar and intrahepatic cholangiocarcinoma is controversial because of the limited organ availability and the high recurrence rate of the tumour (peritoneal spread, or distant metastases)
    • results of liver transplantation for cholangiocarcinoma in 207 patients:
      • 2- and 5-year-survival rates were 48% and 23%, but >50% of patients had a recurrence within 2 years, with a median time from transplantation to recurrence of 9 months and a median time between recurrence and death of 2 months

Reference:

• 1. P.F. Saldinger and L.H. Blumgart. Resection of hilar cholangiocarcinoma - a European and United States experience. J Hepatobiliary Pancreat Surg 2000;7: 111-114.
• 2. C.G. Meyer, I. Penn and L. James. Liver transplantation for cholangiocarcinoma: results in 207 patients. Transplantation 2000;69:1633-1637.