Biliary Cancer Metastatic

Biliary cancer metastatic, also known as metastatic cholangiocarcinoma, occurs when cancer cells that began in the bile ducts have spread to distant parts of the body. Most people with bile duct cancer are diagnosed when the disease has already advanced beyond the bile ducts, making treatment more challenging.

Table of contents

• What Is Metastatic Bile Duct Cancer?
• How Bile Duct Cancer Spreads
• Signs and Symptoms
• Getting a Diagnosis
• Treatment Options
• Managing Symptoms and Quality of Life
• What to Expect

What Is Metastatic Bile Duct Cancer?

Bile duct cancer, also called cholangiocarcinoma, is a rare condition where cancer cells grow in your bile ducts. These ducts are small tubes that carry bile, a fluid that helps your body break down fats during digestion. The ducts connect your liver, gallbladder, and small intestine^[1].

Cancer is considered metastatic when it has spread to distant regions of your body, far from where it started. Unfortunately, most people with bile duct cancer already have advanced cancer when they are diagnosed. This is because bile duct cancer usually doesn’t cause symptoms early on, and when it does, they can be vague and difficult to spot^[6].

Bile duct cancer can be divided into different types based on where it starts. Intrahepatic bile duct cancer forms inside your liver. Extrahepatic bile duct cancer forms outside your liver and is the more common type. This includes cancer in the area where ducts leave the liver (called perihilar or Klatskin tumor) and cancer in the ducts farther from the liver near your small intestine (called distal bile duct cancer)^[2].

How Bile Duct Cancer Spreads

Advanced bile duct cancer means the cancer has spread either outside the bile ducts into nearby tissues and organs, or to another part of the body such as the lungs. When cancer spreads to other parts of the body, it is also called secondary cancer^[6].

Bile duct cancers tend to spread locally along the bile ducts into nearby structures. The cancer might spread into the liver, small intestine, pancreas, or nearby major blood vessels^[6]. The most common places for bile duct cancer to spread to distant areas are^[6]:

• The lining of the abdomen (called the peritoneum)
• The liver, in areas further away from the bile ducts
• Lymph nodes away from the bile ducts
• Lungs
• Bones
• Brain
• Skin

Cancer cells can spread through the bloodstream or through the lymphatic system, which is a network of vessels and nodes that helps fight infection^[10].

Signs and Symptoms

Cholangiocarcinoma symptoms don’t usually start until the cancer advances and blocks a bile duct. Signs that you may have bile duct cancer can include^[1][2]:

• Skin or eyes with a yellow cast, called jaundice
• Dark urine
• Clay-colored or light-colored bowel movements
• Belly pain, which may be concentrated in the right side of your abdomen, underneath your ribs
• Fever
• Itchy skin
• Nausea and vomiting
• Weight loss without trying
• Fatigue

Cholangiocarcinoma isn’t usually painful in the early stages. But a large tumor can cause pain that may shift to other regions in your abdomen or back. This type of pain is common in many conditions, not just bile duct cancer. It’s important to see a healthcare provider to determine what’s causing unusual abdominal pain^[2].

Getting a Diagnosis

Unlike some other cancers, there’s no routine screening you can have to detect bile duct cancer^[1]. If you have symptoms of bile duct cancer, your doctor will take several steps to make a diagnosis. That will start with taking your health history and a physical exam.

Tests you might have include^[1]:

• Liver function tests, to see whether this organ is producing high levels of substances that indicate a problem
• Ultrasound exam, which bounces sound waves off your body to produce images of your organs and other tissue
• Magnetic resonance imaging (MRI), which uses a magnet and radio waves to produce images of the inside of your body
• Blood tests to check for a protein called CA 19-9, which can be elevated in bile duct cancer (though it can also be high in other bile duct diseases)
• Endoscopic procedures to examine your bile duct with a small camera
• Biopsy to obtain a sample of tissue for examination under a microscope

Doctors also need to determine the stage of the cancer, which describes how far it has spread. In stage IV 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^[4].

Treatment Options

Deciding which treatment to have, or whether to have treatment at all, can be difficult. Unfortunately, treatment for advanced bile duct cancer may affect your quality of life. It is important to understand what the aim of treatment is and what the side effects are^[6].

Surgery is the only potential cure for bile duct cancer. If you can’t have surgery, or if the cancer comes back after the operation, the aim of treatment is to control the symptoms and improve your quality of life^[6]. Advanced bile duct cancer is unlikely to be cured^[18].

Treatment for advanced bile duct cancer usually involves^[6][12]:

Chemotherapy uses anti-cancer drugs to destroy cancer cells. You normally have a combination of chemotherapy drugs as your first treatment for advanced bile duct cancer. You might have them with an immunotherapy drug. Immunotherapy uses your immune system to attack cancer cells^[6].

Targeted therapy drugs can slow cancer growth if the bile duct cancer has certain gene changes (called mutations). People with advanced bile duct cancer have the cancer checked for gene changes. If the cancer has a gene change, targeted drugs or immunotherapy may be options. You may have them if the first chemotherapy treatment doesn’t work^[6].

Radiation therapy uses high-energy x-rays to treat cancer cells. Some people might have radiotherapy to help control the symptoms of bile duct cancer^[6][12].

Palliative procedures may be done to relieve symptoms caused by a blocked bile duct and improve quality of life. These can include placing a stent (a thin, flexible tube) to drain bile that has built up, or surgery to create a new pathway around the blocked area^[12].

Managing Symptoms and Quality of Life

Patients with advanced bile duct cancer have reduced health-related quality of life due to both tumor- and treatment-related symptoms. It is important for doctors to recognize and manage these symptoms early^[24].

End-of-life care for patients with stage 4 bile duct cancer centers on enhancing comfort, controlling symptoms, and maintaining emotional well-being^[23]. Important aspects of care include:

Pain and symptom management: Making sure the patient is comfortable and pain-free is one of the most important elements. Healthcare workers offer medications, therapies, and techniques meant to reduce pain, nausea, and other symptoms^[23].

Nutritional support: Patients may lose their appetite as the disease advances. Nutritionists can offer advice to help patients maintain their strength and energy^[1][23].

Emotional and psychological support: A terminal diagnosis can bring great emotional strain. Support through counselors, social workers, and spiritual advisers can help patients come to terms with their illness. Family members also need support during this difficult time^[1][23].

Many people find it helpful to find out more about the cancer and the treatments they might have. Knowing more about your situation can make it easier to cope. You might want to talk about the cancer but find it hard to do. Everyone copes with a cancer diagnosis differently. There is no right or wrong way. You should do whatever you feel is right for you^[18].

What to Expect

Cholangiocarcinoma is an aggressive cancer, which means it spreads fast. Most people receive a cholangiocarcinoma diagnosis after it’s already spread outside of their bile ducts. At this point, bile duct cancer is difficult to treat, and the chance of recovery is usually poor^[2].

Five-year survival rates are currently less than 5% for unresectable disease (cancer that cannot be removed with surgery)^[7]. Prognosis is typically dismal for patients with bile duct cancer. As bile duct cancers are generally without symptoms in early stages, 60–85% of patients present with disease that has spread or cannot be removed^[24].

Experts are continually researching and developing new treatments that can slow cancer spread and improve outcomes associated with cholangiocarcinoma. Clinical trials to improve the outcomes of cholangiocarcinoma are ongoing^[2].

You are likely to feel a range of powerful emotions if you are diagnosed with advanced bile duct cancer. You might feel confused, angry, fearful, or sad. There can be a lot of uncertainty that is very difficult to deal with. Some families want to discuss what’s happening and others don’t. Specialist nurses can help if you’re finding it difficult to cope or if you have any problems. Support groups and counseling services are also available^[18].