Cholangiocarcinoma Guidelines

Updated: Jun 23, 2017
  • Author: Peter E Darwin, MD; Chief Editor: N Joseph Espat, MD, MS, FACS  more...
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Guidelines

Guidelines Summary

Guidelines Contributor:   Elwyn C Cabebe, MD Physician Partner, Valley Medical Oncology Consultants; Medical Director of Oncology, Clinical Liason Physician, Cancer Care Committee, Good Samaritan Hospital

Diagnosis

The National Comprehensive Cancer Network (NCCN) recommends early surgical consultation with a multi-disciplinary team as part of the initial workup for suspected intrahepatic cholangiocarcinoma. Direct visualization of the bile duct with directed biopsy is ideal. Additional recommendations for diagnostic testing include the following [33] :

  • Liver function tests
  • Consider carcinoembryonic antigen (CEA) and CA 19-9 testing
  • Delayed contrast-enhanced CT/MRI when extrahepatic cholangiocarcinoma is suspected; CT/MRI also helpful in determining tumor resectability in intrahepatic tumors
  • Esophagogastroduodenoscopy and colonoscopy, in patients with intrahepatic cholangiocarcinoma, to assess for T3 disease and rule out endobiliary metastasis from colorectal cancer mimicking intrahepatic cholangiocarcinoma [34]

Guidelines from the American Society for Gastrointestinal Endoscopy (ASGE) recommend magnetic resonance cholangiography (MRCP) to assess for resectability if a CT scan suggests cholangiocarcinoma. ERCP is recommended to obtain tissue or facilitate further evaluation of indeterminate strictures. [35]

Staging

Cholangiocarcinoma cancer staging follows the tumor-node-metastasis (TNM) classification of the American Joint Cancer Committee/Union for International Cancer Control/ (AJCC/UICC) and is staged separately for intrahepatic, perihilar, and distal bile duct tumors. [36]

TNM groupings by stage are as follows for each group: [36]

Table. 1 (Open Table in a new window)

Intrahepatic bile duct tumor
Stage T N M
0 Tis N0 M0
I T1 N0 M0
II T2 N0 M0
III T3 N0 M0
IVA T4 N0 M0
  Any T N1 M0
IVB Any T Any N M1

Table. 2 (Open Table in a new window)

Perihilar bile duct tumor
Stage T N M
0 Tis N0 M0
I T1 N0 M0
II T2a-b N0 M0
IIIA T3 N0 M0
IIIB T1-3 N1 M0
IVA T4 N0-1 M0
IVB Any T N2 M0
  Any T Any N M1

Table. 3 (Open Table in a new window)

Distal bile duct tumor
Stage T N M
0 Tis N0 M0
IA T1 N0 M0
IB T2 N0 M0
IIA T3 N0 M0
IIB T1 N1 M0
  T2 N1 M0
  T3 N1 M0
III T4 Any N M0
IV Any T Any N M1

Treatment

The NCCN and ESMO guidelines concur that the only potentially curative treatment for cholangiocarcinoma is complete surgical resection with negative margins. However, few patients are diagnosed with early-stage resectable tumors. [33, 37]

For intrahepatic cholangiocarcinomas that are resected with microscopic margins or extrahepatic cholangiocarcinomas that are resected with negative margins and negative regional nodes, the NCCN recommends fluoropyrimidine chemoradiation, or fluoropyrimidine-based or gemcitabine-based chemotherapy.

For intrahepatic resections with residual local disease, gemcitabine/cisplatin combination therapy is a category 1 recommendation by the NCCN. Enrollment in clinical trials, and fluoropyrimidine-based or gemcitabine-based chemotherapy are also options. [33]

For extrahepatic resections with positive margins, residual disease or positive regional nodes, the NCCN recommends fluoropyrimidine chemoradiation followed by fluoropyrimidine-based or gemcitabine-based chemotherapy. For positive regional nodes, fluoropyrimidine-based or gemcitabine-based chemotherapy is also an option.

For management of patients with unresectable or metastatic disease, NCCN makes the following recommendations [33] :

  • Gemcitabine/cisplatin combination therapy (category 1)
  • Enrollment in clinical trial
  • Fluoropyrimidine or gemcitabine chemotherapy
  • Fluoropyrimidine chemoradiation Locoregional therapy
  • Supportive care