Bile Duct Cancer Treatment
If you’ve been diagnosed with bile duct cancer, your care team will discuss your options with you. Treatment options are determined by several factors, including:
- Where the cancer is located and its extent
- Whether the cancer is removable by surgery (resectable)
- Potential treatment side effects
- Your overall health
- The likelihood of curing the disease, extending your life, or relieving symptoms you may be experiencing
Treatment options for bile duct cancer may include:
Surgery for Bile Duct Cancer
Surgery offers the best chance for a cure, making it the preferred treatment approach for bile duct cancer. However, it can be challenging due to the location and sensitivity of the bile ducts, requiring a high level of expertise from a hepatobiliary surgeon.
There are two general types of surgery performed for bile duct cancer: potentially curative surgery for resectable cancer and palliative surgery for unresectable cancer. Surgery is more likely to be done for resectable bile duct cancers.
Treating Bile Duct Cancer With Potentially Curative Surgery
Resectable (potentially curative surgery) means that there's a good chance the surgeon can remove all of the cancer along with a margin of healthy tissue around it. Unfortunately, this is only possible in a small percentage of patients at the time of initial diagnosis.
If curative surgery is being planned, the hepatobiliary surgeon first needs to check if the cancer has spread to the point where surgery is not an option. This is often performed via laparoscopy. During the laparoscopy, the surgeon can look for areas of cancer that were not obvious on imaging tests. Laparoscopy can also help your surgeon plan the operation if the cancer is resectable.
Surgery for resectable bile duct cancers
Common surgical procedures for bile duct cancer include:
- Removal of the bile duct: This surgical procedure removes part of the bile duct if the tumor is small and contained within the bile duct. Lymph nodes are removed, and tissue from the lymph nodes is viewed under a microscope to determine if cancer is present.
- Partial hepatectomy: This surgical procedure involves removing the part of the liver where cancer is found. The part removed may be a wedge of tissue, an entire lobe, a larger part of the liver, and some normal tissue around it.
- Whipple procedure: During this procedure, the head of the pancreas, the gallbladder, part of the stomach, part of the small intestine, and the bile duct are removed. Enough of the pancreas is left to produce digestive juices and insulin.
- Liver transplant: In some cases, for individuals with early-stage, unresectable intrahepatic or perihilar bile duct cancers, it may be possible to remove the liver and bile ducts and then transplant a donor liver. The surgical procedure to remove the liver is called a total hepatectomy.
Palliative surgery for bile duct cancer
The following types of palliative surgery may be done to relieve symptoms caused by a blocked bile duct and improve quality of life:
- Biliary bypass: This procedure is performed if the cancer is obstructing the bile duct and causing bile to build up in the gallbladder. During the operation, the surgeon will cut the gallbladder or bile duct in the area before the blockage and connect it to the part of the bile duct that is past the blockage or to the small intestine. This creates a new pathway around the blocked area.
- Endoscopic stent placement: If the tumor is blocking the bile duct, a stent (a thin, flexible tube) may be inserted during surgery to drain the built-up bile. The stent may be placed through a catheter that drains the bile into a bag on the outside of the body, or around the blocked area to drain the bile into the small intestine.
Some patients may receive chemotherapy or radiation therapy after surgery to eliminate any remaining cancer cells. Treatment given after surgery to lower the risk of the cancer returning is called adjuvant therapy.
Radiation Therapy for Bile Duct Cancer
Radiation therapy uses high-energy doses of radiation to kill cancer cells. There are two main ways radiation therapy is administered to treat bile duct cancer:
External beam radiation therapy
This type of radiation therapy involves a machine outside the body sending radiation toward the area of the body with cancer. ERBT can be administered in a variety of ways, including:
- Three-dimensional conformal radiation therapy (3D-CRT) uses a technique that allows doctors to direct radiation beams to conform to the shape of the tumor.
- Intensity-modulated radiation therapy (IMRT) uses multiple radiation beams that conform to the tumor’s shape and adjusts the intensity of some of the beams to deliver radiation only to the targeted area. This helps to avoid or reduce damage to healthy tissues. Hypofractionated radiation therapy, which delivers a higher dose of radiation during each session over a shorter period of time, may be an option for some patients.
- Stereotactic body radiotherapy (SBRT) uses CT scan images and delivers a very high radiation dose with great precision, limiting damage to surrounding tissue. The advanced technology of SBRT allows for a shorter course of treatment compared to other radiation techniques.
Brachytherapy
Internal radiation therapy, commonly called brachytherapy, is a treatment method in which a radioactive source is placed into or near the bile duct. Some patients with bile duct cancer may receive intrabiliary brachytherapy, which is brachytherapy administered with a thin radioactive wire that's put into the bile duct for a short time. Typically, brachytherapy is used as a palliative treatment.
Radiation therapy can be given along with other treatments, including chemotherapy. The combination of these two treatments is referred to as chemoradiation.
While radiation therapy is not commonly used to treat bile duct cancer, it can be helpful in certain situations, including:
- After surgery to remove the cancer: This is known as adjuvant therapy and is used to eliminate any cancer cells left after surgery. It might also be used for bile duct cancer after surgery to reduce the chance of cancer returning.
- Before surgery for resectable (removable) cancers: Some doctors may use radiation therapy before surgery to shrink the tumor and make it easier to remove. This is called neoadjuvant therapy.
- As the main therapy for some advanced cancers: Radiation therapy can be used as the primary treatment for patients whose cancer has not spread widely but cannot be surgically removed. While this treatment does not offer a cure, it may help patients live longer.
- As palliative therapy: Radiation therapy might be offered to relieve symptoms in patients whose cancer is too advanced to be cured. Radiation can help shrink tumors that block bile ducts or blood vessels or press on nerves, resulting in less pain.
Targeted Therapy for Bile Duct Cancer
For individuals with bile duct cancer that has advanced or cannot be removed through surgery, targeted therapy may be recommended. Targeted therapy involves the use of drugs or other substances to identify and attack specific cancer cells. Since not all tumors of the same type or tissue origin have the same targets, your doctor may recommend biomarker testing to help predict your response to specific targeted therapy drugs.
The mutated genes associated with bile duct cancer and potential targeted therapies are:
- FGFR2: The fibroblast growth factor receptor is responsible for normal cell growth and division. Inhibitors targeting FGFR2 may be used to block the abnormal protein in bile duct cancer cells, preventing their growth and spread.
- IDH1: Mutations in the IDH1 gene lead to the production of abnormal IDH1 proteins, disrupting normal cell maturation. IDH1 inhibitors can block these abnormal proteins, helping cancer cells mature into more normal cells.
- NTRK: A small percentage of bile duct cancers have alterations in the NTRK gene, resulting in the production of abnormal TRK proteins. This can lead to abnormal cell growth and cancer. TRK inhibitors can be used to treat advanced bile duct cancer in such cases.
- RET: Changes in the RET gene can create a fusion protein that promotes tumor growth. RET inhibitors are used to treat advanced bile duct cancers with this gene alteration.
- BRAF: Mutations in the BRAF gene lead to the production of abnormal proteins that drive uncontrolled cell growth and bile duct cancer development. The combination of a BRAF inhibitor and a MEK inhibitor can be used to treat tumors with the BRAF V600E mutation.
- KRAS: The KRAS gene produces the K-RAS protein, which controls cell growth, replication, and differentiation. KRAS inhibitors are used to treat advanced bile duct cancer with the KRAS G12C mutation after other treatments have been used.
Immunotherapy to Treat Bile Duct Cancer
Immunotherapy uses medications to stimulate the body's immune system to identify and fight cancer cells more effectively. Currently, a type of drug known as checkpoint inhibitors is available as a treatment option for certain bile duct cancers. There are different types of checkpoint inhibitors:
- PD-1 inhibitors target PD-1, a checkpoint protein on immune system cells known as T cells. PD-1 normally prevents T cells from attacking other cells in the body, including some cancer cells. By blocking PD-1, this drug boosts the immune response against cancer cells. This can result in shrinking some tumors or slowing their growth.
- PD-L1 inhibitor targets PD-L1, a protein related to PD-1 found on some tumor cells and immune cells. Blocking this protein can help enhance the immune response against cancer cells. Chemotherapy may be used in combination with a PD-L1 inhibitor to treat unresectable or advanced bile duct cancer.
- CTLA-4 inhibitor blocks CTLA-4, which is another protein on T cells that normally prevents overactivity.
Immunotherapy drugs are administered through intravenous (IV) infusion, usually once every 3 or 6 weeks.
Chemotherapy for Cancers of the Bile Duct
Chemotherapy is used to kill cancer cells, whether they are in the primary location or in other areas of the body. While it is not typically a standard treatment for bile duct cancer, it may be used in combination with other cancer treatments in the following ways:
- After surgery (adjuvant) to reduce the chance of recurrence
- Before surgery (neoadjuvant) to shrink the tumor
- During the liver treatment process to manage the cancer while the patient waits for a transplant
- To control advanced cancer that has spread
- To relieve symptoms caused by cancer (palliative care)
The number of treatment cycles and how long the rest period lasts depend on the anticancer drugs used and the patient’s response.
Chemo for bile duct cancer can be administered in two ways:
- Hepatic artery infusion (HAI) involves administering the drugs directly into the hepatic artery, which supplies most bile duct tumors. By putting the chemo into this artery, the drug's impact on the rest of the body is reduced, ultimately lessening chemo side effects.
- Trans-arterial chemoembolization (TACE) uses a catheter to administer beads of chemo into the artery that "feeds" the tumor. The beads become lodged there, blocking blood flow while releasing the chemo.
Clinical Trials for Bile Duct Cancer
Clinical trials play an important role in enhancing treatment options for cancer patients, including those with bile duct cancer. Your oncologist will discuss whether there is a suitable trial available for you. Participation in a clinical trial is completely voluntary, and patients may stop at any time. If you would like more information, you may speak to your oncologist about the available clinical trials at Compass Oncology.Bile Duct Cancer Palliative Care
Palliative care is not meant to cure cancer, but rather to manage symptoms caused by the disease. Medications may be given to reduce pain or control nausea to improve your comfort.
Some examples of procedures that may be used as part of palliative care for bile duct cancer include:
- Stent placement or biliary catheter to keep a blocked bile duct open.
- Biliary bypass to connect a part of the bile duct before the blockage with a part of the duct that lies past the blockage.
- Destroying the tumor (ablation) with a heated (radiofrequency ablation) or frozen (cryosurgery) probe inserted near the tumor, or with an injection of an alcohol solution (alcohol ablation).
- Photodynamic therapy (PDT), which involves injecting a light-activated drug into a vein. An endoscope with a special laser light activates the drug to kill cancer cells.
Additionally, chemotherapy and radiation are other palliative options that may be recommended. Your cancer care team will discuss the advantages and disadvantages of the palliative treatment options and which might benefit you the most.
The Latest Bile Duct Treatment Options in Portland-Vancouver
Compass Oncology offers the latest treatments and specialists in bile duct cancer, including surgeons, at all of our cancer centers in the region. We also provide second opinions to ensure you feel confident about your diagnosis and recommended bile duct cancer treatment plan. Choose one of our Portland area locations to request a consultation.
