How Can Cholangiocarcinoma Be Treated by Surgery and Radiotherapy?

This is the fourth part of our series about the condition based on our patient booklet “Fast Facts for Patient and Supporters: Cholangiocarcinoma”. This article deals with the treatment of cholangiocarcinoma by means of surgery and radiotherapy.

Surgery

To attempt to cure cholangiocarcinoma, the complete tumor and a surrounding area of normal tissue need to be removed. A surgical oncologist, liver transplant surgeon or hepatobiliary surgeon should evaluate you when you are diagnosed to assess whether surgery is likely to be successful.

For intrahepatic cholangiocarcinoma, a piece of the liver (a wedge or lobe) is removed, sometimes with nearby lymph nodes.

Before this surgery, you may need a portal vein embolization to increase the size of the remaining part of your liver. This involves stopping the blood flow to the portion of the liver that will be removed to encourage the remaining liver to grow.

For extrahepatic cholangiocarcinoma, the bile duct, gallbladder, the surrounding piece of liver and nearby lymph nodes will be removed. The bile duct will be re-attached to the small intestine.

If the tumor is in the lower (distal) part of the bile duct, the lower part of the bile duct and nearby lymph nodes will be removed together with a piece of your pancreas and small intestine (a Whipple procedure). The remaining bile duct will be re-attached to the small intestine.

Ask your doctor to show you the areas that will be removed on this illustration.

Liver transplant is sometimes used in certain patients with extrahepatic cholangiocarcinoma when surgical resection is not possible. These transplants are typically done in specialized cancer centers and should only be considered after careful discussion with your care team.

Radiation Therapy

If your tumor is potentially curable but large or close to important structures such as blood vessels, radiation therapy may be used as neoadjuvant therapy to decrease the tumor size or move it away from other structures. This can increase the chances that surgery will be successful.

Radiation can also be used as adjuvant therapy if all the cancer cells were not removed by surgery or if the tumor is extrahepatic.

Medication may be given by mouth or by vein to help increase the chances that the radiation will kill the cancer cells – this is called radiosensitization. These medications are typically given at a low dose.

If your tumor remains localized to the primary site, and surgery is not an option, radiation can be used to give long-term control of tumor growth.

Finally, if your tumor has spread and one area is causing pain, radiation can be used to shrink that mass to help control that pain.

Radiation can be delivered to the cancer by:

external beams
radioembolization, in which radioactive beads are injected into arteries in the liver
brachytherapy, which involves inserting radioactive seeds directly into the tumor

External Beam

The radiation dose and schedule depend on the size and location of your tumor. Markers are placed on your skin or in the tumor itself to help direct the beam.

You may have therapy every day for a time. You may also have low-dose chemotherapy at the same time, to help make the radiation more effective; this is called sensitizing chemotherapy.

Stereotactic body radiotherapy (SBRT) involves delivering a high dose of radiation precisely to the tumor. It is usually given over a shorter time than traditional external beam radiotherapy and without any sensitizing chemotherapy.

Radioembolization

Radioembolization delivers radioactive glass beads directly into the arteries that supply blood to the tumor. X-rays are used to guide the placement of the catheter that delivers the beads.

There is usually a planning stage that involves mapping the blood supply to the tumor. In the treatment stage, the radioactive beads are delivered to the tumor.

Brachytherapy

Brachytherapy involves implanting radioactive seeds into the tumor. It is typically used for tumors in the region where the right and left hepatic ducts meet (a perihilar tumor), usually when a tumor cannot be fully removed by surgery.