Overview of Biliary Tract Cancers and Diagnosis

Transcript:
Laura W. Goff, MD: Welcome to this OncLive® Insights® titled “Treatment Updates in the Management of Biliary Tract Cancers.” I’m Dr Laura Goff from Vanderbilt University Medical Center in Nashville, Tennessee.

Milind Javle, MD: Welcome from me as well. I’m Milind Javle, a professor of medical oncology at [The University of Texas] MD Anderson Cancer Center in Houston, Texas.

Laura W. Goff, MD: I’m excited to have a conversation with you, Milind. I’m going to kick it off by having you give us an overview of the different types of biliary tract cancers.

Milind Javle, MD: Thank you, Laura. Biliary tract cancer is referred to colloquially as 1 entity, but there are 3 different cancers. There are cancers that arise in the small bile ducts above the bifurcation, which is intrahepatic cholangiocarcinoma. There’s the biliary tract cancer that occurs at the junction of the major hepatic ducts. This was [first] described by Dr [Gerald] Klatskin from Yale [School of Medicine], so some call it the Klatskin tumor, but it’s also referred to as perihilar cholangiocarcinoma. The bile duct below the bifurcation, all the way to the pancreas or the ampulla, is extrahepatic distal cholangiocarcinoma. Separate from that is gallbladder cancer, which is a different type of biliary cancer. Clearly all of these are grouped as biliary cancers, but they’re different in terms of epidemiology, clinical presentation, and sometimes treatment.

Laura W. Goff, MD: Can you speak to the relative incidence of each type and how patients do?

Milind Javle, MD: These cancers are described as rare in the Western world, but unfortunately they’re increasing. The number of [patients with] biliary tract cancer isn’t known because intrahepatic cholangiocarcinoma is often included in the term primary liver cancer. But we think the total number is between 12,000 and 15,000 new patients in the United States every year. Biliary cancer is largely a disease in Asia, where the incidence is much higher in some countries. Intrahepatic cholangiocarcinoma is often linked with fatty liver NASH [nonalcoholic steatohepatitis]. Unfortunately, because of changing lifestyles, that incidence is increasing. In terms of the relative proportion, 5000 are probably gallbladder cancer. Among the others, there’s a slight dominance of extrahepatic vs intrahepatic, a higher incidence of extrahepatic, but that ratio is reversing with increasing number of intrahepatic cholangiocarcinomas.

Laura, you see a lot of patients with biliary tract cancer at Vanderbilt. How do patients typically present in your clinic? What symptoms do they have before they are referred to you?

Laura W. Goff, MD: As you described, [biliary tract cancer] is an umbrella term. The most common subtype that we’re seeing is intrahepatic cholangiocarcinoma. Those will present as a primary liver mass, maybe with pain, sometimes with jaundice, depending on the location. Those hilar tumors will present with some degree of jaundice in the distals as well. Of course, with gallbladder cancer, we see a relatively high incidence in the United States and in Nashville. Gallbladder cancer often presents like a gallbladder attack—a painful right upper quadrant—and sometimes is discovered only after the gallbladder is removed.

Milind Javle, MD: One of the vexing issues in our field is that patients who present with, for instance, perihilar cholangiocarcinoma undergo a lot of work-up. A lot of time is spent before intrahepatic cholangiocarcinoma is diagnosed. Do you have any suggestions for community oncologists so that we can find these patients earlier? Unfortunately, most seem to be diagnosed at an advanced stage where curative therapies are less likely.

Laura W. Goff, MD: That’s a great point that the diagnosis of cholangiocarcinoma can be quite difficult to make. We know that it’s still critical to, if we can, get tissue on these patients whenever possible. Pursuing biopsy for any liver mass can help distinguish whether this is a primary hepatocellular carcinoma vs a primary intrahepatic cholangiocarcinoma. One takeaway for community oncologists or physicians is not to give up too early because it’s important to make this diagnosis.

Experienced endoscopists can be critical to the diagnosis through endoscopic ultrasound. Specialized techniques like SpyGlass can get up higher and to the biliary system to make the diagnosis. We also involve the multidisciplinary team, whether or not down-the-road liver transplant may be considered. [There are] a lot of considerations in the early stages of making this diagnosis.

Milind Javle, MD: I try to talk to my fellows about looking at the literature on this topic by Dr Klatskin. He said the only way to definitively make this diagnosis is surgical resection and removing of the perihilar ducts. Because that’s not possible, we have to make a clinical diagnosis based on radiology and blood- and tissue-based biomarkers. Do you agree with that?

Laura W. Goff, MD: I do. In the case of hilar cholangiocarcinoma, especially hilar cholangiocarcinoma being considered for liver transplantation, that’s often a clinical diagnosis using brushings and FISH [fluorescence in situ hybridization] testing, as well as the overall imaging characteristics. We can make our best educated guess about the pathology if we can’t get at the tissue. At times we’re using circulating tumor DNA, which can also provide more circumstantial evidence that this is cholangiocarcinoma with some characteristic molecular alterations. It can point us in that direction, as can CA [cancer antigen] 19-9 [testing]. All those things can stack up to point you in the direction of the diagnosis.

Transcript edited for clarity.