Gallbladder cancer and bile duct cancer

What are gallbladder cancer and bile duct cancer?

Cancers of the gallbladder and bile duct are comparatively very rare types of cancer. Gallbladder cancer is a malignant tumor that forms in the gallbladder. It originates in the mucous membrane of the gallbladder. It is located in the immediate vicinity of the liver and intestines. The gallbladder develops from a protrusion of the bile duct and looks like a small sac. It stores the bile that the liver produces. The bile enters the duodenum via the bile duct, where it helps to digest fat. Gallbladder cancer is also known medically as gallbladder carcinoma.

In bile duct cancer, on the other hand, the malignant tumor develops from the cells of the bile ducts. This type of cancer is also known medically as cholangiocarcinoma or cholangiocellular carcinoma. A special form of bile duct cancer is the so-called Klatskin tumor. It occurs at the point where the two bile ducts coming from the liver meet.

Gallbladder cancer and bile duct cancer – frequency and age

Gallbladder cancer and bile duct cancer are extremely rare compared to other types of cancer such as breast cancer, prostate cancer, bowel cancer or lung cancer. Only around 330 people in Switzerland are diagnosed with one of these two types of cancer each year. Overall, they account for less than one percent of all cancers in Switzerland.

Women are affected slightly more often than men: 55 percent compared to 45 percent. Gallbladder cancer occurs almost exclusively in older people. Two thirds of all women and men are 70 or older when they are diagnosed with cancer.

Both types of cancer are very dangerous

Both types of cancer often cause no symptoms for a long time and therefore remain undetected. They are therefore often more advanced at the time of diagnosis. Small tumors at an early stage can often be cured by surgery. In the case of advanced cancer in the gallbladder or bile ducts, chemotherapy or radiotherapy or a combination of both can sometimes help. Both types of cancer are very dangerous. They tend to spread quickly to other organs and form metastases (metastases) there, for example in the liver or pancreas. The prospects of recovery are then rather unfavorable. However, the progression of the cancer can often be slowed down by palliative treatment.

Gallbladder cancer and bile duct cancer: causes and risk factors

The causes of gallbladder cancer and bile duct cancer are still largely unknown. However, there appear to be some risk factors that increase the likelihood of these cancers. These include, for example, some other diseases such as chronic inflammation of the bile ducts or gallbladder.

Gallbladder cancer – risk factors

• Age over 50 and female gender
• Very large gallstones: Many people with gallbladder cancer also have gallstones. However, the reverse is not true: very few people with gallstones develop gallbladder cancer.
• Chronic inflammation of the gallbladder: The wall of the gallbladder can calcify due to the permanent inflammation. A so-called porcelain gall bladder develops, which is considered a precancerous condition.
• Benign polyps in the gallbladder

Bile duct cancer – risk factors

• Chronic inflammation of the bile ducts – the technical term is primary sclerosing cholangitis (PSC)
• Permanent bile duct stones
• Benign tumors or cysts in the bile duct
• Chronic infections with parasites in the bile ducts, such as liver flukes or sucking worms
• Smoking appears to be a risk factor for cholangiocarcinoma outside the liver.
• Existing diseases: Chronic hepatitis B or C, HIV infection, liver cirrhosis, diabetes mellitus and chronic inflammatory bowel disease (Crohn’s disease, ulcerative colitis) appear to increase the risk of cholangiocarcinoma in the liver.

General risk factors

• Certain chemicals such as nitrosamines
• Alcohol abuse
• Overweight and obesity (adiposity)

Symptoms: Gallbladder cancer and bile duct cancer

Gallbladder cancer and bile duct cancer usually cause no symptoms at first. Many people therefore do not realize the imminent danger posed by these organs. Later, the symptoms are so uncharacteristic that they can also indicate many other diseases.

Doctors usually only find tumors in the gallbladder or bile ducts when they are already well advanced. The first sign is often that the bile can no longer drain into the duodenum due to the tumor and accumulates in the liver.

These warning signs indicate a bile blockage:

• The urine turns dark in color.
• Jaundice – the skin and conjunctiva of the eyes turn yellow.
• The stool becomes discolored.
• The skin is often extremely itchy.
• Abdominal pain, mostly in the upper abdomen
• Loss of appetite and weight loss
• Nausea and vomiting

Always consult your doctor quickly if you experience such symptoms. The symptoms may indicate gallbladder or bile duct cancer, but do not necessarily have to. They also occur in other benign diseases of the bile ducts, such as gallstones or liver inflammation. Nevertheless, the earlier we discover a cancer, the easier it is to treat and the better the chances of recovery.

Gallbladder cancer and bile duct cancer – how we proceed with the diagnosis

We always start by asking you about your medical history in an anamnesis interview. For example, the following questions are important:

• What complaints do you have, for example abdominal pain?
• How long have the symptoms been present and how pronounced are they?
• Do you have any known diseases of the gallbladder or bile ducts or other diseases? e.g. stones, inflammation, hepatitis, infections?
• Do you smoke? If yes: Since when and how much?

These and other questions help us to make an initial assessment of the possible causes of the complaints.

This is followed by a physical examination. We palpate the abdomen and feel the size and position of organs. An enlarged gallbladder and sometimes the tumor itself can often be felt from the outside. The signs of jaundice are easily recognizable by the yellow discoloration of the skin and eyes.

The blood test also provides important indications of gallbladder or bile duct cancer. Elevated liver values are particularly revealing when bile builds up in the liver: gamma-GT, alkaline phosphatase and bilirubin. In addition, laboratory doctors often determine the cancer antigen 19-9 (Ca 19-9) or the carcinoembryonic antigen (CEA).

Cancer diagnosis using imaging techniques

Imaging examinations show whether gallbladder cancer or bile duct cancer is actually present and where exactly it is located. They also provide an indication of how far the tumor has already spread. The following procedures are used:

• Ultrasound examination (sonography) of the abdomen: This method uses sound waves that are emitted and received by a transducer. We can then see the images on a monitor. Changes in the gallbladder and bile ducts can thus be visualized. Sometimes we also use a special ultrasound examination, intraductal endosonography (IDUS). It works with a very small ultrasound probe. This allows us to determine the spread of the tumor directly in the bile duct.
• Computed tomography: This examination uses X-rays and provides high-resolution cross-sectional images of the inside of the body.
• Magnetic resonance imaging (MRI or magnetic resonance imaging): It works with strong magnetic fields and images the body “slice by slice” – this produces detailed cross-sectional images on which tumors and metastases can be easily identified. In particular, MRI also allows detailed visualization of the bile ducts.
• X-ray examination of the chest to detect any metastases in the lungs.
• Positron emission tomography/CT (PET/CT): PET/CT shows particularly metabolically active areas, for example metastases. We usually use the radioactively labeled sugar “18F-FDG” as the radioactive substance.
• Endoscopic retrograde cholangiography (ERC): This method is suitable for detecting cancer in the bile ducts. We carefully push a flexible tube with a small camera (endoscope) through the esophagus and stomach into the duodenum. We then inject a contrast agent and take an X-ray. At the same time, tissue samples (biopsies) can be taken from suspicious areas during ERC. A pathologist then analyzes them under a microscope.
• Percutaneous transhepatic cholangiography (PTC): This involves inserting a needle through the skin into a bile duct in the liver and injecting a contrast agent into the bile ducts. This is followed by an X-ray. This allows us to see whether there is a tumor in the gallbladder or the bile ducts.

Sometimes we find cancer in the gallbladder or bile ducts by chance, for example during gallstone surgery and removal of the gallbladder.

Gallbladder cancer and bile duct cancer: prevention, early detection, prognosis

You cannot really prevent gallbladder cancer or bile duct cancer. The most important advice is therefore to consult your doctor as soon as possible if you have any complaints. Sometimes we are able to detect tumors in the gallbladder or bile ducts at a small, early stage. There are also no targeted measures for the early detection of either type of cancer – this is different for breast or bowel cancer, for example.

Gallbladder cancer and bile duct cancer – progression and prognosis

The chances of recovery from cancer always depend on the size, aggressiveness and spread of the tumor. In many cases, however, we only find malignant tumors in the gallbladder or bile ducts when they are already more advanced. In addition, both have the ability to spread early to the liver, pancreas or intestine and form metastases there. The course and prognosis are therefore rather unfavorable. Only a few survive the first five years after diagnosis.

People in whom we find the cancer by chance often have a better prognosis, for example because they remove existing gallstones and the gallbladder. In these cases, the tumor is often still small and has not yet metastasized to other organs. The cancer is then often still curable.

The prognosis is somewhat better for a Klatskin tumor. It usually develops more slowly and, due to its location (at the bifurcation of the two bile ducts coming out of the liver), causes early bile stasis – this is the symptom by which we often recognize the cancer.

Aftercare and rehab

Aftercare is important for every cancer. We treat the effects of cancer and cancer therapies. We also monitor the physical and mental condition of our patients. It is also important to detect a return of the cancer (relapse, recurrence) as early as possible. Because this risk of relapse is greatest in the first few years after diagnosis, check-ups are initially carried out very closely every three months. After that, the time intervals become longer and longer.

Rehabilitation can also help cancer patients to cope better with the disease, both physically and emotionally. It also empowers those affected and in many cases improves their quality of life.

Gallbladder cancer and bile duct cancer: Possible treatments

The treatment of gallbladder cancer and bile duct cancer is always based on several pillars. Surgery, chemotherapy and radiation. We usually combine several cancer treatments in order to increase their effectiveness.

A complete cure can only be achieved by surgery if we succeed in completely eliminating the tumor. However, it is often so advanced at the time of diagnosis that it can no longer be removed by surgery. If metastases have also formed, gallbladder cancer and bile duct cancer are no longer curable. Palliative treatment then helps. It aims to slow down the progression of the tumor, alleviate symptoms, prolong life and maintain a good quality of life for as long as possible.