Diagnosing biliary cancer, also known as cholangiocarcinoma, involves a comprehensive approach that includes a combination of medical history review, physical examinations, imaging studies, laboratory tests, and biopsy procedures. Here’s an overview of how medical professionals diagnose biliary cancer:

1. Medical History and Physical Examination: The diagnostic process typically begins with a detailed medical history and a thorough physical examination. The doctor will inquire about symptoms such as jaundice, abdominal pain, weight loss, and other related signs. They will also review any risk factors, such as a history of liver disease, chronic biliary tract inflammation, or a family history of cancer. During the physical examination, the doctor will look for signs of jaundice, liver enlargement, or tenderness in the abdomen.

2. Imaging Studies: Imaging studies play a critical role in diagnosing biliary cancer. Ultrasound is often the initial imaging test used to assess the bile ducts and liver. More advanced imaging techniques, such as computed tomography (CT) scans and magnetic resonance imaging (MRI), provide detailed images of the bile ducts, liver, and surrounding structures. These imaging tests help to identify tumours, determine their size and location, and assess whether the cancer has spread to other parts of the body. Magnetic resonance cholangiopancreatography (MRCP) is a specialised MRI technique that provides detailed images of the bile ducts and pancreatic ducts, aiding in the diagnosis of bile duct obstructions and tumours.

3. Endoscopic Procedures: Endoscopic procedures such as endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) are commonly used to diagnose biliary cancer. ERCP involves inserting an endoscope through the mouth, oesophagus, and stomach into the small intestine to reach the bile ducts. A contrast dye is injected into the bile ducts, and X-ray images are taken to visualise the ducts and detect abnormalities. EUS combines endoscopy and ultrasound to obtain high-resolution images of the bile ducts and surrounding tissues, allowing for precise visualisation and guided biopsies.

4. Biopsy: A biopsy is the definitive method for diagnosing biliary cancer. During a biopsy, a tissue sample is obtained from the suspected tumour and examined under a microscope by a pathologist. Biopsy samples can be obtained through various methods, including ERCP, EUS-guided fine needle aspiration (FNA), or percutaneous (through the skin) needle biopsy. The biopsy results provide information on the type and grade of cancer, which is essential for planning treatment.

5. Laboratory Tests: Laboratory tests are also important in the diagnosis of biliary cancer. Blood tests may include liver function tests to assess liver health and levels of bilirubin, alkaline phosphatase, and other enzymes that may be elevated in biliary obstruction or cancer. Tumour markers such as CA 19-9 and CEA (carcinoembryonic antigen) can be measured in the blood, although they are not specific for biliary cancer and are used in conjunction with other diagnostic tests.

6. Multidisciplinary Consultation: Once biliary cancer is suspected or diagnosed, a multidisciplinary team of specialists, including gastroenterologists, oncologists, radiologists, pathologists, and surgeons, collaborate to review the diagnostic findings and develop a comprehensive treatment plan. This team-based approach ensures that all aspects of the patient’s condition are considered, and the most appropriate and personalised treatment strategy is formulated.

1. Surgery: Surgery is often the primary treatment for biliary cancer if the tumour is localised and resectable. The goal of surgery is to remove the cancerous tissue along with a margin of healthy tissue to ensure complete excision. Surgical procedures vary depending on the tumour’s location:

• Intrahepatic Cholangiocarcinoma:This occurs within the liver and may require partial hepatectomy, where a portion of the liver containing the tumour is removed.
• Perihilar Cholangiocarcinoma (Klatskin Tumours):These occur at the junction where the left and right bile ducts join and often involve complex surgeries that may include bile duct resection, partial liver resection, and reconstruction of the bile ducts.
• Distal Cholangiocarcinoma:This occurs further down the bile ducts near the pancreas and is often treated with a pancreaticoduodenectomy (Whipple procedure), which involves removing the bile duct, part of the pancreas, and parts of the small intestine and stomach.

2. Chemotherapy: Chemotherapy uses drugs to kill cancer cells or inhibit their growth and is often used in conjunction with surgery or as the main treatment for advanced biliary cancer. Commonly used chemotherapy drugs include gemcitabine and cisplatin. Chemotherapy can be administered before surgery (neoadjuvant chemotherapy) to shrink tumours and make them more operable, or after surgery (adjuvant chemotherapy) to eliminate any remaining cancer cells and reduce the risk of recurrence. In cases of advanced or metastatic biliary cancer, chemotherapy may help control the disease, alleviate symptoms, and improve quality of life.

3. Radiation Therapy: Radiation therapy uses high-energy rays to target and destroy cancer cells. It may be used alone or in combination with surgery and chemotherapy. External beam radiation therapy (EBRT) is the most common type of radiation therapy for biliary cancer . It is often used to shrink tumours before surgery, reduce the risk of recurrence after surgery, or alleviate symptoms in advanced stages. Stereotactic body radiation therapy (SBRT) is a more precise form of radiation that delivers higher doses to the tumour while minimising damage to surrounding healthy tissue.

4. Targeted Therapy: Targeted therapy drugs specifically target molecules or pathways involved in the growth and spread of cancer cells. For biliary cancer, targeted therapies may include drugs that inhibit specific genetic mutations or proteins that drive cancer growth. These therapies are often used in cases where the cancer has specific genetic markers that make it susceptible to targeted treatments.

5. Immunotherapy: Immunotherapy aims to enhance the body’s immune system to recognize and attack cancer cells. While still being studied, immunotherapy shows promise for treating biliary cancer, particularly in cases with certain biomarkers. Checkpoint inhibitors, which block proteins that prevent the immune system from attacking cancer cells, are among the immunotherapy drugs being explored.

6. Palliative Care: Palliative care focuses on relieving symptoms and improving quality of life for patients with advanced biliary cancer. This may involve pain management, nutritional support, and treatments to address bile duct obstructions, such as stent placement or biliary bypass surgery. Palliative care can be integrated with other treatments to ensure comprehensive support for the patient’s physical, emotional, and psychological needs.

A multidisciplinary team of medical professionals works together to provide the most effective and compassionate care, aiming to improve survival outcomes and enhance the quality of life for patients with biliary cancer.