How is bile duct cancer diagnosed?

Procedures that make pictures of the bile ducts and the nearby area help diagnose bile duct cancer (cholangiocarcinoma) and show how far the cancer has spread. The process used to find out if cancer cells have spread within and around the bile ducts or to distant parts of the body is called staging.

In order to plan treatment, it is important to know if the bile duct cancer can be removed by surgery. Tests and procedures to detect, diagnose, and stage bile duct cancer are usually done at the same time. Every person will not receive all the tests described below.

The following tests and procedures may be used:

• Physical exam and health history: A physical exam of the body will be done to check a person's health, including checking for signs of disease, such as lumps or anything else that seems unusual. A history of the person's health habits and past illnesses and treatments will also be taken.
• Liver function tests: During this procedure a blood sample is checked to measure the amounts of bilirubin and alkaline phosphatase released into the blood by the liver. A higher than normal amount of these substances can be a sign of liver disease that may be caused by bile duct cancer.
• Laboratory tests: These medical tests use samples of tissue, blood, urine, or other substances in the body in order to help diagnose disease, plan and check treatment, or monitor the disease over time.
• Carcinoembryonic antigen (CEA) and CA 19-9 tumor marker test: Tumor markers are released into the blood by organs, tissues, or tumor cells in the body. Increased levels of CEA and CA 19-9 may be a sign of bile duct cancer.
• Ultrasound exam: This procedure uses high-energy sound waves (ultrasound) that are bounced off internal tissues or organs, such as the abdomen, and make echoes. The echoes form a picture of body tissues called a sonogram.
• CT scan (CAT scan): This procedure uses a computer linked to an x-ray machine to make a series of detailed pictures of areas inside the body, such as the abdomen, taken from different angles. A dye may be injected into a vein or swallowed to help the organs or tissues show up more clearly. This procedure is also called computed tomography, computerized tomography, or computerized axial tomography.
• Magnetic resonance imaging (MRI): This procedure uses a magnet, radio waves, and a computer to make a series of detailed pictures of areas inside the body.
• Magnetic resonance cholangiopancreatography (MRCP): This procedure uses a magnet, radio waves, and a computer to make a series of detailed pictures of areas inside the body such as the liver, bile ducts, gallbladder, pancreas, and pancreatic duct.

Different procedures may be used to obtain a sample of tissue and diagnose bile duct cancer. Cells and tissues are removed during a biopsy so they can be viewed under a microscope by a pathologist to check for signs of cancer. The type of procedure used depends on whether the person is well enough to have surgery.

Types of biopsy procedures include:

• Laparoscopy: This surgical procedure is done to look at the organs inside the abdomen, such as the bile ducts and liver, to check for signs of cancer. Small incisions (cuts) are made in the wall of the abdomen and a laparoscope (a thin, lighted tube) is inserted into one of the incisions. Other instruments may be inserted through the same or other incisions to perform procedures such as taking tissue samples to be checked for signs of cancer.
• Percutaneous transhepatic cholangiography (PTC): This procedure is used to x-ray the liver and bile ducts. A thin needle is inserted through the skin below the ribs and into the liver. Dye is injected into the liver or bile ducts and an x-ray is taken. A sample of tissue is removed and checked for signs of cancer. If the bile duct is blocked, a thin, flexible tube called a stent may be left in the liver to drain bile into the small intestine or a collection bag outside the body. This procedure may be used when a person cannot have surgery.
• Endoscopic retrograde cholangiopancreatography (ERCP): This procedure is used to x-ray the ducts (tubes) that carry bile from the liver to the gallbladder and from the gallbladder to the small intestine. Sometimes bile duct cancer causes these ducts to narrow and block or slow the flow of bile, causing jaundice. An endoscope (thin, tube-like instrument with a light and a lens for viewing) is passed through the mouth and stomach and into the small intestine. Dye is injected through the endoscope into the bile ducts and an x-ray is taken. A sample of tissue is removed and checked for signs of cancer. If the bile duct is blocked, a thin tube may be inserted into the duct to unblock it. This tube (or stent) may be left in place to keep the duct open. This procedure may be used when a person cannot have surgery.
• Endoscopic ultrasound (EUS): During this procedure an endoscope is inserted into the body, usually through the mouth or rectum. A probe at the end of the endoscope is used to bounce high-energy sound waves (ultrasound) off internal tissues or organs and make echoes. The echoes form a picture of body tissues called a sonogram. A sample of tissue is removed and checked for signs of cancer. This procedure is also called endosonography. 

What affects bile duct cancer prognosis?

Once bile duct cancer has been diagnosed, the prognosis (chance of recovery) and treatment options depend on:

• whether the cancer is in the upper or lower part of the bile duct system
• the stage of the cancer (whether it affects only the bile ducts or has spread to the liver, lymph nodes, or other places in the body)
• whether the cancer has spread to nearby nerves or veins
• whether the cancer can be completely removed by surgery
• whether the person has other conditions, such as primary sclerosing cholangitis
• whether the level of CA 19-9 is higher than normal
• whether the cancer has just been diagnosed or has recurred (come back)

Treatment options may also depend on the symptoms caused by the cancer. Bile duct cancer is usually found after it has spread and can rarely be completely removed by surgery. Palliative therapy may relieve symptoms and improve the person's quality of life.