Diagnosis

Patients generally present in three ways:

  • Incidental finding during cholecystectomy
  • Incidental finding during workup for cholecystectomy
  • Advanced disease

History

Presenting Complaint

Patients often have symptoms similar to cholecystitis - right upper quadrant pain. Advanced cases may present complaining of jaundice and weight loss.

Past History

A history of cholelithiasis or repeated episodes of cholecystitis may be present. Most patients have gallstones found during operation.
It is important to determine the patient's operability - patients without cystectomy have a < 1% 5 year survival.


Examination

General assessment of health (operability).
Abdominal examination to evaluate hepatomegaly, signs of liver failure (jaundice, ascites, splenomegaly).


Bloods

Bloods are either consistent with biliary obstruction or normal. There are no screening bloods available.


Imaging

Ultrasound may be able to visualise a mass within the gallbladder or biliary obstruction, but is operator dependent.
CT provides evaluation of regional nodes as well as local invasion if given with contrast.
MRI with MRCP provides evaluation of the biliary tree as well as the extent of the local disease.
ERCP remains a useful tool in patients with jaundice as it may allow stenting at the time of the procedure to relieve biliary obstruction.


Histological Diagnosis

Fine-needle aspiration may be unsuccessful due to the dense stroma associated with cholangiocarcinoma. Incisional biopsy is advised against as there is a risk of tumour spillage and seeding.


Pre-operative Evaluation

Evaluation of occult peritoneal or intra-abdominal spread with staging laparoscopy is often recommended as it avoids a laparotomy for patients with unresectable and incurable disease.


Staging

Staging is through TNM.

T Stage

T1a: Invasion into submucosa
T1b: Invasion into muscular wall
T2: Invasion outside gallbladder
T3: Invasion through the serosa, into the liver, or other adjacent organ
T4: Invasion of hepatic artery/portal vein, or two adjacent organs (excluding the liver).

N Stage

N1: Cystic, portal or hepatic artery nodes
N2: Coeliac, pancreatic or para-aortic nodes

M Stage

M1: Distant metastases

Overall Stage

  • Stage 0 is in situ disease - 80% 5 year survival
  • Stage I is T1 disease - 50% 5 year survival
  • Stage II is T2 disease - 30% 5 year survival
  • Stage III is subdivided: - <10% 5 year survival
    • IIIA is T3 with no nodes
    • IIIB is T1-3 with N1 nodes
  • Stage IV is subdivided - < 5% 5 year survival
    • IVA is T4 with N0 or N1 disease
    • IVB is N2 or M1 disease

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