Cholangiocarcinoma: risk factors, diagnosis and management

Cholangiocarcinomas are malignant tumors of the intra- or extrahepatic biliary tract. An increasing incidence of cholangiocarcinomas has been documented. This increase might be only apparent, due to the progress in investigation and changes in tumor codification. The major clinical sign of cholangiocarcinomas is obstructive jaundice, which is persistent and progressive. Biological tumor markers are nonspecific: an increased serum level of carcinoembryonic antigen is relevant when associated with an increased level of CA 19-9 or CA-125. K-ras mutation and aberrant expression of p53 are present in one third of intrahepatic cholangiocarcinomas. The firstline imaging investigation is ultrasonography, which always detects dilatation of the bile ducts, but more rarely the tumor itself. Classically, endoscopic retrograde cholangiopancreatography (ERCP), the "gold standard" investigation in case of obstructive jaundice, has been performed following ultrasonography. The actual recommendations, based on grade B and C evidences, are to start investigations with ultrasonography and to continue with noninvasive methods: MRI/MRCP or spiral CT, whenever a malignant obstructive jaundice is suspected. Invasive cholangiography (ERCP, PTC) should be reserved for tissue diagnosis or therapeutic decompression when cholangitis is present, or for stent insertion in unresectable tumors. If MRI, CT or cholangiography do not exclude resectability, hepatic arteriography and portal vein evaluation should be performed preoperatively. All patients who do not have unequivocal cholangiographic and angiographic signs of unresectability should undergo surgery, in order to benefit of a possible tumor resection. The radical surgical procedures relieve the obstruction and jaundice by resecting the tumor. The palliative (surgical or endoscopic) procedures cure the jaundice, but do not remove the tumor. Prognosis of cholangiocarcinomas is dismal, although five-year survival rates for these tumors have improved due progress in surgery and adjuvant oncological therapy.