Endoscopy has always been an indispensable tool in the modern management of hepatic cancers such as cholangiocarcinoma (CCA). It is important in helping physicians arrive at an accurate diagnosis of CCA, especially when patients present with nonspecific complaints, such as jaundice and constitutional symptoms.
Joe Geraghty from the Department of Gastroenterology at the Manchester Royal Infirmary in the UK has written an excellent piece on current perspectives on the role of endoscopy in the management of CCA. We will explore his work, as well as others, to better understand the evolving role of endoscopy in CCA management.
A New Way Of Seeing
CCA is extremely rare: it affects approximately 1 per 100,000 persons in the United States. However, the incidence rate has been rising. Worryingly, patients tend to present late due to the often vague and varied constellation of symptoms they experience; this means many patients have unresectable disease by the time they seek a doctor and thus have a poor prognosis.
Read more about CCA etiology
Gaddam and Coté wrote an editorial published in Gastrointestinal Endoscopy arguing for the role of “endoscopic oncologists” in the multidisciplinary management of CCA. They provided a summary of the important role of endoscopic retrograde cholangiopancreatography (ERCP) in the diagnosis and management of CCA: “The majority (60%-70%) of CCA originates in the perihilar region and requires referral to a center having expertise in ERCP and interventional radiology because of the intricacies in achieving a definitive diagnosis and durable biliary drainage.”
In my personal experience working in a busy hospital in Borneo, diagnostic ERCPs are conducted fast and furious to deal with the overwhelming number of patients that present with possible pancreato-hepatic cancers. When conducted in the hands of a seasoned expert, ERCP provides excellent visualization of tumors, and biopsies can be extracted and sent to the lab for immediate analysis. Further surgical decisions can then be made with accuracy and haste.
Determining Treatment Goals
When it comes to the use of ERCP in the management of CCAs, Geraghty wrote that it is important for surgeons to first ask themselves what the overall goal of treatment is: is it curative resection, or the long-term palliation of symptoms? Granted, this can be a difficult decision to make, hence the importance of multidisciplinary discussions. Geraghty recommended that routine biliary drainage should generally be avoided before staging and assessment of resectability are completed.
“In palliative cases, endoscopic approaches are superior to surgical drainage in terms of improved survival (19 vs 16 months) and reduced morbidity and overall costs,” Geraghty wrote.
The Bismuth classification of CCAs can also provide valuable insight on the appropriateness of ERCP as a management tool. In Bismuth types 1 and 2, ERCP is generally the correct approach, with percutaneous trans-hepatic cholangiography and drainage (PTCD) being the backup if endoscopic drainage fails. In patients with Bismuth type 2 CCA, the appropriateness of ERCP depends on stricture anatomy, especially the angulation of the duct in the part that requires drainage. For unresectable Bismuth type 4 CCAs, evidence suggests that PTCD may be superior to ERCP. “Overall, for most cases, an ERCP first approach seems appropriate,” Geraghty wrote.
As for stents, they can be installed through 3 approaches:
- Endoscopic ultrasound-guided stent delivery
Stents can be installed within a single obstructed lobar segment or bilaterally, depending on the Bismuth classification. There is ongoing debate on the best type of stents to be used (metal or plastic), as well as how they should be installed.
Geraghty quoted a study in which unilateral opacification was compared to drainage with bilateral in Bismuth 2 CCA patients. The results indicated there was a quicker decrease in bilirubin with bilateral drainage, but this method was associated with a greater risk of long-term problems such as stent migrating and clogging; however, there was no difference in 12-month survival between the methods.
Benefits of a Multidisciplinary Approach
Beyond the use of ERCP in CCA management, Gaddam and Coté emphasized the important role of systemic chemotherapy in the management of CCA: “Systemic chemotherapy prolongs life, albeit modestly, for patients with resectable, unresectable, and metastatic extrahepatic CCA.” Hence, oncologists have an important role in working with hepatobiliary surgeons to come up with the best individualized management plan for the patient.
Read more about CCA treatment
“In addition, the role of the gastroenterologist as an endoscopic oncologist is epitomized by the importance of successful and sustained biliary drainage in this patient population,” they wrote.
In other words, a multidisciplinary approach, involving input from oncologists, radiologists, hepatobiliary surgeons, gastroenterologists, and nutritionists give patients with CCA the best chance of holistic care. In addition, future clinical trials should ideally be designed in a multidisciplinary setting as well. When it comes to an aggressive cancer like CCA, in which prognosis is already known to be poor, nothing should be left to chance.
Geraghty J. Endoscopic considerations for the management of cholangiocarcinoma. Liver Cancer Int. Published online November 5, 2021. doi:10.1002/lci2.40
Gaddam S, Coté GA. The importance of the “endoscopic oncologist” in the treatment of nonoperable cholangiocarcinoma. Gastrointest Endosc. 2020;92(6):1213-1215. doi:10.1016/j.gie.2020.06.013