Surgical oncologist Michael I. D'Angelica cares for patients with benign and malignant (cancerous) diseases of the liver, bile ducts, gallbladder, and pancreas.
Depending on the stage of the disease and the patient’s health, the treatment team will determine the most appropriate therapy, including surgery, chemotherapy, biologic therapy, and radiation therapy. Surgery is the preferred treatment for gallbladder and bile duct cancer, and offers the best chance for a cure. Additional treatments are available for patients who are not eligible for surgery.
Cholecystectomy — a procedure that involves surgical removal of the gallbladder, regional lymph nodes, and some of the tissues surrounding the organ — is the most effective treatment for localized gallbladder tumors. Part of the liver also may be removed if doctors suspect the tumor has spread (metastasized). A laparoscope is sometimes used to guide liver surgery, but not to remove the gallbladder, as the laparoscope can spread cancer cells to nearby tissue.
Bile Duct Surgery
As with gallbladder cancer, surgery to remove the bile duct and regional lymph nodes using traditional, open techniques is the most effective treatment for localized tumors. Minimally invasive surgery (laparoscopy) is not generally used for bile duct surgery.
Additional surgery may be required if the cancer has spread to the liver or other organs and tissues.
This procedure involves removing a wedge of liver tissue, an entire lobe, or a larger part of the liver, plus a safety margin (extra portion) of normal tissue surrounding the diseased part of the liver. This surgical approach is often used to treat large bile duct tumors that are found inside the liver (intrahepatic peripheral tumors). In some cases, techniques such as portal vein embolization, which redirects the blood supply to the healthy portion of the liver to stimulate cell growth, may be used to make patients who were previously considered ineligible for surgery able to tolerate partial hepatectomy.
The Whipple Procedure
This procedure (also known as a pancreatoduodenectomy) involves removing the gallbladder, part of the stomach, part of the small intestine, the bile duct, and the head (right-most section) of the pancreas, which allows for the production of insulin and digestive enzymes. The Whipple procedure is commonly used to treat extrahepatic bile duct tumors. Also known as distal tumors, these are found closer to the pancreas. For more information about the Whipple operation, visit the Pancreatic Cancer section of the Web site.
Minimally Invasive Symptom Relief
Although surgery is the most effective therapy for gallbladder and bile duct cancer, many patients are not candidates for surgery by the time their cancer is detected. Some patients may benefit from minimally invasive, image-guided procedures that allow bile to drain out of the gallbladder or a bile duct that is blocked by a tumor. These procedures are not curative, but can relieve symptoms caused by a blocked bile duct such as jaundice, itching, nausea, vomiting, and infection.
This procedure involves sewing the gallbladder or bile duct directly to the small intestine to create a new pathway around tumors that are blocking the flow of bile from the gallbladder.
A small drainage tube, called a stent, can be used to relieve a blocked bile duct. The stent allows bile to flow across the blockage to the small intestine. When possible, the stent is placed through an endoscope (a thin, tube-like instrument inserted through the mouth). When endoscopy cannot be performed, the stent can be placed percutaneously (with a needle) through the liver. During this procedure a bile duct within the liver is punctured with a small needle, and imaging is used to identify the obstruction and place a stent or drainage catheter though the blockage. In some patients a catheter remains in place for a period of time, and bile may drain into a bag during this time.
Many patients with bile duct or gallbladder cancer are diagnosed with disease too advanced to be treated surgically. Pain is a frequent and debilitating symptom for these patients. Although the exact reason remains poorly understood, it is thought that the pain may be caused by cancer cells that invade a cluster of nerves near the liver known as the celiac plexus. Patients who have inadequate pain relief with conventional analgesics may benefit from a procedure called neurolytic celiac plexus block (NCPB), in which a local anesthetic is injected into the celiac plexus to disrupt pain signals. NCPB has been shown to reduce pain significantly and improve mood and life expectancy for patients with advanced bile duct or gallbladder cancer.
Most cancer centers perform NCPB percutaneously (through the skin) under x-ray guidance, an approach that is associated with side effects such as muscle and limb weakness. Doctors at Memorial Sloan Kettering, however, have demonstrated that NCPB can be performed with a laparoscope — a thin, lighted tube with a camera at its tip that is inserted through small incisions in the abdomen. This procedure can be performed during laparoscopic staging — a 20-minute diagnostic technique that allows surgeons to obtain a detailed view of the gallbladder, liver, and celiac plexus. Laparoscopic NCPB may provide similar or better pain relief than percutaneous NCPB in reducing pain, with fewer potential side effects.
NCPB also can be performed under the guidance of endoscopic ultrasound (EUS), in which a small probe is inserted through the mouth and into the stomach to obtain a detailed view of the celiac plexus. During this procedure, a local anesthetic can be injected directly into the celiac plexus. As with the laparoscopic approach, endoscopic NCPB may be at least as effective as the percutaneous approach, with fewer potential side effects.
Multimodal Therapy for Advanced Gallbladder and Bile Duct
Even after successful surgery or other treatments, gallbladder and bile duct cancer can spread (metastasize). Some patients may benefit from additional (adjuvant) therapies, including treatment with systemic therapies such as chemotherapy and/or biologic therapy, radiation therapy, or other forms of treatment used alone or in combination. Embolization (blockage of blood flow to the tumor) of the hepatic artery can also be used to treat intrahepatic bile duct cancer.
Several chemotherapeutic regimens and techniques have been shown to shrink gallbladder and bile duct tumors and possibly improve survival.
The standard of care for gallbladder and bile duct cancers is gemcitabine plus platinum-based chemotherapy, which has recently shown to improve survival of patients with these cancers. (1) Our team is currently working on incorporating biologic therapy within this regimen. Biologic therapy refers to a host of new drugs that stop tumor cells from replicating and/or disrupt a tumor’s blood supply. Sorafenib is a new biologic therapy that is currently under evaluation at Memorial Sloan Kettering in combination with gemcitabine plus cisplatin for gallbladder and bile duct cancers.
Researchers are evaluating the potential of a new chemotherapy technique called HAI in the treatment of gallbladder and bile duct cancer. HAI, which has been shown to extend survival in patients with liver cancer, involves delivering a high dose of chemotherapy drugs directly to the liver through a tiny pump implanted under the skin in the lower abdomen. Additional chemotherapy medicine is injected into the pump, as needed, on an outpatient basis. HAI therapy may be used to shrink tumors before surgery or, after surgery, to prevent recurrence.
Radiation therapy is another treatment option for patients whose tumors cannot be surgically removed. Radiation may be administered alone or in combination with chemotherapy or other treatments.
External beam radiation, used alone or in combination with a radiosensitizer (a drug that makes the tissue more sensitive to radiation), is the most common type of radiotherapy used to treat gallbladder and bile duct cancer. Radiation may be administered in the area where the gallbladder once lay or in the nearby lymph nodes to destroy tumor cells that may remain following surgery. Radiation also is occasionally used to shrink a tumor, either to increase the chance that it may be surgically removed or to relieve symptoms.
Image-guided radiation therapy (IGRT) and respiratory gating are two approaches that have the potential to reduce toxicity (damage) to normal tissue during radiation therapy for bile duct cancer and, less commonly, gallbladder cancer.
IGRT targets tumors with greater precision than conventional radiation therapy. Using highly sophisticated computer software and 3-D images from CT scans, the radiation oncologist can develop an individualized treatment plan that delivers high doses of radiation to cancerous tissue while sparing surrounding organs and reducing the risk of injury to healthy tissue.
Because tumors and organs in the abdomen shift during breathing, precise delivery of radiation therapy to cancerous tissue can be difficult. Respiratory gating is the delivery of radiation only at certain points during a patient’s breathing cycle, when the “mobile” tumors and/or regions of the abdomen are in a specific position. This approach decreases the radiation dose to the surrounding healthy tissue.
At Memorial Sloan Kettering, our investigators are constantly evaluating new chemotherapy combinations and novel medications that may improve the standard of care for patients with gallbladder and bile duct cancer. In addition, our researchers are studying several novel biologic compounds.