An Overview on Biliary Tract Cancers

Opening their discussion on biliary tract cancers, a multidisciplinary panel of experts consider how specific subsets of these malignancies differ from one another.


Milind Javle, MD: Hello, and welcome to this OncLive® Peer Exchange® titled “The Evolving Landscape of Biliary Tract Cancers.” I’m Milind Javle. I’m a professor in the department of gastrointestinal [GI] medical oncology at The University of Texas MD Anderson Cancer Center. I’m privileged to have an experienced panel with me. Joining me in this discussion are my colleagues Dr Aiwu Ruth He from Georgetown University MedStar Health, Dr Anjana Pillai from the University of Chicago Medicine, Dr Flavio G. Rocha from Oregon Health & Science University, and Dr Mark Yarchoan from Johns Hopkins Medicine. Would you all please introduce yourselves briefly? Let me start with you, Dr He.

Aiwu Ruth He, MD: Thanks for having me. I’m Ruth He. I’m a GI medical oncologist working at [MedStar] Georgetown University Hospital in Washington, DC, with a research focus on hepatobiliary cancer.

Milind Javle, MD: Dr Pillai?

Anjana Pillai, MD: Hi, thank you for having me. I am Anjana Pillai. I’m an associate professor of medicine at the University of Chicago [in Chicago, Illinois]. I am a hepatologist, which slightly different from what everyone else does. But I direct our liver tumor program, and we see a number of patients with both HCC [hepatocellular carcinoma] and bile duct cancer. That’s my clinical and research focus.

Milind Javle, MD: Dr Rocha?

Flavio G. Rocha, MD, FACS, FSSO: Hello. My name is Flavio Rocha. I’m a professor of surgery and the division head of surgical oncology at Oregon Health & Science University [in Portland, Oregon]. I serve as the physician in chief of the Knight Cancer Institute as well. I’m a surgical oncologist by training and a hepatobiliary surgeon. I’m happy to be here with this esteemed group.

Milind Javle, MD: Dr Yarchoan?

Mark Yarchoan, MD: Hi, my name is Mark Yarchoan. I’m a medical oncologist at Johns Hopkins, focusing on hepatobiliary tumors. I lead a research laboratory focused on immunotherapy for liver cancers. It’s a pleasure to be here.

Milind Javle, MD: Wonderful. Welcome, and thank you for joining us. I’m very excited to discuss this topic, which has seen a lot of changes, particularly over the last 4 to 5 years. We’ve divided our discussion into several modules. We’ll first discuss the landscape of biliary tract cancer. We’ll be discussing staging, some of the newer therapies, targeted approaches, and then finally there will be an open discussion.

Let’s start with the landscape of biliary tract cancer. Biliary tract cancer is often referred to as 1 entity, but it seems to be diverse anatomically, perhaps pathologically. Flavio, could you clarify what types of malignancies are included in this definition? How are these cancers similar or different?

Flavio G. Rocha, MD, FACS, FSSO: That’s a great place to start, Milind. Biliary tract cancers become a catchall phrase for anything that involves biliary epithelium. The biliary epithelium starts in the liver with the small bile ducts and then coalescences the major hepatic ducts down to the common bile duct and all the way into the head of the pancreas. It’s a long geographic spread. The gallbladder, as you know, is an outpouching that’s connected to the biliary tree. They get lumped together in a lot of studies and trials, but they’re very different biologic entities. When you have the intrahepatic cholangiocarcinoma with the ones in the bile duct, they’re presenting as liver masses. The operation to remove them is to do a liver resection, for example. Contrast that with hilar cholangiocarcinomas, which are usually lumped in as extrahepatic cholangiocarcinomas. Those are typically 1 of the more challenging operations that we need to do with surgeons because they involve not only a liver resection but also a bile duct resection. The proximity to the portal vessels also sometimes require a vascular resection reconstruction.

Gallbladder cancers are even their own entity because they’re mostly diagnosed incidentally after a cholecystectomy for suspected benign disease, which comes back with cancer and pathology and then typically requires resection. The distal cholangiocarcinomas, which are also considered extrahepatic cholangiocarcinomas, are often hard to diagnose preoperatively and sometimes get mixed with pancreatic cancer because the operation to remove them is a Whipple procedure, which is the same for pancreatic cancer. They’re also different biologically in the way they present in their patterns of recurrence. I’ll let my colleagues weigh in on some of the molecular differences as well.

Milind Javle, MD: Thank you, Flavio. That was very insightful. I have to say that in my practice, patients often get confused. Do I have a bile duct cancer or cholangiocarcinoma? Do I have gall bladder cancer? Do I have Klatskin tumor, extrahepatic cholangiocarcinoma, or perihilar cholangiocarcinoma? Anjana, what approach do you use to educate them about the differences and this colloquialism, which are often confusing, not just to patients but sometimes to providers?

Anjana Pillai, MD: That’s such an important question. You’re absolutely right. It’s not just patients. I feel like sometimes we get an incorrect diagnosis of maybe someone having intrahepatic, but it’s perihilar or hilar. We have a multidisciplinary clinic, so that means it’s myself, our surgeon, and 1 of our oncologists that are often available at the same time. We do a lot of our education through diagrams. We have a basic diagram of the liver, the bowel ducts, the gallbladder, and all the ducts, and then we draw and put the location. This is intrahepatic. This happens X amount of time. This is hilar, perihilar, and extrahepatic, just as Dr Rocha said. Then also explain if they have underlying liver disease, which is a good chunk of my practice—why that’s also important, and how that can affect their therapies.

Milind Javle, MD: Wonderful. This is very insightful because we realize that they’re grouped under 1 umbrella. However, they’re distinct. I wouldn’t call them disparate, but they’re distinct in terms of anatomy, in terms of surgical management and molecular pathology. I’ll ask Mark to give some input on that in a few minutes.

Transcript edited for clarity.

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