Editing Cholangiocarcinoma (section)

==Diagnosis==
[[File:Cholangiocarcinoma - high mag.jpg|thumb|right|[[Micrograph]] of an intrahepatic, i.e. in the liver, cholangiocarcinoma (right of image); benign [[hepatocyte]]s are seen (left of image).  Histologically, this is a cholangiocarcinoma as (1) atypical bile duct-like cells (left of image) extend from the tumor in an interlobular septum (the normal anatomical location of bile ducts), and (2) the tumor has the abundant desmoplastic stroma often seen in cholangiocarcinomas.  A [[portal triad]] (upper-left of image) has a [[histologically]] normal [[bile duct]]. [[H&E stain]].]]

===Blood tests===
There are no specific [[blood test]]s that can diagnose cholangiocarcinoma by themselves. Serum levels of [[carcinoembryonic antigen]] (CEA) and [[CA19-9]] are often elevated, but are not [[sensitivity (tests)|sensitive]] or [[specificity (tests)|specific]] enough to be used as a general [[screening (medicine)|screening]] tool. They may be useful in conjunction with [[medical imaging|imaging methods]] in supporting a suspected diagnosis of cholangiocarcinoma.<ref>Studies of the performance of serum markers for cholangiocarcinoma (such as carcinoembryonic antigen and CA19-9) in patients with and without primary sclerosing cholangitis include the following:
* {{cite journal | vauthors = Nehls O, Gregor M, Klump B | title = Serum and bile markers for cholangiocarcinoma | journal = Seminars in Liver Disease | volume = 24 | issue = 2 | pages = 139–54 | date = May 2004 | pmid = 15192787 | doi = 10.1055/s-2004-828891 | s2cid = 260316851 }}
* {{cite journal | vauthors = Siqueira E, Schoen RE, Silverman W, Martin J, Rabinovitz M, Weissfeld JL, Abu-Elmaagd K, Madariaga JR, Slivka A, Martini J | display-authors = 6 | title = Detecting cholangiocarcinoma in patients with primary sclerosing cholangitis | journal = Gastrointestinal Endoscopy | volume = 56 | issue = 1 | pages = 40–7 | date = July 2002 | pmid = 12085033 | doi = 10.1067/mge.2002.125105 }}
* {{cite journal | vauthors = Levy C, Lymp J, Angulo P, Gores GJ, Larusso N, Lindor KD | title = The value of serum CA 19-9 in predicting cholangiocarcinomas in patients with primary sclerosing cholangitis | journal = Digestive Diseases and Sciences | volume = 50 | issue = 9 | pages = 1734–40 | date = September 2005 | pmid = 16133981 | doi = 10.1007/s10620-005-2927-8 | s2cid = 24744509 }}
* {{cite journal | vauthors = Patel AH, Harnois DM, Klee GG, LaRusso NF, Gores GJ | title = The utility of CA 19-9 in the diagnoses of cholangiocarcinoma in patients without primary sclerosing cholangitis | journal = American Journal of Gastroenterology | volume = 95 | issue = 1 | pages = 204–7 | date = January 2000 | doi = 10.1111/j.1572-0241.2000.01685.x | pmid = 10638584 | s2cid = 11325616 }}</ref>

===Abdominal imaging===
[[File:CT cholangioca.jpg|right|thumb|[[Computed tomography|CT scan]] showing cholangiocarcinoma]]
[[Ultrasound]] of the [[liver]] and [[biliary tree]] is often used as the initial imaging modality in people with suspected obstructive jaundice.<ref>{{cite journal | vauthors = Saini S | title = Imaging of the hepatobiliary tract | journal = New England Journal of Medicine | volume = 336 | issue = 26 | pages = 1889–94 | date = June 1997 | pmid = 9197218 | doi = 10.1056/NEJM199706263362607 }}</ref><ref>{{cite journal | vauthors = Sharma MP, Ahuja V | title = Aetiological spectrum of obstructive jaundice and diagnostic ability of ultrasonography: a clinician's perspective | journal = Tropical Gastroenterology | volume = 20 | issue = 4 | pages = 167–9 | year = 1999 | pmid = 10769604 }}</ref> Ultrasound can identify obstruction and ductal dilatation and, in some cases, may be sufficient to diagnose cholangiocarcinoma.<ref>{{cite journal | vauthors = Bloom CM, Langer B, Wilson SR | title = Role of US in the detection, characterization, and staging of cholangiocarcinoma | journal = Radiographics | volume = 19 | issue = 5 | pages = 1199–218 | year = 1999 | pmid = 10489176 | doi = 10.1148/radiographics.19.5.g99se081199 | doi-access = free }}</ref> [[Computed tomography]] (CT) scanning may also play an important role in the diagnosis of cholangiocarcinoma.<ref>{{cite journal | vauthors = Valls C, Gumà A, Puig I, Sanchez A, Andía E, Serrano T, Figueras J | display-authors = 6 | title = Intrahepatic peripheral cholangiocarcinoma: CT evaluation | journal = Abdominal Imaging | volume = 25 | issue = 5 | pages = 490–6 | year = 2000 | pmid = 10931983 | doi = 10.1007/s002610000079 | s2cid = 12010522 }}</ref><ref>{{cite journal | vauthors = Tillich M, Mischinger HJ, Preisegger KH, Rabl H, Szolar DH | title = Multiphasic helical CT in diagnosis and staging of hilar cholangiocarcinoma | journal = AJR. American Journal of Roentgenology | volume = 171 | issue = 3 | pages = 651–8 | date = September 1998 | pmid = 9725291 | doi = 10.2214/ajr.171.3.9725291 }}</ref><ref>{{cite journal | vauthors = Zhang Y, Uchida M, Abe T, Nishimura H, Hayabuchi N, Nakashima Y | title = Intrahepatic peripheral cholangiocarcinoma: comparison of dynamic CT and dynamic MRI | journal = Journal of Computer Assisted Tomography | volume = 23 | issue = 5 | pages = 670–7 | year = 1999 | pmid = 10524843 | doi = 10.1097/00004728-199909000-00004 }}</ref>

===Imaging of the biliary tree===
[[File:ERCP cholangioca.jpg|thumb|right|[[Endoscopic retrograde cholangiopancreatography|ERCP]] image of cholangiocarcinoma, showing common bile duct stricture and dilation of the proximal common bile duct]]
While abdominal imaging can be useful in the diagnosis of cholangiocarcinoma, direct imaging of the [[bile duct]]s is often necessary. [[Endoscopic retrograde cholangiopancreatography]] (ERCP), an [[endoscopy|endoscopic]] procedure performed by a [[gastroenterologist]] or specially trained surgeon, has been widely used for this purpose. Although ERCP is an invasive procedure with attendant risks, its advantages include the ability to obtain [[biopsy|biopsies]] and to place [[stent]]s or perform other interventions to relieve biliary obstruction.<ref name="feldman2"/> [[Endoscopic ultrasound]] can also be performed at the time of ERCP and may increase the accuracy of the biopsy and yield information on [[lymph node]] invasion and operability.<ref>{{cite journal | vauthors = Sugiyama M, Hagi H, Atomi Y, Saito M | title = Diagnosis of portal venous invasion by pancreatobiliary carcinoma: value of endoscopic ultrasonography | journal = Abdominal Imaging | volume = 22 | issue = 4 | pages = 434–8 | year = 1997 | pmid = 9157867 | doi = 10.1007/s002619900227 | s2cid = 19988847 }}</ref> As an alternative to ERCP, [[percutaneous transhepatic cholangiography]] (PTC) may be utilized. [[Magnetic resonance cholangiopancreatography]] (MRCP) is a [[non-invasive]] alternative to ERCP.<ref>{{cite journal | vauthors = Schwartz LH, Coakley FV, Sun Y, Blumgart LH, Fong Y, Panicek DM | title = Neoplastic pancreaticobiliary duct obstruction: evaluation with breath-hold MR cholangiopancreatography | journal = AJR. American Journal of Roentgenology | volume = 170 | issue = 6 | pages = 1491–5 | date = June 1998 | pmid = 9609160 | doi = 10.2214/ajr.170.6.9609160 | doi-access = free }}</ref><ref>{{cite journal | vauthors = Zidi SH, Prat F, Le Guen O, Rondeau Y, Pelletier G | title = Performance characteristics of magnetic resonance cholangiography in the staging of malignant hilar strictures | journal = Gut | volume = 46 | issue = 1 | pages = 103–6 | date = January 2000 | pmid = 10601064 | pmc = 1727781 | doi = 10.1136/gut.46.1.103 }}</ref><ref>{{cite journal | vauthors = Lee MG, Park KB, Shin YM, Yoon HK, Sung KB, Kim MH, Lee SG, Kang EM | display-authors = 6 | title = Preoperative evaluation of hilar cholangiocarcinoma with contrast-enhanced three-dimensional fast imaging with steady-state precession magnetic resonance angiography: comparison with intraarterial digital subtraction angiography | journal = World Journal of Surgery | volume = 27 | issue = 3 | pages = 278–83 | date = March 2003 | pmid = 12607051 | doi = 10.1007/s00268-002-6701-1 | s2cid = 25092608 }}</ref> Some authors have suggested that MRCP should supplant ERCP in the diagnosis of biliary cancers, as it may more accurately define the tumor and avoids the risks of ERCP.<ref>{{cite journal | vauthors = Yeh TS, Jan YY, Tseng JH, Chiu CT, Chen TC, Hwang TL, Chen MF | display-authors = 6 | title = Malignant perihilar biliary obstruction: magnetic resonance cholangiopancreatographic findings | journal = American Journal of Gastroenterology | volume = 95 | issue = 2 | pages = 432–40 | date = February 2000 | doi = 10.1111/j.1572-0241.2000.01763.x | pmid = 10685746 | s2cid = 25350361 }}</ref><ref>{{cite journal | vauthors = Freeman ML, Sielaff TD | title = A modern approach to malignant hilar biliary obstruction | journal = Reviews in Gastroenterological Disorders | volume = 3 | issue = 4 | pages = 187–201 | year = 2003 | pmid = 14668691 }}</ref><ref>{{cite journal | vauthors = Szklaruk J, Tamm E, Charnsangavej C | title = Preoperative imaging of biliary tract cancers | journal = Surgical Oncology Clinics of North America | volume = 11 | issue = 4 | pages = 865–76 | date = October 2002 | pmid = 12607576 | doi = 10.1016/S1055-3207(02)00032-7 }}</ref>

===Surgery===
[[File:Cholangiocarcinoma.png|right|thumb|Photograph of cholangiocarcinoma in human liver.]]
[[Surgery|Surgical exploration]] may be necessary to obtain a suitable [[biopsy]] and to accurately [[cancer staging|stage]] a person with cholangiocarcinoma. [[Laparoscopy]] can be used for staging purposes and may avoid the need for a more invasive surgical procedure, such as [[laparotomy]], in some people.<ref>{{cite journal | vauthors = Weber SM, DeMatteo RP, Fong Y, Blumgart LH, Jarnagin WR | title = Staging laparoscopy in patients with extrahepatic biliary carcinoma. Analysis of 100 patients | journal = Annals of Surgery | volume = 235 | issue = 3 | pages = 392–9 | date = March 2002 | pmid = 11882761 | pmc = 1422445 | doi = 10.1097/00000658-200203000-00011 }}</ref><ref>{{cite journal | vauthors = Callery MP, Strasberg SM, Doherty GM, Soper NJ, Norton JA | title = Staging laparoscopy with laparoscopic ultrasonography: optimizing resectability in hepatobiliary and pancreatic malignancy | journal = Journal of the American College of Surgeons | volume = 185 | issue = 1 | pages = 33–9 | date = July 1997 | pmid = 9208958 | doi = 10.1016/s1072-7515(97)00003-3 }}</ref>

===Pathology===
[[File:Immunohistochemistry for CK19 in metastatic cholangiocarcinoma to the liver.jpg|thumb|[[Immunohistochemistry]] for [[CK19]] in metastatic cholangiocarcinoma to the liver. The positive staining supports the diagnosis, in contrast to a [[hepatocellular carcinoma]] which is typically CK19 negative.<ref>Image by 
Mikael Häggström, MD. Source for caption:<br>- {{cite web|url=https://www.pathologyoutlines.com/topic/stainsck19.html|title=Cytokeratin 19 (CK19, K19)|website=Pathology Outlines|author=Nat Pernick, M.D.}} Last author update: 1 October 2013</ref>]]
Histologically, cholangiocarcinomas are classically well to moderately differentiated [[adenocarcinoma]]s. [[Immunohistochemistry]] is useful in the diagnosis and may be used to help differentiate a cholangiocarcinoma from [[hepatocellular carcinoma]] and metastasis of other gastrointestinal tumors.<ref>{{cite journal | vauthors = Länger F, von Wasielewski R, Kreipe HH | title = [The importance of immunohistochemistry for the diagnosis of cholangiocarcinomas] | language = German | journal = Der Pathologe | volume = 27 | issue = 4 | pages = 244–50 | date = July 2006 | pmid = 16758167 | doi = 10.1007/s00292-006-0836-z | s2cid = 7571236 }}</ref> [[Cytopathology|Cytological scrapings]] are often nondiagnostic,<ref>Darwin PE, Kennedy A. {{EMedicine|med|343|Cholangiocarcinoma}}</ref> as these tumors typically have a [[desmoplasia|desmoplastic]] stroma and, therefore, do not release diagnostic tumor cells with scrapings.

===Staging===
Although there are at least three [[Cancer staging|staging systems]] for cholangiocarcinoma (e.g. those of Bismuth, Blumgart, and the [[American Joint Committee on Cancer]]), none have been shown to be useful in predicting survival.<ref>{{cite journal | vauthors = Zervos EE, Osborne D, Goldin SB, Villadolid DV, Thometz DP, Durkin A, Carey LC, Rosemurgy AS | display-authors = 6 | title = Stage does not predict survival after resection of hilar cholangiocarcinomas promoting an aggressive operative approach | journal = American Journal of Surgery | volume = 190 | issue = 5 | pages = 810–5 | date = November 2005 | pmid = 16226963 | doi = 10.1016/j.amjsurg.2005.07.025 }}</ref> The most important staging issue is whether the tumor can be [[Segmental resection|surgically removed]], or whether it is too advanced for surgical treatment to be successful. Often, this determination can only be made at the time of surgery.<ref name="feldman2"/>

General guidelines for operability include:<ref>{{cite journal | vauthors = Tsao JI, Nimura Y, Kamiya J, Hayakawa N, Kondo S, Nagino M, Miyachi M, Kanai M, Uesaka K, Oda K, Rossi RL, Braasch JW, Dugan JM | display-authors = 6 | title = Management of hilar cholangiocarcinoma: comparison of an American and a Japanese experience | journal = Annals of Surgery | volume = 232 | issue = 2 | pages = 166–74 | date = August 2000 | pmid = 10903592 | pmc = 1421125 | doi = 10.1097/00000658-200008000-00003 }}</ref><ref>{{cite journal | vauthors = Rajagopalan V, Daines WP, Grossbard ML, Kozuch P | title = Gallbladder and biliary tract carcinoma: A comprehensive update, Part 1 | journal = Oncology | volume = 18 | issue = 7 | pages = 889–96 | date = June 2004 | pmid = 15255172 }}</ref>
* Absence of [[lymph node]] or [[liver]] [[Metastasis|metastases]]
* Absence of involvement of the [[portal vein]]
* Absence of direct invasion of adjacent organs
* Absence of widespread metastatic disease