Biliary+Tract

Less common clinical features are [3]: Distal bile duct cancers, Perihilar (hilar) bile duct cancers, Intrahepatic bile duct cancers, Other Metastatic spread include GX Grade Cannot Be Assessed G1 Well Differentiated G3 Poorly Differentiated G4 Undifferentiated || 0 Tis N0 M0 **I** T1 N0 M0  **II** T2 N0 M0  **IIIA** T3 N0 M0  **IIIB** T1-T3 N1 M0  **IVA** T4 N0-1 M0  **IVB** Any T N2 M0 ||
 * **Epidemiolgy:** || Biliary tract cancer is a rare cancer in Europe and North America. There is a high incidence in Latin America and Asia. There are decreasing trends in mortality rates since the 1980s because of the frequency, and earlier use of cholecystectomy for gallstones (because the major risk for biliary cancer is gallstones).[1] ||
 * **Etiology:** || Some risk factors for biliary tract tumors are: [2]
 * Family history of congenital fibrosis or cysts
 * Parasitic infestations
 * Gallstones and hepatolithiasis
 * Primary sclerosing cholangitis (PSC)
 * Ulcerative colitis
 * Toxic materials
 * Drugs
 * Chronic typhoid carriers
 * Biliary cirrhosis ||
 * **Signs & Symptoms:** || More than 90% of patients present with jaundice. Jaundice usually occurs late in the course of the disease.
 * Pruritus
 * Fever
 * Mild abdominal pain
 * Fatigue
 * Anorexia
 * Weight loss
 * Cholangitis (not frequent, but develops commonly after cholangiography) ||
 * **Diagnostic Procedures:** || The initial radiographic evaluation consists of either an abdominal ultrasonography or computed tomography (CT) scan. If a bile duct dilation is documented, a cholangiography is performed either through percutaneous, transhepatic or endoscopic retrograde routes. Endoscopic retrograde cholangiopancreatography (ERCP), magnetic resonance cholangiopancreatography, MRI angiography, and conventional angiography can be done to evaluate vascular involvement. [3] ||
 * **Histology:** || More than 95% of bile duct cancers are adenocarcinomas having glandular cells origins. [4] Glandular cells are responsible for the production of mucus and fluids in ducts to move substances, in the case of bile ducts moving bile from the gall bladder to the intestines. Bile duct carcinomas can be divided into three groups
 * Furthest away from liver closest to small intestines.
 * Most common.
 * Form where duct leaving the liver converge.
 * Form in ducts with in the liver itself.
 * Often misdiagnoses as liver cancer.
 * Most rare. ||
 * **Lymph node drainage:** || Lymph node drainage includes
 * Porta hepatis ( with in the transverse fissure of the liver)
 * Pancreaticoduodenal (nodes along superior and inferior pancreaticoduodenal arteries) ||
 * **Metastatic spread:** || Due to the close proximity of the liver to the bile ducts the most common site of metastatic disease is the liver, more often some intrahepatic bile duct cancers are misdiagnosed as liver cancer. Along with the liver there are peritoneal and pulmonary involvements. [4]
 * Ovaries
 * Spleen
 * Bones
 * Nearby blood vessels ||
 * **Grading:** || Histological Grading[6]
 * **Staging:** || ** Stage T N M **
 * **Radiation side effects:** || ====== Side effects of external radiation therapy might include: ======
 * ====== Skin changes (like a sunburn) where the radiation enters the body ======
 * ====== Nausea and vomiting ======
 * ====== Diarrhea ======
 * ====== Fatigue ======

Often these go away after treatment. When radiation is given with chemotherapy, the side effects are often worse.
|| || 2. Nickloes TA, Geibel J, Reed B, et al. Bile Duct Tumors. //Medscape//. Oct. 7, 2011. Available at: [|http://emedicine.medscape.com/article/189843-overview#showall]. Accessed June 8, 2012. 3. Lenhard RE, Osteen R, Gansler T. //The American Cancer Society’s Clinical Oncology//. Williston, VT: Blackwell Publishing, Inc; 2001. 4. Chao KS, Perez CA, Brady LW. Radiation Oncology: Management Decisions. Philadelphia, PA: Lippincott Williams & Wilkins; 2002. 5. Emami B, Lyman J, Brown A, et al. Tolerance of normal tissue to therapeutic irradiation. Int J Radiat Oncol Biol Phys. 1991. 6. Liver Cancer- Symptoms, Treatments and Therapies. 2009. Available at: []. Accessed at: June 6, 2012. 7. VanDeusen, JB. Biliary Tract Cancers. //Emedicine.// 2012. Available at: http://emedicine.medscape.com/article/2003719-overview. Accessed at: June 6, 2012. ||
 * **Prognosis:** || Prognosis depends on location, nodal involvement and local extension. The most resectable are distal common bile duct and ampulla of Vater tumors, and have the best prognosis while mid-ductal Gallbladder lesions have the worst prognosis.[4] ||
 * **Treatments:** || A number of surgical treatments are available which can increase long term survival. If surgery takes place clips can serve as markers for radiation fields. Various treatment schemes are available ranging from 40 to 70 Gy depending on extent of disease and location. Some the liver and kidneys are the most dose limiting structures for radiation. 5-FU and Mitomycin-C are chemo agents that can effect tumor growth. [4] ||
 * **TD 5/5:** || TD 5/5 is a statistical guideline to consider which states that there has been a five percent probability of complication in five years. These values are based on a 200cGy 5 fraction a week treatment schedule.[5] The table includes the five most commonly evaluated structures for irradiation
 * **References:** || 1. Randi G, Malvezzi M, Levi F, et al. Epidemiology of biliary tract cancers: an update. Annals of oncology official journal of the European Society for Medical Oncology. 2009;20(1):146-159. PMID: 18667395. Accessed June 4, 2012.

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