Bile Duct and Gallbladder Cancer Treatment
MD Anderson has experts with years of experience treating bile duct and gallbladder cancer with surgery, radiation and chemotherapy. Choosing a treatment depends on the disease stage, a patient’s physical condition and tumor characteristics. MD Anderson’s treatment approach is individualized for every patient.
Surgery
Complete removal of the tumor is the most effective biliary cancer treatment. This may be possible depending on the location of the tumor along the bile duct. This surgery is most often offered to patients with early-stage disease who are in good physical condition.
For all patients with intrahepatic tumors and nearly all patients with perihilar tumors, surgery requires removal of portions of the liver (hepatectomy) and sometimes the main bile duct.
The bile duct travels through the pancreas to reach the intestine. Surgery on tumors at the end of the bile ducts typically require removing parts of these organs. This may be called a Whipple procedure.
If the main bile duct is removed during surgery, reconstruction must be performed to reconnect the bile flow from the liver to the intestine.
Portal vein embolization
If a biliary cancer patient needs surgery to have part of the liver removed, doctors will determine whether enough liver will remain to function properly. If the remaining liver (called the future liver remnant) will not be large enough, the patient may need a procedure to grow their liver.
MD Anderson is a leader in using portal vein embolization (PVE) to spur liver growth. This involves the injection of tiny plastic pellets through a needle into the blood vessel closest to the tumor. The pellets block the blood vessel, which “tricks” the other side of the liver to grow to make up for the loss. If the future liver remnant grows large enough and fast enough, the tumor can be removed safely.
Management of biliary obstruction
Obstruction of the bile ducts and bile duct infection (cholangitis) can be a life-threatening complication of biliary cancer. To manage these, a doctor may use a scope to insert a stent (a tube made of plastic or wire mesh) into the bile duct to keep it open. Stents also correct obstructions and prevent complications like infection.
Radiation therapy
Radiation therapy uses focused, high-energy radiation beams to destroy cancer cells. It can improve survival and provide a chance of a cure or prolonged disease control in patients who don’t receive surgery.
MD Anderson experts have pioneered ways to safely deliver high doses of radiation to the tumor site. This includes using image guidance to deliver radiation in order to prevent damage to the stomach, small bowel, colon, and healthy parts of the liver. CT or MRI scans are also used during radiation treatment to make sure a patient is properly positioned for the dose.
Depending on a patient’s anatomy and liver function, MD Anderson radiation oncology experts will develop a personalized treatment plan that may include the following options:
Intensity modulated radiation therapy (IMRT): This technique uses high-energy photons to treat tumors. The radiation beams are controlled by changing beam intensity, using customized shielding to shape the beams, or both. These options are used when the tumor is near the gastrointestinal tract.
Stereotactic body radiation therapy (SBRT): Very high doses of radiation are delivered to the tumor in the span of one or two weeks. This method is best for smaller tumors that are not near the gastrointestinal tract.
Proton therapy: This radiation treatment uses high energy particles to target tumors without harming nearby organs.
Radioembolization: Tiny pellets of plastic or another material are injected into the arteries that carry blood to the tumor. The pellets carry a radiation source that kills tumor cells.
Chemotherapy
Most biliary cancers are discovered at an advanced stage when surgical treatment options are limited. Chemotherapy works by killing fast growing cells, including cancer cells, all over the body. It is typically used to control the spread of the cancer, alleviate symptoms and improve overall survival.
Targeted therapy
Targeted therapy is an important area of biliary cancer research. Several genetic mutations are treatment targets for biliary cancer. Targeted therapies seek out and destroy these abnormalities within cancer cells. Targeted therapies are given orally or by IV injection.
Clinical trials
MD Anderson is developing new treatments and clinical trials to improve the prognosis and survival of patients with biliary cancers.
We offer clinical trials combining chemotherapy with surgery to remove biliary tumors. Chemotherapy may be offered before surgery to shrink tumors or after surgery to decrease the risk of cancer returning.
Other clinical trials are exploring the use of targeted therapies for driving mutations of biliary cancers including IDH, FGFR, and BRAF proteins.
Supportive care
Biliary cancer and the therapies used to treat it can cause complications. These may include:
- Stomach obstruction (gastric outlet obstruction)
- Slowing of the stomach (gastroparesis)
- Weight loss
- Malnutrition
- Fluid buildup in the abdomen (ascites)
- Abdominal pain
- Chronic nausea/vomiting
- Bile duct obstructions
As a top-ranked cancer center, MD Anderson takes a multidisciplinary approach to address these issues. We offer services in disciplines including supportive care, gastroenterology, interventional radiology and pain management. Our dedicated Survivorship Clinics also provide patients with follow-up care plans and support as they navigate life after cancer.
Ethan Ludmir, M.D., grew up watching Star Wars. But unlike other fans, his favorite character wasn’t Luke Skywalker or Han Solo. Instead, Ludmir favored a character who got much less screen time: the man tasked with controlling the Death Star’s laser beams.
Today, Ludmir’s work as a radiation oncologist in Gastrointestinal Radiation Oncology has certain similarities to the movies he grew up watching. But instead of using lasers to help the Empire, Ludmir uses radiation to help treat patients facing cancers in the biliary tract, such as bile duct and gallbladder cancer.
Now, Ludmir is sharing how radiation therapy is used to treat biliary cancer – and how the field is advancing.
What radiation therapy options are available to bile duct and gallbladder cancer patients?
Biliary cancers are relatively uncommon diseases that can occur in the bile ducts within or outside of the liver, as well as in the gallbladder. Radiation therapy for biliary cancer may be given after surgery to control a tumor from spreading or instead of surgery to provide relief from symptoms.
Common radiation approaches for biliary cancer treatment include intensity modulated radiation therapy (IMRT) or stereotactic body radiation therapy (SBRT). These photon-based approaches use image guidance to send high dose radiation directly to the tumor.
While the words “high-dose radiation” may give a patient pause at first mention, research shows dose-escalated radiation can improve tumor control and survival among biliary cancer patients while limiting side effects and damage to surrounding organs such as the liver, stomach and small bowel.
“Data from MD Anderson has demonstrated that if you can safely turn up the dial with radiation, you are more likely to control and kill off these tumors,” Ludmir says.
Proton therapy, which utilizes larger radiation particles and has different dose distribution properties compared to photon-based approaches, may also be used to treat biliary cancers.
Oncologists decide which type of radiation to use on a case-by-case basis that considers each patient’s anatomy, liver function and tumor location.
“These different radiation options are part of a toolbox of techniques. No one technique is the right choice 100% of the time, so we pick the technique that works best for each patient,” Ludmir says.
What are the challenges of using radiation therapy for biliary cancer?
The bile ducts are located in what Ludmir calls “prime real estate” near the gallbladder, liver, stomach and small bowel. Because even small movements from breathing and digestion can alter the position of the bile ducts, special techniques and technologies are used to make sure radiation is delivered precisely to the tumor site while avoiding unnecessary exposure to these neighboring organs, which could lead to damage or side effects.
Prior to treatment, patients learn how to hold their breath during radiation and are instructed to limit what they eat and drink to minimize gas bubbles in the stomach. In some cases, spacers are surgically inserted to protect parts of the body from radiation.
During treatment, radiologists use an array of image guidance technologies to accurately target tumors and avoid critical structures.
“It’s a testament to expertise and technological advances that we can treat these tumors while paying attention to how patients are breathing, ensuring we're treating exactly where we want to be and not where we don’t,” Ludmir says.
What is the process for receiving radiation therapy for bile duct and gallbladder cancers?
Radiation treatment can last anywhere from a week to multiple weeks with individual appointments lasting about an hour. Patients lie in a bean-bag-like-device molded to the shape of their body, while a pre-treatment CT scan ensures proper alignment. Aside from an intercom message announcing the radiation has begun and for the patient to hold their breath, a patient may not even notice the process is underway. Twenty minutes later, the process is complete.
“Folks often walk out of the room after the first day of treatment and say, ‘Oh, that was not nearly as bad as I thought it would be,’” Ludmir says. “It’s a misconception people have that radiation is painful.”
What’s next in the field of radiation therapy for biliary cancer?
New advances in radiation therapy for biliary cancers include everything from the types of subatomic particles to the machines used to deliver radiation. New forms of radiation are being explored in clinical trials, dose-escalation continues to advance, and equipment continues to improve.
“Advances in technology, which are often behind the curtain, are really what have allowed us to do things that weren’t possible before,” Ludmir says. “As much as technology has changed over the last five years, we anticipate even further advances in the coming five years.”
With these advances come better and better patient outcomes. And, for Ludmir, a job even more gratifying than anything depicted on screen.
“There's really nothing like seeing patients come back months and years after treatment, and they're doing well. The end result is satisfying beyond words.”
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