Biliary tract cancer

This review highlights advances in the cellular biology, treatment, and outcome of gallbladder and proximal bile duct adenocarcinomas. Markers indicating increased cell proliferation (proliferating cell nuclear antigen and Ki-67) help in differentiating between invasive cancers and nonneoplastic lesions of the biliary tract. In gallbladder cancer, apoptosis expressed as the maximal apoptotic index correlates with increased size and depth of invasion. Carcinoembryonic antigen bile levels may be used to determine recurrence after resection of cholangiocarcinoma. Biliary tract cancers are associated with elevated bile levels of total and cellular fibronectin, and more data on the accuracy of this test are needed. Recent clinical studies confirm the trend toward a more aggressive approach, including liver resection for proximal bile duct adenocarcinoma in order to achieve curative resection (negative margins). Curative resection emerged as an important factor in three of four studies using multivariate analysis to evaluate the outcome following resection. An increased number of early recurrences including port-site recurrences are reported after laparoscopic cholecystectomy for unsuspected gallbladder cancer. Gallbladder carcinoma or suspicion of gallbladder carcinoma is a contraindication to laparoscopic cholecystectomy. A second intervention including hepatic wedge resection or hepatoduodenal lymphadenectomy with or without common bile duct resection is indicated for pT2 and pT3 stages. Several studies reporting on long-term survivors after resection of gallbladder cancer even in advanced stages support an aggressive surgical approach toward resection or repeat resection.