Gallbladder, Liver, Bile Duct Cancer Diagnosis

Medical exam: The first step in diagnosis is to do a physical exam and take your complete medical history. If hepatobiliary cancer is suspected, your doctor will check:

• Your abdomen for masses, tenderness, or fluid buildup
• Your skin and the whites of your eyes for a yellowish color that would suggest jaundice
• The skin on your collarbone for lumps that could indicate cancerous cells in your lymph nodes

If the physical exam and/or symptoms suggest you might have cancer, your doctor will order more tests. Below is an overview of the possible tests.

Blood tests: Your doctor will be looking for the amount of bilirubin in your blood. This is the chemical that gives bile its yellow color. If you have problems in your gallbladder or liver, the level of bilirubin may increase. This is what can cause yellow skin or eyes.

Your doctor will be testing your blood for other substances, such as:

• Albumin: evaluates liver function
• Alpha-fetoprotein (AFP): used to detect liver cancer
• Alkaline phosphatase: released by damaged liver cells
• AST (aspartate aminotransferase): tests for liver damage
• ALT (alanine aminotransferase): tests for liver damage
• GGT (gamma-glutamyl transpeptidase): used to detect liver disease and bile duct obstruction

Any of these may be abnormally high if you have liver or gallbladder disease.

Tumor markers: These are proteins found in the blood when specific cancers are present. CEA and CA 19-9 are tumor markers for hepatobiliary cancers. High levels of these substances in your blood can indicate hepatobiliary cancer. However, keep in mind that other cancers or health conditions can cause the CEA and CA 19-9 levels to be high.

Imaging tests: These use X-rays, magnetic fields, or sound waves to create pictures of the inside of your body. Your doctor may want an imaging test to:

• Help find a suspicious area that might be cancerous
• Help a doctor guide a biopsy needle into a suspicious area to take a sample
• Learn how far cancer may have spread
• Help guide certain types of treatments
• Help determine if treatment has been effective
• Look for a possible recurrence of the cancer

An ultrasound is usually the first imaging test done. This test uses a small instrument called a transducer. It is shaped like a wand. The transducer sends out sound waves. The sound waves bounce off your internal organs, and the transducer picks up their echoes. A computer converts these echoes into a black and white image that is displayed on a screen. Most tumors release echoes that are different from normal tissue echoes. Your doctor can use this pattern of echoes to help locate tumors. Also, he or she can figure out how far the tumors may have grown or spread.

An ultrasound uses no radiation. You lie down on a table, and your skin is lubricated with gel. Then the doctor or technician moves the transducer along the skin over your upper right abdomen.

Endoscopic or laparoscopic ultrasound: These special kinds of ultrasounds put the ultrasound transducer inside your body. This puts it closer to your organs, and the doctor can get more detailed pictures.

Here’s how it works. The transducer is on the end of a thin, lighted tube. This tube has an attached device called an endoscope or laparoscope. Your doctor will put the tube through your mouth and down your stomach. A laparoscopic ultrasound requires a surgical cut in your belly for the transducer to be inserted.

If your doctor finds a tumor, the ultrasound will tell if the tumor has invaded your surrounding organs. If it has, then the ultrasound will tell how far.

CT scan (CAT scan or computed tomography): This type of scan produces detailed pictures of your body. Instead of taking one picture, like a regular X-ray does, a CT scanner takes many pictures. It does this by rotating around you while you lie on a table. Then a computer combines all these images. That produces a 3-dimensional picture.

Before any pictures are taken, you may have to drink 1 to 2 pints of a liquid. It is called oral contrast. This fluid helps outline your intestine. This helps the doctor identify tumors. You may also receive an IV (intravenous line) in your arm or hand. A different type of contrast dye can be injected through the IV. Its purpose is also to outline structures in your body.

A special type of CT known as CT angiography can be used to look at the blood vessels near your liver, gallbladder, and/or bile duct. This tells your doctor if surgery is a good option.

MRI (magnetic resonance imaging): An MRI scan provides detailed pictures like CT scans. The difference is that MRI scans use radio waves and strong magnets instead of X-rays. The energy from the radio waves produces patterns. A computer takes these and turns them into detailed images of specific parts of your body.

MRI scans are helpful in looking at your gallbladder, nearby bile ducts, liver, and other organs. Sometimes they can help tell a benign tumor from a malignant one.

There are 2 special kinds of MRIs used to diagnose hepatobiliary cancer:

• MR cholangiopancreatography (MRCP) is used to look at the bile ducts.
• MR angiography (MRA) is used to look at the blood vessels.

MRI scans are often little more uncomfortable than CT scans. For one thing, an MRI takes up to an hour. You may be placed inside a narrow tube. This can feel confining. There are newer, open MRI machines in many hospitals and clinics around the country.

PET scan (positron emission tomography): This scan requires a special radioactive sugar to be injected in your vein. The cancerous tissues then take up the sugar. That enables a scanner to easily see those areas. PET scans are useful for finding cancer that has spread.

Cholangiography: Another type of imaging test is a cholangiogram. This test looks at the bile ducts to see if they are blocked, dilated, or narrowed. A cholangiogram is often used to plan a surgery. There are 3 types of cholangiograms:

• Magnetic resonance cholangiopancreatography (MRCP): This uses a standard MRI machine. It does not require an IV of a contrast agent.
• Endoscopic retrograde cholangiopancreatography (ERCP): In an ERCP, your doctor puts a long, flexible tube called an endoscope down your throat. The tube goes through your esophagus and stomach and into the first part of your small intestine. A small tube goes from the end of the endoscope into the common bile duct. A small amount of contrast dye is injected through this tube. This fluid outlines the bile and pancreatic ducts. Then X-rays are taken. These images can reveal narrowing or blockage of the bile ducts. The benefit to an ERCP is that your doctor can take samples of cells or fluid.
• Percutaneous transhepatic cholangiography (PTC): In a PTC, your doctor puts a thin needle through the skin of your abdomen and into a bile duct in your liver. You will be given an IV line before the procedure. You’ll be given medicine to make you sleepy through the IV. Your doctor will also rub a local anesthetic on your abdomen to numb it. A contrast dye will be injected through the needle. As this fluid travels through the bile ducts, X-rays are taken.

Angiography: This X-ray test looks at blood vessels. A small amount of contrast dye is injected into an artery. A local anesthetic is used to numb the area before the catheter is inserted. Then the dye is quickly injected to outline all the vessels. This outlines blood vessels while X-ray images are taken. These images show doctors if blood flow in an area is blocked. These X-rays also show any abnormal blood vessels in the area. Angiography can show whether a gallbladder cancer has grown through the walls of blood vessels. All this information helps your surgeon decide if a cancer can be removed.

Laparoscopy: In this test, the doctor inserts a thin tube with a light and a small video camera on the end. This instrument is called a laparoscope. It is inserted through a small incision (cut) in the front of your abdomen. This device enables your doctor to look at your gallbladder, liver and other organs. This test is done in the operating room. You will be given general anesthesia.

Laparoscopy can help your doctor plan your surgery or other treatments. It is also useful in determining how advanced your cancer is.

Laparoscopy is often also used to remove the gallbladder to treat gallstones or chronic inflammation of the gallbladder. This operation is called a laparoscopic cholecystectomy. Sometimes the surgeon finds or suspects gallbladder cancer during that operation. If this happens, the surgeon will do an open cholecystectomy. This is also a removal of the gallbladder but it involves a larger cut in your abdomen. This opening lets the surgeon see more. It can reduce the chance of releasing cancer cells into your abdomen.

Biopsy: During a biopsy, your doctor removes a small piece of tissue from the area that looks suspicious. Then the tissue is examined under a microscope. The goal is to determine:

• If cancer cells are present and if so,
  • What type of cancer cells they are.

Types of Biopsies

• Needle biopsy : In a needle biopsy, a thin, hollow needle is inserted through your skin and into the tumor. Your skin will be numbed ahead of time with a local anesthetic. The needle is usually guided by ultrasound or CT scans. When the images show that the needle is in the tumor, a sample is drawn into the needle. This sample is then examined under a microscope.

Usually this is done as a fine needle aspiration (FNA) biopsy. FNA uses an extremely thin needle that is attached to a syringe. It can be done as a core needle biopsy, which uses a slightly larger needle.

• Laparoscopic surgery: The surgeon makes a few small incisions (cuts) in your abdomen. Then he or she inserts a very thin, tube with a light. It is called a laparoscope. This instrument has a tool on the end to remove tissue.

• Open surgery: The surgeon makes a regular, large incision and removes the tissue. In this case, the surgeon will probably try to remove the entire tumor as well as some healthy tissue to help ensure all of the cancer is removed.