Bile Duct and Liver Cancer Treatments

There are 2 types of surgery: liver transplant and partial hepactomy.

Partial Hepatectomy

Partial hepatectomies are used to treat both primary liver cancer and liver metastases. You may only need to have part of your liver removed if:

• Lab tests show your liver is working well
• The cancer has not spread to nearby lymph nodes or other parts of your body

Surgery to remove part of your liver is called a partial hepatectomy. In this procedure, the surgeon removes your tumor. The surgeon also removes a margin of normal liver tissue around the tumor. The extent of the surgery depends on several things:

• Size of the tumor
• Number of tumors
• Location of the tumor

It also depends on how well the liver is working.

Your surgeon may remove up to 80 percent of your liver. The surgeon leaves behind normal liver tissue. The remaining healthy tissue takes over the work of your liver. Your liver can regenerate, meaning that the removed part of your liver can grow back from the left over healthy tissue. The new liver cells grow over several weeks.

Surgery to remove your tumor may not be possible if:

• You have cirrhosis.
• You have a condition that causes poor liver function.
• The tumor is in a part of your liver that cannot be safely removed.
• You have other health problems that make the surgery unsafe.

What to Expect from a Partial Hepatectomy

It takes time to heal after surgery. Each person requires a different amount of time. When you first wake up from surgery, after the anesthesia wears off, you may have a Foley catheter and a central line. A Foley catheter is a thin, flexible tube inserted into the bladder to drain urine. A central line is a more long-term form of IV. You can expect some pain or discomfort for the first few days. Medicine can help control your pain. It's also common to feel tired or weak for a while. You may also have constipation from lack of movement and pain medications. You will need someone to drive you home from the hospital and help you with your daily activities.

Liver Transplant

Liver transplants are usually only used in the treatment of primary liver cancer. Liver transplants are not usually a treatment option for liver metastases.

In a liver transplant, the surgeon removes your whole liver and replaces it with healthy liver tissue from a donor. This is an option if:

• The tumors are small
• The disease has not spread beyond the liver
• Compatible donated liver tissue can be found

Donated liver tissue comes from either a deceased person or a live donor. In the case of a living donor, the tissue is part of, not the whole, liver.

If you need a transplant, your health care team will monitor your health until donated liver tissue becomes available.

What to Expect From a Transplant

Once the healthy liver tissue is available, the transplant surgeon removes your liver and replaces it with the donated tissue. After surgery, you receive medicine to control the pain. When you first wake up from surgery, after the anesthesia wears off, you may have a Foley catheter and a central line. A Foley catheter is a thin, flexible tube inserted into the bladder to drain urine. A central line is a more long-term form of IV. You might need to stay in the hospital for several weeks. While you’re in the hospital, the doctors and nurses will monitor how well your body is accepting the new liver tissue. You will take medicine to prevent your body’s own immune system from rejecting the new liver. These drugs can cause side effects like:

• Puffiness in your face
• High blood pressure
• Increase in body hair

You will need someone to dive you home from the hospital and to help you with your daily activities.

If you cannot have surgery, there are other treatment options.

Gallbladder Surgery

Most doctors agree that surgery offers the best chance for curing gallbladder cancer. However, doctors may disagree about whether advanced gallbladder cancers can be treated with surgery. Gallbladder cancer surgery can be very complex. Also, these surgeries may not be available in every community.

Even if the cancer has spread beyond your gallbladder, surgery may still be an option. If the cancer has spread into major blood vessels, surgery may not be effective.

There are 2 types of surgeries for gallbladder cancer:

• Potentially curative surgery is done when imaging tests show there is a good chance the surgeon will be able to remove all the cancer. The term resectable describes cancers that can be removed completely. Unresectable describes cancers that have spread too far or are in a difficult place and can’t be entirely removed.
• Palliative surgery is done to relieve pain and prevent complications. This surgery is not expected to cure the cancer. It can help relieve your symptoms and prolong life.

You should discuss surgery with your doctor. Surgery to remove gallbladder cancer is complex and can have a lot of side effects. It also may take several weeks to recover. If your cancer is not curable, you may want to weigh the benefits and risks of surgery.

Let’s look at each of the different types of surgeries:

Cholecystectomy: This is an operation to remove the gallbladder.

This operation may be used to remove the gallbladder for other reasons such as gallstones. However, this procedure is generally not done if gallbladder cancer is suspected. (A more extensive operation is done.) A simple cholecystectomy can be done in 2 ways:

• Laparoscopic cholecystectomy: This is the most common way to remove a gallbladder. This method is used for conditions like gallstones. This procedure uses a laparoscope. This is a thin, flexible tube. It has a tiny video camera on the end. The laparoscope is inserted through a small cut in the skin of your abdomen. Long surgical tools are placed through several other small openings to remove the gallbladder. The benefit of laparoscopic surgery is that the incision size is small.
• Open cholecystectomy: In this procedure, the surgeon removes your gallbladder through a large incision (cut) in your abdomen. This method is sometimes used if a non- cancerous gallbladder problem is suspected (such as gallstones), which in some cases may lead to the discovery of gallbladder cancer. But if gallbladder cancer is suspected before surgery, doctors prefer to do an extended cholecystectomy.

Extended (radical) cholecystectomy: In most cases of gallbladder cancer, an extended (or radical) cholecystectomy is done. This is a very involved, complex surgery. An extended cholecystectomy removes at least:

• Your gallbladder
• About an inch or more of liver tissue next to the gallbladder
• All of the lymph nodes in the region

Your surgeon may also find it necessary to remove:

• More of your liver
• The common bile duct
• Part or all of the ligament that runs between your liver and intestines
• Lymph nodes around your pancreas, around the major blood vessels leading to the liver, and around the artery that brings blood to your small intestine and pancreas.
• Your pancreas
• The duodenum (the first part of the small intestine into which the bile duct drains)
• Any other areas of organs to which cancer has spread.

What to Expect

For any of these surgeries, you will be given anesthesia so you are asleep and not in any pain during the procedure. You may spend a few days in the hospital. You will need someone to drive you home after your hospital stay and help with your daily tasks until you feel better.

Laparoscopic cholecystectomy is the least invasive operation. It tends to have fewer side effects. You will probably have some pain from the incisions for a few days. This pain can be managed with medications. There is more pain and a longer recovery time with an open cholecystectomy.

Extended cholecystectomy is a major operation and involves removing parts of several organs. Most of these organs are involved in digestion. That makes eating difficult for a while after surgery.

Bile Duct Surgery

Treatment of bile duct cancer depends on the size of the tumor, where the tumor is located, and whether cancer cells have spread to other parts of the body. Bile duct cancers are usually grouped by how the cancer may be treated. The two groups are called localized and unresectable disease.

• Localized bile duct cancer means that the tumor cells are found only at the bile duct and may be completely removed by surgery.
• Unresectable bile duct cancer means that the tumor cells have spread to lymph nodes, the liver or other areas of the body.  Since the cancer has spread, it cannot be completely removed by surgery alone. However, surgery may still alleviate symptoms.

The best treatment option for bile duct cancer that has not spread outside of the bile duct is surgery. If the patient is too sick to go through surgery, radiation therapy to the cancer site can be a treatment option. Radiation therapy along with chemotherapy may also be considered once the cancer has been surgically removed in an effort to remove any remaining cancer cells.

There are a few surgical options for bile duct surgery:

Removal of the bile duct: If the cancer is only in the bile duct, then surgery to remove the bile duct and surrounding lymph nodes may be the best option.

Partial hepatectomy: If the cancer is also in or near the liver, you may need a partial hepatectomy. This is a surgery where part of your liver is removed. Your surgeon may remove up to 80 percent of your liver along with the bile duct. The surgeon leaves behind normal liver tissue. The remaining healthy tissue takes over the work of your liver. Your liver can regenerate, meaning that the removed part of your liver can grow back from the left over healthy tissue. The new liver cells grow over several weeks.

Whipple procedure: If the cancer is close to the pancreas, your doctor may suggest a Whipple procedure. In this procedure, the surgeon removes:

• Part of the pancreas
• Part of both the stomach and small intestine
• Gallbladder
• Part of the common bile duct
• Nearby lymph nodes

After these are removed, the surgeon attaches the rest of the duodenum, pancreas, and bile duct to the small intestine. This way bile and pancreatic enzymes can still enter the digestive system normally.

Chemotherapy treatment (usually called “chemo”) is the use of drugs that prevent cancer cells from growing and spreading. Chemotherapy medicines either destroy cancer cells altogether or stop them from dividing. Usually chemo drugs are given by vein (intravenous or IV). This way, they enter your bloodstream quickly and travel through your body. This means the chemo drugs will affect your whole body—not just the cancer cells.

Chemo doesn’t refer to one treatment but many, because there are lots of different chemotherapy medicines. Some forms of chemo can be given by mouth. Your medical oncologist will tell you how many cycles or courses of chemotherapy are best for you.

The number of cycles of chemotherapy needed vary.

Different oncologists used different schedules. The type of chemo drug being used is another factor. You may also want to ask your doctor if you are a good candidate for chemotherapy research trials.

You can receive chemo in:

• Outpatient clinic
• Doctor’s office
• Home
• Hospital

When is chemotherapy used?

Chemo can be used in several ways:

• As the main treatment
• Neoadjuvant: treatment before surgery to shrink the cancer and make it easier to remove
• Adjuvant: treatment after surgery to try to kill any tumor cells that were too small to be seen and may have been left behind or if there is lymph node involvement
• Palliative: treatment to help control symptoms like pain when the cancer can’t be cured.

Palliative chemotherapy may be given alone or with radiation.

The side effects of chemotherapy depend mainly on which drugs are given and how much. Common side effects include nausea and vomiting, loss of appetite, headache, fever, chills, and weakness.

Some drugs lower the levels of healthy blood cells, and you're more likely to get infections, bruise or bleed easily, and feel very weak and tired. Your health care team will check for low levels of blood cells.

What to Expect

Chemotherapy not only weakens and destroys cancer cells at the site of the tumor, but throughout the body as well. Unfortunately, this means that chemo can unintentionally harm the development of normal cells like your hair, nails, mouth, and digestive tract.

Some chemo drugs can cause bleeding in your mouth and a deep, toothache like pain. The side effects of chemo depend on the type of chemotherapy you receive and how many cycles you receive. The most common side effects of chemo are:

• Nausea and vomiting
• Fatigue or tiredness
• Confusion, forgetfulness (“chemo brain”)
• Decreased blood cell counts, sometimes causing bruising, bleeding, and/or infection
• Sores inside your mouth
• Numbness in your hands and feet (peripheral neuropathy)
• Diarrhea (loose stool)
• Increased urgency to have a bowel movement or urinate
• Loss of appetite
• Hair loss

When chemotherapy is given at a lower dose, these side effects are less common. If you experience side effects, call your physician. It is better to address side effects right away. There are many drugs available to help manage side effects.

Most side effects go away once treatment is over. Anyone who has problems with side effects should talk with their doctor or nurse as there are often ways to help.

How You Receive Chemo

Chemo medicines come in different forms and can be given in different ways:

• Intravenously (IV): As an infusion, the medicine comes through a thin needle (IV) in a vein, such as in your hand or lower arm. An oncology nurse will insert the needle before each infusion and take it out afterwards.
• Injection: As a single shot into a muscle in your leg, arm, hip, or under the skin in the fatty part of your stomach, leg or arm.
• By mouth: As a pill or capsule. You may take this yourself at home.
• Through a port: This is inserted in your chest during a short outpatient surgery. It is about the size of a quarter and sits right under your skin. A port is a small disc made of plastic or metal. A catheter (soft thin tube) connects the port to a large vein. The chemo medicines are delivered through a thin needle right into the port. You can also get your blood drawn through the port. Once you have finished chemo, the port is removed in a brief outpatient procedure.
• Through a catheter in your chest or arm. This is a soft thin tube that is inserted into a large vein. This is done in a short outpatient surgery. The other end of the catheter stays outside your body. This is similar to having a port.

If you have a catheter or port, your medical team will tell you what signs could indicate and infection.

Port vs. Catheter

Many doctors recommend getting a catheter or port. It makes chemotherapy easier and more comfortable each time, as you don’t have to be restuck each time, like with an IV or injection. Some cancer patients have a portable pump attached to the port or catheter. This controls how much and how fast the chemotherapy medicine goes in. The pump can either be internal (implanted under the skin during a short outpatient procedure) or external (carried with you). Once your rounds of chemo are done, the pump is removed.

Setting Your Schedule

Your oncologist will set your treatment regimen. Every chemo regimen is made up of cycles. This means a period of treatment followed by a period of recovery. For example, you may get chemo one day and then have a few weeks of recovery with no treatment. That would be one cycle. Or you may get chemo for several days in a row and then have a recovery period. Several cycles make up a complete chemotherapy regimen.

The number of cycles in a regimen and the length of each regimen vary from patient to patient. A lot depends on the medicines used.

If you take chemo in a clinic, hospital or doctor’s office, you may go home between treatments. In some cases, you may stay in the hospital to be monitored. This is especially true if your immune system isn’t working as well as it should be which increases your risk for infections. Your doctor will explain where you’ll be getting your treatment.

Passing Time During Chemotherapy

A chemotherapy treatment at a hospital or clinic can take anywhere from one to several hours. Although many chemo treatment areas have televisions and magazines, you may want to bring something to help pass the time. Ideas include:

• A laptop
• Knitting, needlepoint or crochet
• A thick novel
• Crossword or other puzzle book
• Sketchbook and pencils
• Cards or board games (if you have someone to play with)
• MP3 player or portable CD player to listen to music
• Paper and pens to keep a journal or write letters

Planning Ahead for Chemotherapy

Chemotherapy treatment can drain most of your energy. This is a major process your body is going through. There are some things you should take care of before you start chemo:

• Get your teeth cleaned and get a dental check-up. Chemo weakens your immune system, so you may be more vulnerable to infections caused by bacteria that are dislodged during teeth cleaning.
• Get any heart tests (like an EKG) that your doctor recommends.
• If you’re a woman, a routine pap smear is usually recommended. Chemo can alter the results of your Pap smear, so get one beforehand.
• Find someone to help around the house. Chemo causes extreme fatigue. Line up someone to help with your daily chores such as cleaning, grocery shopping, carpooling, and cooking. Don’t be too proud or stoic to ask for help. Friends and family members will be happy to do something that helps you during this treatment phase. Ask yourself: wouldn’t you be willing to do it for someone else?
  • Join a support group if that sounds helpful.
  • Find out ahead of time what you should and shouldn’t eat or drink on treatment days.
  • Tell your doctor all the vitamins, supplements, over-the-counter and prescription medicines you take.
  • Talk to your doctor about hair loss. Most chemo medicines cause some amount of hair loss. If you plan on wearing a wig, you might want to go ahead and get it so you can match it to your hair color and style.

Radiation uses high-energy rays to destroy cancer cells. There are 2 kinds of radiation used to treat cancer:

External radiation therapy: The radiation comes from a large machine. This machine directs beams of radiation at your chest and abdomen.

Internal radiation therapy: Tiny radioactive microspheres contain radiation. A doctor uses a catheter to inject the tiny microspheres into your hepatic artery. These microspheres become trapped in the tumors and are permanent.  They give off radiation that only penetrates about ¼ inch in all directions from the microsphere and kills the tumor but spares the nearby normal liver.

Side Effects

The goal of radiation is to kill as much cancer as possible while preserving normal tissue. However, there can still be adverse side effects.

The side effects of radiation therapy depend on:

• The type of radiation therapy
• The dose of radiation
• The part of the body that is being treated

Here are a few of the possible side effects:

• Red, dry, and tender skin at treatment site
• Hair loss in the treated area
• Fatigue
• Nausea, vomiting, and diarrhea

Most of the side effects of radiation are short term, but some may be long term.

If you have radiation therapy and chemotherapy at the same time, your side effects may be worse.

Tell your healthcare team about any new or worsening side effects. Most side effects can be easily managed.

Targeted Therapy

This treatment slows the growth of your liver tumors. It also reduces the blood supply to your tumor.

The first targeted therapy that was approved for liver cancer is Sorafenib (Nexavar) tablets. Side effects associated with targeted therapy can include:

• Nausea
• Vomiting
• Mouth sores
• Loss of appetite

Ablation

Ablation is a treatment that controls liver tumors by destroying cancer cells. Ablation is used for people waiting for a liver transplant. The treatment can also be used for people who can't have surgery or a liver transplant. There are several different methods of ablation:

Cryoablation

This treatment uses cold to kill cancer cells in your liver. Here’s what you can expect. Your doctor will put an instrument called a cryoprobe directly onto your liver tumors. This probe contains liquid nitrogen. This freezes the cancer cells. Usually an ultrasound is used to guide the probe.

Radiofrequency ablation

 In this procedure the doctor uses a special probe. It contains tiny electrodes to kill your cancer cells with heat. Your doctor might use tools like an ultrasound, CT, or MRI to guide the probe to the tumor. Usually this can be done through your skin. If this is the case, you will probably need only local anesthesia.

If the tumor cannot be reached this way, you may need surgery and general anesthesia. If this is the case, the doctor inserts the probe through a small incision in your abdomen. This is done with a laparoscope. It might also be done through a wider incision that opens your abdomen.

You may experience some pain or a slight fever after this procedure. You probably will not have to stay overnight in the hospital.

Radiofrequency ablation is a type of hyperthermia therapy. Other therapies that use heat to destroy liver tumors are laser or microwave therapy. They are less common than radiofrequency ablation.

Embolization

In this procedure, your doctor inserts a tiny catheter into an artery in your groin. Then the catheter is moved into your hepatic artery. The doctor will inject tiny sponges or other particles into the catheter. These particles block the flow of blood through the artery near the tumors in the liver. This blockage may be either temporary or permanent.

When the blood flow from the hepatic artery stops, your tumor dies.  Your healthy liver tissue will continue to get blood from your hepatic portal vein.

Chemoembolization

In this treatment, your doctor injects a chemotherapy drug into your artery. Then your doctor injects tiny particles that block blood flow. This helps the drug stay in your liver longer.

You’ll need to be sedated for this procedure, but you probably will not need general anesthesia. You’ll probably need to be in the hospital for 2 to 3 days.

There are some side effects to either form of embolization. These can include:

• Nausea
• Abdominal pain
• Vomiting
• Fever
• General fatigue

Palliative therapy is treatment given to help control or reduce symptoms caused by advanced cancer. It does not try to cure the cancer. If the cancer has spread too far to be completely removed by surgery, your doctor may recommend one of several palliative therapies. The following are explanations of several palliative therapies.

Biliary Stent or Biliary Catheter

Often cancer is blocking the bile duct that carries bile from your gallbladder to your small intestine. This can cause jaundice and other problems. Your doctor may insert a small tube (either a stent or a catheter) into the bile duct or gallbladder to help the bile drain out. This may be done as part of a cholangiography procedure or surgically.

• A stent is a small metal or plastic tube that keeps the duct open. This allows the bile to drain into your small intestine.
• A catheter is a thin, flexible tube that drains into a bag outside your body. The bag can be emptied when needed. If you have a catheter, your doctor or nurse will teach you how to care for it.

The stent or catheter may need to be replaced every few months.

Biliary Bypass

If you are healthy, another option may be to use a surgery called biliary bypass to drain bile from your liver and gallbladder. This operation creates a new way for bile to get past the blockage in the bile ducts.

There are several different biliary bypass operations. Your doctor will recommend the best one to use, based on where the blockage is.

• A choledochojejunostomy joins the common bile duct to the jejunum (the second part of the small intestine).
• A gastrojejunostomy joins the stomach directly to the jejunum.
• A hepaticojejunostomy joins the duct that carries bile from the liver to the jejunum of the small intestine.

Sometimes these operations can be done through several small holes made in the abdomen using special long surgical tools. This is known as laparoscopic or keyhole surgery. A biliary bypass is a major operation. That’s why it is important that you are healthy enough to withstand it. You should also talk to your doctor about the possible benefits and risks.

Alcohol injection

To relieve pain, doctors may deaden the nerves that carry sensations of pain from your hepatobiliary system and intestinal area to the brain by injecting these nerves with alcohol.

This can be done during surgery or by guiding a long, hollow needle into place with the help of a CT scan.

Pain medicines

Doctors can prescribe strong pain-relieving drugs if needed. It's important to let your cancer care team know if you are having pain so it can be treated and managed effectively.