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How We Diagnose Biliary Cancer

  • Timely, accurate diagnosis is key to effective biliary cancer treatment. Our diagnostic team includes pathologists, radiologists, gastroenterologists, and surgeons with extensive experience in confirming this diagnosis with the latest technology.

    Beginning with your first appointment at the Pancreas and Biliary Tumor Center at Dana-Farber/Brigham and Women's Cancer Center (DF/BWCC), our specialists care for you and manage your diagnosis as a team. We make every effort to coordinate your testing and care.

    • Concentrated expertise: Our surgical, radiology and pathology teams specialize in cancer imaging and diagnostics. This means that we have in-depth experience with this disease process.
    • Radiologists and pathologists at the Center specialize specifically in gastrointestinal and pancreaticobiliary malignancies.

    Rapid response

    We know the importance of making an early diagnosis, and we efficiently move you through the testing process. If a diagnosis of biliary cancer is determined, your clinical team will work with you to create and oversee a personalized treatment plan.

    A Team Approach

    Before treatment can begin, you will have a diagnostic workup by a team that includes a gastroenterologist, pathologist, radiologist, and surgeon — all of whom specialize in the biliary tract. This process ensures that your care is carefully coordinated to save time and achieve optimal results.

    Your tests are conducted and reviewed by the doctors whom you see during appointments, as well as their colleagues at our Center, who meet to review your test results together.

    Diagnostic tests and procedures that produce images of the biliary tree and the surrounding area are used to detect, diagnose, and stage biliary cancer. Upon diagnosis, our entire specialty team meets to determine the optimal treatment plan for you.

    Endoscopy

    We use advanced endoscopic techniques to evaluate tumors and to relieve any obstruction of the bile duct through stenting, including:

    • Endoscopic ultrasound (EUS): A procedure used to look through the wall of the nearby stomach and intestine. An endoscope (a thin, tube-like instrument with a light and a lens for viewing) is inserted into the body, usually through the mouth, to form a picture of body tissues and check for signs of cancer. This gives us the highest resolution imaging available and guides whether — and how — we conduct a biopsy. The most common diagnostic study for gallstone-related disease is ultrasound.
    • Endomicroscopy: A procedure that takes images from inside the body in real-time through a highly specialized probe. This can be a powerful tool that can help us better target the biopsies.
    • Endoscopic retrograde cholangiopancreatography (ERCP): A procedure used to x-ray the ducts (tubes) that carry bile from the liver to the gallbladder and from the gallbladder to the small intestine. An endoscope (a thin, lighted tube) is passed through the mouth, esophagus, and stomach into the first part of the small intestine. A catheter (a smaller tube) is then inserted through the endoscope into the biliary ducts. A dye is injected through the catheter into the ducts, and an x-ray is taken. If the ducts are blocked by a tumor, a fine tube may be inserted relieve the block in the duct. The tube (or stent) may be left in place to keep the duct open. Samples may also be taken.

    Our Advanced Endoscopy Research

    Learn more about advanced endoscopic research at Brigham and Women’s Hospital that has led to new techniques and devices.

    Gastroenterology

    A gastroenterologist is often the first physician you see for the initial diagnosis. We use advanced endoscopic techniques, including evaluation of tumors with endoscopic ultrasound, to conduct biopsies and make a diagnosis. You will also see a gastroenterologist if you develop a complication such as a blocked bile duct that should be cleared in order for you to start or continue treatment.

    • Biliary cancer can sometimes lead to blockages in the bile duct. In the initial diagnosis, you will be evaluated for this.
    • We use tiny scopes (endoscopes) to see if there is a blockage that we can open with dilation.
    • You may have a stent placed to allow bile to drain.

    It is important to relieve these blockages because if bile is backed up, it can cause discomfort and prevent doctors from being able to administer chemotherapy.

    Gastroenterology at Our Center

    Gastroenterology at the Pancreas and Biliary Tumor Center includes physicians who manage biliary diseases and physicians who perform complex endoscopic procedures to diagnose and manage problems. We also have gastroenterologists who focus on patients who are at high risk for developing biliary cancer.

    If you have a family history of gastrointestinal cancer, you can meet with our genetic counselors for an in-depth risk assessment, including:

    • A detailed family history analysis
    • Genetic evaluation through state-of-the-art molecular tests
    • Tailored cancer screening and prevention recommendations

    Radiology

    Annick Van den Abbeele, MD, FACR
Chief, Department of Imaging

    Diagnosis and treatment planning are highly dependent on the correct interpretation of complex imaging studies.

    Our team of 13 gastrointestinal radiologists is highly specialized, focusing exclusively on these malignancies. This specialization — and our high volume of pancreaticobiliary imaging — allows a far greater depth of familiarity with pancreaticobiliary tumors than can be found in most centers.

    The Center's imaging protocols are tailored specifically to biliary cancer. Our methods detect subtle changes that may determine whether a tumor can be considered for surgical resection, enabling us to differentiate between scar tissue and a possible malignancy.

    These biliary cancer-specific protocols — many of which we have developed — allow our team to understand how large the primary tumor is and if it has invaded other structures, such as the blood vessels or organs. Other tests include:

    • Chest x-ray: An x-ray of the organs and bones inside the chest.
    • CT scan (CAT scan): A procedure that makes a series of detailed images of areas inside the body taken from different angles.
    • MRI (magnetic resonance imaging): A procedure that uses a magnet, radio waves, and a computer to make a series of detailed images of areas inside the body.
    • PET scan (positron emission tomography scan): A procedure to find malignant tumor cells in the body. A small amount of radionuclide glucose (sugar) is injected into a vein. The PET scanner rotates around the body and makes an image of where glucose is being used in the body. Malignant tumor cells show up brighter in the image, as they are more active and involve more glucose than normal cells do.
    • Percutaneous transhepatic cholangiography (PTC): A procedure used to x-ray the liver and bile ducts. This test is used only if ERCP cannot be performed.

    Radiology Research

    Our team regularly publishes its findings about the use of imaging in the diagnosis, treatment response, and clinical management of cancer care.

    • Our team has published hundreds of articles on cancer imaging.
    • We are investigating new approaches in cancer imaging, including dual-energy CT. This research can optimize our understanding of biliary cancer and inform the decision of whether or not to operate.
    • We are studying potential side effects of new treatments, such as immunotherapy.

    Pathology

    Pathologists play an important role in not only diagnosing cancer, but also determining how far it has progressed and which therapies will best treat your cancer. Our team of gastrointestinal pathologists subspecializes in biliary pathology, and has a strong expertise in this kind of cancer. Our pathologists determine the specific type of biliary tumor to help the team decide on the optimal treatment plan.

    Our pathologists also evaluate biopsies from patients whose tests were conducted elsewhere to detect cancer and determine the specific type of tumor.

    How pathologists conduct an evaluation depends on where you are in the diagnostic process:

    For a premalignant pancreaticobiliary diagnosis

    Our Center's gastroenterologists specialize in pancreatic and biliary diseases, and our surgeons have extensive experience in the management of premalignant biliary disease. This expertise is especially important for patients who have a complex history, or for those who have not had a definitive diagnosis.

    For suspected tumors

    In many cases, it can be difficult to come to a definitive diagnosis, especially if a patient's tumor is small. Therefore, it is essential that you are evaluated by an experienced team of gastroenterologists, pathologists, surgeons, medical oncologists, and radiologists with expertise in the management of suspected tumors and cysts.

    Some patients with a suspected tumor might have a non-neoplastic or neoplastic pancreaticobiliary diagnosis. Cystic disease of the bile ducts (known as choledochal cysts or biliary cysts) are rare disorders that in some cases have a high risk of progression to malignancy. Our Center has gastroenterologists and hepatobiliary surgeons who specialize in biliary diseases, both benign and malignant. If a patient has a non-neoplastic or neoplastic pancreaticobiliary condition, they will likely be seen by both a gastroenterologist and hepatobiliary surgeon.

    For diagnosed biliary cancer

    In many instances, patients do not have proven metastatic cancer, and are seen by a hepatobiliary surgeon to assess if the tumor can be removed surgically. Depending on the stage of the cancer, you will meet with the appropriate team, which may include a surgical oncologist, medical oncologist, and radiation oncologist.

    Some patients with suspected cancer have their tumor removed surgically, which will both confirm the suspected diagnosis and treat the cancer.

    Care for People with Biliary Cysts

    About 15 percent of biliary cysts become cancerous. If you have a biliary cyst, you should be evaluated by hepatobiliary specialists to determine what kind of cyst you have. Based on the evaluation, doctors will determine the appropriate treatment plan.

    Your scans are studied by radiologists with expertise in reviewing CAT scans and MRIs focused on the biliary tract.

    • You may have a specialized endoscopic procedure to biopsy the cyst.
    • The fluid will be sent for testing to see if there is evidence of cancer in the cyst.
    • If you are at very high risk, a surgical oncologist will speak with you about the possibility of surgery as a preventive measure.

    Staging

    If you have a cancerous tumor, an important initial step is staging to discern if it is contained in the biliary tract or gallbladder, or has spread elsewhere. This determines your prognosis and your treatment regimen.

    We use protocols specifically tailored to biliary cancer to understand how large the primary tumor is and how far it has spread to other structures, such as blood vessels or organs.

    In order to get a more accurate understanding of the cancer for precise staging, a surgeon will likely remove cells from the affected area and send them to a pathologist for study. Surgeons at our Center use a variety of innovative, minimally-invasive surgical techniques, such as laparoscopic and other minimally-invasive procedures.

    Biliary cancer is staged according to where the tumor originates. The majority of bile duct tumors are found in the upper one-third of the biliary tract.

    There are several very complex staging systems used for bile duct and gallbladder cancer, and the American Joint Committee on Cancer (AJCC) is the preferred classification system in the United States. Generally, the four types of staging are:

    • Resectable: Surgery is the primary treatment, often with chemotherapy and/or radiation.
    • Borderline resectable: Chemotherapy and/or radiation (and possibly targeted agents from a clinical trial) are followed by surgery, if possible.
    • Unresectable: Chemotherapy and sometimes radiation (and possibly targeted agents from a clinical trial).
    • Metastatic: Chemotherapy (and possibly targeted agents from a clinical trial).

    Second opinions

    It is important to be seen immediately if you have been diagnosed with biliary cancer so that you can start treatment quickly. We see patients for initial diagnosis or second opinions within days. We provide evaluation and diagnostic services for people who:

    • Have suspected tumors or abnormal test results and want to be evaluated
    • May have a biliary cyst
    • Have received a diagnosis of biliary cancer and want to be treated at our Center
    • Would like a second opinion, including from referring doctors throughout the country or internationally

    Our team often coordinates with providers at other hospitals to:

    • Conduct specialized scans
    • Recommend a treatment plan
    • Perform surgery
    • Continue in an advisory role
    • Evaluate if a patient may be eligible for a clinical trial

    If you cannot travel to Greater Boston in person, you can take advantage of our Online Second Opinion service.