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Forum Name: Gall Bladder Cancer

Question: cholangiocarcinoma


 satadeep - Wed Nov 18, 2009 12:17 pm

My father is 53 years old and has been diagnosed with obstructive jaundice and a stricture in common bile duct. He has been advised to undergo a ca 19-9 test and the result was initially >1000. After about a week he had undergone the test again and the result was >25000. Then a stent was successfully placed in his bile duct to facilitate the flow of bile which had caused his bilirubin to rise to 15. While the stenting was being done the doctor found a stone struck in his bile duct and also found the bile duct narrower than it should be, so he took a brushing from the region which was sent for a histo-pathology test the result to which was negative. We were then advised to discharge him and bring him back for further treatment after a month and go for regular ca 19-9 and bilirubin tests during the period. As advised we had his blood sample tested and the result showed bilirubin to be 4.2 and ca 19-9 to be >5500 which is less than the previous value.
I would be ever indebted if you find time out of your busy schedule to reply me and tell me what inference can be drawn from the above mentioned facts.
Thank you
 Dr.M.Aroon kamath - Sun Dec 20, 2009 8:33 pm

User avatar Hi,

You have not indicated if your father has primary sclerosing cholangitis or if he has had any past biliary surgery.

Diagnosing early cholangiocarcinoma (CC) in patients with primary sclerosing cholangitis (PSC) with available radiological modalities is very difficult. This type of tumor is the second most common cause of mortality after liver failure in these patients. One special variety, the 'Klatskin’s tumor', or perihilar cholangiocarcinoma involving the bifurcation of the hepatic duct, accounts for approximately 70% of all bile duct cancers. The recognition of CC is important for the selection of patients for, and the prognosis following liver transplantation.

Tumor markers as a diagnostic tool in diagnosing CC in patients with PSC are unfortunately not as valuable as previously thought.
One such tumor marker,Carbohydrate Antigen 19-9 (CA 19-9), has also been studied.

Elevated levels of CA 19-9 are most commonly seen in patients with pancreatic cancer, though it can also be elevated in colonic and gastric cancers. Other non-cancer medical conditions, such as pancreatitis, cirrhosis, cholangitis, SLE and gallstones can also cause an elevated CA 19-9.

The serum levels of CA 19-9 often rise temporarily in association with episodes of biochemical relapse of PSC (often associated with increased levels of serum alkaline phosphatase).You have not mentioned his 'alkaline phosphatase' levels.

The marker product of CA 19-9 and Carcinoembryonic antigen (CEA) have been found to have a low sensitivity but a relatively high specificity for the detection of CC in PSC patients.

Studies have investigated the use of CA 19-9 in detecting cholangiocarcinoma. However there have run into several problems. It has been difficult to determine how high a CA 19-9 needs to be in order to indicate if a malignancy is present. Part of this difficulty is caused by the fact that biliary stasis, & cholangitis (infection of the bile ducts), which is caused by blockage of the bile ducts, can be associated with both cholangiocarcinoma & benign medical conditions, Hence, in studies of people who do not have active cholangitis or biliary stasis, a cut off of level of 37 U/ml has been proposed by some. However, in people with active cholangitis or biliary stasis a cutoff level of 300-400 U/ml has been used.

Currently, the best use for CA 19-9 may not be as a screening test for cholangiocarcinoma but rather as a means to check if the disease is responding to treatments(by comparing with base-line values).It has a 'negative predictive value' of approximately 90% (meaning it is more useful to exclude cancer).

Patients with unresectable cholangiocarcinoma have been noted to have significantly greater mean CA 19-9 concentrations compared to patients with resectable cholangiocarcinomas.
The highest levels of CA 19-9 are generally seen in cancers of the exocrine pancreas.

In your father's case,the levels were certainly very high. CA 19-9 concentration has been seen to be highly correlated to the tumor size in most pancreatic cancers. Did they find any suspicious lesion in his pancreas? As the levels had been very high, although the brush biopsy was 'benign', follow up is needed to see how that 'stricture' behaves and also the pancreas needs watching.

18F-FDG PET/CT has been reported to be highly useful by some in this kind of situation.

Best wishes!

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