Klatskin Tumor

From WikiLectures

Klatskin tumor is malignant cholangiocarcinoma arising from extrahepatic bile duct near the confluence of left and right hepatic ducts. It is hilar carcinoma. [1]

Epidemiology and Etiology[edit | edit source]

Klatskin tumor is quite rare, more in male sex in age > 60 years.[1] There is prooved connection between this malignant tumor and primary sclerosis cholangitis (autoimmune disease) and parasitic infection in biliary ducts (Clonorchis sinensis and Opisthorchis viverrini, both in Southeast Asia).

Pathology[edit | edit source]

It is cholangioccarcinoma (usually cylindrocellular adenocarcinoma) in more than 90% of cases, grows slowly, is locally agressive – can penetrate to portal vein, hepatic artery, liver parenchym. Metastasise quite late (lymph nodes in porta hepatis, liver).[1]

Searchtool right.svg For more information see Cholangiocarcinoma.

Clinical Features[edit | edit source]

Symptomes are very similar to pancreatic head cancer:

Diagnostic Methods[2][edit | edit source]

  • lab: higher bilirubin, tumormarker CA 19-9 (but is not specific, can be found in patients with colon cancer, pancreatic cancer or biliary obstruction);
  • USG: possible biliary duct dilatation, gallbladder dilatation;
  • EUSG: through the wall of the stomach or duodenum is possible find the tumor;
  • MRCP: is prefered more than ERCP, because MRCP is noninvasive methode which can show stage of tumor process;
  • ERCP (endoscopic retrograde cholangio-pancreatography) should be prefered only if there is no MRCP examination possible or is neccesary therapeutic intervention of biliary obstruction (stent);
  • CT: computer tomography is always neccesary in staging, results of CT will decide about the therapy, should be always performed before ERCP (because we need to have images before intervention)!

Classification[edit | edit source]

TNM Classification[3][edit | edit source]

  • Tis – carcinoma in situ;
  • T1 – tumor is in muscular layer of biliar duct;
  • T2a – tumor penetrates to lipid tissue;
  • T2b – tumor petetrates to liver parenchym;
  • T3 – tumor penetrates to left or right portal vein or left or right hepatic artery;
  • T4 – tumor penetrates to portal vein, or left and right portal vein, or common hepatic artery, ...
Searchtool right.svg For more information see TNM.
Stage 0 Tis N0 M0
Stage I T1 N0 M0
Stage II T2a, T2b N0 M0
Stage IIIa T3 N0 M0
Stage IIIb T1, T2, T3 N1 M0
Stage IVa T4 N0, N1 M0
Stage IVb T1-T4 N0, N1 M1

Bismuth Classification[edit | edit source]

is based on tomor’s localization in extrahapatic biliary tree:

  • Bismuth I – tumor of common hepatic duct, not reaching the junction;
  • Bismuth II – tumor of common hepatic duct, reaching the junction;
  • Bismuth III – tumor of common hepatic duct and left or right hepatic duct;
  • Bismuth IV – tumor of common hepatic duct and left ahd right hepatic duct.

Therapy[edit | edit source]

Curative Therapy[edit | edit source]

Only radical tumor resection can be curative and should be performed only in stage I or II of TNM classification. It is extensive surgery with bile duct and right liver lobe (or extend right liver lobe) resection and hepaticojejunoanastomosis (Roux Y-loop).

Paliative Therapy[edit | edit source]

In nonoperable tumors (TNM stage III and IV) is chemotherapy performed. Usually gemcitabine (nukleosid analogue) and cisplatin. Average survival time is 8.5 months.[4]

Paliative therapy is based on hepatic ducts patency (drainage of bile):

  • internal drainage – (metalic) stent via ERCP;
  • external drainage – PTD (percutaneous transhepatic drainage).

Last but not least is therapy of pain.

Links[edit | edit source]

Related articles[edit | edit source]

References[edit | edit source]

  1. a b c POVÝŠIL, Ctibor, et al. Speciální patologie. 2. edition. Prague : Galén, 2007. pp. 199. ISBN 978-80-7262-494-2.
  2. a b BURKITT, H. George – QUICK, Clive R. G. Essential surgery :  problems, diagnosis and management. 4. edition. Edinburgh ; New York : Churchill Livingstone, 2007. 793 pp. pp. 369-373. ISBN 9780443103469.
  3. SOBIN, L.H – GOSPODAROWITZ, M.K – WITTEKIND, Ch. TNM : Classification of Malignent Tumors. 7. edition. 2009. ISBN 978-80-904259-6-5.
  4. ŠMAKAL, Martin. Komplexní léčení nádorů - role onkologa [lecture for subject Surgery, specialization Surgery, 1. LF UK Charles University in Prague]. Prague. 2011-10-21.