Download - Colangiocarcinoma
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ColangiocarcinomaUMAE Manuel Ávila CamachoPérez Rubio Nalleli Adriana
Residente de segundo año de cirugía general
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Epidemiologia
• Necropsias 0.3%
• 1.0/100 000h
• 3000 casos nuevos
• 1.3-1 H:M
• 50-70 años
Hepatobiliary Cancer. National Comprehesive Cancer Network. 2009 S A Khan. Guilines for the diagnosis and treatment of colangiocarcinoma: consensus document. 2002
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Definición
“ Involucra a todos los tumores originados en la vía biliar”
• Intrahepáticos 20-25%
• Extrahepáticos (tumores hiliares: Klastkin)
• 50-60%
• 20-25% distales
• 5% multifocal
Hepatobiliary Cancer. National Comprehesive Cancer Network. 2009 S A Khan. Guilines for the diagnosis and treatment of colangiocarcinoma: consensus document. 2002
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Hepatobiliary Cancer. National Comprehesive Cancer Network. 2009 S A Khan. Guilines for the diagnosis and treatment of colangiocarcinoma: consensus document. 2002
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Factores de riesgo
No en mayoría de pacientes• Edad 65 años 65 % • Colangitis primaria esclerosante 5-15%
tabaquismo• Coledocolitiasis• Enf caroli 7%• Cáncer vesicular• Quiste coledociano 5%• Infecciones: asiaVHC: intrahepáticos
Hepatobiliary Cancer. National Comprehesive Cancer Network. 2009 S A Khan. Guilines for the diagnosis and treatment of colangiocarcinoma: consensus document. 2002
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Diagnostico molecular
• Es asociado con la inactivación de los genes supresores p53, APC, Smad-4, bcl-2, p16
• Mutación en oncogenes K-ras, c-myc, c-erB-2, c-neu
Hepatobiliary Cancer. National Comprehesive Cancer Network. 2009 S A Khan. Guilines for the diagnosis and treatment of colangiocarcinoma: consensus document. 2002
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Diagnóstico
• En estadios tempranos es asintomático
• Intrahepático con síntomas inespecíficos
• Extrahepático: síntomas obstructivos
Hepatobiliary Cancer. National Comprehesive Cancer Network. 2009 S A Khan. Guilines for the diagnosis and treatment of colangiocarcinoma: consensus document. 2002
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• PFH con patron obstructivo
• FA 5 veces
• Transaminasas 1-2 veces
• Una obstrucción prolongada Vit A D E y K
• Hb, albumina y DHL
Hepatobiliary Cancer. National Comprehesive Cancer Network. 2009 S A Khan. Guilines for the diagnosis and treatment of colangiocarcinoma: consensus document. 2002
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Ca 19.9
• No es especifico 85% pac
• 100U/ml S 75% y E 80%.
• Ictericia persistencia descompresión
• No distingue entre carcinoma gástrico o pancreático, incluso de lesión hepática severa
Hepatobiliary Cancer. National Comprehesive Cancer Network. 2009 S A Khan. Guilines for the diagnosis and treatment of colangiocarcinoma: consensus document. 2002
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ACE y Ca 125
• ACE 30%
• Puede elevarse en EII, obstruccion biliar, otros tumores y lesión hepática severa
• Ca 125 se eleva en el 40-50% de los pacientes con colangiocarcinoma
Hepatobiliary Cancer. National Comprehesive Cancer Network. 2009 S A Khan. Guilines for the diagnosis and treatment of colangiocarcinoma: consensus document. 2002
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USG
• Primera línea obstrucción de vía biliar
• La lesión intrahepática puede ser vista como una masa pero es inusual
• El USG doppler puede detectar la compresión de la porta o arteria hepática
Hepatobiliary Cancer. National Comprehesive Cancer Network. 2009 S A Khan. Guilines for the diagnosis and treatment of colangiocarcinoma: consensus document. 2002
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TAC y RM
• TAC: Provee buenas imágenes acerca de lesiones intrahepaticas, dilatación de ductos intrahepaticos.
• RM provee información acerca de la anatomía del árbol biliar, extensión local de tumor y anormalidades en el parénquima hepático
Hepatobiliary Cancer. National Comprehesive Cancer Network. 2009 S A Khan. Guilines for the diagnosis and treatment of colangiocarcinoma: consensus document. 2002
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Hepatobiliary Cancer. National Comprehesive Cancer Network. 2009 S A Khan. Guilines for the diagnosis and treatment of colangiocarcinoma: consensus document. 2002
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Hepatobiliary Cancer. National Comprehesive Cancer Network. 2009 S A Khan. Guilines for the diagnosis and treatment of colangiocarcinoma: consensus document. 2002
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Hepatobiliary Cancer. National Comprehesive Cancer Network. 2009 S A Khan. Guilines for the diagnosis and treatment of colangiocarcinoma: consensus document. 2002
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Hepatobiliary Cancer. National Comprehesive Cancer Network. 2009 S A Khan. Guilines for the diagnosis and treatment of colangiocarcinoma: consensus document. 2002
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Hepatobiliary Cancer. National Comprehesive Cancer Network. 2009 S A Khan. Guilines for the diagnosis and treatment of colangiocarcinoma: consensus document. 2002
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Hepatobiliary Cancer. National Comprehesive Cancer Network. 2009 S A Khan. Guilines for the diagnosis and treatment of colangiocarcinoma: consensus document. 2002
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Hepatobiliary Cancer. National Comprehesive Cancer Network. 2009 S A Khan. Guilines for the diagnosis and treatment of colangiocarcinoma: consensus document. 2002
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Patología y estadificación
• 90% adenocarcinomas
Hepatobiliary Cancer. National Comprehesive Cancer Network. 2009 S A Khan. Guilines for the diagnosis and treatment of colangiocarcinoma: consensus document. 2002
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Hepatobiliary Cancer. National Comprehesive Cancer Network. 2009 S A Khan. Guilines for the diagnosis and treatment of colangiocarcinoma: consensus document. 2002
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Bismuth
Hepatobiliary Cancer. National Comprehesive Cancer Network. 2009 S A Khan. Guilines for the diagnosis and treatment of colangiocarcinoma: consensus document. 2002
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TNM
• Tx: no se puede evaluar
• T0: no evidencia
• Tis: in situ
• T1: a (tejido subepitelial) y b (plano fibromuscular)
• T2: invade tejido fibromuscular
• T3 Estructutas adyacentesHepatobiliary Cancer. National Comprehesive Cancer Network. 2009 S A Khan. Guilines for the diagnosis and treatment of colangiocarcinoma: consensus document. 2002
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• Nx: no pueden ser evaluados
• N0: no ay ganglios
• N1: pericoledocianos
• N2: peripancreaticos, periduodenales, periportales, celiacos, msentericos superiores, pancreatico duodenales posteriores
Hepatobiliary Cancer. National Comprehesive Cancer Network. 2009 S A Khan. Guilines for the diagnosis and treatment of colangiocarcinoma: consensus document. 2002
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Hepatobiliary Cancer. National Comprehesive Cancer Network. 2009 S A Khan. Guilines for the diagnosis and treatment of colangiocarcinoma: consensus document. 2002
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Chamberlain
• T1: confluencia pero sin infiltración de vena porta
• T2: confluencia con atrofia pero sin infiltración
• T3:confluencia, con infiltración de rama portal
• T4: ambos hepáticos y compromiso del tronco de la vena
Hepatobiliary Cancer. National Comprehesive Cancer Network. 2009 S A Khan. Guilines for the diagnosis and treatment of colangiocarcinoma: consensus document. 2002
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Hepatobiliary Cancer. National Comprehesive Cancer Network. 2009 S A Khan. Guilines for the diagnosis and treatment of colangiocarcinoma: consensus document. 2002
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Hepatobiliary Cancer. National Comprehesive Cancer Network. 2009 S A Khan. Guilines for the diagnosis and treatment of colangiocarcinoma: consensus document. 2002
Tratamiento intrahepaticos
• Cirugía única.
• Lobectomia que envuelve el tumor o segmento que lo contiene.
• La sobrevida a los 5 años es del 20-43%
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seguimiento
• R0 podrian ser candidatos a quimioterapia
• R1 margenes microscopicos positivos
• R2 enfermedad local residual
Tx incluye local resección, terapia ablativa, quimioradiación con fluoropirimidina
Quimioterapia con Fluoropirimidina o gemcitabina
Hepatobiliary Cancer. National Comprehesive Cancer Network. 2009 S A Khan. Guilines for the diagnosis and treatment of colangiocarcinoma: consensus document. 2002
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Hepatobiliary Cancer. National Comprehesive Cancer Network. 2009 S A Khan. Guilines for the diagnosis and treatment of colangiocarcinoma: consensus document. 2002
Con enfermedad irresecable
• Quimioterapia fluoropirimidina o gemcitabina
• Quimiorradiacion con fluoropirimidina
• Medidas paliativas
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Tratamiento extrahepáticos
• Resección completa es el principal manejo
• Supervivencia del 20-40% en pac con tumor hiliar, 37% en lesiones de tercio distal
• Tumores pequeños pueden ser resecados solamente y realizar linfadenectomia
Hepatobiliary Cancer. National Comprehesive Cancer Network. 2009 S A Khan. Guilines for the diagnosis and treatment of colangiocarcinoma: consensus document. 2002
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Hepatobiliary Cancer. National Comprehesive Cancer Network. 2009 S A Khan. Guilines for the diagnosis and treatment of colangiocarcinoma: consensus document. 2002
seguimiento
• Drenaje: colangitis 10%
• R0 observacion unicamente o recibir quimioterapia con fluoropirimidina o gemcitabina
• R1 o R2, carcinoma in situ o ganglios regionales positivos las opciones pueden ser:
. Quimiorrradiacion con fluoropirimidina
. Quimioterapia con fluoropirimidina o gemcitabina
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Hepatobiliary Cancer. National Comprehesive Cancer Network. 2009 S A Khan. Guilines for the diagnosis and treatment of colangiocarcinoma: consensus document. 2002
• La biopsia tambien es recomendada para confirmar el diagnostico antes de iniciar algun otro tratamiento.
• Otras opciones de tratamiento incluyen
• Quimioradiacion con fluoropirimidina
• Quimioterapia con fluoropirimidina o gemcitabina
• paliación
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• Terapia fotodinámica
• IV de una droga fotosensitiva
• Radiacion con luz de ondas especificas
• Activacion local de la droga y es usada para la paliación
Hepatobiliary Cancer. National Comprehesive Cancer Network. 2009 S A Khan. Guilines for the diagnosis and treatment of colangiocarcinoma: consensus document. 2002
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Hepatobiliary Cancer. National Comprehesive Cancer Network. 2009 S A Khan. Guilines for the diagnosis and treatment of colangiocarcinoma: consensus document. 2002
Seguimiento
• El seguimiento de los pac con reseccion debe de incluir estudios de imagen cada 6 meses por 2 años
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Hepatobiliary Cancer. National Comprehesive Cancer Network. 2009 S A Khan. Guilines for the diagnosis and treatment of colangiocarcinoma: consensus document. 2002
El papel de la quimioterapia
• Debido a la baja incidencia de los coalngiocarcinomas la mayoria de los estudios se encuentran en fase 2. por lo que no hay indicaciones especificas
• El rol de la adyuvancia también esta pobremente definida. No hay estudios a largo plazo que lo definan.
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Hepatobiliary Cancer. National Comprehesive Cancer Network. 2009 S A Khan. Guilines for the diagnosis and treatment of colangiocarcinoma: consensus document. 2002
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Hepatobiliary Cancer. National Comprehesive Cancer Network. 2009 S A Khan. Guilines for the diagnosis and treatment of colangiocarcinoma: consensus document. 2002
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Hepatobiliary Cancer. National Comprehesive Cancer Network. 2009 S A Khan. Guilines for the diagnosis and treatment of colangiocarcinoma: consensus document. 2002
• Intrahepaticos: lobectomía
• Tipo l y ll: reseccion de toda la via biliar extrahepatica, colecistectomia, linfadenectomia, anastomosis hepatico yeyunal
• Tipo lll: lobectomia hepatica derecha o izquierda
• Tipo IV: lobectomia hepatica extendida