The title of my talk is Cholangiocarcinoma and Gallbladder Cancer. So if we have to discuss the patient that comes up with a tumour in his liver we have to distinguish what type of tumour is it so we have to have our radiology friends with us to distinguish is this a tumour that is originating from the liver itself, is it an [?? 0:30] tumour, a cholangiocarcinoma, is it a benign tumour or is it a metastasis? So we first of all have to distinguish to find out is it cholangiocarcinoma. Then if we decide that the intrahepatic tumour is a cholangiocarcinoma then we have several treatment options.

Coming back to the diagnosis, cholangiocarcinoma is not only in the liver, it can also be in the bile duct itself. The most common bile duct tumour is the Klatskin tumour which is originating from the bile duct bifurcation. Then we have the distal cholangiocarcinoma which is located at the end of the bile duct within the pancreas requiring a pancreatic resection and then we have the gallbladder cancer. There are four entities that are summarised as cholangiocarcinoma.

As every newly diagnosed cancer, we have to discuss them in a multidisciplinary board where we decide what treatment options are available. I mainly talk about the surgical options because I’m a surgeon. Also I do a lot of medical oncology as well so therefore in the tumour board we have to decide how big is the tumour, is it metastasised or is it just a localised tumour that we can treat surgically. In cholangiocarcinoma that’s different depending on the location. So intrahepatic is treatment size dependent – the larger it is the more extensive liver surgery the patient requires. If it’s located in the bile duct as the Klatskin tumour that requires not only a bile duct resection it requires in 99 out of 100 patients a major liver resection as well. So there the problem and the discussion is first of all the patient comes in icteric, so with high bilirubin, do we have to drain the patient and do we have to do portal vein embolization which is basically an interventional radiology treatment where we can extend and hypertrophy the liver that we are trying to preserve. If we have distal cholangiocarcinoma surgical-wise we do a duodenopancreatectomy so we basically remove the pancreatic head with a reconstruction of the organs that are preserved, so pancreas, bile duct and the stomach.

If we have gallbladder cancer the most important issue there is is it a tumour that is diagnosed as a real big gallbladder cancer? Much more often nowadays we see patients that come with the histology report, their gallbladder has been taken out due to gallstones and then the histology says there was a gallbladder cancer in it. What the patients require if the tumour is extending into the wall, which is the definition of a gallbladder cancer, that the patient requires a re-resection of the adjacent liver segments, which is IVb and 5, and a lymphadenectomy. Because what we have shown is doing re-resection in these patients is very beneficial in regards to overall outcome.

So these are the four entities of cholangiocarcinoma and the four surgical treatment options. In regards to adjuvant treatment we have very new data coming from ASCO from a few weeks ago where BILCAP, so the UK group, ABC group, which is studying a lot in cholangiocarcinomas, have demonstrated in a phase III trial that giving adjuvant capecitabine, so the oral 5FU, compared to observation was significantly beneficial in regards to overall survival, extending the patients that received the drug by nearly 1½ years compared to the ones that did not receive the drug.

So lots going on with cholangiocarcinoma, also it’s a small entity compared to other GI cancers and it requires decent discussion with doctors that have seen this tumour before.