How is biliary cancer diagnosed?
Diagnosis of biliary tract cancer
A diagnosis of biliary tract cancer is usually based on the results of clinical examination of the abdomen, imaging scans using ultrasound, magnetic resonance imaging (MRI) or computed tomography (CT) and a biopsy.
Biliary cancer tests and investigations
Several tests, scans and examinations are used to confirm a biliary cancer diagnosis. Your doctors will use the test results to work out the best treatment for you. You may not need all the tests listed below. Your specialist will give you more detailed information about what tests are most appropriate for your condition.
If you have symptoms of biliary tract cancer, your doctor may carry out a general clinical examination to feel your abdomen to check for lumps or swelling. The doctor will ask about your medical history to learn about your symptoms and possible risk factors.
Your doctor may recommend that you have blood tests. These are to check your liver function (LFTs), your overall health (FBE), your kidney function (U&Es) or levels of a tumour biomarker called cancer antigen 19-9 (CA 19-9).
People with biliary tract cancer might have raised levels of CA 19-9 in their blood. However, raised CA 19-9 levels can also occur in other conditions (including non-cancerous conditions). For these reasons, a blood test alone cannot provide a diagnosis.
An ultrasound scan can look at your bile ducts, gallbladder and the surrounding organs for signs of cancer. An ultrasound probe is placed onto the abdomen and produces sound waves to create a picture of the internal organs.
CT scans are a type of X-ray technique that lets doctors see your internal organs in cross-section. A CT scan uses X-ray to build up a three-dimensional picture of the biliary ducts, gallbladder and the other organs around it. It is also usual to scan your chest and pelvic area to check for any signs of cancer outside the bile ducts and gallbladder. A CT scan can also be used to guide the needle during a biopsy that is performed in some cases. This procedure involves a tissue sample being taken for examination under a microscope.
MRI uses magnetic fields and radio waves to produce detailed images of the inside of the body. A particular type of MRI scan called a magnetic resonance cholangiopancreatography (MRCP) may be used to give a very detailed picture of the bile ducts, gallbladder, pancreas and any tumours. An MRI scan may also be used to look at the liver in more detail.
If the imaging tests detect a tumour, your doctor may wish to take a biopsy. This involves taking samples of tissue from the biliary tract to look for cancer cells. you will need to have a biopsy before starting chemotherapy or taking part in a clinical trial, to obtain a definite cancer diagnosis. These tests may include:
Endoscopic retrograde cholangiopancreatography (ERCP)
ERCP-guided biopsies are commonly used in patients with biliary tract cancer. During an ERCP, a long flexible tube with a small camera and light at the end (endoscope) is passed down the throat to take X-rays of the bile ducts, gallbladder and pancreas. This allows the doctor to see the location and size of the tumour, and biopsies or brushings can be taken at the same time.
Endoscopic ultrasound (EUS)
A procedure called endoscopic ultrasound (EUS)-guided fine needle aspiration or biopsy can be used to obtain small samples. During an EUS, a long flexible tube with a small camera and light at the end (endoscope) is passed down the throat and at the end of the endoscope is an ultrasound probe, which creates images of the bile ducts, gallbladder and pancreas from inside the body. A very thin needle is then used to take some fluid and cells from abnormal areas.
Biliary/gallbladder cancer is increasingly discovered by chance when patients undergo procedures for other gallbladder conditions (e.g. a cholecystectomy for gallstones). In these cases, the cancer is diagnosed through pathology tests on the removed tissue.
The ERCP is a procedure that involves the use of an endoscope. Additionally, the ERCP takes X-rays during the procedure. During an ERCP scan, dye is injected through the tube directly into the opening of the pancreatic duct (the ampulla of Vater) so that any blockages will be seen on the X-ray. While the endoscope is in place, the doctor may also take tissue samples for biopsy. If there is a blockage in your bile duct, the doctor may insert a small tube (called a stent) into the duct.
A laparoscopy is small operation done under general anaesthetic by a surgeon. A long tube with a camera at one end is inserted through a small cut in your abdomen so that the doctor can examine your organs internally. Other small cuts may be made so instruments can be inserted to help with the examination. This test can help to clarify whether a tumour has spread to other regions and can be removed by surgery. Sometimes an ultrasound probe (laparoscopic ultrasound) is also used to help identify suspicious areas and take a biopsy. This test may or may not be performed depending on your surgeon’s practices and the results of other tests.
Waiting to have tests carried out
Even if you have been given an urgent referral for a particular scan or investigation you may have to wait several days or possibly weeks for your appointment. This can be frustrating and worrying, especially if you are already feeling unwell.
If your symptoms get worse or you start to feel more unwell while you are waiting, it’s a good idea to get in touch with your GP or specialist if you already have one. If you cannot get in contact with them you may need to present to the closest emergency department of your symptoms cannot be controlled at home.
How long will I have to wait for my test results?
Depending on which tests you have had it may take from a few days to a few weeks for the results to come through. Waiting for test results can be an anxious time.
It is a good idea to ask how long you may have to wait when you go for tests. If you think you have been waiting too long, then contact your GP or a specialist to follow up on the progress of your results. Usually the doctor who does the test will write a report and send it to your specialist. If your GP sent you for the test the results will be sent to the GP clinic.
You will need an appointment with your specialist or GP to discuss the test results and how they might affect your treatment. Usually your specialist will discuss your results and plan your subsequent care.
Your test results will give your doctors a detailed diagnosis and also tell them at what stage your cancer is. Staging is how doctors refer to the size of a cancer and whether it has spread around the tumour site or to other areas of the body. It is an important part of their assessment and contributes to treatment planning.
Biliary tract cancer is staged using the TNM system. This gives a number according to tumour size (T), how many lymph nodes are affected (N), and how far the cancer has spread, or metastasised, to distant parts of the body (M). This information is used to help decide the best treatment.
Histologically confined to bile duct
Invasion beyond bile duct
Invasion of gallbladder, pancreas, duodenum, other adjacent organs without involvement of celiac axis or SMA
Involvement of celiac axis or SMA
Regional nodal metastasis
Receiving a biliary cancer diagnosis
Receiving the diagnosis of biliary cancer can be unnerving, confusing, and disorienting. You have mixed emotions of surprise, disbelief, and anger; and you may feel sad and disappointed, with fear and uncertainty for the future. But you are not alone, our PanSupport team are here to support you.
> Biliary cancer treatment options