A 75-Year-Old Man with Metastatic Cholangiocarcinoma - Episode 3

Improved Screening Measures for Cholangiocarcinoma

Dr Afsaneh Barzi explains why screening measures for cholangiocarcinoma are so important to patient outcomes.

Afsaneh Barzi, MD, PhD: There is no standard or recommended screening strategy for cholangiocarcinoma. These patients are diagnosed based on their symptoms, even in the population with high risk for development of cholangiocarcinoma, such as primary biliary cirrhosis. Given the challenges and difficulties in identifying the cancer, it’s not generally recommended to screen these patients. There is no imaging modality or laboratory tests that would identify these patients. I think the one thing that’s very important is for patients, such as this gentleman, who present with persistent symptoms like abdominal pain going on for month after month, it’s important to not just assume that the abdominal pain is related to GERD [gastroesophageal reflux disease], or for a young female to assume it’s related to IBS [irritable bowel syndrome. We need to look radiographically to see if there are any tumors identified by imaging. I would say the best screening modality is paying attention to the symptoms that these patients present with. Look for early identification of the disease with the appropriate use of imaging in patients with persistent symptoms.

I cannot say I have a recommendation that’s ready for prime time and for implementation in practice [for earlier detection of cholangiocarcinoma]. I would state that there is newer pan-cancer screening technology based on cell-free DNA and methylation patterns that are discovered in the cell-free DNA, such as a test from GRAIL, that is providing a window of opportunity for early detection of these cancers. I would caution that these technologies are not ready for wide adoption and use, but I am hopeful that work on these technologies and better development would provide a tool for early detection of these patients in the near future.

Transcript edited for clarity.

Case: A 75-Year-Old Man with Metastatic Cholangiocarcinoma

May 2021

Initial presentation

  • A 75-year-old man presents with abdominal pain and weight loss.

Clinical workup

  • History of hepatitis B infection more than 10 years ago and hypertension which is controlled with medication
  • Blood work reveals serum levels of CA 19-9 (1200 U/ml), bilirubin 1.5 mg/dL, ALT 250 U/L, AST 95 U/L
  • MRI imaging shows multiple liver masses
  • Histopathological examination identifies adenocarcinoma with primarily mucin-producing glands
  • Patient is identified to have intrahepatic cholangiocarcinoma (iCCA).
  • CBC is unremarkable (absolute neutrophil count 3,500/mm3, platelets 300,000/ml, hemoglobin 10.1 g/dL)
  • ECOG PS is 1 and the patient is in good health.
  • Patient is referred to oncologists for next steps and is started on treatment with gemcitabine and cisplatin in June 2021.

Sept. 2021

  • Patient is experiencing grade 2-3 neutropenia and fatigue and the oncologist has adjusted the dose to reduce toxicities with chemotherapy.