Colangiocarcinoma

1. Colangiocarcinoma UMAE Manuel Ávila Camacho Pérez Rubio Nalleli Adriana Residente de segundo año de cirugía general

2. 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

3. Definici ón “ Involucra a todos los tumores originados en la v í a biliar” Intrahep á ticos 20-25% Extrahep áticos (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

4. Hepatobiliary Cancer. National Comprehesive Cancer Network. 2009 S A Khan. Guilines for the diagnosis and treatment of colangiocarcinoma : consensus document. 2002

5. Factores de riesgo No en mayor ía de pacientes Edad 65 años 65 % Colangitis primaria esclerosante 5-15% tabaquismo Coledocolitiasis Enf caroli 7% Cáncer vesicular Quiste coledociano 5% Infecciones: asia VHC: intrahepáticos Hepatobiliary Cancer. National Comprehesive Cancer Network. 2009 S A Khan. Guilines for the diagnosis and treatment of colangiocarcinoma : consensus document. 2002

6. Diagnostico molecular Es asociado con la inactivaci ó n de los genes supresores p53, APC, Smad-4, bcl-2, p16 Mutaci ón 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

7. Diagn óstico En estadios tempranos es asintom á tico Intrahep ático 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

8. PFH con patron obstructivo FA 5 veces Transaminasas 1-2 veces Una obstrucci ó n 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

9. Ca 19.9 No es especifico 85% pac 100U/ml S 75% y E 80%. Ictericia persistencia descompresi ón No distingue entre carcinoma g á strico o pancre á tico, incluso de lesi ó n hep á tica severa Hepatobiliary Cancer. National Comprehesive Cancer Network. 2009 S A Khan. Guilines for the diagnosis and treatment of colangiocarcinoma : consensus document. 2002

10. ACE y Ca 125 ACE 30% Puede elevarse en EII, obstruccion biliar, otros tumores y lesi ó n hep á tica 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

11. USG Primera l í nea obstrucci ó n de v í a biliar La lesi ó n intrahep á tica puede ser vista como una masa pero es inusual El USG doppler puede detectar la compresi ó n de la porta o arteria hep á tica Hepatobiliary Cancer. National Comprehesive Cancer Network. 2009 S A Khan. Guilines for the diagnosis and treatment of colangiocarcinoma : consensus document. 2002

12. TAC y RM TAC: Provee buenas imágenes acerca de lesiones intrahepaticas , dilataci ó n de ductos intrahepaticos . RM provee informaci ón acerca de la anatom í a del á rbol biliar, extensi ó n local de tumor y anormalidades en el par é nquima hep á tico Hepatobiliary Cancer. National Comprehesive Cancer Network. 2009 S A Khan. Guilines for the diagnosis and treatment of colangiocarcinoma : consensus document. 2002

13. Hepatobiliary Cancer. National Comprehesive Cancer Network. 2009 S A Khan. Guilines for the diagnosis and treatment of colangiocarcinoma : consensus document. 2002

14. Hepatobiliary Cancer. National Comprehesive Cancer Network. 2009 S A Khan. Guilines for the diagnosis and treatment of colangiocarcinoma : consensus document. 2002

15. Hepatobiliary Cancer. National Comprehesive Cancer Network. 2009 S A Khan. Guilines for the diagnosis and treatment of colangiocarcinoma: consensus document. 2002

16. Hepatobiliary Cancer. National Comprehesive Cancer Network. 2009 S A Khan. Guilines for the diagnosis and treatment of colangiocarcinoma: consensus document. 2002

17. Hepatobiliary Cancer. National Comprehesive Cancer Network. 2009 S A Khan. Guilines for the diagnosis and treatment of colangiocarcinoma: consensus document. 2002

18. Hepatobiliary Cancer. National Comprehesive Cancer Network. 2009 S A Khan. Guilines for the diagnosis and treatment of colangiocarcinoma: consensus document. 2002

19. Hepatobiliary Cancer. National Comprehesive Cancer Network. 2009 S A Khan. Guilines for the diagnosis and treatment of colangiocarcinoma: consensus document. 2002

20. Patolog ía 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

21. Hepatobiliary Cancer. National Comprehesive Cancer Network. 2009 S A Khan. Guilines for the diagnosis and treatment of colangiocarcinoma: consensus document. 2002

22. Bismuth Hepatobiliary Cancer. National Comprehesive Cancer Network. 2009 S A Khan. Guilines for the diagnosis and treatment of colangiocarcinoma : consensus document. 2002

23. 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 adyacentes Hepatobiliary Cancer. National Comprehesive Cancer Network. 2009 S A Khan. Guilines for the diagnosis and treatment of colangiocarcinoma : consensus document. 2002

24. 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

25. Hepatobiliary Cancer. National Comprehesive Cancer Network. 2009 S A Khan. Guilines for the diagnosis and treatment of colangiocarcinoma : consensus document. 2002

26. Chamberlain T1: confluencia pero sin infiltraci ó n de vena porta T2: confluencia con atrofia pero sin infiltraci ó n T3:confluencia, con infiltraci ó n de rama portal T4: ambos hep á ticos 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

27. Hepatobiliary Cancer. National Comprehesive Cancer Network. 2009 S A Khan. Guilines for the diagnosis and treatment of colangiocarcinoma: consensus document. 2002

28. Tratamiento intrahepaticos Cirug í a ú nica. Lobectomia que envuelve el tumor o segmento que lo contiene. La sobrevida a los 5 años es del 20-43% Hepatobiliary Cancer. National Comprehesive Cancer Network. 2009 S A Khan. Guilines for the diagnosis and treatment of colangiocarcinoma: consensus document. 2002

29. seguimiento R0 podrian ser candidatos a quimioterapia R1 margenes microscopicos positivos R2 enfermedad local residual Tx incluye local resecci ó n, terapia ablativa, quimioradiaci ó n 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

30. Con enfermedad irresecable Quimioterapia fluoropirimidina o gemcitabina Quimiorradiacion con fluoropirimidina Medidas paliativas Hepatobiliary Cancer. National Comprehesive Cancer Network. 2009 S A Khan. Guilines for the diagnosis and treatment of colangiocarcinoma: consensus document. 2002

31. Tratamiento extrahep á ticos Resecci ón completa es el principal manejo Supervivencia del 20-40% en pac con tumor hiliar , 37% en lesiones de tercio distal T umores 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

32. 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 Hepatobiliary Cancer. National Comprehesive Cancer Network. 2009 S A Khan. Guilines for the diagnosis and treatment of colangiocarcinoma: consensus document. 2002

33. 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 paliaci ón Hepatobiliary Cancer. National Comprehesive Cancer Network. 2009 S A Khan. Guilines for the diagnosis and treatment of colangiocarcinoma: consensus document. 2002

34. Terapia fotodin á mica IV de una droga fotosensitiva R adiacion con luz de ondas especificas A ctivacion 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

35. Seguimiento El seguimiento de los pac con reseccion debe de incluir estudios de imagen cada 6 meses por 2 años Hepatobiliary Cancer. National Comprehesive Cancer Network. 2009 S A Khan. Guilines for the diagnosis and treatment of colangiocarcinoma: consensus document. 2002

36. 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 tambi é n esta pobremente definida. No hay estudios a largo plazo que lo definan. Hepatobiliary Cancer. National Comprehesive Cancer Network. 2009 S A Khan. Guilines for the diagnosis and treatment of colangiocarcinoma: consensus document. 2002

37. Hepatobiliary Cancer. National Comprehesive Cancer Network. 2009 S A Khan. Guilines for the diagnosis and treatment of colangiocarcinoma: consensus document. 2002

38. Hepatobiliary Cancer. National Comprehesive Cancer Network. 2009 S A Khan. Guilines for the diagnosis and treatment of colangiocarcinoma: consensus document. 2002

39. Intrahepaticos : lobectom ía 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 Hepatobiliary Cancer. National Comprehesive Cancer Network. 2009 S A Khan. Guilines for the diagnosis and treatment of colangiocarcinoma: consensus document. 2002