How is CCA Diagnosed

What is an MDT?

An MDT is a group of healthcare experts who specialise in different areas of medicine.^1,3 The team will meet regularly and together help to decide the best plan of action for your treatment and care

These experts usually include:

Click on an icon to learn more about each expert

A healthcare professional who treats gastrointestinal (stomach and intestines) and hepatological (liver, gallbladder, biliary tract and pancreas) diseases

A healthcare professional who uses images to diagnose and treat medical conditions and injuries

A healthcare professional who diagnoses and treats people with cancer

A healthcare professional who examines samples of tissues/cells for the diagnosis and treatment of medical conditions

A healthcare professional who performs laboratory tests, examines the DNA, RNA and/or protein within cells taken by biopsy, and supports other healthcare professionals in the diagnosis and treatment of medical conditions

A healthcare professional trained to support the care and treatment of medical conditions

A healthcare professional who performs operations in planned and/or emergency situations

What tests might be carried out in the diagnosis of CCA?

Many different tests can be performed to diagnose CCA. These will help you and your doctor to decide the best treatment plan. These tests may be done at different stages along your journey with CCA

Not all patients will undergo all tests –
this could be due to differences in individual cases (such as disease stage), familiarity of tests among the healthcare team or differences in healthcare systems (for example, access to services)

If you see a test here that you have not had, you can ask your doctor to help you understand why

The most common imaging tests (that take images of the inside of your body) for diagnosing CCA include:^5–10

Ultrasound scan

A painless process where a handheld scanner is placed onto the abdomen and produces sound waves to create an image of structures (such as organs or glands) inside the body; commonly used during pregnancy

CT scan

A process that uses X-rays taken from many angles to create computerised, 3-dimensional images of the inside of the body

MRI scan

A process that uses a magnetic field and radio waves to create computerised, 3-dimensional images of the inside of the body. An MRI scan might be used when a doctor wants to see more accurate, detailed images of the body

ERCP

A process that uses a long, thin, flexible telescopic camera (an endoscope) that is gently passed through your mouth into your stomach and the first part of the small intestine (duodenum). A small tube is passed down the endoscope and some dye is injected, which shows up on X-rays. This allows the doctor to look at the bile and pancreatic ducts inside your body. Biopsies can be taken at the same time

EUS

A process that also uses an endoscope that is passed through to the duodenum; an ultrasound probe attached to the tip of the endoscope creates detailed images of organs and structures inside your body. Biopsies can be taken at the same time

PTC

A process that uses ultrasound to allow a long, thin, flexible needle to be inserted through your skin and into the liver. Dye is then injected through the needle, which shows up on X-rays and allows the doctor to look at the bile ducts inside your body. Biopsies can be taken at the same time

PET

A process where a small amount of a radioactive drug (tracer) is injected into blood vessels in your arm or hand, which will then accumulate in areas of your body that have higher levels of metabolic or biochemical activity. This can often pinpoint the location of the cancer as cancer cells are more active than normal cells

Other tests/procedures

Angiography – Dye is injected into the blood vessels, which shows up on X-rays to determine any blockages in the blood vessels in and surrounding the liver and bile ducts. This may be performed with CT or MRI
Laparoscopy– A minor operation during which a small cut is made (usually near the belly button) to insert a long, thin tube with a high-intensity light and a high-resolution video camera at the front (a laparoscope), which allows a doctor to see inside your body

Your healthcare team will also run general health tests to see how fit you are. This can help you and your doctor to understand how well you may be able to cope with certain treatments and will help guide your treatment plan

What are the different stages of CCA?

Staging is used to describe the size of the cancer and whether it has spread. The cancer can spread in the body through the blood stream or the lymphatic system¹¹

The lymphatic system is a large network of lymph vessels and nodes (located in many parts of the body, including the neck, armpit and groin) that contain immune cells to fight against infection and disease

There are different approaches to staging CCA. The TNM system is commonly used in Europe and is based on three pieces of information determined from diagnostic tests:^2,11

Tumour – The size of the primary tumour

Node – Whether the cancer has spread to the nearby lymph nodes

Metastasis – Whether the cancer has spread to distant lymph nodes or distant organs, such as the liver, lungs, bones or brain

The TNM staging system is specific for each type of CCA (intrahepatic, perihilar and distal)^2,11

TNM staging can be used to decide on an overall stage of cancer:¹²

Local

The cancer is located only within the bile duct with no evidence of spreading to areas outside of the bile duct. These cancers can often be removed surgically (known as resectable cancer)

Locally advanced

The cancer is located only in the area around the bile duct, with no evidence of spreading to distant parts of the body

Metastatic

The cancer has spread to distant parts of the body. It is unlikely that surgery can remove all of the cancer, as it has spread too far or is in too difficult a location to remove (known as unresectable cancer)

What is molecular profiling?

Molecular profiling is a type of test that looks for gene changes in cancer cells taken from a biopsy⁸

The cells in our body are constantly dividing. Sometimes faults can occur, leading to changes in the DNA of our cells. When this happens, the cells can behave differently

Molecular profiling looks for faults or changes in the DNA of cancer cells

This helps doctors understand more about what is driving a cancer to survive and keep growing, and therefore which treatments are best for their patient

Approximately 50% of people with diagnosed CCA are estimated to have DNA changes (genomic alterations), which might mean they are eligible to receive treatment with a targeted therapy^13,14 (see ‘How is cholangiocarcinoma managed’)

Your healthcare team is responsible for ordering your molecular profiling test. This is performed using a sample of your cancer (biopsy)⁸. Your doctor will then receive a report with the results of your molecular profiling, which can help them decide the next steps in your treatment plan

Molecular profiling can be done at any time in your treatment journey. However, the sooner it can be performed the better, as it can provide your doctor with important information to help guide treatment decisions^14,15

Watch the animated video below for the perspectives of a patient and a doctor on the importance of molecular testing

Learn more about the terms used in this website

References: 1. Patel T. Nat Rev Gastroenterol Hepatol. 2011;8:189–200; 2. Valle JW, et al. Ann Oncol. 2016;27(suppl 5):v28–37; 3. Bañales JM, et al. Nat Rev Gastroenterol Hepatol. 2020;17:557–88; 4. Bañales JM, et al. Nat Rev Gastroenterol Hepatol. 2016;13:261–80; 5. Forner A, et al. Liver Int. 2019;39(suppl 1):98–107; 6. Yang CM, Shu J. Oncology. 2021;99:72–83; 7. Rizvi S, Gores GJ. Gastroenterology. 2013;145:1215–29; 8. Biliary tract cancer. An ESMO guide for patients. https://www.esmo.org/content/download/266801/5310983/1/EN-Biliary-Tract-Cancer-Guide-for-Patients.pdf (accessed 19 October 2022); 9. American Cancer Society. https://www.cancer.org/cancer/bile-duct-cancer/detection-diagnosis-staging/how-diagnosed.html (accessed 19 October 2022); 10. Weber A, et al. World J Gastroenterol. 2008;14:4131–6; 11. AMMF. https://ammf.org.uk/staging-2/ (accessed 19 October 2022); 12. Cancer.Net. https://www.cancer.net/cancer-types/bile-duct-cancer-cholangiocarcinoma/stages (accessed 19 October 2022); 13. Lowery MA, et al. Clin Cancer Res. 2018;24:4154–61; 14. Bekaii-Saab TS, et al. Ann Oncol. 2021;32: 1111–26; 15. Malka D, et al. EMJ Oncol. 2020;8:82–94.

How is cholangiocarcinoma (CCA) diagnosed?