Still Alive Three Years after Being Diagnosed with Inoperable Cholangiocarcinoma

Case Report

Austin J Clin Case Rep. 2015;2(3): 1073.

Still Alive Three Years after Being Diagnosed with Inoperable Cholangiocarcinoma

Øistein Hovde1,2*, Mildrid Asgeirsdatter Ullerud³, Maiken Schultz4, Kjetil Weyde4, Oline Sofie Berget5, Krzysztof Wladslaw Grzyb6 and Sigmund Lavik7

¹Department of Gastroenterology, Innlandet Hospital Trust, Norway

²Department of Clinical Medicine, University of Oslo, Norway

³Department of Internal Medicine, Innlandet Hospital Trust, Norway

4Department of Oncology, Innlandet Hospital Trust, Norway

5Department of Radiology, Innlandet Hospital Trust, Norway

6Department of Pathology, Oslo University Hospital, Norway

7Department of Surgery, Innlandet Hospital Trust, Norway

*Corresponding author: Øistein Hovde, Department of Gastroenterology, Innlandet Hospital Trust, Gjøvik, Norway and Department of Clinical Medicine, University of Oslo, Norway

Received: March 31, 2015; Accepted: June 02, 2015; Published: June 03, 2015


A 52 year old female with inoperable cholagiocarcinoma is presented. She was treated with two different chemotherapy regimens and a total of four stents (one stent in the common bile duct and three gastroduodenal stents). The cancer slowly progressed, but more than three years after inoperability was confirmed, she is still alive. Even if the clinical situation seems difficult, some patients live much longer than expected.


Cholangiocellular Carcinoma (CCC) is the second most common primary hepatic malignancy. The incidence worldwide is rising, but the etiology is unknown.Numerous clinical trials have been conducted, and different chemotherapy regimens have been used, but still we have limited systemic therapeutic options for CCC.This neoplasm arises from the biliary epithelium and remains highly resistant to current chemoradiation therapies, but gemcitabine- and cisplatin - regimens are considered the first line therapy for patients with advanced disease. Other chemotherapy regimens that have been used are gemcitabine/oxaliplatin, gemcitabine/capecitabine, and 5-fluorouracil [1]. Complete surgical resection is the only chance for cure, but only about 10 % of the patients are candidates for surgery. Patients with unresectable or metastatic CCC have a median overall survival time of less than one year [1]. 5-year survival rate for CCC remains poor and five-year survival even in patients undergoing liver resection does not exceed 35 % [2]. Due to its rising incidence and the relatively poor prognosis there is an increasing focus on cholangiocarcinoma. Treatment options are chemotherapy, surgery, photodynamic treatment, or combinations of these options. The cause of death is usually the tumor burden, but biliary obstruction, leading to cholangitis and liver failure, is also a major cause. For that reason, relief of biliary obstruction is crucial in the treatment for patients with CCC. We present a relatively young patient with inoperable cholangiocarcinoma who is still alive more than three years later.


A female patient, 52 years old, was admitted to the hospital 3 ½ years back with upper abdominal pain. Ultrasound examination revealed a moderately enlarged gallbladder with sludge. Cholecystectomy was performed. The bile ducts and surrounding tissue seemed to be inflamed. Perioperative cholangiography was consistent with cholangiocarcinoma. CT and MRI showed no signs of metastases. Laparoscopy was performed as a preparation for liver transplant. This examination revealed eight peritoneal lesions, each with a diameter of about one cm. Histological examination revealed infiltration of adenocarcinoma, biliary type, in the connective tissue and adipose tissue (Figures 1-2). In addition one lymph node from the area around the hepatic artery was removed, but no tumor tissue was found here. Two months later, because of jaundice and dilated biliary ducts, Endoscopic Retrograde Cholangiopancreatography (ERCP) was performed. A 3-4 millimeter long stricture in the common bile duct four cm from the papilla was found. Implantation of a 10 cm long and eight mm wide Self-Expanding Uncovered Metal Stent (SEMS) (WallFlex, Boston Scientific) was performed. Serum-bilirubin, which had been around 100 mmol/l, normalized, and the next month chemotherapy was started. A combination of gemcitabine and capecitabine was the first regimen used. The dosage for gemcitabine was 1000 mg/sqm on day 1 and 8 and capecitabine 625 mg/sqm were given twice daily every day for two weeks with a new cycle starting every third week. This treatment was given for eight months followed by a discontinuation of seven months when the same treatment was given for an additional month when the treatment, because of adverse effects, was stopped.Four months later gastroscopy for vomiting was done and a stenosis in duodenum was dilated and later stented; ultimately, three stents (duodenal stents, WallFlex, Boston scientific), were required because of tissue ingrowth (Figure 3). Two years after diagnosis and the next three months eight treatments with FLOX- (fluorouracil, leucovorin, oxaliplatin) regimen were given. The dosage was 5- fluorouracil 500 mg/sqm on day 1 and 2, calciumfolinate 100 mg on day 1 and 2, and oxaliplatin 85 mg/sqm on day 1. Three years after diagnosis the clinical situation deteriorated. CT and MRI (Figure 4) indicated progression of the disease with ascites and increased tumor metastases diffusely spread in the abdomen leading to surgery for small and large bowel obstruction. Due to tumor ingrowth it was impossible to restore bowel continuity with by-pass procedures. An ileostomy with placement of a deflating tube into an obstructed right colon and a gastrostomy were performed.In the same procedure permanent ascites drainage was established. Three weeks after the surgery the patient was discharged to her home. She is still alive 3 ½ years after diagnosis and is able to ski or walk one hour a day.