{"type":"rich","version":"1.0","provider_name":"Transistor","provider_url":"https://transistor.fm","author_name":"Board Pearls","title":"Chapter 24, Ep 3 of 4: Cholangiocarcinoma by Anatomy","html":"","width":"100%","height":180,"duration":644,"description":"Episode three organizes cholangiocarcinoma anatomy first, biology second, because where the tumor sits dictates the operation and the transplant path. Intrahepatic disease is resected when possible and is a transplant contraindication over two centimeters, distal disease gets a Whipple, and perihilar disease is resected when resectable with a narrow unresectable subset going through a neoadjuvant-then-transplant protocol. The imaging is delayed enhancement without washout, the mirror image of HCC, because the fibrous stroma traps contrast rather than letting it run through. CA 19-9 is a trend rather than a yes-or-no and is unusable in Lewis-negative patients, so sclerosing cholangitis patients with a new dominant stricture get FISH on the brushings when cytology fails them.\n \nTopics covered\n\nThree anatomic subtypes and their operations\nPerihilar subclassification and hepatectomy extent\nDelayed enhancement versus HCC washout\nShared inflammatory risk factors\nCA 19-9 interpretation and Lewis-negative patients\nThe indeterminate stricture and FISH\nPerihilar transplant protocol\nFirst-line systemic therapy\nFGFR2 and IDH1 targeted subtypes\n \n \nKey decisions\n\nLocation dictates the operation: intrahepatic tumors come out with the piece of liver, perihilar tumors need a hemihepatectomy plus extrahepatic bile duct plus Roux-en-Y, and distal tumors need a pancreaticoduodenectomy.\nIntrahepatic cholangiocarcinoma takes up contrast progressively in the venous and delayed phases with no washout, the opposite of HCC, because the dense fibrous stroma traps and slowly releases contrast.\nCA 19-9 is not specific because it rises in benign biliary obstruction and cholangitis, and it is useless in Lewis-antigen-negative patients who cannot make it, so it is best read as a trend in a high-risk patient.\nIn a sclerosing cholangitis patient with a new dominant stricture and atypical but non-diagnostic ERCP brushings, the right next step is FISH on those brushings, where polysomy carries...","thumbnail_url":"https://img.transistorcdn.com/-FuAdDBcPDLhEoUmroZKtOBRvuBn_FHPpYlh41hOnU4/rs:fill:0:0:1/w:400/h:400/q:60/mb:500000/aHR0cHM6Ly9pbWct/dXBsb2FkLXByb2R1/Y3Rpb24udHJhbnNp/c3Rvci5mbS9iNzlh/ZTU4Y2MzNWExMjQ5/MjA5OWMwMmI3ZTk5/NGFiZS5wbmc.webp","thumbnail_width":300,"thumbnail_height":300}