Biliary Tract Carcinoma (BTC) - intrahepatic cholangiocarcinoma challenges in diagnosis and management

Abstract

Cholangiocarcinoma is an aggressive malignancy of the epithelial tissue of the biliary tract, which has been classified as either intrahepatic or extrahepatic. A 62-year-old woman with recurring heartburn for a year was diagnosed with dyspepsia syndrome. MRI examination of the abdomen showed multiple hepatic masses compressing the common bile duct. A multiphase abdominal CT scan examination and histological picture of liver mass biopsy showed hepatocellular carcinoma, with a differential diagnosis of cholangiocarcinoma. Quantitative CEA was high, and Ca 19-9 examinations were normal. The final diagnosis
of intrahepatic cholangiocarcinoma was given to patients with a plan of cisplatin-gemcitabine chemotherapy. However, the BPJS restrictions prevented gemcitabine from being used for BTC cases, so patients were instead given 5-fluorouracil and leucovorin (FUFA) for 6 cycles, but by the third cycle, there was progression with the onset of metastatic lung nodules, and the patient eventually passed away. The progression of the disease in this case was attributed to delayed diagnosis, suboptimal management, and the unavailability of first-line systemic
therapy regimens. The most significant impediments to the management of this case were the absence of molecular profiling, a crucial component in the selection of targeted therapy, and BPJS’s restriction on the utilization of firstline chemotherapy agents, specifically gemcitabine. The standard of care in the management of advanced biliary tract cancer-cholangiocarcinoma cases involves performing next-generation sequencing (NGS) for molecular profiling and administering first-line therapy consisting of a combination of systemic chemotherapy (cisplatin-gemcitabine) with targeted therapy (durvalumab).