Which statements about extrahepatic bile duct cancer are correct?

A. Cholangiography is essential in evaluating patients for resectability.

C. The location of the tumor determines the type of surgical procedure.

DISCUSSION: Cholangiography is essential for both diagnosis and evaluation of resectability. Brushings of the lesion for diagnosis and temporary stenting, done percutaneously or endoscopically, are often done at the time of cholangiography. Angiography and CT are helpful, but in the absence of hepatic artery or portal vein occlusion these tests are not accurate predictors of resectability. The primary obstacles to complete resection are invasion of the portal vein or the hepatic artery and proximal extension of the tumor into the liver. The long-range prognosis for patients who undergo treatment for extrahepatic bile duct cancer is poor, even when the lesion is surgically resectable and adjuvant therapy is given. Only about 10% of patients are alive without disease at 10 years. Nevertheless, bile duct cancer tends not to metastasize to distant sites, so resection and radiation therapy are useful in prolonging symptom-free life. Tumors in the proximal third of the extrahepatic bile duct system are treated by a Roux-en-Y biliary-enteric anastomosis. To ensure excision of the entire tumor this anastomosis usually must be made to the individual hepatic ducts, which must be stented individually. Tumors of the middle third usually require anastomosis to the proximal hepatic duct. In contrast, lesions of the distal third require Whipple's procedure with appropriate reconstruction. Thus, the treatment of extrahepatic bile duct cancer depends on the location of the tumor. Pain is not a prominent feature of bile duct cancer. Most cases become manifest by the insidious development of jaundice.