Specialist Viewpoint – or cholangiocarcinoma as they see it …

Article 4

John ChetwoodDetecting Cholangiocarcinoma

by John Chetwood 

Final Year Medical Student.

Imperial College London

BSc in Gastroenterology and Hepatology

I’m delighted and honoured to be able to contribute to the Viewpoint series! I am a final year medical student at Imperial College School of Medicine, with a specialist interest in cholangiocarcinoma. Recently some research we undertook won both a prize at a national research conference, and a special Innovation in Global Health competition panelled by Sir Liam Donaldson, Sarah Brown, and the BBC’s Jane Dreaper – and I’m here to report to you the exciting results we are finding in this area.

To read about the Innovation in Global Health competition, click here.

What was the research?

Simply, we were looking for an easier and better way to detect this cancer. As Dr Khan explained in his viewpoint article, cholangiocarcinoma (CC) often is only detected very late, and even when doctors suspect it may be there there is no single simple test that conclusively proves a diagnosis of CC as many other things can cause similar symptoms. However if we could detect it earlier, or even say with confidence if someone has this cancer, then this would have much better outcomes for sufferers.

How would you detect it?

We were looking for any changes this cancer was causing in the urine of patients, so that, hopefully we can develop a test using urine alone.

‘Dipstick’ urine tests use chemicals that change colour in the presence of certain things you are testing for. Currently they are used for detecting pregnancies, looking for sugar and blood in the urine etc – and they are good not only because they are accurate but because they are cheap, easy, non-invasive, and safe, and transportable if you are testing someone in a less developed country (where this cancer is most common).

If we had such a test for cholangiocarcinoma it would be easy to look for it if you had the slightest suspicion of this cancer, plus you could test people during treatment to see if the cancer was responding

How did you look for it?

Collaborating with Khon Kaen University, Thailand, I went to North-East Thailand – an area with the highest rate of cholangiocarcinoma in the world due to liver parasite infestation. There I took samples from healthy volunteers and cancer patients, and after processing and transporting them to Imperial I used complicated techniques to look at everything present in the urine and how much of it there was.

Collecting samples from volunteers

Collecting samples from volunteers

Collecting samples from a Thai monk

Collecting samples from a Thai monk

NB All volunteers consented for the research and were aware that photographs were taken. To date we have samples from 70 volunteers and are aiming to collect a much larger database later this year.

What did you find?

Excitingly we found we could pick out who had the cancer based on what was in the urine alone.

What does this mean?

This supports the exciting idea that we may be able to develop a test looking at the urine alone. However this was the first ever study to look at this cancer in this way, and given how new this is we were limited in how many patients we were able to take samples from. Imperial’s hepatology unit is now looking further into this area and what exactly this means, and I am hopefully going back out to Thailand in 2013 using the money we won in the Global Health competition.

It is still early days but I am extremely excited that this research is steadily progressing towards that dream-goal of a urinary dipstick test – and we are excitedly waiting to see what results we get from the next stage in this research.

John Chetwood
Final Year Medical Student, Imperial College London
BSc in Gastroenterology and Hepatology

Comment from Professor Simon Taylor-Robinson
Professor of Translational Medicine,Clinical Dean of the Faculty of Medicine, Imperial College London

“We were very pleased with John’s preliminary work which has formed the platform of ongoing larger studies with the Liver Fluke and Cholangiocarcinoma Centre in Khon Kaen in Thailand.

Chloangiocarcinoma is 300 times more common there than in the UK. One of our team, Dr Simon Ralphs, is building on John’s sterling work and is going out to Thailand this November to collect more samples from the healthy Thai population, from those infected with liver flukes and from those with cholangiocarcinoma to see whether we can confirm these initial findings in a larger patient population.”

September 2012

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6 Responses to Specialist Viewpoint – or cholangiocarcinoma as they see it …

  1. Sandie Gapper says:

    This is excellent news.

    Sandie: It is indeed – let’s hope that the continued research proves as positive as the preliminary results seem to be.

    Helen

  2. Debra says:

    Its wonderful to think that CC could be detected earlier. My partner died from CC and the first sign he had that something was wrong was from a routine urine test. It then took 3 months of tests before he was eventually diagnosed. So if a dipstick test becomes available it could save all that valuable time. Please keep up the hard work, and I wish you the best of luck.

    Debra: Thank you for your good wishes. AMMF will continue to encourage and support research until we have the answers that are so badly needed!

    Helen

  3. Bob Talbot says:

    A diagnostic test would be a great advance on the present woeful process which can mean a diagnosis only 3 months before the patient dies. Even if the test is not 100% perfect then it is still worthwhile since the experience of years of prolonged inability to produce a meaningful diagnosis is I suspect all too common. Since the surgical treatment for this cancer is so drastic it is only available to the young and fit and not the old, by the time the medics are reasonably certain, it is usually accompanied with the “go home and die” message.

    Just one question though, cholangiocarcinoma is much more common in Thailand because of the infestations of liver flukes, supposedly, but in the UK it is much less common because we don’t have as many liver flukes?? (A) is this really true? (B) Does this mean that it is always caused by liver-flukes, even in UK patients? (C) Why is the liver fluke so special? and (D) would a blood test of some sort be able to detect that a patient had been infected with liver fluke at some time in their life?

    I hope that the research will be continued even after Mr Chetwood graduates.

    Bob: Liver fluke induced CC is the most common type in Thailand because of the widespread habit of eating raw fish and so ingesting the fluke, which then can cause CC. In the west, although there are a few other liver problems that can lead to CC, by far and away the most common type is “sporadic”, caused by reasons as yet unknown, but not by the liver fluke. The work John Chetwood has begun and has had such promising results with, will continue. In fact, we are in touch with someone who will be going out to Thailand in a few weeks time to carry on this work, and John will also be back out there next year. And the major hope for all of us is that this work will fulfil its early promise, and will be of benefit when diagnosing not only liver fluke induced CC, but the sporadic variety too.

    Helen

  4. Suzan Carr says:

    I read with interest your findings. My brother, Robert, passed away about 6 weeks ago due to CC. Our family has a gentic predisposition to Lynches Syndrome ( HNPCC). Our doctor has just told me that cc comes under this spectrum although only about 1% as cc is so rare. Have you found any relationship between these two cancers. Did any of your volunteers also have any other cancers? Thank you for your time.

    Suzan: I am so sorry to hear about your brother – sincere condolences to you and to all your family.

    I have not come across any link with CC and Lynches Syndrome, and for most of the people we come into contact with CC is the only cancer they have. It might be worth going on the the discussion boards on the US Cholangiocarcinoma Foundation site, as the number of people you could contact for information there would be far greater than here in the UK. I will ask around though, and if I come across any information I will, of course, get back to you.

    Helen

  5. Dan Keighley says:

    John, Helen

    It’s great to hear such promise regarding the detection of CC. From what I’ve read and heard this type of cancer often goes undetected until a very advanced stage and so early detection could be key to increasing survival rates. Keep up the good work.

    My father was diagnosed with CC approx 5 years ago and underwent chemoembolization to shrink the 150x100mm tumour followed by a surgical resection which took away 80% of the liver. He has recovered remarkably since the intial liver resection and has since undergone further surgery to remove part of the right lung where another tumour was found. At the age of 54 he is still fiting fit but in the last month has been told the cancer has returned with two small tumours in the liver and another in the lung, all at present are approx 25mm in size and slow growing.

    The prognosis is poor and life expectancy uncertain. We were told some people live 6 months, some live 9/10 years and in my dads case they (IF the growth stays constant/slows down) they wouldn’t be suprised to see him here in 1 to 2 years, so it’s all very woolly. Unfortunately, he has been told by surgeons in Sheffield and Leeds that he is inoperable and that they won’t consider chemo until it advances to a later stage. As you can imagine this is quite a hard thing to hear or accept but we are trying to remain positive. We are also looking in to other forms of treatments and made changes to diet and lifestyle.

    If there is any information or guidence you can proffer I would very much like to hear from you. Likewise, if I can help further your research I would be happy to help.

    Best Wishes.

    Dan

    Hi Dan:
    Thank you for your comment. You are quite right that cholangiocarcinoma is difficult to detect until often it is at a very advanced stage – so something that would give an easy, accurate and early way to diagnosis would be something of a Holy Grail.

    I’m not sure why chemo is not being considered for your father at the moment – might be worth asking for the reasons, or even seeking a second opinion if you haven’t already done so. Very hard to take on board – but they may be considering his quality of life above quantity at this stage, and keeping chemo as some sort of palliative option …

    The updated Guidelines to Treatment and Diagnosis have recently been published and are now available on this site, so it might be worth having a look at them.

    http://www.ammf.org.uk/cholangiocarcinoma/guidelines-for-diagnosis-and-treatment-uk/

    Kind regards to you and your father

    Helen

  6. Matt Sheppard says:

    My wife was only 44 when diagnosed with advanced c.c in February by which time surgery was out of the question and as I realise now chemo only really on a palliative basis. She passed away at the beginning of April. I had some prepared questions for our consultant that he has encouraged me to ask. One of these questions is the diseases genetic predisposition? The Lynches Syndrome is a new one and might be worth quering? We have two daughters. Her actual cause of death was a massive pulmonary embolism which I now understand to be quite a common side effect of many cancers. I wondered if there were any other questions that others could help me with.

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