Guideline sources The following summarized guidelines for the evaluation and management of cholangiocarcinoma are prepared by our editorial team based on guidelines from the Enhanced Recovery After Surgery Society (ERASS 2023), the European Association for the Study of the Liver (EASL/ILCA 2023), the European Society of Medical Oncology (ESMO 2023; 2016), the Society for Immunotherapy of Cancer (SITC 2023), the American Society for Radiation Oncology (ASTRO 2022), the European Association for the Study of the Liver (EASL 2022), the American Society for Gastrointestinal Endoscopy (ASGE 2021; 2013), the International Liver Transplantation Society (ILTS 2020), the British Society of Gastroenterology (BSG 2019), the American Society of Clinical Oncology (ASCO 2019), the American College of Radiology (ACR 2019), and the American Association for the Study of Liver Diseases (AASLD 2014). 1 2 3 4 5 6 7 8 9 10 12 13 14 15 16 https://web.pathway.md/diseases/recJik0Rvwp7Xjjzd 1/13 6/29/23, 3:51 AM Cholangiocarcinoma Pathway Calculator Calculator Calculator Eastern Cooperative Oncology G Karnofsky performance status s TNM class Guidelines 1. Screening and diagnosis Indications for screening, primary sclerosing cholangitis: As per ILCA/EASL 2023 guidelines, consider obtaining annual surveillance for cholangiocarcinoma with noninvasive radiologic modalities, preferably with MRI plus MRCP, in patients with PSC. C As per EASL 2022 guidelines, consider obtaining screening for cholangiocarcinoma with ultrasound and/or MRI/MRCP at least annually in patients with large-duct PSC, regardless of disease stage. C As per ESMO 2016 guidelines, consider obtaining screening for biliary cancer only in at-risk patients, such as patients with PSC. E Indications for screening (liver cirrhosis): consider obtaining abdominal ultrasound surveillance at 6-monthly intervals for the detection of intrahepatic cholangiocarcinoma at an early stage in patients with cirrhosis. C Indications for screening (liver flukes): obtain abdominal ultrasound surveillance at 6-monthly intervals for the detection of intrahepatic cholangiocarcinoma in patients with liver flukes. B 2. Classification and risk stratification Classification: As per EASL 2023 guidelines: Consider subclassifying intrahepatic cholangiocarcinoma into large duct type and small duct type, as this may have clinical utility based on its prognostic and therapeutic implications. C Consider obtaining intrahepatic cholangiocarcinoma macro classification in combination with pathological subclassification. C As per ESMO 2023 guidelines: Classify biliary tract cancer according to the International Classification of Diseases-11 criteria. B Stage biliary tract cancer according to the 8th edition of the UICC staging manual, specific to every subtype of biliary tract cancer. Subclassify perihilar cholangiocarcinoma further according to the Bismuth-Corlette classification to describe their anatomical location. B https://web.pathway.md/diseases/recJik0Rvwp7Xjjzd 2/13 6/29/23, 3:51 AM Cholangiocarcinoma Pathway Prognosis: As per ESMO 2023 guidelines, recognize that elevated CA19-9 is associated with poorer prognosis. B As per ESMO 2016 guidelines, recognize that the prognosis of distal cholangiocarcinoma is better than that of pancreatic head adenocarcinoma. B 3. Diagnostic investigations Diagnostic imaging: As per ESMO 2023 guidelines, obtain radiological imaging before ERCP or percutaneous transhepatic cholangiography in patients with jaundice. B As per ESMO 2016 guidelines, consider obtaining abdominal ultrasound for initial evaluation (identification of biliary obstruction). E Show 2 more As per ASGE 2013 guidelines, perform MRCP to assess for resectability if CT suggests cholangiocarcinoma, particularly of the bifurcation. A Show 2 more Imaging for staging, CT/MRI: As per ILCA/EASL 2023 guidelines, consider obtaining MRI instead of CT for staging intrahepatic cholangiocarcinoma within the liver. B As per ESMO 2023 guidelines: Obtain MRI to evaluate for local extension of perihilar cholangiocarcinoma and distal cholangiocarcinoma and to identify hepatic metastases. B Obtain chest and abdominopelvic CT to evaluate for lymph node and metastatic extension. B Imaging for staging, PET: As per ILCA/EASL 2023 guidelines, obtain FDG-positron emission tomography routinely in patients with apparent resectable intrahepatic cholangiocarcinoma to identify lymph node metastasis not apparent on standard CT or MRI during the staging evaluation. B As per ESMO 2023 guidelines, consider obtaining FDG-positron emission tomography to evaluate for nodal metastases, distant metastases, and disease recurrence. C Imaging for staging, EUS: As per ILCA/EASL 2023 guidelines, obtain EUS with lymph node sampling via FNA to identify lymph node metastases during the staging evaluation in patients with apparent resectable intrahepatic cholangiocarcinoma, if a positive result would alter management. B As per ESMO 2016 guidelines, consider obtaining EUS, with or without nodal biopsy, to clarify the N-stage and to acquire information regarding vessel involvement. E 4. Diagnostic procedures https://web.pathway.md/diseases/recJik0Rvwp7Xjjzd 3/13 6/29/23, 3:51 AM Cholangiocarcinoma Pathway Exploratory laparoscopy: consider performing staging laparoscopy on an individual basis to exclude the presence of peritoneal metastases, if it will influence the decision to proceed with major resection. E Biopsy and histopathology: As per EASL 2023 guidelines: Perform tumor biopsy to obtain a definitive diagnosis. B Consider obtaining immunohistochemistry to confirm/diagnose intrahepatic cholangiocarcinoma and its subtypes in order to distinguish it from metastatic liver tumors. C As per ESMO 2023 guidelines, perform a core biopsy for diagnostic pathology and molecular profiling before any nonsurgical treatment. B Show 2 more As per ESMO 2016 guidelines: Follow standardized reporting tools (minimum dataset) for pathology examination and reporting of surgically-resected specimens. E Report the size and number of tumors, grade, the presence of satellite nodules, and vascular and/or perineural invasion to guide decisions regarding adjuvant therapy. B Molecular testing: As per EASL 2023 guidelines, consider obtaining molecular profiling with a comprehensive panel at the time of diagnosis in patients at high risk for recurrence (such as node or margin positive, vascular invasion, or multifocal intrahepatic disease). C As per ESMO 2023 guidelines, obtain molecular analysis in patients with advanced disease suitable for systemic treatment. A 5. Medical management General principles: Provide patients with biliary tract cancer with a designated point of contact within the multidisciplinary team for advice and support (such as a nurse specialist). E Ensure full access to palliative care and symptom management (including pain control) for patients with biliary tract cancer. E Neoadjuvant chemotherapy: consider offering neoadjuvant systemic chemotherapy in patients with technically challenging but resectable intrahepatic cholangiocarcinoma if an R1 resection is likely to be achievable. C Adjuvant chemotherapy: As per EASL 2023 guidelines, offer oral fluoropyrimidine (capecitabine or tegafur/gimeracil/oteracil) for 6 months following curative resection of intrahepatic cholangiocarcinoma. B As per ESMO 2023 guidelines, consider offering adjuvant chemotherapy with capecitabine in patients with cholangiocarcinoma following resection. B https://web.pathway.md/diseases/recJik0Rvwp7Xjjzd 4/13 6/29/23, 3:51 AM Cholangiocarcinoma Pathway As per ASCO 2019 guidelines: Offer adjuvant capecitabine chemotherapy for 6 months in patients with resected biliary tract cancer. B Consider offering chemoradiotherapy in patients with extrahepatic cholangiocarcinoma with a microscopically positive surgical margin resection (R1). C Definitive systemic therapy, first-line therapy: As per ILCA/EASL 2023 guidelines: Offer gemcitabine-cisplatin as first-line chemotherapy, with the addition of durvalumab if available, in patients with unresectable intrahepatic cholangiocarcinoma and good performance status. A Consider offering gemcitabine monotherapy or plus tegafur/gimeracil/oteracil combination therapy in patients with intrahepatic cholangiocarcinoma and impaired performance status. C As per ESMO 2023 guidelines, offer cisplatin plus gemcitabine as first-line therapy in patients with a performance status of 0-1. A Show 3 more Landmark trials: TOPAZ-1 In patients with previously untreated unresectable or metastatic biliary tract cancer or with recurrent disease, durvalumab was superior to placebo with respect to overall survival. Do-Youn Oh et al. NEJM Evid. 2022. Definitive systemic therapy, second- and later-line therapy: As per ILCA/EASL 2023 guidelines, offer the following options in patients with intrahepatic cholangiocarcinoma with good performance status progressed on first-line therapy: oxaliplatin/fluorouracil chemotherapy or ivosidenib in patients with IDH1 mutations FGFR inhibitors in patients with FGFR2 fusions or rearrangements immune checkpoint inhibitors in patients with mismatch repair deficiency/MSI-high not received durvalumab in first-line. B As per ESMO 2023 guidelines, offer 5-fluorouracil, leucovorin, and oxaliplatin as second-line therapy after cisplatin plus gemcitabine. A Show 7 more As per SITC 2023 guidelines, offer pembrolizumab monotherapy in patients with previously treated, advanced high MSI/mismatch repair-deficient biliary tract cancer. Offer dostarlimab monotherapy for mismatch repair-deficient tumors only. B Show 3 more 6. Therapeutic procedures https://web.pathway.md/diseases/recJik0Rvwp7Xjjzd 5/13 6/29/23, 3:51 AM Cholangiocarcinoma Pathway Radiotherapy, indications: As per ILCA/EASL 2023 guidelines, insufficient evidence to recommend for or against external beam ablative dose radiotherapy as an alternative to systemic therapy in patients with unresectable liver-limited intrahepatic cholangiocarcinoma. I As per ESMO 2023 guidelines, consider offering radiotherapy after completion of adjuvant capecitabine in selected patients (R1 resection of distal/perihilar cholangiocarcinoma). C Show 2 more As per ASTRO 2022 guidelines, offer external beam radiation therapy as consolidation therapy after induction chemotherapy, alone or in combination with chemotherapy, in patients with unresectable intrahepatic cholangiocarcinoma. B Show 2 more Radiotherapy (technical considerations): consider administering dose-escalated ultra- or moderately hypofractionated external beam radiation therapy with fractionation based on tumor location, underlying liver function, and available technology in patients with unresectable intrahepatic cholangiocarcinoma receiving external beam radiation therapy. Do not use concurrent systemic therapy with ultrahypofractionated external beam radiation therapy. C Show 4 more Local ablation: As per EASL 2023 guidelines, consider performing thermal ablation as an alternative in patients with a single (< 2 cm) unresectable or inoperable cholangiocarcinoma. C As per ESMO 2023 guidelines: Consider performing local ablation in patients with intrahepatic cholangiocarcinoma 3 cm having contraindications to surgery. B Do not offer intraductal radiofrequency ablation in patients with perihilar cholangiocarcinoma outside a clinical trial. D Intra-arterial therapies: As per EASL 2023 guidelines, consider offering transarterial procedures (selective internal radiotherapy, chemoembolization, and intra-arterial chemotherapy) as an alternative in selected patients with unresectable intrahepatic cholangiocarcinoma. C As per ESMO 2023 guidelines, consider offering intra-arterial therapies in combination with chemotherapy to improve response and disease control in patients with liver-limited intrahepatic cholangiocarcinoma. C Right portal vein embolization: as per ESMO 2023 guidelines, consider performing right portal vein embolization to induce hypertrophy of the future liver remnant. B Photodynamic therapy: do not offer photodynamic therapy in patients with perihilar cholangiocarcinoma outside a clinical trial. D Biliary stenting: As per ESMO 2023 guidelines, perform biliary drainage and subsequent treatment in patients with biliary obstruction. Perform percutaneous transhepatic drainage when endoscopic access is https://web.pathway.md/diseases/recJik0Rvwp7Xjjzd 6/13 6/29/23, 3:51 AM Cholangiocarcinoma Pathway not possible. B Prefer a metal stent in patients with a life expectancy of > 3 months. B Show 2 more As per ASGE 2021 guidelines, consider performing either endoscopic or percutaneous transhepatic biliary drainage in patients with unresectable malignant hilar obstruction undergoing palliative drainage. Make the final decision based on patient preferences, disease characteristics, and local expertise. C Show 3 more As per ACR 2019 guidelines: Place a percutaneous internal/external biliary catheter as an initial therapeutic procedure in patients with malignant hilar obstruction. B Place an endoscopic internal biliary catheter with a removable plastic stent as an initial therapeutic procedure in patients with dilated bile ducts and coagulopathy (INR > 2.0 or platelet count < 60, 000) or moderate-to-massive ascites. B As per ASGE 2013 guidelines, perform endoscopic palliation of jaundice using MRCP as a guide for unilateral drainage to minimize the risk of cholangitis if the lesion is unresectable on MRCP. A 7. Perioperative care Preoperative care (counseling): Provide preoperative information and counseling regarding the upcoming liver surgery. Consider using brochures and multimedia support to improve verbal counseling. B Advise preoperative smoking cessation at least 4 weeks before hepatectomy. Advise alcohol cessation in heavy drinkers (> 24 g/day for females or > 36 g/day for males) 4-8 weeks before surgery. A Preoperative care (nutrition): obtain a nutritional assessment before liver surgery. Administer enteral supplementation at least 7-14 days before surgery to optimize nutritional status in malnourished patients (weight loss > 10% or > 5% over 3 months and reduced BMI or a low fat- free mass index). A Show 2 more Preoperative care (rehabilitation): offer prehabilitation in high-risk patients (elderly, malnourished or overweight patients, smokers, or patients with psychological disorders) before liver surgery. Initiate prehabilitation 4-6 weeks before the operation depending upon the urgency of surgery. Insufficient evidence to recommend the content (physical exercises, dietary interventions, or anxiety reduction exercises) and duration of the prehabilitation program for liver surgery. B Preoperative care (biliary drainage): perform biliary drainage in the cholestatic liver (> 50 mmol/L). Prefer percutaneous over endoscopic biliary drainage in perihilar cholangiocarcinoma. Avoid performing surgery until the bilirubin level drops < 50 mmol/L. B https://web.pathway.md/diseases/recJik0Rvwp7Xjjzd 7/13 6/29/23, 3:51 AM Cholangiocarcinoma Pathway Preoperative care (antibiotic prophylaxis): administer antibiotic prophylaxis (such as cefazolin) within 60 minutes before surgical incision with no extension into the postoperative period. Consider administering a targeted antibiotic preemptive regimen based on preoperative bile culture in case of complex liver surgery with biliary reconstruction. B Preoperative care (corticosteroids): administer a preoperative dose of corticosteroids (methylprednisolone 500 mg). Insufficient evidence for its use in diabetic patients undergoing liver surgery. B Preoperative care (preanesthetic medication): avoid administering long-acting anxiolytic drugs, particularly in the elderly. D Show 3 more Intraoperative care (anesthesia and analgesia): Administer multimodal analgesia, including the potential use of intrathecal opioids, both for open A and laparoscopic surgery. B Recognize that thoracic epidural analgesia can provide excellent analgesia for open liver surgery but has significant disadvantages. Do not use regional anesthesia techniques in laparoscopic surgery as multimodal analgesia combined with judicious IV opioids provide functional analgesia. Perform continuous local anesthetic wound infiltration to provide lower complication rates and overall equivalent analgesia to thoracic epidural analgesia. Perform local anesthetic transversus abdominis plane blockade as a supplement to standard analgesia to improve pain control and reduce opioid usage. A Intraoperative care (temperature management): maintain perioperative normothermia with multimodal temperature management (including circulating water garments or forced warm air) during open and minimally invasive liver surgery. B Intraoperative care (fluid management): Maintain low central venous pressure (< 5 cmH O) with close monitoring during hepatic transection. A Prefer balanced crystalloids over 0.9% saline or colloids for fluid maintenance. Provide goal- directed fluid therapy to optimize cardiac output and end-organ perfusion, recognizing that this may be particularly beneficial after the intraoperative liver resection during a low central venous pressure state to restore tissue perfusion, with patients having comorbidities and reduced cardiac function benefiting the most. A Postoperative care (thromboprophylaxis): administer routine postoperative LMWH or UFH to reduce the risk of thromboembolic events unless exceptional circumstances make this unsafe. Use intermittent pneumatic compression devices to reduce this risk further. B Postoperative care (early mobilization): initiate early mobilization (out of bed) after liver surgery from the operative day until hospital discharge. Insufficient evidence regarding the optimal duration of mobilization. B Postoperative care (nutrition): implement early oral intake with a normal diet after hepatectomy. Assess the individualized needs for artificial nutrition in malnourished patients, patients with https://web.pathway.md/diseases/recJik0Rvwp7Xjjzd 8/13 6/29/23, 3:51 AM Cholangiocarcinoma Pathway complications causing several days of fasting, and patients with liver cirrhosis. Prefer enteral administration for artificial nutrition. A Show 2 more Postoperative care (antiemetics): use a multimodal approach to postoperative nausea and vomiting. Administer postoperative nausea and vomiting prophylaxis with at least 2 antiemetic drugs, such as dexamethasone and ondansetron. A Postoperative care (laxatives): insufficient evidence to support the routine use of postoperative laxatives, gum chewing, herbal medicine, or decoction to stimulate bowel movement after liver surgery. I 8. Surgical interventions Surgical resection, indications: As per ILCA/EASL 2023 guidelines: Consider performing tumor resection in selected patients with multifocal, unilobar intrahepatic cholangiocarcinoma. C Insufficient evidence to recommend resection over locoregional and/or systemic treatments in patients with intrahepatic cholangiocarcinoma and macroscopic vascular involvement of the IVC, hepatic vein, or portal vein. I As per ESMO 2023 guidelines, perform radical surgery (including lymphadenectomy) as the only curative-intent treatment for biliary tract cancers. Decide on the exact nature and extent of surgery depending on tumor subtype and location agreed at a specialist hepatobiliary multidisciplinary tumor board meeting. B Show 2 more Surgical resection (technical considerations): perform liver resection laparoscopically, in trained teams and when clinically appropriate, to reduce the postoperative length of stay and complication rates. B Show 3 more Liver transplantation, indications: As per ILCA/EASL 2023 guidelines: Consider performing liver transplantation in patients with early-stage intrahepatic cholangiocarcinoma ( 3 cm) arising in the setting of cirrhosis, preferably under study protocols. C Do not perform liver transplantation in patients with locally advanced intrahepatic cholangiocarcinoma outside of clinical trials. D As per ESMO 2023 guidelines, avoid performing liver transplantation as a standard treatment in patients with perihilar cholangiocarcinoma. Encourage participation in clinical trials. D As per ILTS 2020 guidelines, consider performing liver transplantation in patients with unresectable perihilar cholangiocarcinoma after neoadjuvant chemoradiation in centers with a specific protocol. C https://web.pathway.md/diseases/recJik0Rvwp7Xjjzd 9/13 6/29/23, 3:51 AM Cholangiocarcinoma Pathway Show 3 more As per AASLD 2014 guidelines: Consider performing liver transplantation in combination with neoadjuvant chemoradiation in patients with early-stage cholangiocarcinoma deemed unresectable due to parenchymal liver disease or anatomic location. B Refer patients with cholangiocarcinoma being potential transplant candidates to centers having established protocols for oncologic assessment and treatment. B Liver transplantation (technical considerations): Ensure the diagnosis of perihilar cholangiocarcinoma in the setting of liver transplantation include a dominant stricture of the perihilar bile duct and 1 of the following: positive cytology by endoscopic brushing biopsy demonstrating perihilar cholangiocarcinoma FISH polysomy elevated cancer antigen 19.9 > 100 U/mL in the absence of cholangitis. B Show 3 more 9. Specific circumstances Patients with gastric outlet obstruction: consider placing self-expandable metallic stents or performing surgical gastrojejunostomy in patients with incurable malignant gastric outlet obstruction undergoing palliative intervention. Decide between these approaches based on patient characteristics and preferences, multidisciplinary input, and local expertise. C Show 2 more 10. Preventative measures Primary prevention: As per EASL 2023 guidelines: Consider developing educational campaigns towards changing behavior to prevent liver fluke infection and re-infection. C Insufficient evidence to recommend hepatic resection as a strategy to prevent intrahepatic cholangiocarcinoma in patients with hepatolithiasis. I As per BSG 2019 guidelines, do not use UDCA for the prevention of cholangiocarcinoma in patients with PSC. D 11. Follow-up and surveillance Assessment of treatment response: Consider obtaining CA 19-9 for the assessment of treatment response. C https://web.pathway.md/diseases/recJik0Rvwp7Xjjzd 10/13 6/29/23, 3:51 AM Cholangiocarcinoma Pathway Re-assess patients by a multidisciplinary team to discuss surgery in case of response following locoregional or systemic treatment of locally advanced tumors. B Follow-up: As per EASL 2023 guidelines: Obtain liver imaging surveillance to assess recurrence after surgery or interventional procedures with curative intent, with the choice of imaging modality depending on technical issues related to different treatments (such as transarterial chemoembolization, transarterial radioembolization, and surgery). B Consider obtaining CT of the chest, abdomen, and pelvis in addition to any imaging evaluation of the liver since recurrence may occur inside or outside the liver. C As per ESMO 2023 guidelines, follow up patients developing treatment-related complications and cancer recurrence. Consider obtaining surveillance with 3-6 monthly visits during the first 2 years and 6-12-monthly visits for up to 5 years or as clinically indicated. Consider obtaining clinical assessment, laboratory tests, tumor markers, and chest and abdominopelvic CT. B Show 4 more Rehabilitation: consider offering rehabilitation to counteract impairments related to cancer and its treatments to maximize the quality of life in survivorship. B Clinical findings Symptoms Integument exam Abdominal pain Jaundice Dark urine Imaging findings Epigastric pain Fatigue Bile duct stricture Fever Dilated bile ducts Generalized pruritus Loss of appetite Nausea Pale stools RUQ pain Vomiting Weight loss Lab findings serum AFP serum ALP serum CA 19-9 serum CEA serum TBIL https://web.pathway.md/diseases/recJik0Rvwp7Xjjzd 11/13 6/29/23, 3:51 AM Cholangiocarcinoma Pathway serum gamma- Studies 2023 Lidocaine in Hepatectomy In patients undergoing elective hepatectomy, lidocaine was superior to placebo with respect to a moderate-to-severe movement-evoked pain at 24 hour postoperatively. Yan Xu et al. Br J Anaesth. 2023 May 16. 2022 TOPAZ-1 In patients with previously untreated unresectable or metastatic biliary tract cancer or with recurrent disease, durvalumab was superior to placebo with respect to overall survival. Do-Youn Oh et al. NEJM Evid. 2022. References 1. Ga tan-Romain Joliat, Kosuke Kobayashi, Kiyoshi Hasegawa et al. Guidelines for Perioperative Care for Liver Surgery: Enhanced Recovery After Surgery ERAS Society Recommendations 2022. World J Surg. 2023 Jan;47 1 11 34. Open 2. European Association for the Study of the Liver. EASL ILCA Clinical Practice Guidelines on Intrahepatic Cholangiocarcinoma. J Hepatol. 2023 Mar 22;S0168 8278 23 00185 X. Open 3. A Vogel, J Bridgewater, J Edeline et al. Biliary tract cancer: ESMO Clinical Practice Guideline for diagnosis, treatment and follow-up. Ann Oncol. 2023 Feb;34 2 127 140. Open 4. Bashar J Qumseya, Laith H Jamil, Badih Joseph Elmunzer et al. ASGE guideline on the role of endoscopy in the management of malignant hilar obstruction. Gastrointest Endosc. 2021 Aug;94 2 222 234.e22. Open 5. Gonzalo Sapisochin, Milind Javle, Jan Lerut et al. Liver Transplantation for Cholangiocarcinoma and Mixed Hepatocellular Cholangiocarcinoma: Working Group Report From the ILTS Transplant Oncology Consensus Conference. Transplantation. 2020 Jun;104 6 1125 1130. Open 6. J W Valle, I Borbath, S A Khan et al. Biliary cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2016 Sep;27(suppl 5):v28-v37. Open 7. Paul Martin, Andrea DiMartini, Sandy Feng et al. Evaluation for liver transplantation in adults: 2013 practice guideline by the American Association for the Study of Liver Diseases and the American Society of Transplantation. Hepatology. 2014 Mar;59 3 1144 65. Open 8. Chapman MH, Thorburn D, Hirschfield GM et al. British Society of Gastroenterology and UK PSC guidelines for the diagnosis and management of primary sclerosing cholangitis. Gut. 2019 Aug;68 8 1356 1378. Open 9. ASGE Standards of Practice Committee, Terry L Jue, Andrew C Storm et al. ASGE guideline on the role of endoscopy in the management of benign and malignant gastroduodenal obstruction. Gastrointest Endosc. 2021 Feb;93 2 309 322.e4. Open https://web.pathway.md/diseases/recJik0Rvwp7Xjjzd 12/13 6/29/23, 3:51 AM Cholangiocarcinoma Pathway 10. Smith Apisarnthanarax, Aisling Barry, Minsong Cao et al. External Beam Radiation Therapy for Primary Liver Cancers: An ASTRO Clinical Practice Guideline. Pract Radiat Oncol. Jan-Feb 2022;12 1 28 51. Open 11. Jean-Marc Dumonceau, Andrea Tringali, Ioannis S Papanikolaou et al. Endoscopic biliary stenting: indications, choice of stents, and results: European Society of Gastrointestinal Endoscopy ESGE Clinical Guideline Updated October 2017. Endoscopy. 2018 Sep;50 9 910 930. Open 12. Anderson MA, Appalaneni V, Ben-Menachem T et al. The role of endoscopy in the evaluation and treatment of patients with biliary neoplasia. Gastrointest Endosc. 2013 Feb;77 2 167 74. Open 13. Ronan J Kelly, Katherine Bever, Joseph Chao et al. Society for Immunotherapy of Cancer SITC clinical practice guideline on immunotherapy for the treatment of gastrointestinal cancer. J Immunother Cancer. 2023 Jun;11 6):e006658. Open 14. Rachna T Shroff, Erin B Kennedy, Melinda Bachini et al. Adjuvant Therapy for Resected Biliary Tract Cancer: ASCO Clinical Practice Guideline. J Clin Oncol. 2019 Apr 20;37 12 1015 1027. Open 15. European Association for the Study of the Liver. EASL Clinical Practice Guidelines on Sclerosing Cholangitis. J Hepatol. 2022 May 31;S0168 8278 22 00326 9. Open 16. Expert Panel on Interventional Radiology:, Alexandra H Fairchild, Eric J Hohenwalter et al. ACR Appropriateness Criteria Radiologic Management of Biliary Obstruction. J Am Coll Radiol. 2019 May;16 5S S196 S213. Open 17. Christopher L Bowlus, Lionel Arriv , Annika Bergquist et al. AASLD Practice Guidance on Primary Sclerosing Cholangitis and Cholangiocarcinoma. Hepatology. 2022 Sep 9. Open 18. Christopher L Bowlus, Joseph K Lim, Keith D Lindor. AGA Clinical Practice Update on Surveillance for Hepatobiliary Cancers in Patients With Primary Sclerosing Cholangitis: Expert Review. Clin Gastroenterol Hepatol. 2019 Nov;17 12 2416 2422. Open https://web.pathway.md/diseases/recJik0Rvwp7Xjjzd 13/13