Non-governmental organization

"NGO" redirects here. For other uses, see NGO (disambiguation).

Non-governmental organization (NGO) is a term that has become widely accepted for referring to a legally constituted, non-governmental organization created by natural or legal persons with no participation or representation of any government. In the cases in which NGOs are funded totally or partially by governments, the NGO maintains its non-governmental status therefore it excludes government representatives from membership in the organization. Unlike the term intergovernmental organization, "non-governmental organization" is a term in generalized use but not a legal definition, in many jurisdictions these type of organizations are defined as "civil society organizations" or alternative terms.

The number of internationally operating NGOs is estimated at 40,000.^[1] National numbers are even higher: Russia has 277,000 NGOs.^[2] India is estimated to have between 1 million and 2 million NGOs.^[3]

Contents [hide] 1 History 2 Types of NGOs 3 Methods 3.1 Public relations 3.2 Consulting 3.3 Project management 4 Staffing 5 Funding 6 Monitoring and control 7 Legal status 8 Citizen organization 9 See also 10 Notes and references 11 Further reading 12 External links

[edit] History

International non-governmental organizations have a history dating back to at least 1839.^[4] Rotary, later Rotary International, was founded in 1904. It has been estimated that by 1914 there were 1083 NGOs.^[5] International NGOs were important in the anti-slavery movement and the movement for women's suffrage, and reached a peak at the time of the World Disarmament Conference.^[6] However, the phrase "non-governmental organization" only came into popular use with the establishment of the United Nations Organization in 1945 with provisions in Article 71 of Chapter 10 of the United Nations Charter^[7] for a consultative role for organizations which are neither governments nor member states—see Consultative Status. The definition of "international NGO" (INGO) is first given in resolution 288 (X) of ECOSOC on February 27, 1950: it is defined as "any international organization that is not founded by an international treaty". The vital role of NGOs and other "major groups" in sustainable development was recognized in Chapter 27^[8] of Agenda 21, leading to intense arrangements for a consultative relationship between the United Nations and non-governmental organizations.^[9]

Rapid development of nongovernmental sector occurred in western countries as a result of the processes of restructurization of the welfare state. Further globalisation of that process occurred after a fall of communist system and was important part of Washington consensus ^[10].

Globalization during the 20th century gave rise to the importance of NGOs. Many problems could not be solved within a nation. International treaties and international organizations such as the World Trade Organization were perceived as being too centred on the interests of capitalist enterprises. Some argued that in an attempt to counterbalance this trend, NGOs have developed to emphasize humanitarian issues, developmental aid and sustainable development. A prominent example of this is the World Social Forum which is a rival convention to the World Economic Forum held annually in January in Davos, Switzerland. The fifth World Social Forum in Porto Alegre, Brazil, in January 2005 was attended by representatives from more than 1,000 NGOs.^{[citation needed]} Some have argued that in forums like these, NGOs take the place of what should belong to popular movements of the poor. Others argue that NGOs are often imperialist in nature, that they sometimes operate in a racialized manner in dominated countries, and that they fulfill a similar function to that of the clergy during the high colonial era. The philosopher Peter Hallward argues that they are an aristocratic form of politics. ^[11] Whatever the case, NGO transnational networking is now extensive.^[12]

[edit] Types of NGOs

Apart from "NGO", often alternative terms are used as for example: independent sector, volunteer sector, civil society, grassroots organizations, transnational social movement organizations, private voluntary organizations, self-help organizations and non-state actors (NSA's).

Non-governmental organizations are a heterogeneous group. A long list of acronyms has developed around the term "NGO". See

These include:

• BINGO is short for business-oriented international NGO, or big international NGO;
• CSO, short for civil society organization;
• DONGO: Donor Organized NGO;
• ENGO: short for environmental NGO, such as Global 2000;
• GONGOs are government-operated NGOs, which may have been set up by governments to look like NGOs in order to qualify for outside aid or promote the interests of the government in question;
• INGO stands for international NGO; Education charter international is an international NGO
• QUANGOs are quasi-autonomous non-governmental organizations, such as the International Organization for Standardization (ISO). (The ISO is actually not purely an NGO, since its membership is by nation, and each nation is represented by what the ISO Council determines to be the 'most broadly representative' standardization body of a nation. That body might itself be a nongovernmental organization; for example, the United States is represented in ISO by the American National Standards Institute, which is independent of the federal government. However, other countries can be represented by national governmental agencies; this is the trend in Europe.)
• TANGO: short for technical assistance NGO;
• GSO: Grassroots Support Organization
• MANGO: short for market advocacy NGO

There are also numerous classifications of NGOs. The typology the World Bank uses divides them into Operational and Advocacy:^[13]

The primary purpose of an operational NGO is the design and implementation of development-related projects. One frequently used categorization is the division into :relief-oriented: or :development-oriented: organizations; they can also be classified according to whether they stress service delivery or participation; or whether they are religious or secular; and whether they are more public or private-oriented. Operational NGOs can be community-based, national or international.

The primary purpose of an Advocacy NGO is to defend or promote a specific cause. As opposed to operational project management, these organizations typically try to raise awareness, acceptance and knowledge by lobbying, press work and activist events.

USAID refers to NGOs as private voluntary organisations. However many scholars have argued that this definition is highly problematic as many NGOs are in fact state and corporate funded and managed projects with professional staff.^{[citation needed]} Furthermore it has often been argued that USAID is in fact a key arm of American imperialism and that it sets up and supports NGOs in order to further imperial agendas. ^[14]

NGOs exist for a variety of reasons, usually to further the political or social goals of their members or funders. Examples include improving the state of the natural environment, encouraging the observance of human rights, improving the welfare of the disadvantaged, or representing a corporate agenda. However, there are a huge number of such organizations and their goals cover a broad range of political and philosophical positions. This can also easily be applied to private schools and athletic organizations.

[edit] Methods

NGOs vary in their methods. Some act primarily as lobbyists, while others conduct programs and activities primarily. For instance, an NGO such as Oxfam, concerned with poverty alleviation, might provide needy people with the equipment and skills to find food and clean drinking water, whereas an NGO like the FFDA helps through investigation and documentation of human rights violations and provides legal assistance to victims of human rights abuses.

[edit] Public relations

Non-governmental organizations need healthy relationships with the public to meet their goals. Foundations and charities use sophisticated public relations campaigns to raise funds and employ standard lobbying techniques with governments. Interest groups may be of political importance because of their ability to influence social and political outcomes.

[edit] Consulting

Many international NGOs have a consultative status with United Nations agencies relevant to their area of work. As an example, the Third World Network has a consultative status with the UN Conference on Trade and Development (UNCTAD) and the UN Economic and Social Council (ECOSOC). While in 1946, only 41 NGOs had consultative status with the ECOSOC, by 2003 this number had risen to 3,550.

[edit] Project management

There is an increasing awareness that management techniques are crucial to project success in non-governmental organizations.^[15] Generally, non-governmental organizations that are private have either a community or environmental focus. They address varieties of issues such as religion, emergency aid, or humanitarian affairs. They mobilize public support and voluntary contributions for aid; they often have strong links with community groups in developing countries, and they often work in areas where government-to-government aid is not possible. NGOs are accepted as a part of the international relations landscape, and while they influence national and multilateral policy-making, increasingly they are more directly involved in local action.

[edit] Staffing

Not all people working for non-governmental organizations are volunteers. The reasons people volunteer are not necessarily purely altruistic, and can provide immediate benefits for themselves as well as those they serve, including skills, experience, and contacts.

There is some dispute as to whether expatriates should be sent to developing countries. Frequently this type of personnel is employed to satisfy a donor who wants to see the supported project managed by someone from an industrialized country. However, the expertise these employees or volunteers may have can be counterbalanced by a number of factors: the cost of foreigners is typically higher, they have no grassroot connections in the country they are sent to, and local expertise is often undervalued.^[13]

The NGO sector is an important employer in terms of numbers.^{[citation needed]} For example, by the end of 1995, CONCERN worldwide, an international Northern NGO working against poverty, employed 174 expatriates and just over 5,000 national staff working in ten developing countries in Africa and Asia, and in Haiti.

[edit] Funding

Large NGOs may have annual budgets in the hundreds of millions or billions of dollars. For instance, the budget of the American Association of Retired Persons (AARP) was over US$540 million in 1999.^[16]. Funding such large budgets demands significant fundraising efforts on the part of most NGOs. Major sources of NGO funding include membership dues, the sale of goods and services, grants from international institutions or national governments, and private donations. Several EU-grants provide funds accessible to NGOs.

Even though the term "non-governmental organization" implies independence from governments, most NGOs depend heavily on governments for their funding^[10]. A quarter of the US$162 million income in 1998 of the famine-relief organization Oxfam was donated by the British government and the EU. The Christian relief and development organization World Vision collected US$55 million worth of goods in 1998 from the American government. Nobel Prize winner Médecins Sans Frontières (MSF) (known in the USA as Doctors Without Borders) gets 46% of its income from government sources.^[17]

[edit] Monitoring and control

In a March 2000 report on United Nations Reform priorities, former U.N. Secretary General Kofi Annan wrote in favor of international humanitarian intervention, arguing that the international community has a "right to protect" citizens of the world against ethnic cleansing, genocide, and crimes against humanity. On the heels of the report, the Canadian government launched the Responsibility to Protect R2PPDF (434 KiB) project, outlining the issue of humanitarian intervention. While the R2P doctrine has wide applications, among the more controversial has been the Canadian government's use of R2P to justify its intervention and support of the coup in Haiti.^{[citation needed]}

Years after R2P, the World Federalist Movement, an organization which supports "the creation of democratic global structures accountable to the citizens of the world and call for the division of international authority among separate agencies", has launched Responsibility to Protect - Engaging Civil Society (R2PCS). A collaboration between the WFM and the Canadian government, this project aims to bring NGOs into lockstep with the principles outlined under the original R2P project.

The governments of the countries an NGO works or is registered in may require reporting or other monitoring and oversight. Funders generally require reporting and assessment, such information is not necessarily publicly available. There may also be associations and watchdog organizations that research and publish details on the actions of NGOs working in particular geographic or program areas.^{[citation needed]}

In recent years, many large corporations have increased their corporate social responsibility departments in an attempt to preempt NGO campaigns against certain corporate practices. As the logic goes, if corporations work with NGOs, NGOs will not work against corporations.

In December 2007, The United States Department of Defense Assistant Secretary of Defense (Health Affairs) [1] established an International Health Division under Force Health Protection & Readiness [2]. Part of International Health's mission is to communicate with NGOs in areas of mutual interest. Department of Defense Directive 3000.05 [3], in 2005, requires DoD to regard stability-enhancing activities as a mission of importance equal to warfighting. In compliance with international law, DoD has necessarily built a capacity to improve essential services in areas of conflict such as Iraq, where the customary lead agencies (State Department and USAID) find it difficult to operate. Unlike the "co-option" strategy described for corporations, the OASD(HA) recognizes the neutrality of health as an essential service. International Health cultivates collaborative relationships with NGOs, albeit at arms-length, recognizing their traditional independence, expertise and honest broker status. While the goals of DoD and NGOs may seem incongruent, the DoD's emphasis on stability and security to reduce and prevent conflict suggests, on careful analysis, important mutual interests.

[edit] Legal status

The legal form of NGOs is diverse and depends upon homegrown variations in each country's laws and practices. However, four main family groups of NGOs can be found worldwide:^[18]

• Unincorporated and voluntary association
• Trusts, charities and foundations
• Companies not just for profit
• Entities formed or registered under special NGO or nonprofit laws

NGOs are not subjects of international law, as states are. An exception is the International Committee of the Red Cross, which is subject to certain specific matters, mainly relating to the Geneva Convention.

The Council of Europe in Strasbourg drafted the European Convention on the Recognition of the Legal Personality of International Non-Governmental Organizations in 1986, which sets a common legal basis for the existence and work of NGOs in Europe. Article 11 of the European Convention on Human Rights protects the right to freedom of association, which is also a fundamental norm for NGOs.

[edit] Citizen organization

There is a growing movement within the “non”-profit and “non”-government sector to define itself in a more constructive, accurate way. Instead of being defined by “non” words, organizations are suggesting new terminology to describe the sector. The term “civil society organization” (CSO) has been used by a growing number of organizations, such as the Center for the Study of Global Governance. ^[19] The term “citizen sector organization” (CSO) has also been advocated to describe the sector — as one of citizens, for citizens.^[20] This labels and positions the sector as its own entity, without relying on language used for the government or business sectors. However some have argued that this is not particularly helpful given that most NGOs are in fact funded by governments and business and that some NGOs are clearly hostile to independently organized people's organizations.^[10][21]

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Bead

A bead is a small, decorative object that is pierced for threading or stringing. Beads range in size from under a millimeter to over a centimeter or sometimes several centimeters in diameter.

Glass, plastic, and stone are probably the most common materials, but beads are also made from bone, horn, ivory, metal, shell, pearl, coral, gemstones, polymer clay, metal clay, resin, synthetic minerals, wood, ceramic, fiber, paper, and seeds.

A pair of beads made from Nassarius sea snail shells, approximately 100,000 years old, are thought to be the earliest known examples of jewellery. ^[1][2]

Beadwork is the art or craft of making things with beads. Beads can be woven together with specialized thread, strung onto thread or wire, or adhered to a surface (e.g. fabric, clay).

Beads

Types of beads

Types of decorative beads include:

• Bugle beads
• Chevron beads
• Cloisonné beads
• Dichroic beads
• Ethnic beads
• Faux natural beads
• Fire-polished beads
• Furnace glass beads
• Fused glass beads
• Fusible beads
• Lampwork beads
• Lead crystal beads
• Lucite beads
• Millefiori beads
• Pressed glass beads
• Seed beads
• Trade beads or Slave beads
• Tagua Beads
• Vintage Beads

[edit] Chevron beads

Main article: Chevron bead

Chevron Beads are special glass beads, originally made for trade in the New World and the slave trade in Africa by glassmakers in Italy as far back as the early 15th century. They are composed of many consecutive layers of colored glass. The initial core is formed in a star-shaped mold, and can have anywhere between five and fifteen points. The next layer of glass conforms to that star shape. Several layers of glass can be applied (typically four to seven layers), either star-shaped or smooth. After all layers have been applied, the glass is drawn out to the desired thickness and when cooled, cut into short segments showing the resulting star pattern at their ends. The ends can be ground to display the chevron pattern. Chevron beads are traditionally composed of red, blue, and white layers, but modern chevrons can be found in any color combination. Original beads made for trade to the New World and Africa were typically composed of green, white, blue and red layers.

[edit] Dichroic glass beads

Increasingly, dichroic glass is being used to produce high-end art beads. Dichroic glass has a thin film of metal fused to the surface of the glass, resulting in a surface that has a metallic sheen that changes between two colors when viewed at different angles. Beads can be fused, pressed, or made with traditional lampworking techniques. The metal coating used was originally developed by NASA for the space program.

[edit] Ethnic beads, including stone beads

Carved Cinnabar lacquer beads

Other beads considered trade beads are those made in West Africa, by and for Africans, such as Mauritanian Kiffa beads, and Ghanaian and Nigerian powder glass beads. Other ethnic beads include Tibetan Dzi beads and African-made brass beads. Rudraksha beads are seeds that are customary in India for making Buddhist and Hindu rosaries (malas). Magatama are traditional Japanese beads, and cinnabar was often used for beads in China. Wampum are cylindrical white or purple beads made from quahog or North Atlantic channeled whelk shells by northeastern Native American tribes, such as the Wampanoag and Shinnecock.^[3]

[edit] Faux natural beads

Often beads are made to look like a more expensive original material, especially in the case of fake pearls and simulated rocks, minerals, and gemstones. Precious metals and ivory are also imitated.

Tagua nuts from South American are used as an ivory substitute since the natural ivory trade has been restricted worldwide.

Fire polished beads (10 millimetres (0.39 in)) with AB coating

[edit] Fire-polished beads

"Fire-polished" beads are faceted glass beads made in the Czech Republic. They are faceted by machine and then drawn through ovens to make the surfaces molten, and thus shiny when the beads cool. This method of "polishing" is faster and cheaper than buffing and results in a reasonably attractive bead, though generally less perfect than buffed beads. Czech fire-polish beads are made in an area called Jablonec nad Nisou. Production of glass beads in the area dates back to the 14th century, though production was depressed under communist rule. They commonly come in sizes from 3 millimetres (0.12 in) to 22 millimetres (0.87 in).

[edit] Furnace glass beads

Furnace glass beads

Furnace glass beads are a special type of art bead. They are made using traditional glassworking techniques from Italy that are more often used to make art glass objects. The manufacture of these beads requires a large glass furnace and annealing kiln.

Furnace glass beads, also called cane glass beads, are sliced from long glass rods, often decorated with stripes and other color, also known as canes.

[edit] Lampwork beads

Main article: Lampworking

Lampwork beads are made by using a torch to heat a rod of glass and spinning the resulting thread around a metal rod covered in bead release. When the base bead has been formed, other colors of glass can be added to the surface to create many designs.

[edit] Lead crystal beads

Swarovski crystal beads (6 mm–8 mm), pendant 3 cm

Lead crystal beads (also known as machine cut crystal) are cut crystal beads made with hi-tech precise machinery. Thanks to this state of the art machine cut processing the crystal items achieve outstanding geometry and excellent optical parameters. Many lead crystal beads are enhanced with surface coatings. Aurora Borealis, or AB, is a very common surface coating that diffuses light into a rainbow. Other common surface coatings are vitrail, moonlight, dorado, satin, star shine, heliotrope.

Swarovski along with Preciosa branded crystal beads are prized by jewelers and hobbyists. They are a high-lead content crystal although today production of lead-free crystal is common. Lead crystals have an incredible sparkle and clarity, and are often multi-faceted to resemble gemstones. Styles and colors go in and out of production, so vintage cuts and colors are often prized with a similarly associated price tag. Swarovski along with Preciosa bicones are the most popular crystal beads in sizes 4 mm and 6 mm. Other Czech companies such as PAS Jablonec make similar styles of crystal beads.

[edit] Lucite beads

Lucite is a term that commonly refers to many plastic beads. However, Lucite is one of the many name brands used to describe Poly(methyl methacrylate) (PMMA) or poly(methyl 2-methylpropenoate) the synthetic polymer of methyl methacrylate. Lucite methyl methacrylate polymer was among the first plastics derived from petrochemicals. DuPont chemists discovered Lucite in 1931 while exploring the high-pressure technology developed for ammonia production. The polymer’s crystal-clear appearance and its strength were far superior to nitrocellulose-based plastics. Lucite was in heavy demand during World War II for use in windshields, nose cones, and gunner turrets for bombers and fighter planes. After the war, DuPont marketed it for use in a variety of decorative and functional uses, such as lamps, hairbrushes and jewelry.

[edit] Millefiori beads

Main article: Millefiori

The millefiori technique involves the production of glass canes or rods, known as murrine, with multicolored patterns which are viewable only from the cut ends of the cane. Millefiori beads are made of plain wound glass bead cores and thin slices of cut cane (murrine) which are being pressed into the bead surface, forming mosaic-like patterns, while the glass is still hot. Another name for Millefiori bead is mosaic bead.

[edit] Pressed glass beads

Pressed glass beads (matte finish with an AB coating)

Pressed glass beads are formed by pressing the hot glass into mold to give the bead its shape. Often pressed beads are made using machines that stamp the shape from the molten glass. The shapes can have holes punched in virtually any direction. The Czech Republic is the primary producer of pressed beads, although India and China also produce significant amounts.

[edit] Seed beads

Main article: Seed bead

Seed beads are uniformly shaped spheroidal or tube shaped beads ranging in size from under a millimetre to several millimetres. "Seed Bead" is a generic term for any small bead. Usually rounded in shape, seed beads are most commonly used for loom and off-loom bead weaving.

[edit] Tagua beads

Main article: Tagua

The ivory-nut palm, Phytelephas aequatorialis, is a plant that can be harvested for vegetable ivory. It is often used for beads, buttons, and jewelry, and can be dyed. The beads can take a form of the whole Tagua nut or various slices, beads and shapes carved and cut from raw Tagua nuts. In its natural form Tagua resembles Ivory and hence the name vegetable ivory is sometimes used to describe it. However unlike Elephant ivory Tagua is completely eco-friendly.

[edit] Trade beads or Slave beads

Main article: Slave beads

Trade beads are various types of beads made in Europe specifically to be used in the slave trade and other trading in Africa. Chevron beads are a specific, historically important type of trade bead. Africa was not the only outlet for these beads. As far back as Christopher Columbus' expeditions, these beads were traded to Native Americans for goods and slaves.

[edit] Vintage Beads

"Vintage", in the collectibles & antique market, is a term used to refer to an item that is 25 or more years old. This term and its meaning has been widely adopted in the bead industry as well. Vintage beads are available in a variety of materials including lucite, plastic, crystal, metal and glass.

[edit] Fusible beads

Fusible beads in many different solid colors

Also known as Perler Beads, sometimes called "melty beads" by young children, these small, plastic and colorful beads are placed on a peg array with a solid plastic backing to form pictures and designs and then melted together with a clothes iron. Fusible beads come in many different opaque colors, transparent colors and with sparkles (flakes inside the plastic) and peg boards come in various shapes (e.g. figures) and squares and rectangles. They also can be strung into necklaces or bracelets, or even woven into keychains.

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2009 swine flu outbreak A/H1N1 virus

The 2009 swine flu outbreak is an epidemic of a new strain of Influenza A virus subtype H1N1 identified in April 2009. It is thought to be a mutation (reassortment) of four known strains of influenza A virus subtype H1N1: one endemic in humans, one endemic in birds, and two endemic in pigs (swine).^[59] A June 10th update by the U.N.'s World Health Organization (WHO) states that "74 countries have officially reported 27,737 cases of influenza A(H1N1) infection, including 141 deaths."^[60]

The outbreak began in Mexico, where early reports indicated a surge of cases that had already killed at least 81 people by April 26. As a result, WHO and the U.S. Centers for Disease Control and Prevention (CDC) expressed concern that this could become a worldwide flu pandemic, with WHO raising its alert level to Phase 5 out of the six maximum, indicating that a flu pandemic is "imminent". Most cases throughout the world have so far been mild relative to seasonal flu.^[61] But because this is a new virus, most people do not have immunity to it, and illness may eventually become more severe and widespread in different demographic and population groups. This new H1N1 flu mainly spreads in humans in the same way that regular seasonal influenza spreads, which is through the air from coughs and sneezes or touching those infected. It cannot be transmitted from eating properly cooked pork.^[62]

There was no vaccine available to prevent infection as of June 2009^[update], although companies were developing one and estimates of availability ranged from three to six months. There is also concern that the virus could mutate over the coming months to a more dangerous flu outbreak later in the year, and a vaccine produced now might be less effective in preventing its spread. Health officials in the U.S. pointed out that the "terrible experience" of the 1918 flu pandemic, which killed approximately 600,000 in the United States alone, was preceded by a mild "herald" wave of cases in the spring.^[63]

By early June, most of the deaths from the illness had taken place in Mexico. This led to speculation that Mexico may have been in the midst of an unrecognized epidemic for months prior to the current outbreak, thereby showing a fatality rate that was much higher than it would have been if earlier cases had been counted. According to the CDC, the fact that the flu's infection activity is now monitored more closely may also help explain why more flu cases than normal are being recorded in many countries.^[63]

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Cholangiocarcinoma

Cholangiocarcinoma is a cancer of the bile ducts which drain bile from the liver into the small intestine. Other biliary tract cancers include pancreatic cancer, gall bladder cancer, and cancer of the ampulla of Vater. Cholangiocarcinoma is a relatively rare adenocarcinoma, with an annual incidence of 1–2 cases per 100,000 in the Western world,^[1] but rates of cholangiocarcinoma have been rising worldwide over the past several decades.^[2]

Prominent symptoms of cholangiocarcinoma include abnormal liver function tests, abdominal pain, jaundice, weight loss, and sometimes generalized itching, fever, or changes in stool or urine color. The disease is diagnosed through a combination of blood tests, imaging, endoscopy, and sometimes surgical exploration. Cholangiocarcinoma is often in an advanced stage by the time symptoms develop, which may limit treatment options. Known risk factors for cholangiocarcinoma include primary sclerosing cholangitis (an inflammatory disease of the bile ducts), congenital liver malformations, infection with the parasitic liver flukes Opisthorchis viverrini or Clonorchis sinensis, and exposure to Thorotrast (thorium dioxide), a chemical formerly used in medical imaging. However, most patients with cholangiocarcinoma have no specific risk factors.

Cholangiocarcinoma is considered to be an incurable and rapidly lethal disease unless all of its tumors can be fully resected (that is, cut out surgically). There is no potentially curative treatment except surgery, but unfortunately most patients have advanced and inoperable disease at the time of diagnosis. Patients with cholangiocarcinoma are generally managed, though never cured, with chemotherapy or radiation therapy as well as palliative care measures, and these are also used as adjuvant therapies post-surgically in cases where resection has been successful. Some areas of ongoing medical research in cholangiocarcinoma include the use of newer targeted therapies (such as erlotinib) or photodynamic therapy for treatment, and the concentration of byproducts of cancer stromal cell formation in the blood for diagnosis.

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Staging

Although there are at least three staging systems for cholangiocarcinoma (e.g. Bismuth, Blumgart, American Joint Committee on Cancer) none have been shown to be useful in predicting survival.^[3] The most important staging issue is whether the tumor can be surgically removed, or whether it is too advanced or invasive for surgical treatment. Often, this determination can only be made at the time of surgery.^[4]

General guidelines for operability include:^[5][6]

• Absence of lymph node or liver metastases
• Absence of involvement of the portal vein
• Absence of direct invasion of adjacent organs
• Absence of widespread metastatic disease

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Symptoms

The most common physical indications of cholangiocarcinoma are abnormal liver function tests, jaundice (yellowing of the eyes and skin), which occurs only when bile ducts are blocked by the tumor, abdominal pain (30%–50%), generalized itching (66%), weight loss (30%–50%), fever (up to 20%), or changes in stool or urine color.^[7][8] To some extent, the symptoms depend upon the location of the tumor: Patients with cholangiocarcinoma in the extrahepatic bile ducts (outside the liver) are more likely to have jaundice, while those with tumors of the bile ducts within the liver often have pain without jaundice.^[9]

Blood tests of liver function in patients with cholangiocarcinoma often reveal a so-called "obstructive picture," with elevated bilirubin, alkaline phosphatase, and gamma glutamyl transferase levels, and relatively normal transaminase levels. Such laboratory findings suggest obstruction of the bile ducts, rather than inflammation or infection of the liver, as the primary cause of the jaundice.^[4] CA19-9 is elevated in most cases.

[edit] Risk factors

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Risk factors

Although most patients present without any known risk factors evident, a number of risk factors for the development of cholangiocarcinoma have been described; in the Western world, the most common of these is primary sclerosing cholangitis (PSC), an inflammatory disease of the bile ducts which is in turn closely associated with ulcerative colitis (UC).^[10] Epidemiologic studies have suggested that the lifetime risk of developing cholangiocarcinoma for a person with PSC is 10%–15%,^[11] although autopsy series have found rates as high as 30% in this population.^[12] The mechanism by which PSC increases the risk of cholangiocarcinoma is not well understood.

Certain parasitic liver diseases may be risk factors as well. Colonization with the liver flukes Opisthorchis viverrini (found in Thailand, Laos, and Malaysia) or Clonorchis sinensis (found in Japan, Korea, and Vietnam) has been associated with the development of cholangiocarcinoma.^[13][14][15] Patients with chronic liver disease, whether in the form of viral hepatitis (e.g. hepatitis B or C),^[16][17][18] alcoholic liver disease, or cirrhosis from other causes, are at increased risk of cholangiocarcinoma.^[19][20] HIV infection was also identified in one study as a potential risk factor for cholangiocarcinoma, although it was unclear whether HIV itself or correlated factors (e.g. hepatitis C infection) were responsible for the association.^[19]

Congenital liver abnormalities, such as Caroli's syndrome or choledochal cysts, have been associated with an approximately 15% lifetime risk of developing cholangiocarcinoma.^[21][22] The rare inherited disorders Lynch syndrome II and biliary papillomatosis are associated with cholangiocarcinoma.^[23][24] The presence of gallstones (cholelithiasis) is not clearly associated with cholangiocarcinoma. However, intrahepatic stones (so-called hepatolithiasis), which are rare in the West but common in parts of Asia, have been strongly associated with cholangiocarcinoma.^[25][26][27] Exposure to Thorotrast, a form of thorium dioxide which was used as a radiologic contrast medium, has been linked to the development of cholangiocarcinoma as late as 30–40 years after exposure; Thorotrast was banned in the United States in the 1950s due to its carcinogenicity.^[28][29]

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Pathophysiology

Cholangiocarcinoma can affect any area of the bile ducts, either within or outside the liver. Tumors occurring in the bile ducts within the liver are referred to as intrahepatic; those occurring in the ducts outside the liver are extrahepatic; and tumors occurring at the site where the bile ducts exit the liver may be referred to as perihilar. A cholangiocarcinoma occurring at the junction where the left and right hepatic ducts meet to form the common bile duct may be referred to eponymously as a Klatskin tumor.^[30]

Although cholangiocarcinoma is known to be an adenocarcinoma of the epithelial cells lining the biliary tract, the actual cell of origin is unknown, although recent evidence has suggested that it may arise from a pluripotent hepatic stem cell.^[31][32][33] Cholangiocarcinoma is thought to develop through a series of stages — from early hyperplasia and metaplasia, through dysplasia, to the development of frank carcinoma — in a process similar to that seen in the development of colon cancer.^[34] Chronic inflammation and obstruction of the bile ducts, and the resulting impaired bile flow, are thought to play a role in this progression.^[34][35][36]

Histologically, cholangiocarcinomas may vary from undifferentiated to well-differentiated. They are often surrounded by a brisk fibrotic or desmoplastic tissue response; in the presence of extensive fibrosis, it can be difficult to distinguish well-differentiated cholangiocarcinoma from normal reactive epithelium. There is no entirely specific immunohistochemical stain that can distinguish malignant from benign biliary ductal tissue, although staining for cytokeratins, carcinoembryonic antigen, and mucins may aid in diagnosis.^[37] Most tumors (>90%) are adenocarcinomas.^[38]

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Diagnosis

Cholangiocarcinoma is definitively diagnosed from tissue, i.e. it is proven by biopsy or examination of the tissue excised at surgery. It may be suspected in a patient with obstructive jaundice. Considering it as the working diagnosis may be challenging in patients with primary sclerosing cholangitis (PSC); such patients are at high risk of developing cholangiocarcinoma, but the symptoms may be difficult to distinguish from those of PSC. Furthermore, in patients with PSC, such diagnostic clues as a visible mass on imaging or biliary ductal dilatation may not be evident.

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Blood tests

There are no specific blood tests that can diagnose cholangiocarcinoma by themselves. Serum levels of carcinoembryonic antigen (CEA) and CA19-9 are often elevated, but are not sensitive or specific enough to be used as a general screening tool. However, they may be useful in conjunction with imaging methods in supporting a suspected diagnosis of cholangiocarcinoma.^[39]

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Abdominal imaging

Ultrasound of the liver and biliary tree is often used as the initial imaging modality in patients with suspected obstructive jaundice.^[40][41] Ultrasound can identify obstruction and ductal dilatation and, in some cases, may be sufficient to diagnose cholangiocarcinoma.^[42] Computed tomography (CT) scanning may also play an important role in the diagnosis of cholangiocarcinoma.^[43][44][45]

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Imaging of the biliary tree

While abdominal imaging can be useful in the diagnosis of cholangiocarcinoma, direct imaging of the bile ducts is often necessary. Endoscopic retrograde cholangiopancreatography (ERCP), an endoscopic procedure performed by a gastroenterologist or specially trained surgeon, has been widely used for this purpose. Although ERCP is an invasive procedure with attendant risks, its advantages include the ability to obtain biopsies and to place stents or perform other interventions to relieve biliary obstruction.^[4] Endoscopic ultrasound can also be performed at the time of ERCP and may increase the accuracy of the biopsy and yield information on lymph node invasion and operability.^[46] As an alternative to ERCP, percutaneous transhepatic cholangiography (PTC) may be utilized. Magnetic resonance cholangiopancreatography (MRCP) is a non-invasive alternative to ERCP.^[47][48][49] Some authors have suggested that MRCP should supplant ERCP in the diagnosis of biliary cancers, as it may more accurately define the tumor and avoids the risks of ERCP.^[50][51][52]

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