Biliary/HCC

Question 1

Localized cholangio treatment

Answer 1

Resection with lymphadenectomy
Adjuvant chemo or chemoRT for positive margins or N+

Chemo = 5-FU/capecitabine +/- cisplatin/oxaliplatin

Question 2

Incidental gallbladder cancer treatment

Answer 2

Need re-resection of adjacent liver segment + lymphadenectomy, except for stage 1 disease

Stage 1 = invades lamina propria or muscular layer, no nodes

Question 3

1st line metastatic biliary treatment

Answer 3

Gem/cis

Can substitute oxaliplatin if cis-ineligible

Question 4

2nd line metastatic biliary treatment

Answer 4

FOLFOX

Question 5

Cholangio with FGFR2 fusion/rearrangement treatment

Answer 5

Can use pemigatinib 2nd line or later

Question 6

Cholangio with IDH1 mutation treatment

Answer 6

Can use ivosidenib in 2nd or 3rd line

Question 7

Localized HCC criteria for transplant

Answer 7

1 tumor 2-5cm or 2-3 tumors each < 3cm
No macrovascular involvement
No extrahepatic disease

Question 8

Localized HCC criteria for resection

Answer 8

Child-pugh class A (no ascites, no encephalopathy, bili < 2, albumin > 3.5, INR <1.7)
No portal HTN
Suitable tumor location
Adequate liver reserve

Question 9

Unresectable localized HCC treatment

Answer 9

Ablative therapies (TACE/TARE, RFA, EBRT)
Tumors >5cm treat with arterially directed therapy, RT, or systemic therapy

No role for adjuvant sorafenib after ablation

Question 10

1st line advanced HCC treatment options

Answer 10

Atezo + bev
Lenvatinib
Sorafenib

All drugs for Child-Pugh class A only
Consider nivo for child-pugh class B

Question 11

2nd line advanced HCC treatment options

Answer 11

For patients who progressed on sorafenib:

• Regorafenib
• Ramucirumab if AFP > 400
• Nivolumab

Others:

• Lenvatinib
• Sorafenib

Question 12

3rd line advanced HCC treatment

Answer 12

Cabo (approved after sorafenib + 1 other systemic therapy and only for patients who tolerated sorafenib at least 400mg/day)