Hepatobiliary Flashcards
Fibrolamellar cancer is a variant of HCC, who is it most common in? And how is it treated?
Its most common in women and Asian patients. It has a bimodal age distribution and is seen in a lot of younger patients (18-30). It is treated w/surgical resection
After a patient undergoes surgical resection or ablation of HCC, what is the criteria to give adjuvant therapy and what is it?
Tumor greater than 5cm, more than 3 tumors, macro or micro vascular invasion, grade 3/4. You give Atezolizumab plus Bevacizumab.
What are the resection criteria for HCC?
Solitary mass w/o vascular invasion, Child Pugh A w/o portal HTN (sometimes mild PHTN is okay), adequate future liver remnant (at least 20% w/o cirrhosis and at least 30-40% with Child Pugh A cirrhosis).
What candidates right away should be considered for transplant?
Afp less or equal to 1000, a single lesion of 2 or higher up to 5cm, or 2 or 3 lesions 1-3cm in size. Also no macrovascular disease or extrahepatic dx.
What are the preferred options for first line tx of advanced/metastatic HCC?
Atezolizumab+Bevacizumab or Tremelimumab+Durvalumab (OS benefit only)
What are other Cat 1 options for first line tx for locally advanced/metastatic HCC?
Durvalumab, Lenvatinib, Sorafenib, Tislelizumab
What are the options for 2nd line tx for advanced/metastatic HCC?
Cabozantinib (Cat 1), Regorafenib (Cat 1), Ramucirumab (For AFP of 400 or more, Cat1), Pembro (can be used for MSI-H or MSI low), Ipi/Nivo, can also do Nivo alone.
What is the indication of Dostarlimab in advanced/metastatic HCC?
It is used in 2nd line tx for patients with MSI-H/dMMR
Targeted therapy options in advanced/metastatic disease.
Repotrectinib-first line, Cat 2B
Selpercatinib-2nd line, Cat 2B
For gall bladder cancers that are T1b, T2, T3 that are incidentally found on cholecystectomy what additional management is needed?
They need re-resection to include lymphadenectomy and bile duct resection to achieve a RO resection
Neoadjuvant therapy for gall bladder cancer hasn’t been studied, but NCCN says you can consider it and use the regimens you use in the metastatic setting. Given for 2-6 months.
What is the survival benefit with adjuvant chemo or chemo/RT in gall bladder cancer? What is the Cat 1 rec for this and who do you especially give this to? What can you use for chemo/RT?
There are data that show a survival benefit with either modality. Give in those w/nodal dx. Give up to 6 months. Chemo-Capecitabine (showed OS benefit). Other options-Gem w/Cisplatin or Capecitabine. 5-FU and Capecitabine can be used with RT.
What is the first line tx for advanced/metastatic Gall Bladder cancer?
Gem w/Cisplatin and Durvalumab (Cat 1)
Pembro w/Gem and Cis (Cat 1). You can also do Gem/Cis alone (Cat 1).
What is the preferred 2nd line agent for Gall Bladder cancer that is advanced or metastatic?
FOLFOX is the preferred option. You can also do FOLFIRI and NALIRI (Cat 2B) (liposomal irinotecan, 5-FU, Leucovorin).
Don’t forget that you have targeted therapy as options for metastatic Gall Bladder Cancer
