Treatment/Prognosis Flashcards
What % of CC and GB cancers are potentially resectable Dz at presentation?
Intrahepatic: 30%–90%
Hilar: ∼50%
Distal extrahepatic: 80%–90%
GB cancer: 10%–30% of preoperatively diagnosed pts (most are incidentally diagnosed)
What is the classification system used to determine resectability of hilar CC?
Bismuth classification; type IV is unresectable
Type I/II: involving CBD without involving left/right hepatic ducts
Type III: involving either left or right hepatic duct in addition to CBD
Type IV: involves both left and right hepatic ducts
What is the surgical approach for each subtype of CC and GB cancer?
The surgical approach depends on site:
Intrahepatic: usually requires a lobectomy.
Hilar: at least lobectomy, resection of extrahepatic bile duct, roux-en-Y hepaticojejunostomy, and LN staging.
Distal extrahepatic: pancreaticoduodenectomy (Whipple) with LN staging
GB cancer: extended cholecystectomy with LN staging
When is a routine cholecystectomy sufficient Sg for an incidentally diagnosed GB cancer?
Following cholecystectomy for presumed benign Dz, pts with T1a (not beyond the lamina propria) GB cancer do not require a 2nd oncologic resection. 5-yr OS rates approach 100%.
How is an extended cholecystectomy different from a routine cholecystectomy?
Extended cholecystectomy should include en bloc resection of GB, liver segments IVb and V, and regional LN dissection.
What 2nd Sg should be performed after ≥T1b GB cancer is discovered on cholecystectomy?
After cholecystectomy for presumed benign Dz, pts with incidental ≥T1b GB cancer require radical re-resection of the GB bed (2-cm margins), regional nodes, and port sites.
Is liver transplantation more appropriate for IHCC or for EHCC?
Liver transplantation is generally contraindicated for IHCC (d/t poor outcomes); transplantation shows promise in well-selected, early-stage, hilar/extrahepatic Dz. (Rea DJ et al., Ann Surg 2005)
What is the 5-yr survival for pts after resection +/- RT or CRT?
IHCC: 17%–40% (MS 26–37 mos)
Hilar CC: 10%–35% (MS 14–37 mos)
Distal EHCC: 23%–50% (MS 18–36 mos)
GB cancer (T3–T4): 0%–45% (MS 23–58 mos)
What prospective data exist supporting adj CRT in CC or GB cancer?
Adj Gem + cape × 4 cycles f/b concurrent cape + EBRT to 45 Gy to LN and 54–59.4 Gy to tumor bed resulted in MS of 35 mos in the SWOG 0809 phase II trial of pT2–4 or N+ EHCC and GB cancer. (Ben-Josef E et al., JCO 2015)
What is the recommended adj Tx for localized GB cancer?
Acceptable options for R0 resections include observation, 5-FU–based CRT, 5-FU or gemcitabine-based chemo alone, or clinical trial enrollment. Retrospective series and meta-analyses suggest that adj CRT or chemo alone may benefit resected GB cancer pts. Pts with N+, R1, or > stage I pts deriving the most benefit. (Kresl JJ et al., IJROBP 2002; Ben-David MA et al., IJROBP 2006; Czito BG et al., IJROBP 2005; Yu JB et al., JCO 2008; Gold DJ et al., IJROBP 2009; Horgan AM et al., JCO 2012; Yamanaka K et al., Int JCO 2015; Ma N et al., BMC Cancer 2015; McNamara MG et al., Am JCO 2015)
What is the Tx approach for localized, unresectable GB cancer?
The approach is similar to unresectable pancreatic cancer: a combination of systemic chemo alone and/or CRT. Gemcitabine and cisplatin is the reference systemic regimen.
What is the recommended adj Tx for localized, resectable CC with good PS?
Single-institution series suggest that 5-FU or gemcitabine-based CRT is an appropriate adj Tx for localized resectable CC. (Hughes MA et al., IJROBP 2007; Nelson JW et al., IJROBP 2009; Shinohara T et al., IJROBP 2008; Kim TH et al., IJROBP 2011) This is also appropriate for unresectable CC. (Pitt HA et al., Ann Surg 1995)
Does neoadj CRT improve survival in biliary cancer?
Prospectively collected single institution retrospective data suggest NA gemcitabine × 3 cycles and 50–60 Gy (2 Gy/fx) improves 3-yr RFS (78% vs. 58%, p = 0.02) and OS (p = 0.002, HR 0.35) compared to Sg alone. (Kobayashi S et al., Eur J Surg Oncol 2017)
What is the recommended Tx for localized, unresectable CC?
A combination of chemo alone and/or CRT is recommended for definitive Tx of unresectable CC. (Urego M et al., IJROBP 1999; Leong E et al., J GI Cancer 2012; Morganti AG et al., IJROBP 2000; Crane CH et al., IJROBP 2002; Ben-David MA et al., IJROBP 2006; Tao R et al., JCO 2016; Hong TS et al., JCO 2016)
Gem + cisplatin is sup to gemcitabine alone in a phase III RCT (ABC-02) of locally advanced or metastatic CC or GB cancer (Valle J et al., NEJM 2010), with MS 11.7 mos vs. 8.1 mos.
What evidence supports hypofractionated RT or stereotactic body radiotherapy (SBRT) in unresectable CC?
Phase II data show 2-yr LC of 94.1% for IHCC treated to 67.5 Gy in 15 fx (Hong TS et al., JCO 2016). Retrospective data suggest an MS of 30 mos and 3-yr OS of 73% vs. 38% when treating with hypofractionated or SBRT to a dose generating a biologic effective dose of >80.5 Gy10 (3–30 fx, 35–100 Gy). (Tao R et al., JCO 2016)
