Distal Cholangiocarcinoma Atuhani Burnett, MD, PhD, Michael Choti, - PowerPoint PPT Presentation

International Society of Gastrointestinal Oncology November 1-2, 2018 Case Presentation Distal Cholangiocarcinoma Atuhani Burnett, MD, PhD, Michael Choti, MD, FACS

JM 73yM • 73 y/o M with 50 lb weight loss 4 months, jaundice, pruritus • MRCP: mild to moderate intrahepatic biliary duct dilatation, no soft tissue mass • ERCP: moderate mid CBD stricture, brushings sent, stent placed • Malignant cells found on brushings • PMH: CAD s/p 2vCABG, HTN, HLD, GERD • CA19-9 = 55, Tbili 8.0 -> normalized to 1.5 after stent

ARS Question Which of the following further diagnost stic st studies s would yo you recommend? A. PET Scan B. Staging laparoscopy and cytology washings C. Additional biopsy with EUS/FNA D. No additional studies

ARS Question If biopsy sy were non-diagnost stic or negative ve, which of the following further diagnost stic st studies s would yo you recommend recommend? A. PET Scan B. Staging laparoscopy and cytology washings C. EUS/FNA D. No additional studies

ARS Question What would yo you recommend at this s point? A. Surgery (pancreaticoduodenectomy) B. Neoadjuvant chemotherapy C. Neoadjuvant chemoradiation therapy

JM 73yM • Patient received up front surgery • Operative findings: – Procedure: pancreaticoduodenectomy – No contact with portal SMV or SMA – End to side pancreaticojejunostomy – soft gland, 3mm duct, duct-to-mucosa anastomosis, no stent – End to side hepaticojejunostomy – Retrocolic gastrojejunostomy • Patient did well post op, drain amylase 300 on day 1, resolved by day 3, with low drain outputs • Diet tolerated, out of bed ambulating, discharged by PO day 7, without drain • Final path: intestinal type adenocarcinoma consistent with cholangiocarcinoma, 2cm ypT3N0, negative margins

ARS Question What would yo you recommend at this s point? A. Adjuvant chemotherapy B. Adjuvant chemoradiation therapy C. No post-operative therapy

ARS Question If yo you recommend post stoperative ve chemotherapy y alone, which regimen would yo you advi vise se? A. Gemcitabine B. Gemcitabine + Capecitabine C. Gem + nab-paxlitaxel D. Gem + cisplatin E. FORFIRINOX F. FOLFOX G. Something Else

ABC-02 RCT • RCT, N=410, locally advanced/metastatic biliary tract CA, gem vs gem + cisplatin 11.7 m vs 8.1 m Cisplatin plus gemcitabine versus gemcitabine for biliary tract cancer . Valle J, Wasan H, Palmer DH, Cunningham D, Anthoney A, Maraveyas A, Madhusudan S, Iveson T, Hughes S, Pereira SP, Roughton M, Bridgewater J; ABC-02 Trial Investigators. N Engl J Med. 2010 Apr 8;362(14):1273-81.

ABC-02 RCT • RCT, N=410, locally advanced/metastatic biliary tract CA, gem vs gem + cisplatin • extra-hepatic N=73 Cisplatin plus gemcitabine versus gemcitabine for biliary tract cancer . Valle J, Wasan H, Palmer DH, Cunningham D, Anthoney A, Maraveyas A, Madhusudan S, Iveson T, Hughes S, Pereira SP, Roughton M, Bridgewater J; ABC-02 Trial Investigators. N Engl J Med. 2010 Apr 8;362(14):1273-81.

Distal Cholangio, +/- Adjuvant Chemo • Retrospective, NCDB, propensity score matched N=500:500 25.2 m O vs 31.2 m AT N=348:348 HR 0.79 (0.67 – 0.94) 29.5 m CT vs 32.1 m CRT Improved Survival in Surgically Resected Distal Cholangiocarcinoma Treated with Adjuvant Therapy: a Propensity Score Matched Analysis. Hester C, Nassour I, Adams-Huet B, Augustine M, Choti MA, Minter RM, Mansour JC, Polanco PM, Porembka MR, Wang SC, Yopp AC. J Gastrointest Surg. 2018 Jul 20.

ACTICCA-1 trial • Still accruing Gallbladder CA Cholangio CA Curative intent resection Gemcitabine Capecitabine Cisplatin