Distal Cholangiocarcinoma

International Society of Gastrointestinal OncologyNovember 1-2, 2018

Case Presentation

Atuhani Burnett, MD, PhD, Michael Choti, MD, FACS

• 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

JM 73yM

Which of the following further diagnostic studies would you recommend?

A. PET ScanB. Staging laparoscopy and cytology washingsC. Additional biopsy with EUS/FNAD. No additional studies

ARS Question

If biopsy were non-diagnostic or negative, which of the following further diagnostic studies would you recommend?

A. PET ScanB. Staging laparoscopy and cytology washingsC. EUS/FNAD. No additional studies

ARS Question

What would you recommend at this point?

A. Surgery (pancreaticoduodenectomy)B. Neoadjuvant chemotherapyC. Neoadjuvant chemoradiation therapy

ARS Question

• 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

JM 73yM

What would you recommend at this point?

A. Adjuvant chemotherapyB. Adjuvant chemoradiation therapyC. No post-operative therapy

ARS Question

If you recommend postoperative chemotherapy alone, which regimen would you advise?

A. GemcitabineB. Gemcitabine + CapecitabineC. Gem + nab-paxlitaxelD. Gem + cisplatinE. FORFIRINOXF. FOLFOXG. Something Else

ARS Question

• RCT, N=410, locally advanced/metastatic biliary tract CA, gem vs gem + cisplatin

ABC-02 RCT

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.

11.7 m vs 8.1 m

• RCT, N=410, locally advanced/metastatic biliary tract CA, gem vs gem + cisplatin• extra-hepatic N=73

ABC-02 RCT

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.

• Retrospective, NCDB, propensity score matched

Distal Cholangio, +/- Adjuvant Chemo

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.

N=500:50025.2 m O vs 31.2 m ATHR 0.79 (0.67 – 0.94)

N=348:34829.5 m CT vs 32.1 m CRT

• Still accruing

ACTICCA-1 trial

Gallbladder CACholangio CA

Curative intent resection

GemcitabineCisplatin Capecitabine