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Management of biliary tract cancer: a case report

Management of biliary tract cancer: a case report. Giovanni Brandi. Institute of Hematology end Medical Oncology “L e A Seràgnoli” Bologna University. JANUARY 2008. MAN, 74 YEARS OLD 20-01-08: abdominal pain, localized in the superior part of abdomen and involving the lumbar region

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Management of biliary tract cancer: a case report

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  1. Management of biliary tract cancer: a case report Giovanni Brandi Institute of Hematology end Medical Oncology “L e A Seràgnoli” Bologna University

  2. JANUARY 2008 • MAN, 74 YEARS OLD • 20-01-08: abdominal pain, localized in the superior part of abdomen and involving the lumbar region • E.O, CHEST-X-RAY, ABDOMEN-X-RAY : normal • BLOOD TEST: Bil. Tot: 8,22; Bil. Dir: 6,27; AST: 63 UI/L; ALT: 100 UI/L; GGT: 253 UI/l; ALP: 525 UI/L; CA19.9: 928 U/ML • ABDOMINAL ULTRASOUND SCAN: gallstones and presence of a hypoecoicmass in the bottom of the gallbladder (4,5 x 3,0 cm) • ABDOMINAL CT WITH CONTRAST MEAN: lesion of gallbladder corpus with probably infiltration of hepatic parenchyma

  3. FEBRUARY 2008 06/02/2008 SURGERY: resection of IV-V haepatic segments, including gallbladder HISTOLOGICAL DIAGNOSIS: adenocarcinoma not well differentiated of the gallbladder infiltrating the surrounding fat and the liver. Margins of liver resection not involved by neoplasm. Limph node metastasis pT3N1M0, STAGE IIB

  4. Biliary tract cancer treatment : results from the Biliary Tract Cancer Statistics Registry in Japan Gallbladder Cancer OS by staging and lymph node status Nagakawa et al. Journal of HBP Surgery, 2001

  5. OS Staging Lymph node status Hilar-upper lower papilla

  6. Killeen R P M et al, Abdom Imaging, 33(1):54-7, 2008

  7. 15 $1 MILLION 14 $500.000 13 $250.000 12 $100.000 11 $50.000 10 $25.000 9 $16.000 8 $8.000 7 $4.000 6 $2.000 5 $1.000 4 $500 3 $300 2 $200 1 $100 Is adjuvant therapy necessary in the gallbladder cancer? Choose an alternative: Only with N+ No Always It’s not well defined

  8. ADJUVANT THERAPY, TO DO OR NOT TO DO? • ADJUVANT THERAPY IS NOT EXECUTED • FOLLOW-UP • In biliary tract cancer the percentage of curative resection is extremely low (37.7% GBC, 30.4% BDC) • an effective adjuvant therapy could be useful in order to improve the overall survival • standard adjuvant treatment is still not settled • there are only few inadequate randomised trials

  9. Takada T at al. Cancer 2002; 95:1685-95 Randomised clinical trials of adjuvant chemotherapy for pancreatic and biliary tract cancer. Takada, 2002 Mitomycin C and 5FU therapy has not been established as the standard postoperative therapy in BTC, but this trial suggests the efficacy and the need of adjuvant treatments

  10. APRIL 2008 • BLOOD TEST: CA19.9: 87 U/ML (N.V. <33) • PET: high FDG uptake (SUV max 10) at V-VI hepatic segmentswith involvement of hepatic capsule and adjacent peritoneum • CEUS: not homogeneous area at IV-V hepatic segments with fluid component (4.8 x 1.8 cm) near metallic clips • Follow-up was established at 2 months to clarify the clinical picture

  11. APRIL 2008

  12. SEPTEMBER 2008 • BLOOD TEST:CA19.9: 220 U/ML (N.V. <33); AST: 34 U/L; ALT: 48 U/L; ALP: 281 U/L • PET: reduction of uptake at V-VI hepatic segments but find of a weak new area in the hilary region • CEUS: hypoechogenoushilary mass (2,9x2,1x2,0 cm), near main biliary duct • INTRAHEPATIC RECURRENCE OF CHOLANGIOCARCINOMA

  13. SEPTEMBER 2008

  14. OTTOBRE 2008 CONCLUSIONS: unresectable patients. Program: chemotherapy CT CT BSC BSC Yonemoto et al. Jpn J Clin Oncol 2007 Glimelius et al. Ann of Oncol 1996

  15. 15 $1 MILLION 14 $500.000 13 $250.000 12 $100.000 11 $50.000 10 $25.000 9 $16.000 8 $8.000 7 $4.000 6 $2.000 5 $1.000 4 $500 3 $300 2 $200 1 $100 Which is the best chemotherapy? Choose an alternative: Gem-based regimen 5-FU-based regimen Not defined Taxanes

  16. Chemotherapy in advanced BTC HAI GEM CAPE TAXAN CPT11 other GEM+ 5-FU 5-FU POLI GEM OX GEM POLI 70 60 Response % 50 40 30 20 Range RO 10 0 55 81 653 321 155 234 331 437 161 121 N° PTS

  17. Guidelines EBM 2008SINGLE AGENT COMBINATION THERAPY J Furuse. J Hepatobiliary Pancreat Surg 2008

  18. NOVEMBER 2008 • HOSPITALIZATION: obstructive jaundice. Bil. Tot.: 16,56 mg/dl

  19. MANAGEMENT OF UNRESECTABLE BILIARY TUMOR UNRESECTABLE TUMOR JAUNDICE NO JAUNDICE DECOMPRESSION OF BILIARY TRACT (stent/drainage) CHEMOTHERAPY ± RADIOTHERAPY ILBT ± EBRT JAUNDICE RESOLUTION (bil ~ 3-4) CHEMOTHERAPY BSC

  20. NOVEMBER 2008 • PTC: double internal-external trans-stenotic biliary drainage COMMON BILE DUCT STENT HILAR STENT

  21. DICEMBRE 2008 • BRACHITHERAPY: two 7 Gy fractions (total dose 14 Gy)

  22. BRACHYTHERAPY • Approachable lesion • well defined • small size

  23. JANUARY 2009 PET: patological uptake at VI hepatic segment (SUV max: 8.8). Another metastasis next to anterior margin of left hepativ lobe.

  24. PET COMPARISON JANUARY 2009 SEPTEMBER 2008

  25. TERAPIA IN CORSO EXTERNAL BEAM RADIOTHERAPY + METRONOMIC CAPECITABINE + LMWH RT+ CT A B A: OS from diagnosis B: OS from start of chemoradiation CHEMORADIATION STENT ALONE This studies confirmed the role of concurrent chemoradiation in advanced BTC; the role of ILBT boost remains to be further analysed Brunner et al, Strahlenther Onkol 2004

  26. LMWH AND CANCER TREATMENT

  27. A CASE OF STABLE DISEASE AFTER LMWH TREATMENT March2009 November2005

  28. GEM-CAPE Multicentre Phase II trial Koeberle et al , JCO August 2008 TTP : 7,2 m OS: 13,2 m

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