Notdoneyet,

the indications and contraindications for surgery are confusing - they depend in part on the primary site of the tumor, the extent of involvement of the liver and its associated structures (bile ducts and blood vessels), and the evidence for/against spread outside the liver and biliary tree.

If you don't get satisfying answers, I am happy to discuss with you further. Dr Kato is another great suggestion.

Chris Sonnenday
University of Michigan
csonnend@umich.edu

Mayo Clinic Jacksonville has considerable experience with cholangiocarcinoma and would be the closest to you that I would recommend. Feel free to email me and discuss as well; I would be happy to review your films, as I sure would Dr Kato as mentioned above.

Chris Sonnenday
University of Michigan
csonnend@umich.edu

3

(25 replies, posted in New Developments)

Both are clever marketing names - the technologies used are very different.

CyberKnife = robotic radiosurgery system. It is a shame that surgery is used in the name of this technology, because it is not a surgical procedure or operation. It is a technique of providing radiation therapy that uses image guidance and a robotic delivery system in an attempt to deliver the radiation beams more accurately. Most state of the art centers use the technique of stereotactic radiotherapy (image-guided, precisely targeted radiation), and the CyberKnife is one form of that treatment.

NanoKnife = ablation technique using irreversible electroporation to kill tumor cells. As I described above it is an ablation technique like radiofrequency ablation (RFA) - i.e. you stick a probe into the tumor and deliver energy to kill the cells, in this case by disturbing the cell membranes by brief electrical pulses. The advantage of this treatment as opposed to RFA or other ablative techniques is it is more focused energy without as much toxicity to surrounding normal tissues. We are very early in our experience with this treatment and awaiting to see its effect in a disease like cholangiocarcinoma.

CJS

4

(25 replies, posted in New Developments)

We have some experience with the NanoKnife at UM, and I have been watching carefully for any experience from other centers. It is an ablative technique, similar to radiofrequency ablation (RFA) or microwave ablation. It's reported advantage is that it does less damage to surrounding normal structures (bile ducts, blood vessels), thus potentially allowing us to treat centrally located liver tumors, or tumors in the bile duct outside the liver, that are hard to treat with RFA.

Early experience suggests that it is safe and relatively easy to use either in the OR or percutaneously (through the skin) using ultrasound guidance. However the early recurrence rate in limited studies is a bit discouraging. More work is needed to figure out how to best use this therapy. However, given its relative safety it may allow us to treat some tumors we have not been treating well to date.

How it compares to radioembolization or chemoembolization is not clear. My personal opinion is that radioembolization has the most encouraging response rates of the liver-directed therapies.

Happy to discuss further. Feel free to email me any questions.

Chris Sonnenday

5

(7 replies, posted in General Discussion)

unfortunately yes - metastatic disease, including even metastatic deposits within the liver itself, excludes patients from transplant at our center and at the other centers I know that do transplants for cholangiocarcinoma. The reason for this policy is that we have learned that any evidence of disease spread to lymph nodes or other sites is associated with a very high risk of recurrence after transplant.

Again feel free to contact me if other questions.

CJS

6

(7 replies, posted in General Discussion)

Lourdes:

I am sorry to hear of your father's struggles, but am glad to hear he has been discharged home.

Your questions about transplant are excellent, and there are many misunderstandings about the role of transplant in the management of cholangiocarcinoma.

I discussed this recently in an interview that has been distributed in various forms. Here is a link:
http://www.ivanhoe.com/channels/p_chann … ryid=28992

My email is included in the interview. Please feel free to contact me if you have other questions.

CJS

Cathy - thanks for the warm welcome and congratulations on your inspiring personal story. Dr. Chapman is indeed a star in our field and a personal hero of mine. He was one of my instructors and mentors as a medical student at Vanderbilt in the early 1990s, and he remains an important source of encouragement and mentorship to me. Clearly he took great care of you and he continues to advance the fields of hepatobiliary and transplant surgery.

I am honored to be included on this board and will post as much as I can in an effort to be helpful.

You all inspire me to do my job. I am very lucky...

CJS

Amy -

I am so sorry to hear about your mom's bad news. This is always a devastating situation, as 10-20% of the time conventional imaging (CT, MRI, PET) fails to diagnose disease that has spread in this pattern (small nodules throughout the abdomen).

My only advice is to say that if your mom is feeling well, take full advantage of this time with her and continue to do as much as she wants and is able to do. While the typical estimate on survival in this situation is 3-9 months, I have seen patients live much longer than that. How much time chemotherapy could add to that time is unclear, but it could be considered as long as any side effects are tolerable and the administration schedule does not interfere with any plans she wants to make to travel or do other activities.

I wish your mom a quick recovery from her procedure such that she can get back on her feet quickly. I wish you many more wonderful days with her. She sounds like an amazing and strong woman.

Chris Sonnenday
University of Michigan

9

(10 replies, posted in In Remembrance)

Elsie -

You have helped many in telling Jim's story. As I often tell my own patients, choosing to stop treatment requires incredible bravery. It sounds to me like the cancer led to his death, but did not take his life. He lived his life nobly until the end - there are lessons in that for so many others fighting this disease, and for those of us trying to care for them.

I will be thinking of you. My best to you and your family.

Chris Sonnenday
University of Michigan

Congratulations!

Hi CM -

I am a hepatobiliary and transplant surgeon, new to this blog, but excited to participate as it has been a great service to so many of my patients.

Cholangiocarcinoma is generally thought of as an "indolent" cancer - we believe that in most cases it takes months to years to grow such that it eventually causes symptoms or signs that lead to diagnosis. In fact, it is this behavior that leads to many patients being diagnosed at advanced stages, as the disease has had much time to grow and potentially spread prior to diagnosis.

Obviously in any one case it is impossible to answer, but I suspect your loved one had this disease evolving for at least months if not longer prior to his diagnosis.

In some circumstances I meet a patient who had imaging studies or laboratory studies that were performed months (in one case I recall 18 months) prior to diagnosis and in retrospect showed abnormalities that suggested the cancer was there, though unfortunately missed. We obviously need to get better at diagnosing this cancer earlier in its course.

Hope this answer is helpful.

Chris Sonnenday
University of Michigan