Topic: Notes from ASCO GI - Practice Guidelines for intrahepatic CCA

Here are my notes from the "Practice Guidelines for the diagnosis and management of ICCA" session at ASCO-GI

(I will add a link to a video of the presentation if that becomes available)

Presenter -- Greg Gores - Mayo Clinic

Dr. Gores started off by talking about the International Liver Cancer Association (ILCA) -- an international committee he is working with to create guidelines for treatment.

He emphasized that cholangiocarcinoma should be thought of as three distinct diseases:
-Intrahepatic CCA
-Perihilar CCA
-distal CCA

Their recommendation is to not use the "Extra-hepatic" designation.  His remaining talk was focused only on ICC.

He discussed some of the gene sequencing results for ICC. 

One paper he mentioned divided ICC into "Proliferation class vs Inflammation class"  The types of mutations assoicated with each type were different.  He thought this would be important for treatment soon.

He identified two important mutations for near term targeting:
FGFR2 14% incidence in ICC -- drugs currently able to target
IDH1/2 15% incidence in ICC --- not present in any other GI tract cancer, only ICC and able to be targeted in animal models

On diagnosing ICC, one thing I found interesting was he was very down on PET scans.  He said only 55% of CC are pet positive.  Moreover the PET sensitiviity can change over time for a patient.

He said transplantation is not recommended outside of research context due to relatively poor survival.

There was an interesting discussion on TransArterial ChemoEmbolization (TACE) and TransArterial RadioEmbolization (TARE). He suggested these as FIRST LINE treatment when resection is not possible for ICC.

(I talked to the UCSF interventional radiologist afterwards (he was in the session), and he said that there is no established standard, but some institutions take that approach.)

Dr. Gores said that Gem/Cis is a "practiced" standard, but is not a standard of care.  He explained the difference.  If a treatment is a standard of care, then it is deemed unethical to give any other treatment.  Gem/cis has not achieved standard of care status meaning an oncologist can reasonably choose other first line treatments (like folfirinox or radioembolization) on a case by case basis.

Q&A

Q: Is it reasonable to take ICC treatment cues from the pancreatic cancer literature? 
A:  There must be some parallels between ductal cancers. On a case by case basis, this is a rational and reasonable approach if you fail gem / cis.

Q: (from Percy!) Would you consider resecting the liver after a recurrance (or third recurrance?) 

A: Depends on the timing of the recurrance.  If recurrance was immediate after initial resection, would only use systemic treatment.  If recurrance is after a couple of years, would consider a follow-on resection.

Q: Can you downstage from unresectable to resectable? 

A:  We have done that several times, if borderline resectable, then this is worth a shot.

Q:  Given the ABC trial combined all 3 types of CC plus added gallbladder cancer, is there really strong evidence for using Gem/Cis?

A:  While it is true that the best responders were patients with gallbladder cancer, the subgroup analysis was still statistically significant for ICC.  However, peri-hilar results were not significant, so evidence is not as strong for that subgroup.

Q:  What would you do for 2nd line?

A: 2nd line seems to be Irinotican based.  I would think mtor inhibitors, but depends on who paying. (This is in my notes, but I don't remember this that clearly -- Percy, do you recall this Q/A?)

Q: If trying to downstage, should you give standard gem/cis dosage?

A:  Yes

Q:  Should you resect ICC when there are liver metastases?

A:  No, ICC is a systemic disease at this point.  You would not get all the disease with surgery.

Q:  Thoughts on resection for large tumors?

A:  Some institutions don't resect large tumors, thinking that seeding is likely.   For us, if the tumor is large and has not spread, then we think it might have good biology and not a spreading biology.  If technically resectable, we would probably do it.

Q:  What about dosage for adjuvant chemo?

A:  We would reduce dosage, but still use both Gem and Cis


That's all I wrote down.

Jason

Re: Notes from ASCO GI - Practice Guidelines for intrahepatic CCA

This is interesting. Mark's was not ICC but perihilar and we talked PET scans with our ONC...didn't even think about if before surgery....his response was that it was not as accurate as a CT scan in Mark's case and that he did not use it for CC for a diagnostic tool. He went off about why but he kind of lost me at one point then I couldn't catch up.

It's interesting reading about the conference.
Thanks for posting.

KrisV

Any advice given is based on my experiences and should not be substituted for any medical recommendations. Please speak with your provider before making any changes.

Re: Notes from ASCO GI - Practice Guidelines for intrahepatic CCA

Have to disagree with transplant common, May 24 2014 is my 5 year cancer free anniversary! That sounds pretty survivable to me! Maybe he was referring to ICC??
Cathy

Re: Notes from ASCO GI - Practice Guidelines for intrahepatic CCA

Jason, fantastic job, thank you and written so well that all of us can understand it. I do remember when my Teddy had his Whipple 8 years ago they called it distal not 'extra'. This is all excellent. Hope you also enjoyed meeting the "gang".

Teddy ~In our hearts forever~ATTITUDE is EVERYTHING
Any suggestion I offer is intended as friendly advice based solely on my own experience. Please consult your doctor for professional guidance.

Re: Notes from ASCO GI - Practice Guidelines for intrahepatic CCA

Jason,  Thanks for this.  Good job of reporting.  Well written and easy to understand.

Cathy,  Not sure, but I'm thinking that might have been in regard to ICC.  Congrats on coming up on your 5 year cancer free anniversary. 

Darla

"One Day At A Time"

All of my comments and suggestions are just my opinions and are not a substitute for professional medical advice.   You should always seek the advice of your physician or other qualified health care providers.

Re: Notes from ASCO GI - Practice Guidelines for intrahepatic CCA

Thanks, Jason!

This is easy to read/follow.  I should add that Percy spoke to Dr Gores at our booth and one of the things that came up was the fact that he doesn't use PET scans after certain treatments. Said he preferred MRI.

Percy could explain it better but I gathered that he said "Some treatments cause chronic inflammation in an area where a tumor may be dead but which would read as a "false positive" on a PET scan.

Willow

Re: Notes from ASCO GI - Practice Guidelines for intrahepatic CCA

Thanks Lainy.  It was fun meeting "the gang"  All really nice / great people!

Cathy - I am sure Dr. Gores was talking about ICC.  Mayo seems to be a big advocate for transplant of the other cholangiocarcinomas.  If I remember right, he reported 5 year survival rates for ICC transplants at 40-50%.  He did say "relatively" low survival rates.  I took it to mean survival rates for other potential transplant patients was substantially higher.

Jason

Re: Notes from ASCO GI - Practice Guidelines for intrahepatic CCA

Many thanks for that Jason, and also for attending the symposium. Great that you got to meet everyone and hope you all had a good time.

Gavin

Any advice or comments I give are based on personal experiences and knowledge and are my opinions only, they are not to be substituted for professional medical advice. Please seek professional advice from a qualified doctor or medical professional.

Re: Notes from ASCO GI - Practice Guidelines for intrahepatic CCA

Hi, everyone,

I think I have to report something here before I will go to Mayo tomorrow.

1.To Jason  with regard to Q& E section of ICCA;  Dr.Gores did mention mTOR inhibitors is not a 2nd line treatment option since there are not ENOUGH evidence to support such use.
2.with regard to how he determine whether a re-resection is appropriated ;He told me that it depends on the time between each resection; shorter  period NO ,but longer period is yes.  Jason took much better notes than mine (Precise and down to the point).
3. Dr. Gores was only talking about ICCA in "meeting the professor section.
4. He is a physician scientist in the writing committee  of the policy,therefore he looks at ICCA from the point of human biology   (ie; pathways ) than treatments. (Please remember, below is my own interpretation of my conversation with Dr. Gores. and may not represent Dr. Gores's original intent  for the conversation.He will bear no liability with regard to the matter of our conversation)
We, as patients, should have this in our mind first( Dr. gores is a physician scientist). the reason is that,if I understand him correctly, the majority of the ICCA patients will have recurrences ; most patients who have ICCA actually did not have risk factors even there are  stuides  had been listed.
Chemotherapies are difficult to evaluate for its effectiveness.(ie: Gemzar vs Gem/cis-a 3 month difference on survival and it is only a practice standard and not a established recommendation ; there are NO recommendation chemotherapy after resection.
There is not a protocol for ICCA liver transplant because of high  recurrences in ICCA patients;PET scan is insensitive for diagnosis and staging for ICCA;CT or MRI should be used instead for diagnosis purposes; TACE is not recommended ; Overall survival can be up to about 20 months for Y90 (TARE -radioembo)for large tumors ;RFA for tumor size<3cm;and poor prognosis for presentation of  satellite nodules.

Blessings.

Please know that my personal opinion is not intended nor implied to be a substitute for professional medical advice. If  provided, information are for educational purposes.Consult doctor is a MUST for changing of treatment plans.