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:
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: 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?
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.