Search Results for 'chemoradiation after adjuvant'
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Search Results
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In reply to: New member – advice appreciated
Hi,
There is no consensus regarding the optimal management after resection and the true benefit of adjuvant chemotherapy remains uncertain for Ampulary.
In the States, however most of the patients with resected ampullary cancer stage IB or higher will offer adjuvant chemotherapy.
Depending on the true origin of the periampullary tumors which are of intestin al,biliary or pancreatic origin is very important in pts with metastatsis as the approach differs since the optimal regimen for ampullary is not established.GEM/CIS or GEMOX have been used as well as GEMZAR mono therapy; Infusional 5fu is preferred concurrently with chemoradiation,followed by gemcetabine alone for the chemotherapy portion.uptodate.com(oct.2012).
clinical trial is another option.
Ampullary Cancer is among biliary cancers that has the highest 5 yr survival rate than any of other form of CCA.For overall 2nd opinion, MASS Gemeral or John Hopkins is the place to go;
For surgical consult, Dr.KATO is the guy because he is very experienced and willing to be on the cutting edge of liver surgery.Talk to him first is not a bad ideas but should be as soon as possible due to the multiple lymph nodes involvement in your case. If you have peritoneal carcinomatosis(abdominal lymph nodes did mention in your message), then it may be too late for this consult.Mare sure it is not the case.
For oncology consult, MD Anderson in Texas is the place to go.but I will wait for the assessment of DR. KATO first.I took vitamin D1000 units twice daily for about 2 months, it lower the ALP to about 10-12 points withtin one month in my case.But I ask my oncologist what is that mean. he said ,I only monitor and check why the ALP goes up with regard to the CCA; but not about the lower value and what it means.We just don’t do that. and he may be right,he is my friend and I think he spoke the truth. therefore I stop doing vitamin D,( it goes below 32)
I took Celebrex too,but the recommended high dose for cancer is too high and can cause stroke and cardiac problem.it does require a bit of medical and pharmacology knowledge to titrate the dose for the maximum benefit and watch for the side effects as it comes with.I am not a doctor but a patient only, and as I said before,” I am a one man clinical trial specimen” and for that ,please ask your doctor to see Celebrex is right for you.
God bless.In reply to: my father
Hi,
Fever is not common after biliary surgery.Most likely the infection is related to the surgery. In general, it require at least 14 days of antibiotics treatment like ciprofloxacin 400mg twice daily or levofloxacin 500-750mg daily for 14 days to
eradicate the infections; If they put a stent or two in the bile duct to facilitate the bile flow, the infection may be more often. The rule of thumb is if your father has chill and the fever is >39 . Bring him to hospital right way so they can give him antibiotics or ask the doctor to prescribe levofoxacin 500mg daily ,number 14-21 tablets as standby for him to take at home when symptoms occur. In normal situation, the fever will go away in a couple days;keep your father hydrated is also important(6 glasess of 240ml liquid).
Adjuvant therapy ,as far as I am concern , I will do it with no reservation at this time. I do not know what kind of profession you are in, but you may have done research and know that Liver is the only organ that can regenerate itself; that means as few as one cancer cell left inside the biliary system, it will regenerate together with the healthy cells in the liver of the biliary tract ; therefore I believe no matter how well the surgery turn out, due to the fact that 50-75% of cholangiocarcinoma cases may recur for the rest of our life time.( I am a patient of intrahepatic CCA) and adjuvant chemotherapy therefore is warrant to have it done.
Adjuvant may be one of the following.
1. Gemcitabine ,3weks on and one weeks off. (easy to tolerate)
2. Gemcitabine + oxaliplatin. (better tolerate than gemcitabine + cisplatin.)
3. Gemcitabine + cisplatin ( widely used as a reference standard for CC)
4. 5FU infusional pump+ Leucovorin +oxaliplatin (good alternative to # 3)
5. and of course gemcitabine follow by chemoradiation with capecitabine.For systemic chemotherapy for treatment of advance cholangiocarcinoma
below is the link.http://www.cholangiocarcinoma.org/punbb/viewtopic.php?pid=57198#p57198
By the way, may I ask where you get your treatment,in the capital of local hospital;Can you give us any names of the hospitals and doctors that help treating your father . We are an international community and some one in China,like you, may want to know that information too to help their parents or relatives. As you know liver disease is much higher than in China than in the States. your info. will help others in China as well.
God bless
Excellent quality of life after liver transplantation in patients with perihilar cholangiocarcinoma who have undergone neoadjuvant chemoradiation
In reply to: Staging
Hi,
The stage (TNM) has both pTNM=pathologic( pT1N1MX in your case) and cTNM= clinical classification.
And as you may understand that two classifications may be different upon surgical results returned and clinical presentation.
Currently AJCC staging Manual,7th edition(2010) is the one that American physicians used.Personally ,I do not think the p-staging is as important as the c-staging classification. In this sense, your surgeon’comment after the resection was more important than the pTNM staging itself.
Anyway, based on the messages you wrote on this board; your wife might have ECCA .”” according to your description,spread to the liver and one hilar lymph node”. And resection was performed with the right lobe completely removed along with some bile ducts and part of the left lobe and the affected lymph node. If this is correct, then your wife will have a better chance not to have recurrence than ICCA.But it will be still in the 50% as compare to 75% for ICCA.
If you worry about the MX staging; ask the oncologist to order a PET scan and you will know the results.(but please remember PET is not 100% proof of the findings that some one has cancer ;it can be other problems as well)
I rotate my q3-4month scan between PET and Ct scan to get a better picture of my disease condition.
chemoradiation treatment after adjuvant chemotherapy is acceptable. I only had Gemzar after the first surgery and Xeloda after the 2nd resection. No radiation was provided.
The question you should seriously considerNOW is what should you do after the chemoradiation? Follow the doctors recommendations of Ct scan every 3-6month and then after a year or two, change to every year and hope the cancer will not return; or be more progressive in the anticipation of the return of the cancer and refine your thinking and research toward prevention or delay such outcome.
I am happy that you devote so much energy to take care of your wife and she is very lucky to have you at her side. You and Eli are the few men that is details oriented and precise in your pursuit of information and knowledge and in so doing directly and indirectly contribute to this board substantially.
God bless.In reply to: Radiation for R0?
Hi Bruce,
2000miler wrote:I checked the NCCN Guidelines Version 2.2012, Extra-2. It states “Consider fluoropyrimidine chemoradiation {f} (brachytherapy or external beam) followed by additional fluoropyrimidine or gemcitabine chemotherapy or Fluoropyrimidine based or gemcitabine based chemotherapy for positive regional lymph nodes {h}” I don’t know how to interpret that statement. Does consider apply to both part.In my (non-expert) opinion, consider applies to both parts.
Chemoradiation is used to treat positive margins and regional lymph nodes. Chemo is used to treat distant spread. Both treatments lack solid statistical evidence provided by Phase 3 clinical trials. Therefore, they have to use weasel words like “consider”.
2000miler wrote:The paper you linked to, “Adjuvant treatment in biliary tract cancer: To treat or not to treat?” states the following under Guidelines and Current Clinical Practice. “The National Comprehensive Cancer Network (NCCN) guidelines recommend only observation or adjuvant CRT with concomitant fluoropyrimidine for patients with R0 margins or negative lymph nodes and adjuvant therapy with concurrent 5-fluorouracil-based CRT followed or not by additional fluoropyrimidine or gemcitabin-based regimens in patients with R1 margins or metastic lymph nodes.” So it appears here that the NCCN is recommending CRT with or without chemo for positive lymph nodes.The paper is written by Italian doctors. Italy has a strong expertise in treating cholangiocarcinoma. However, I wouldn’t necessarily rely on their interpretation of NCCN guidelines. They may be missing some nuances of the English language. (The rest of the paper is still valuable for its discussion of adjuvant therapies)
Did you have a chance to read the second paper I linked?
Adjuvant Therapy Beneficial in High-Risk Biliary Tract Tumors: Meta-Analysis
http://www.medscape.com/viewarticle/762919They reviewed a very large sample of patients from numerous previous trials. You may need to register for a free Medscape account to read it.
2000miler wrote:Also, it appears that the recommendation is to do radiation followed by chemo, whereas what the Ocshner oncologist proposes is to do chemo followed by radiation.There is no definitive standard.
My wife did chemoradiation followed by 6 cycles of chemo. FYI, she had R1 margins and 2 positive nodes after Whipple resection of extrahepatic CC.
Susie did 3 cycles of chemo, followed by radiation, followed by another 3 cycles of chemo.
Derin (another one of our members) did chemo followed by radiation.
Note: this study focuses on extrahepatic patients
http://www.gastrohep.com/news/news.asp?id=108918Hi Percy,
Here’s what I have in my bookmarks.
Full Text Articles
Multimodality therapy for locoregional extrahepatic cholangiocarcinoma: a population based analysis
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2783824/Adjuvant Radio-chemotherapy for extrahepatic biliary tract cancers
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3141778/Adjuvant concurrent chemoradiation therapy (CCRT) alone versus CCRT followed by adjuvant chemotherapy: Which is better in patients with radically resected extrahepatic biliary tract cancer?
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2761944/Abstracts Only
full articles require payments
Extrahepatic bile duct adenocarcinoma: patients at high-risk for local recurrence treated with surgery and adjuvant chemoradiation have an equivalent overall survival to patients with standard-risk treated with surgery alone
http://www.ncbi.nlm.nih.gov/pubmed/18754070Concurrent chemoradiotherapy in resected extrahepatic cholangiocarcinoma.
http://www.ncbi.nlm.nih.gov/pubmed/18805651Radiotherapy and chemotherapy as therapeutic strategies in extrahepatic biliary duct carcinoma
http://www.ncbi.nlm.nih.gov/pubmed/21136029Is adjuvant radiotherapy needed after curative resection of extrahepatic biliary tract cancers?
http://www.ncbi.nlm.nih.gov/pubmed/21652148Benefits of adjuvant radiotherapy after radical resection of locally advanced main hepatic duct carcinoma
http://www.ncbi.nlm.nih.gov/pubmed/10701737Radiation Enteritis (major side effect of radiation therapy)
http://www.cancer.gov/cancertopics/pdq/supportivecare/gastrointestinalcomplications/HealthProfessional/page6I also highly recommend NCCN Guidelines document:
http://www.nccn.org/professionals/physician_gls/pdf/hepatobiliary.pdfYou need to register for a free account to download the PDF. The Guidelines discuss all available adjuvant treatments: chemo, radiation, chemo-radiation.
An article by Mayo Clinic doctors.
The impact of neoadjuvant chemoradiation on the tumor burden prior to liver transplantation in unresectable cholangiocarcinoma
http://www.ncbi.nlm.nih.gov/pubmed/22140024Eyebrow-raising quote:
“In our series disease recurrence was significantly associated with … shorter waiting time to LT after the chemoradiation protocol”
IOW, waiting longer between chemoradiation and LT might be better.
Topic: My wife’s extrahepatic CC
Hello everyone,
I’m a long-time lurker. My wife is currently in between treatments… I have time to write the introduction post.
My wife and I are both 44. Our daughter is 13. We live in Ottawa, Canada.
My wife’s symptoms showed up in the middle of April 2011. Very strong abdominal pain followed by a whole-body itch a few days later. We went to ER on April 18th.
ERCP was done the next day. The doctor found a tight stricture in the intra-pancreatic portion of the common bile duct. He inserted a temporary stent to releive the obstruction. He also took a brushing biopsy. The biopsy came back as “suspicious for adenocarcenoma”.
The remainder of April and May were spent on doctor consultations and tests. CT, MRI, EUS. We signed the consent to do Whipple early in June. The surgery was done one month later, on July 4th. (Canadian healthcare doesn’t move fast.)
The surgeons deemed Whipple a success. They thought they took the entire tumor out.
Pathology report came out three weeks after the surgery. The report confirmed stage IIB extrahepatic CC (T3/N1/M0). The tumor extended over the entire length of the common bile duct. It also invaded outside the duct wall into pancreas. 2 out of 15 lymph nodes were positive. Surgical margins were microscopically positive where the surgeons cut the bile duct.
My wife’s incision got inflamed while she stayed in the hospital. The surgeons had to reopen the inflamed part before they sent us home. This open wound took almost 2 months to heal, causing a delay in the start of the adjuvant therapy.
Due to positive margins and positive nodes, the oncologists recommended 5FU chemoradiation followed by additional course of GemCis chemo. This is in line with NCCN treatment guidelines.
Chemoradiation started on Sept 12. 28 days of radiation, 1.8Gy daily fractions, for a total dose of 50.4Gy. 5FU was infused continuously around the clock concurrently with radiation. Chemoradiation ended on Oct 20. The last few weeks were very HARSH. My wife experienced pretty much every single side-effect in the book, some of them very severe. One month later, she still gets bouts of nausea almost every day.
My wife was scheduled to start chemo 3-4 weeks after the end of chemoradiation. Given her condition at the end of chemoradiation, our oncologist decided to give her a longer break. She is doing a whole-body CT scan on Dec 2 (next Friday). If the scan is clean, she will start chemo mid-December.
(I know my post sounds exceedingly dry. I decided to stick to the facts and leave emotions out of it. I can’t begin to describe the daily agony of dealing with this horrible disease.)
Finally, a big THANK YOU to the kind people who keep this board up and running.
— Eli
In reply to: My dad has cholangiocarcinoma
mlepp0416 wrote:Marianne:I’m a bit amazed that your dad’s doctors feel a liver transplant would be an option but heck go for it! All Tom’s doctors said that they don’t transplant liver cancer as a general rule because liver’s are hard to come by and most often liver cancer returns even to a new liver. (I may have to do a lot more research on this!)
But, given Tom’s other issues, he would not likely be a candiate anyway as he has other underlying health issues such as diabetes, PAD and Coranary Artery disease, and has had a stroke and heart attack. (all that rules him out I feel)
Keep us posted on what your dad finds out at Mayo!
Go with God and KEEP KICKIN’ THAT cancer.
Margaret
Margaret,
That’s great that your husband’s billirubin is down. I hope he makes a full recovery.
You’re right that liver transplants are not standard procedure for inoperatable bile duct cancer. They stopped doing transplants for this a while back because it became clear that the cancer always comes back and attacks the new liver.
This is a little different though because it’s neoadjuvant therapy (chemoradiation) followed by a liver transplant and it’s only for Hilar Cholangiocarcinoma (Klatskin tumors). It also cannot have began metastasizing yet otherwise it won’t work. The patient does have to be healthy otherwise to qualifiy for the transplant. It’s still in clinical trials. Here is the website for the current clinical trials going on in St. Louis Missouri under Dr. Chapman: http://www.clinicaltrials.gov use identifier# NCT00301379. But Mayo Clinics also do this same protocol. It was actually developed by the team at Mayoclinic Rochester MN under Dr. Gregory Gores and Dr. Charles Rosen. They have been having a 72% success rate. But keep in mind that 72% rate is the 5 year survivial rate at 5 years after transplant. Keep in mind also that some people do not qualify for transplant if it begins metastasizing prior to transplant. So that 72% is assuming the patient stays qualified up to transplant time.
I really hope that your husband recovers and I am sorry you are going through this. I wish nobody had to deal with this. It is horrible.
In reply to: Liver transplantation for cholangiocarcinoma
This popped up today on the radar, and seemed pretty appropriate to include on this discussion:
Liver transplantation for cholangiocarcinoma
Cholangiocarcinoma (adenocarcinoma of the bile ducts) can be hard to diagnose and even harder to treat. It preferentially grows along the length of the common bile duct, often involving the periductal lymphatics, and commonly metastasizes to the lymph nodes.
For hilar cholangiocarcinoma (tumor above the cystic duct), surgical resection is the treatment of choice in the absence of associated primary sclerosing cholangitis (PCS). However, approximately 10% of patients with cholangiocarcinoma have undying PSC, and the results of resection in this setting are dismal. Furthermore, cholangiocarcinoma in the setting of PSC is frequently multicentric, and is often associated with underlying liver disease with eventual cirrhosis and portal hypertension.
This scenario led transplant centers to consider liver transplantation for hilar cholangiocarcinoma; however, the results were disappointing, with three-year survival rates less than 3%. The situation improved with the inclusion of neoadjuvant chemoradiation, which was based on the concept that the growth of hilar cholangiocarcinoma is locoregional.
Neoadjuvant chemoradiation for cholang-iocarcinoma was introduced by the transplant team at the University of Nebraska in the late 1993 by the multidisciplinary team at Mayo Clinic protocol, which begins treatment with external beam radiation therapy, followed by protracted venous infusion of fluorouracil (5-FU) and brachytherapy (Iridium), and then abdominal exploration for staging with endoscopic ultrasound and finally capecitabine for two or three weeks until the final option of liver transplantation. The five-year survival rates for patients undergoing liver transplantation at Mayo Clinic after completing the neoadjuvant cholangiocarcinoma treatment protocol are excellent, at approximately 70%.
According to an associate professor of surgery at the Mayo Clinic College of Medicine and Chief of Liver Transplantation with the Mayo Clinic Transplant Center in Rochester, Minn., of 90 patients who underwent transplantation according to the Mayo Clinic protocol between 1993 and 2007, five-year survival was 71% and disease-free survival was 65%. For 15 patients, disease recurred after the transplant, with a mean time to recurrence of 25 months. Current eligibility for the Mayo Clinic protocol based on the presence of an unresectable tumor above the cystic duct or a resectable cholangiocarcinoma arising in the PSC; radial dimension of the tumor should be 3 cm or less, intra- or extrahepatic metastases should not be present and there should be no history of prior radiation therapy or transperitioneal biopsy.
Combined chemoradiation therapy and liver transplantation achieves excellent results for highly selected patients with early-stage hilar cholangiocarcinoma; five-year patient survival after transplantation with this protocol 71%, and exceeds the results reported with resection for hilar cholangiocarcinoma. These results approach the survival after transplantation for chronic liver disease and HCC. Operative staging is essential, as positive findings preclude transplant in about 20% of patients.
Source: http://traditionalmed.blogspot.com/
