New member — Wife recently diagnosed with ICC

I can’t believe how long it has been (7 months!) since I officially updated this thread.

As I said in November, we had this plan:

“We have decided to continue on Gem/Cis at Stanford until January, and then switch to UCSF and do IMRT + Xeloda.”

and that is pretty much what has happened.

Andrea had her last Gem/Cis treatment Dec. 18. In total, she was one treatment short of twelve cycles. Overall, she handled the chemo really well. A little tired, and a little hair thinning, but pretty manageable all things considered. Towards the end of the treatment though her blood counts were starting to get low and not rebounding quite as quickly as earlier.

The net result of chemo:
-Main tumor 1/3 original size and PET inactive
-Two satellite “medium” tumors significantly small, necrotic looking and PET negative
-“Constellation” of tiny tumors no longer PET active or visible

Pretty good from where we started.

In late January (2014), Andrea started IMRT radiation therapy. The plan was to irradiate the area around the main tumor. The logic given was that this tumor would be the one most likely to cause problems in the future, and that all the shrinkage gave an opportunity to treat it within a manageable IMRT field. The treatment regime consisted of 28 days of radiation (5 days a week for 5.5 weeks).

Radiation, it turned out, was much harder than chemo, both mentally and physically. About halfway through treatment, Andrea was having difficulty keeping down any food or drink. This lasted throughout the remaining weeks of treatment and didn’t really start improving until 3 weeks post treatment. During those weeks, Andrea lost 15-20 pounds and was very weak. Mentally, the challenge was to get up every day and go to another treatment when you knew that was what was causing you to feel so lousy.

Andrea had her last radiation treatment March 5. I guess you never know how you will respond. During chemo, the side-effects for Andrea seemed easier than advertised, but just the opposite was true for radiation.

Andrea also took Xeloda (aka capacitabine aka 5FU) during radiation, since that supposedly helps the effectiveness of the radiation treatment. Since radiation was only treating the main tumor, the Xeloda also acted as systemic therapy for the other tumor areas.

Andrea got her first post radiation scan in late March. Good news. The treated areas looked as expected, and the untreated areas looked dormant (looking at the untreated areas was actually the purpose of the scan since they said it was too early to evaluate the radiation region).

At this point, the oncologist suggested a treatment break until June. The idea was to let Andrea recover from the radiation, and then see what happens to the tumors. If all remained quiet, the likely path would be localized treatment to each “medium” tumor. If there was a recurrence, then that would dictate the treatment path.

By April 1 (Andrea calls it her “Canniversary”), Andrea was mostly recovered from radiation, and quickly getting her strength back. When not knocked on her butt from radiation, Andrea likes to be active and involved. Her new passion is fund raising for CCF…you will all be hearing more on that later!

It is now mid-June, and the last two months without treatment have been fantastic. Andrea feels great, and things seem almost normal. We even got to spend a week in Paris. Neither one of us had ever been to Paris, and it was fantastic. Since the diagnosis last April, I think this was the best two months that we have had.

However, everyone says that this disease is a roller coaster, and I can see that more and more. We just got the results from Andrea’s June PET/CT scan, and the news was not good. Two new tumors in the liver. One is 1cm and one is 2.5 cm, both PET active.

We don’t have much in the way of details yet (we see the oncologist next Monday), but that seems like an awful lot of growth if nothing was showing up in March. My theory is that since the March scan was not a PET scan, but only a CT scan, they missed the beginnings of these tumors. I will find out more in a couple of days.

I guess the one positive is that the tumors are still contained to the liver. The report also indicated that no lymph nodes showed signs of involvement. Still a major bummer.

So that is the latest. Hopefully, Andrea can get back into the “good news / what’s working” column soon.

Jason

Hello everyone,

I can’t believe that I haven’t posted an update since before our trip to MD Anderson. I thought I would let everyone know what we have learned, and how things are going.

Here is a little background on the situation as of October — Andrea was getting treated at Stanford, and had been doing well on her Gem/Cis treatments. However, we were well aware of the fact that Gem/Cis usually gets either ineffective or too hard to endure. We decided that during Gem/Cis cycles 7/8/9, we would get 2nd/3rd/4th opinions on what would be a good next treatment for Andrea.

Our first visit was to UCLA, which I think I already described. Next up was MD Anderson. Wow, that place is huge! Two tips if you decide to go to MD Anderson. First, be sure to use their online web application. This is how we found out the timing of our appointments. Second, if you have a port, don’t be surprised if they refuse to use it. They would not use Andrea’s port for her CT scan even though we had all of the documentation for what type of port it was and where it was. Their policy is that if they did not put in the port they will not use it without a chest x-ray!

Anyway, I think the standard MDACC review includes a meeting with the surgeon (Dr. Vauthey), and a meeting with Dr. Javle. We first met with Dr. Vauthey. We were not surprised at all to hear that Andrea was not, and probably would never be, a candidate for surgery. We have a long list of surgeons with that opinion! We next met with Dr. Javle. We found out from Dr. Javle that the CT scan indicated stable disease since the prior scan. We were hoping for shrinkage, but thankful for stable. Dr. Javle said that in his experience with stable disease, two approaches have been effective at prolonging the time to progression: radiation or Tarceva.

Dr. Javle’s recommendation was to:

1. Get a PT scan to get a baseline for current cancer activity.
2. Continue on Gem/Cis for 3 more cycles (12 total)
3. Come back to MDACC in January and get a PT/CT scan.
4. Assuming the January scan confirmed stable disease, pursue either radiation or Tarceva

I believe the type of radiation would either be proton beam or IMRT depending on an analysis of the collateral radiation (the involvement of the duodenal seemed key here??)

We next met with Dr. Kelley at UCSF. Dr. Kelley recommended continued Gem/Cis for 3 more cycles, and then to use IMRT radiation treatment on the primary tumor location. Given this is the biggest tumor and given the central location, Dr. Kelley thought this would be the area that would cause problems down the road. Hitting it with radiation while it was smaller and well-contained will hopefully extend the amount of time Andrea is stable. Dr. Kelley also suggested Xeloda during the IMRT treatment, and then continuing on Xeloda as a maintenance drug. Xeloda apparently makes the tumor cells more radiation sensitive.

We have decided to continue on Gem/Cis at Stanford until January, and then switch to UCSF and do IMRT + Xeloda. We have found a good match with Dr. Kelley and feel great about the plan (although still apprehensive about new chemo and new radiation treatment).

Andrea also got a PT/CT scan at UCSF to get a new baseline. Fantastic news…the CT part indicated additional shrinkage! The PT part indicated that there were NO VISIBLE SIGNS OF CANCER ACTIVITY! All of the tumors in the liver now have sugar uptake that is indistinguishable from the sugar uptake of the surrounding liver (or less if necrotic). That is just awesome.

Many of you have written with prayers and support. Thank you so much! Sorry that was a bit rambling. Feel free to post or email me if you have questions about our experience to date.

Hopefully, Andrea and I can continue to keep ahead of this monster…

Jason

Hi Pat,

It does sound like your situation and Andrea’s are similar. I know chemo sounds scary. Some people do have bad experiences, and for us, the warnings from the “chemo class” were alarming.

However, I think many people handle it well. In Andrea’s case, the main side effect has been feeling tired and achey for a couple of days. In fact, Andrea said that the fear of the unknown actually made the first few weeks tougher for her. Once she did it, and found out she could handle it, later cycles were actually easier. (She is sitting right here finishing her 18th infusion, and says if you want to talk or e-mail she would be happy to give you more details )

I can’t recall the specifics, but I am pretty sure that people that start chemo while feeling healthy tend to tolerate the side effects better. I do know that starting off healthy is associated with better outcomes from chemo (later progression and longer survival).

Of course, all of these decisions are highly personal, and everyone has to decide what is best for them. I did want you to know Andrea’s experience, and I hope this information is helpful to you in making some of your decisions.

Jason

PS As far as an update on Andrea, there is not much to tell yet. We get another scan later this month and have a visit to MD Anderson scheduled in a couple of weeks as well. Hoping for a good report at that time!

Dorien,

In my experience, the most capable people at reading the CT scans are the radiologists (makes sense I guess!). The amount of information we got from the interventional radiologists (IR) was much more detailed compared to our discussion with the various oncologists. These are the guys who do the RE procedure, and I am pretty sure they do the procedure guided by CT scans.

Anyway, we asked the IR how he could tell the cells were dead. He said that looking at the scans before and after the contrast was injected as well as closely looking at the scans taken while the contrast was spreading was how he came to his conclusion (that is my memory anyway).

The doctors at UCSF, UCLA and Stanford all concurred that if you were having a strong response to Gem/Cis, the time was not right for RE. The IR doctors went further and said they thought identifiable active cancer was a needed before they would suggest RE. By this, I think they mean wait until there is a liver flare up of new cancer before thinking about RE.

If you are having a strong positive response to chemo I would definitely get another opinion or consultation to understand why RE is good now as opposed to later. 66% reduction…wow! Docs have estimated Andrea’s reduction at 50%+, but they are not certain if the remaining tissue is active or scar tissue.

Anyway, I am not meaning to upset the apple cart, but I don’t understand an RE recommendation given the strong response.

Jason