karend

Ali,

Regarding the ABC-02 trial,

Bridgewater, et al. published a really wonderful paper on cholangio in 2014. I have referenced it many times in projects I have worked on.

Regarding ABC-02 trial standard of care chemo (this is Gemzar (Gebcitabine) and Cisplatin.

Gemcitabine and Cisplatin systemic therapy is standard of care for non-resectable disease if the patient has a good performance status with a median survival of 11.2 months versus 7.7 (Bridgewater et al.,2014).

Here is the citation:
Bridgewater, J., Galle, P., Khan, S., Llovet, J., Park, J.W., Patel, T., Pawlik, T., & Gores, G. (2014). Guidelines for the diagnosis and management of intrahepatic cholangiocarcinoma. Journal of Hepatology, 60(6), 1268-1289. doi.org/10.1016/j.jhep.2014.01.021

I hope this helps you.

-Karen

Alikemal,

I should preface this post with the understanding that although a study may come out with a chemotherapy regimen for a specific cancer, there is much room for interpretation. Every oncologist will order differently, and this is not something that I can expound on as I am an oncology nurse. Hospitals also develop their own protocols.
In looking through the chemotherapy orders (or your very organized sheet!) what I see first is the protocol. This protocol appears to be roughly following the standard of care for biliary cancer based off the ABC-02 trial from 2010. Now I will go through the whole order sheet. I will attach the links to the New England Journal of Medicine (NEJM) where the ABC-02 study was published, and also Cancer Therapy Advisor so you may see where I sourced this information for you.

1. The orders state that the chemotherapy administration will be on 1 and 8, every 21 days. (This would be one “cycle”). The ABC-02 trial was to give gemcitabine/cisplatin on days 1 and 8 every 3 weeks (so roughly 21 days). This treatment is to be given in 4 cycles per the study.

2. The order sheet says Cisplatin 30 mg/m2 and Gemcitabine 1000 mg/m2. The ABC-02 study and the Cancer Therapy Advisor list the doses as Cisplatin 25 mg/m2 and Gemcitabine 1000 mg/m2. Why the slight difference for your order sheet? Perhaps this is a case where the oncologist is ordering based on their knowledge base. You could always ask.

3. Numbers 5 and 6 in the list on the order sheet- Cisplatin 40 mg- The cisplatin orders state that this dose is to be 30 mg/m2. BSA is 1.48/m2 so 30mg x 1.48= 44.4 mg. Whoever mixed the chemo did 40 mg of Cisplatin even though the dose is technically 44.4. They chose to round down which I will explain in a bit. Gemcitabine 1000 mg/m2. 1.48 x 1000 = 1,480 mg. The given dose though is 1100 mg. Here again, the dose was decreased.

4. Numbers 1, 2, 3, 4. 1. Dekort I believe must be Decadron, a steroid and a pre-medication to prevent adverse reactions from the chemotherapy. 16 mg looks right to me. 2. My facility happens to give Ondansetron (Zofran) at 8 mg to prevent nausea (another premedication) 3. Benison or Avil, I have not heard of. As it says “antihistamine” on the sheet, I’m guessing this must be something like Benadryl, which I have given as a premedication for many things, including chemotherapy. I cannot remember giving this before Gemcitabine/Cisplatin, but I’m not saying this is wrong for it to be given. 4. Lasix 20 mg. Lasix (Furosemide) is a diuretic to help the body to diurese. The 1000 ml of saline is a kidney protectant as the Cisplatin is toxic to the kidneys. I have not given Lasix with Cisplatin before, but I certainly have pre and post hydrated with saline. Again, this must be oncologist specific per their knowledge base.

5. Number 7, Emend. This medication is an NK-1 antagonist, or a heavy duty anti-nausea medication that has been shown in studies to work very well to fight the kind of nausea that can occur with Cisplatin, which can be very severe. Cisplatin is what we call a “highly emetogenic” chemotherapy so precautions such as the administration of Emend will help to ward off this nausea/vomiting.

Now I will explain about dose reduction and speculate on why the entire 1-7 were given the first time, and not the second. Dose reduction is done for the safety of the patient. Your mother is 70, and perhaps she has some other illnesses (diabetes, heart disease, etc.). She may have underlying kidney or liver function issues…I do not know what her lab work would reveal or her health history. Oncologists will dose reduce to treat, but do as little harm to the body, which I suspect happened in this case. This is again why your mother most likely received Gemcitabine alone without the Cisplatin. Cisplatin can be especially harsh and cause the kidneys to struggle, and greatly affect the bone marrow and resultant lab results. (Platelet count can drop markedly, as well as the white blood cell count (WBC), hemoglobin/hematocrit, neutrophils, etc.). Neuropathy can occur too with the Cisplatin, and this will cause an oncologist to dose reduce or discontinue.

My advice would be to ask the oncologist any questions you may have, and look through the resources that I provide links for. Again, every oncologist orders differently and the information I have provided is my opinion based on experience, but I am not a physician.
Hopefully this will ease your mind, as it appears that the orders are very similar to the current standard of care treatment with some minor changes.

-Karen D.

http://www.nejm.org/doi/full/10.1056/NEJMoa0908721#t=articleDiscussion

http://www.cancertherapyadvisor.com/gastrointestinal-cancers/gallbladder-carcinoma-cancer-intrahepatic-cholangiocarcinoma-treatment-regimens/article/218164/?webSyncID=005a7c3b-869c-6ebe-c066-b65e86dcd414&sessionGUID=dc59e930-726c-873e-1474-ab7cea06e3aa

Strategies for managing cancer- related distress

https://conquer-magazine.com/strategies-managing-cancer-related-distress/

Karen D. BS, RN, CHPN

All,

I have discovered that the links within the previous post on drainage care are old and no longer work. They are now updated with the new links, minus the University of Washington as it is no longer available, and I have added the University of Utah.

In addition, interventional radiology should be aware of excessive leakage from the drain insertion site as they will need to assure that the tubing is patent. If all is well and there is continued leakage, I have often times had wound ostomy nurses secure a bag around the insertion site to prevent bile from continually irritating the surrounding skin. You want to keep the skin clean and dry or it will become quite sore after time.

Information gathered on biliary drains from major centers of care in the United States, search terms: Biliary drain leakage, biliary drains, biliary drains not attached to drain bag, leakage at insertion site from biliary drains

Stanford
https://stanfordhealthcare.org/content/ … cation.pdf

Memorial Sloan Kettering (MSKCC)
https://www.mskcc.org/cancer-care/patie … e-catheter

University of Utah
http://healthcare.utah.edu/radiology/pr … n-care.php

The Ohio State University Medical Center
https://patienteducation.osumc.edu/Docu … yDrain.pdf

University of San Francisco (UCSF)
http://campuslifeservices.ucsf.edu/dmx/ … UR0320.pdf

Beth Israel/Harvard
http://www.bidmc.org/~/media/Files/Cent … 20tube.pdf

Common finding: If leakage, attach to drain bag. These facilities say to flush daily with saline and to call if excessive leakage.

-Karen, BSN, RN, CHPN

• This reply was modified 5 years, 11 months ago by karend.

Steven,

I will say that in my practice of close to 20 years, I recall giving albumin infusions two times for acites related issues/cancer affecting the liver. One of these times was at an academic medical facility, and once at a community cancer center. I do remember that the individuals whom I gave the infusions were stable, though very ill.

There is quite a balancing act that occurs to keep an individual safe, and all treatments must be carefully considered and the risks vs. benefits.

Albumin is a blood product and is infused and treated similarly to a blood transfusion, though it has a lower risk of reaction. It is generally given as a volume expander and must be used with caution.

http://www.fda.gov/downloads/Biolog…ionatedPlasmaProducts/ucm056844.pdf

Your post had me searching through medical literature to see what the experts have to say about albumin infusion for the treatment of ascites/edema, and here is what I found:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3290049/

“Management of patients with ascities in GI malignancies is controversial”.

“A logical approach is to individualize treatment. The rationale in the management of malignant ascites involves consideration of survival and QoL issues. Palliative techniques play an important role in the reduction of symptoms, which bear a direct correlation to patient satisfaction and therapeutic choices”.

QoL= Quality of life

“The most commonly used means of managing malignant ascites was paracentesis, which was also felt to be the most effective by the group surveyed. After paracentesis, diuretics and peritoneovenous shunting were used most frequently, but there was no apparent consensus as to their effectiveness.14 A survey by Lee and colleagues showed that paracentesis and diuretics were the most commonly used procedures in management of malignant ascites followed by peritoneovenous shunts, diet measures and other modalities like systemic or intraperitoneal chemotherapy”.

“There is no evidence of concurrent albumin infusions in patients with malignant ascites”.

It is difficult to find literature on the use of albumin for malignant ascites. Most of what I have found discusses the treatment of ascites in patients with cirrhosis.

The indications for albumin infusion for someone such as your mother may be if she has at least 5 liters of fluid removed via her abdominal catheter (White, 2014). This appears to be a common reason for the use of albumin, and similar to your mother’s situation. This same article by White does state albumin has been used to “mobilize ascites” although the studies cited discussed individuals with cirrhosis of the liver.
Outpatient Interventions for Hepatology Patients With Fluid Retention: A Review and Synthesis of the Literature
White, Asha DNP, RN, ACNS-BC

There are other studies that I have read that state that the use of albumin is well established in certain instances (large volume paracentesis, volume expansion, kidney disease, etc.), but controversial in others (high blood pressure (hypertension), fluid in the lungs (pulmonary edema), anemia, etc).

So, I know that I have thrown a lot of information at you, but it is good to see what the evidence out there says about treatment for ascites. I can say without hesitation that in my experience, treatment of ascites/edema is based on the quality of life of the affected individual. I have seen people have a weekly paracentesis performed, or a valved catheter with which to periodically drain the fluid. I’ve also seen medications like Lasix given to reduce the fluid retention, as well as restricting sodium and fluid intake. Other times no measures are taken as the individual is comfortable and treatment will do more harm than good.

I feel that if I were in your situation, there would be no harm in asking your mother’s oncologist how they feel about albumin infusion for the treatment of her ascites/edema. Perhaps you will find that they may be open to trying it, especially since she is being treated at Rutgers. Although one study I read did not recommend it for use in malignant ascites, this study is from 2009 and new evidence may be available that contradicts the findings of this study.

Most importantly and the reason for putting so much information into this post, is that being informed and able to discuss treatment with the oncologists/nurses will help you as you advocate for your mother. You never know, perhaps you will spark an idea in the oncologist and help them to consider treatments that they might not have otherwise!

All the best to you and your mother, Steven!

Karen D., BSN, RN, CHPN

THIS INFORMATION IS NOT INTENDED NOR IMPLIED TO BE A SUBSTITUTE FOR PROFESSIONAL MEDICAL ADVICE. YOU SHOULD ALWAYS SEEK THE ADVICE OF YOUR PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROVIDER

Great picture!

-Karen