pcl1029

Hi,
Palliative care at this point is a good idea although your mom may not need it at this point.
I think the “quality of life “at this point is more important than the quantity of life if the oncologist give you her opinion as you mentioned.
I am a patient of CCA for 34 months now; if I receive the same opinion from my doctors, I will consider the “quality of life” far more important than the” quantity of life”;that included stopping of the chemotherapy(as you may know, chemo agents are toxic to the body).
May the Love of our Lord,Jesus Christ, the Grace of God, and the Fellowship of the Holy Spirit be with you and your family.
God bless.

Hi, Eli,

for nausea;
Try to suggest to doctor to give your wife the second generation of 5HT3- Palonosetron by mouth and in day2 and day 3. it has a 30-100 fold affinity to the 5-HT3 receptor and a significantly longer half-life(40 hours) than ondansetron.You can also try the new kind of anti-emetic agent -Aprepitant by mouth.

for Headache;
As I suggested before but you do not like it because it contains aspirin; is to take 2 tablets of Excedrin.the aspirin content is very small;otherwise take two tylenol and drink a cup of coffee(35-50mg caffeine) and one Advil(200mg ibuprofen) may provide the same synergistic effect of 2 tabs of Excedrin.

for dizziness,tired and weak;
Besides drinking enough fluids;check the most current level of potassium and magnesium ,if it is low,get a Rx for potassium and magnesium pills to take at home for a couple weeks; if hemoglobln is <8, 2 units of packed cell(blood transfusion)may work or give epogen will work too but it really depends on the judgement of the doctors and the protocol of Canada medical system for using epogenin anemia for chemo cases;some doctor do not do anything especially about giving epogen unless the situation is getting much worse. antihistamines like meclizine may help dizziness as well as dimenhydrinate and diphenhydramine (may cause drowsiness);a warm blanket will help the cold feeling too.
God bless.

Hi,Pamela,
First ,here are some guidelines or principles from a chapter of the textbook of “Oncologic Disorders” title “Cancer chemotherapy and Treatment.”

“The underlying principles of using combination chemotherapy are to use
1. agents with different pharmacologic actions,
2. drugs with different organ toxicities,
3.agents that are active against the tumor and ideally synergistic when use together,
4.agents that do not result in significant drug interactions.”

Even though the combination of 5 FU and Gemzar is not as strong as the Gemzar/Cis combo and at most may be in the same effectiveness as Gemzar alone as indicated by a couple studies.However, base on my research,the toxicities of the drugs in the platinum family like cisplatin will pop up around the 6 cycle time frame as the drug accumulated over the course of treatment;that include allergic reaction to the drug and other side effects like nephrotoxicity(decrease kidney function) and neuropathy( hand-and-foot symptoms) and low blood cells count(WBC,platelets and RBC). ;therefore as a whole, I think your oncologist’s decision is prudent if she decided to eliminate the cisplatin .She is thinking ahead of how to treat your daughter before side effects pop up. this is especially true if the CAT scan or MRI will show STABLE response or tumor shrinkage on March 8.. You can always add the cisplatin back if needed.

So base on what the principles of the text book and the toxicity of the platinum;and the sign of a prudent oncologist that knows what to do .
I will not recommend any change of the suggestion that provided by your oncologist.Also in doing so, you will reserve more options down the road if needed.
good luck in surgery.
God bless.

This is a reprint message: it may provide some help;

Hi,everyone,

This is the current philosophy and practice of using CHEMOTHERAPY in general for treating.CCA that I believe in which is the less,the better.. I think his assessment is reasonable too.The following is quoted from the link at the end of this message under the experts review section if you want to read it through the whole thing even though it is for colon metastasis.

“As we take stock of what is now available, we need to clarify how these agents will be used to maximize outcomes. This might include optimizing RRs with at least three agents when curative resection is the goal, or maintaining quality of life with sequential therapy if exposure to all agents is a reasonable expectation. Sequential monotherapy starting with capecitabine or 5-FU/LV with or without bevacizumab and then proceeding to either oxaliplatin- or irinotecan-based chemotherapy as second-line therapy may be considered in patients who are asymptomatic, in those with relatively slow-growing disease and/or in those with multiple sites of disease that are deemed to be unresectable. This is in line with National Comprehensive Cancer Network guidelines. Additionally, monotherapy may be more appropriate in elderly patients and in those with significant comorbidities. In contrast, initiation with combination therapy is more appropriate in patients who have excellent performance status and clinically aggressive disease, in those with significant symptoms and/or in those who may be considered for salvage via surgical resection.”

http://www.clinicaloncology.com/ViewArt … a_id=20050

God bless.

Hi, Jim,
thanks for the info.
I am sorry,I just discover this message to-day.
God bless.

Hi, Pamela

Here is the list of chemo agents that mostly used for CCA that I can find at this point. most of them are used in combination to get the best results (synergy) out of the combo that used in the regimen.

Taken by Mouth:(not necessary FDA approval indications for CCA but doctors can use them out of protocol)
1.Xeloda(oral form of 5FU)-see 5Fu below;diarrhea and hand and foot symptoms are the side effects.

2.erlotinib(Tarceva)—EGFR cell pathway inhibitor(tyrosine kinase inhibitor);
inhibit angiogensis (cut off blood supply to cancer cells and cause them to die);cause cell death by interrupting the reproduction of cancer cells;smoking will decrease the drug effects by 24% which may result in treatment failure.

3.sorafenib.(Nexavar)—Multiple cancer cell pathways inhibitor; inhibit cell proliferation and angiogenesis(cut of blood supply to cancer)
4. Celecoxib-an antiflammatory agent belongs to the COX2-an enzyme family.but use much less recently.

Taking as Infusion:
1. 5FU.—a chemo agent belongs to the Antimetabolite family that inhibits RNA synthesis and function ; may also on DNA synthesis but to the less degree. in doing so,cause cancer cell to die.

2.Gemzar—a chemo agent belongs to the Antimetabolite family that inhibits the DNA synthesis in the cancer cells;induce tumor cell death (apoptosis);
some study indicated Gemzar is more effective in treating CCA than 5FU,but both 5FU and Gemzar are FIRST LINE chemotherapy agents of choice to combine with other chemo agents in CCA regimens;other study indicated effectiveness of both agents are more or less the same.

3.Cisplatin—1st generation of the platinum family, an alkylating agent affects cell DNA replications thus causes cancer cell death(apoptosis);may cause kidney impairment and impairs hearing (ototoxicity);usually use in combination with Gemzar or 5FU to provide the synergic effect of the regimen of GEM/CIS or FOLFOX.
4.Oxaliplatin— the 3rd. generation of the platinum family;less kidney impairment than cisplatin but more patients experienced peripheral neuropathy
5.Carboplatin— the 2nd generation for the platinum family;decrease platelet production;much less toxicity on the kidney compare to others in the platinum family; cause less peripheral neuropathy than oxaliplatin.

6.Avastin(bevacizumab)-a VEGF cell pathway inhibitor— an angiogensis inhibitor to cut of blood supply to tumor cells.and cause cancer to die.

7.Erbitux(cetuximab)-an EGFR cell pathway inhibitor;blinds to the cancer cells surface receptor of EGFR and block their stimulation;therefore renders the cell pathway useless.

8.Leucovorin(it is not a chemo drug but used to enhance 5 FU effect)

9.FUDR(Floxurdine)-it is an analog of 5FU,belongs to the Antimetabolite family. Administered via the hepatic artery(pump);hepatic toxicity is high.

10.Epirubicin— a chemo agent belongs to the Anthracyclines family which is less used nowadays.
11.Adriamycin—a chemo agent belongs to the Anthracycline family;interrupt the DNA and RNA synthesis in cancer cells and cause cell death;used in chemoembo in CCA;major BOX warning by FDA is myocardial toxicity ;also neutropenia and leukopenia(75%)

12.Irinotecan(Camptosar)-inhibits DNA synthesis in tumor cells by inhibiting an enzyme called topoisomerase1 ; useful but tough to take.

13.Docetaxel-chemo agent belongs to the Taxane family,interrupt the mitosis of the cancers cells cycle to reproduce and cause tumor death.

14.Mitomycin- a chemo agent belongs to the Alkylating family; inhibit DNA and RNA synthesis and thus cause cancer cell death ;use in chemoembo for CCA and can be combined with 5FU for treating CCA too.

15.Panitumumab(similar to cetuximab ;but difference from them is that this is the first 100% HUMAN monoclonal antibody direct against EGFR cell pathway; therefore you may expect less allergic reaction from Panitumumab.

16.paclitaxel-(Taxol) a chemo agent in the Taxane family that primary inhibits the cell cycle during mitosis;thus the tumor cell cannot duplicated and die;Taxol should be given before cisplatin if both drugs are used at the same time for maximum benefit of the combo.;also inhibits angiogenesis but is very tough to take.

God bless.

PCL1029 wrote:

Hi, The following is a reprinted message about CT and MRI scan,it may be easier and of value to those new members who try to search for this info if I duplicated it here again.

Ultrasound (US)of the liver or abdominal area provide the most inexpensive way to check on the hepatobiliary system.It is of great value too when it is used intraoperatively to detect tumors that the liver surgeon cannot see with his/her naked eyes during surgery.But its result is depended on the person who performs the US as well as the interpretation of the image; when the US result is inconclusive,CT scan or MRI is recommended.

Cat Scan is for diagnosis purpose.(including initial diagnosis and follow up after resection or chemo treatment for CC. Both MRI and Cat Scan are used to look for structural changes.PET scan is used to look for functional changes(activity) of the CC.
According to one study compared 20 intrahepatic patients images ,the extent of the tumor enhancement was similar with both MRI and CT methods,however the relationship of the tumor to the vessels and surrounding organs was more easily evaluated on CT scan as opposed to MRI.But for perihilar tumors CT also has limited sensitivity for extra regional nodal disease(ie metastases to the periaortic,pericaval or celiac artery lymph nodes.)—from uptodate .com.

(My own experience told me that MRI with contrast is a good “follow-up” alternative to use right after initial CT with contrast shown inconclusive report in the early stages of CC development .Using MRI or PET to rule out recurrence or give the patient an early and more options to treat the recurrence while the CC is smaller than 2-3cm.MRI can also find additional small lesions which CAT SCAN missed.

I will recommend PET scan right after CAT or MRI if recurrence is confirmed or small lesions detected by MRI but not sure whether they are cancerous or not.This will give the doctor more info about the lesion such as whether the lesion has metastasized or give the doctor a more informed and EARLIER idea what he/she saw on the M R I or CAT scan indeed is a tumor that has metabolic activity(maxSUV) value and required immediate attention such as chemo therapy or resection,RFA,chemoembolization,PDT, SBRT,IRE and radioembrolization.(see beloww link in the cholangiocarcinoma section)

http://www.ajronline.org/doi/full/10.2214/AJR.11.6995

By doing so,the doctors will not be confused with and discard the lesion as being part of the artery or hepatic vein or other forms of lesions and ask the patient to return in 3 months to repeat the scans to make sure.As you all know, 3months is a lot of valuable time for patients as well as caregivers. Who wants to wait for another three months? I think this is the part of early detection that we,ourselves, can monitor and provide the early benefit of more treatment options to the patient.

PET can find or confirm cancer metastasized activities in the other parts of the body.PET may not be a good choice to locate NEARBY and DISTANT metastasized cancer activity such as the lymph nodes that are very close to the primary site of CC because the closest distances between the lymph nodes and other distant organs such as lung,ovary etc.

PET Scan allows visualization of CC because of the high glucose uptake(SUV) of the bile duct epithelium(the lining )– the “Hot spots” will light up on the PET scan and show the relative cancer activity of the lesion by the SUVmax value.

A PET scan therefore can help to tell if the bile duct obstruction is caused by a cancer or benign lesions.PET scan can be useful in determining the cancer may have spread or return after treatment.
In general SUVmax value>3.9 is an indication of cancer activity of the lesion while value<3.9 may not.But the diagnosis must also be made in conjunction with the size or the volume of the lesion that shows the SUV max activity.(the SUVmax range that I saw so far is between 2.0-36.4 in CC);and PET is more accurate when using in intrahepatic lesions than extrahepatic lesions in cholangiocarcinoma diagnosis.(SUVmax values is different from organs and other parts of the body;(ie:the SUVmax>2.5 in lung mass may be indication of metastasis.)

Some hospitals equiped with machine that is able to perform both A PET and CT scan at the same time(PET/CT scan) ;this allows the radiologist to compare areas of higher radioactivity on the PET with the appearance of the that area on the Cat scan. But according to the radiologist I talk to , A (PET/CT scan ) is not the SAME as if you take them SEPARATELY;(PET/CT scan is PET plus CT scan WITHOUT contrast).

Remember Ct scan is for STRUCTURAL (ie: the size) and PET is for FUNCTIONAL (activity) visualization of the lesion. That is why sometimes doctors order a PET scan on this 3 month checkup and on the next checkup, he/she orders a CAT Scan with contrast or MRI instead.

The current recommendation from NCCN in the States for extrahepatic and intrahepatic cholangiocarcinoma are the same for resected patients(R0 )with clear margin-for surveillance purposes–consider imaging every 6 months for 2 years.(But based on my personal experience EVERY 3-4MONTH is more realistic and it can provide more early options for treating the recurrence since the sizes and extended involvement of the tumor is still relatively small.It is because in general,the tumor lesion will be double in size every 2-3 months ,some are slower,some are faster in grow. depend on the type of cancer cells.)

Additional info. from uptodate.com
MRI and CAT SCAN (CT) have similar resolution for liver lesions.
CT has been considered to be superior to MRI for evaluating extrahepatic organs and calcifications. MRI is more specific than CT for differentiating cavernous hemangiomas,diffuse hepatic steatosis and focal fatty infiltration.
Also MRI should be reserved for the evaluation of lesions less than 2 cm,or lesions located adjacent to the heart or to major intrahepatic vessels.
If you are allergic to the IV iodinated contrast agent used for CT,then MRI is the alternative because the contrast agent used is different than CT. and MRI is not involved radiation .
I hope the above info. helps.
God bless;.