pcl1029

Hi,Richard,
You are a good researcher,the reason I said this is -you have a desire to carefully learn and know about this horrible disease so you can take care of your wife in advance to the possible outcome in the future. I salute you on this.
Yes, there are benefit for adjuvant therapy for patients with R0 or R1 margin;but the duration of chemotherapy of 6 month may not be enough to prevent the recurrence.
Additional radiation therapy may add additional survival benefit to CCA patients
Clinical trail whenever possible is also recommended by NCCN and ESMO.
ps. please read my reply to your e mail today for more info.
God bless.

Hi,
All I know is that combination of chemo is tough esp. after radiation.Have you ask the radiologist about PDT ?
God bless.

Hi,
why you schedule your interventional radiologist’s appointment after the CT scan instead of 2 weeks from now,That way will provide a more up to date picture for him to make his assessment .
I think they can do something(ie: RFA on the 2 liver spots ;but the one that fused with the stomach is a bit difficult ,may be he/she will use chemoembo or radioembo for it first;the whole thing also depending on whether how the Gemzar works out so far.Miracle does happen,if the tumor responding to treatment,it may separate from the stomach ,(although I think it is too early to tell )and that will be the best news so far;then your treatment options will be more and better. If he/she say no, ask why? Is it the location of the tumor too close to major organs or major blood vessels? Can he/she go around them and what will be the side effects of such interventional treatment ?Can he /she tell you if your dad is able , will he/she uses RFA ,chemoembo or radioembo or the combinations and why ?
Ask questions to help you learn and retain the knowledge to help your dad;you will be surprised if you asking questions like that;the radiologist will treat you a bit differently knowing that you have done your preparation .
God bless.

Hi,Kate,

“I wonder if it makes a difference that with Richard’s wife we are talking about adjuvant therapy with negative margins. “

Yes, according to ESMO(European society of Medical Oncology) guidelines. they suggested either supportive care or palliative chemotherapy and/or radiotherapy after a noncurative resection of CCA (intra and extra)and consideration of postoperatvie chemoradioptherapy as an option after complete surgical resection. But the NCCN guidelines(National Comprehensive Cancer Network) in the States indicated for extraCCA patients with resected,margin-negative ,observation or fluoropyrimidine-based chemoradiotherapy are acceptable options. for intraCCA patients,have no residual local disease,no adjuvant therapy recommendation are made.

“Is there some evidence you have seen that Gem also works better in adjuvant therapy? The reasons for the Bilcap trial using Xeloda seem to be based on it’s positive results with colon/pancreatic cancers.
I’m wondering what a study of Cap v Gem would yield. ” please go to http://www.mdpi.com/journal/cancers and put in title as Targeted therapy for biliary tract cancer.author=junji Furuse and review the article. It will provide you,on table 1 phase II studies of the most used chemo agents up to date for CCA;except 2 studies, most are very current(after 2004 to 2010) especially table 2.(all are in 2010).

“Also interested in why you think Gem and Cap together might be more effective? “
It is because gemzar and 5FU(or capecitabline) are the 1st-line treatment chemo agents,by EACH itself ,proven to be effective in treating CCA. for Gemzar itself alone is arounf 7-27% and 5FU by itself is around 0-34%.And there were studies indicated when they combined together the objective response rate is 31% with an additional 42% had STABLE disease.(you can read more into it from the above studies from table1 and 2 in that article.)

“Did you find something which shows radiation successful after a resection with good margins? I seem to find studies which say radiation is usually used with positive margins?”
Please see the above NCNN and ESMO recommendations that I have just included in this message. And no.I did not find anything showing radiation is necessary after resection with good margin.But as I talked to Dr, Levy from Mayo during the ASCO 2011 where he presented”Soup and Nuts about CCA” he said one thing about EUS for extrahepatic CCA was that ,”there are always residual CCA cells may involve in recurrence.” in short ,it is difficult even with great care when taking biopsy from tumors .By the same token, it is very difficult,even with good surgeon,to resect with clean margin and expected the CCA will never return for the same reason. I had >1cm in clean margin the 1st resection and still recur after 18 months. (that might mean microscopically the residual CCA cells (not the tumor) may be too small to be pick up by intraoperative ultrasound,but macroscopically ,thru the surgeons naked eyes it is clean even is 1 cm away from the tumor site.)

What I am trying to say is that ,be vigilant,be watchful for your dad’s CCA, even the doctor said is all clean;monitor his CCA every 3-6 months;and deal with the outcome as soon as possible with the best treatment options at that time frame.

Kate, not that many people like to know the details about cancer,but knowledge helps in understanding the tumor biology and hopefully one day the CURE can be find earlier enough for all of the CCA patients and give the caregivers like you the ultimate joyful reward of knowing that your participation is meaningful and rewarding not only to your love ones but as well as to the society- discover the cure or pathways for better and more effective treatment plans with minimun or no toxicity.
God bless.

Hi,
Sorry to hear about the recurrence after 4 years.
You may not know that I am also a CCA patient for 31months and resected twice;currently is between treatment plans.
I try to find out whether you had intrahepatic or extrahepatic CCA,but I could not find out the answer to help. I only know that you were diagnosed around 3/2007, had resection with positive margin and lymph nodes involvement;on simvastatins for several years but I do not know what treatments you were on BEFORE and NOW. If you don’t mind to tell me the name of the drugs or radiation treatment you are on,I appreciated. I am not a doctor but I,like others before me, is not ashamed of having this CCA disease and If I can of any value to my fellow patients,then my job is done.
God bless.

Hi,Richard,
If your wife’s histology reported indicated positive margin;do what the 2nd opinion recommended;that is Gem/cis and radiation. If your wife’s CCA is extrahepatic CCA,Gem/Cap , radiation with or without FUDR or Capecitabine may be a better choice since 5FU or capecitabine for some unknown reason works better for extrahepatic CCA than intrahepatic CCA unless your wife have done some chemo sensitivity test for choosing the proper agents.and it is much easier to take the Capecitabine than the cisplatin.(less toxic to the kidney and hair loss.)
I love to see a copy of the BILCAP procotol if you can e mail me one.
God bless.

Hi,
2nd opinions for surgical and G I consult,medical oncology and interventional radiation consult from John Hopkins is a good start.
Do not give up. Few can have the chance of resection like your mom.
This is the time for the best use of 2nd opinion.
God bless.