Case-Based Panel Discussion: Multidisciplinary Care of CCA

June/July 2022, Vol 3, No 2

At the 2022 annual meeting of the Cholangiocarcinoma Foundation, a case-based panel discussion focused on multidisciplinary care of cholangiocarcinoma. The multidisciplinary panel was co-moderated by Dr Milind Javle, Professor of Gastrointestinal Medical Oncology at MD Anderson Cancer Center, and Dr Flavio Rocha, Chief of the Division of Surgical Oncology at the Oregon Health and Science University. The other panel members included Dr Riad Salem, Section Chief of Interventional Radiology at Northwestern University; Dr Ethan Ludwig, Assistant Professor of Gastrointestinal Radiation Oncology at MD Anderson Cancer Center; Dr Talia Baker, Division Chief of Transplantation and Advanced Hepatobiliary Surgery at the University of Utah; Dr John Bridgewater from University College London. The cases were presented by Dr Tin-Yun Tang, a fellow at MD Anderson Cancer Center.

Case Overview:

  • A 53-year-old man presented with abdominal pain and low-grade fever.
  • Imaging showed a liver mass. CA-99 was remarkably high (2651 U/mL); AFP was normal.
  • History of hypertension and type 2 diabetes. Family history of liver cancer (father).
  • He was not deemed to be a surgical candidate due to the fact that the lesion encased the hepatic artery and abutted the portal vein.
  • Systemic therapy with gemcitabine/cisplatin was started 12/2020.
  • Following ultrasound-guided liver biopsy, a diagnosis was made of liver-limited, locally advanced, stage II intrahepatic cholangiocarcinoma. Lymph nodes were negative, and no metastatic lesions were identified.
  • Biomarker testing of the liver biopsy could not be performed due to inadequate DNA and RNA. With liquid biopsy, there were no somatic findings; germline pathogenic BRCA1 mutation was suspected.

Given the lack of actionable alterations, Dr Baker noted that “although this patient is not suitable for upfront resection, we need to work towards getting him to a point of resectability or transplant.”

The panel concurred that the patient was a candidate for Y-90 radiation therapy. Dr Baker noted that “Y-90 radiation therapy is favored over chemoembolization because in cases where a tumor is abutting a major vascular structure, the radiation effect tends to pull the tumor away from the structure, which allows you to be more likely to get R0 rather than R1 resection.”

Local therapy is also a reasonable option in this setting. Dr Salem said that “local regional therapy would target the left hepatic artery and the anterior sector to clean that margin and create scar tissue across that surgical plane, allowing resection.”

However, sequencing of liver-directed therapies was thought to be critical. Dr Rocha said that “sequencing is important because some therapies may burn the bridge for other therapies. For example, we might consider putting a hepatic artery pump in; another option certainly would be the Y-90. However, the caveat is that for patients that have had previous Y-90, we cannot put a pump in but the reverse is okay.”

Dr Baker favored transarterial radioembolization (TARE): “One of the advantages of TARE is that you can really define the extent of disease. TARE also is a great stress test for the liver, so we can tell how well the liver will respond to therapy and make an informed decision about whether an extended resection or transplant would be a better option at this point. Furthermore, from a transplant perspective, it gives us time to start thinking about intent to treat now and bring in living donation.”

The patient received proton beam therapy concurrently with gemcitabine/cisplatin, while being considered for transplantation (on protocol). Dr Baker said, “In this case after multidisciplinary discussion, external beam radiation was favored over Y-90, considering the vascular supply of this tumor and given that we wanted to consider transplantation.”

The patient responded to treatment and was listed for liver transplantation; however, oligometastatic disease in the brain was detected after 7 months of observation. Given the favorable anatomical location of the lesion, a craniotomy was performed and the oligometastatic lesions were resected.

Biomarker testing of the brain biopsy lesion found several alterations. Based on MSI-H/TMB status, the patient was found to be a candidate for single-agent pembrolizumab, and was tolerating it well (at the time of the meeting). Given the identification of an actionable alteration, Dr Javle noted, “I wanted to illustrate here that the need for molecular testing does not end with one negative biopsy and inadequate DNA sample.”

Dr Rocha concluded, “This case is a great example of therapy that was tailored to the individual based on multidisciplinary discussion, not just at the molecular level, but at the liver level and at the patient level.”

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