I have a patient with recurrent intrahepatic cholangiocarcinoma (originally had R0 resection and was observed). Now 3 years later has recurrents, s/p R1 resection. He has no evidence of metastatic disease and nodes appear to be uninvolved. What would guys treat...surgical bed + margin +porta and celiac?
cholangiocarcinoma
- Thread starter BraggPeak
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deleted4401
Yup. I think celiac traditionally included, but biggest failure sites will be tumor bed and eventually/concurrently the liver. With 5FU or Xeloda.
Had a few gallbladder cases the last few years and did 1.8/2.0 to nodes/tumor bed, with zofran RTC and they sailed through treatment.
Had a few gallbladder cases the last few years and did 1.8/2.0 to nodes/tumor bed, with zofran RTC and they sailed through treatment.
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deleted4401
Yeah, so basically conceptually I just look at it like a spectrum of pancreas cases, whereas if it was tail of pancreas you would include splenic hilum, head you include porta hepatis/duod/peripancreatic LNs, and if it is GB or cholangio, you include porta and medially the adjacent liver for the tumor bed. Essentially the rest of it stays the same, and you can include less of the peripancreatic stuff, but still use the contralateral aspect of vertebral body as a guide for that, and then of course celiac/PA nodes down to L1 or L2 or so. I don't think there are enough cases to have a well defined atlas, but I think this is a reasonable way to approach.
I think the traditional pancreas fields are too big, b/c it wasn't that we were having marginal failures, we just don't have the dose to control in-field disease. Let me see if I can put up a screenshot.
I think the traditional pancreas fields are too big, b/c it wasn't that we were having marginal failures, we just don't have the dose to control in-field disease. Let me see if I can put up a screenshot.
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yup. Some med oncs like to incorporate low-dose gem instead of 5-FU with concurrent XRT, so that's all the more reason to be tight with your fields if you can.
The paradigm now from many GI experts is to just treat the pancreatic tumor +/- immediately adjacent lymphatics in non post-op cases and forget about those big fields.
Stupid question, but:
Would any of you do SBRT to the positive surgical margin and leave out all the nodes and forget about chemo?
sbrt boost to positive margin after standard fractionation ebrt to at least the preop location of tumor + margin OR truly SBRT to the site of positive margin only (basically like a reexicision)?
So just as an update, for INTRAhepatic cholangiocarcinoma, apparently you do NOT need to treat para-aortics of celiac LNs. I emailed a couple of GI oral board examiners and they all said that you treat tumor bed +/- porta. For extrahepatic, you treat like celiac/PA.
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Just the positive margin (although, I doubt you are going to be able to define a very small area anyway and bearing in mind the liver movement, the PTV is bound to get not very small).
But yes, pretty much like a reexcision.
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deleted4401
As far as SBRT for positive margins, there is a series from UPMC. The third author is a fine radiation oncologist, both clinically and aesthetically speaking.
http://www.springerlink.com/content/j570r6j075843818/
http://www.springerlink.com/content/j570r6j075843818/