Cholangiocarcinoma post-op

[bonusking]

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Hello,

What are the regional lymph nodes that I should irradiate for the following case :

Cholangiocarcinoma operated (total right liver resection, lymphadenectomy )
T2aN2M0 R0
Adjuvant chemotherapy realised after the surgery

sorry for my english

Thanks.

 

[Radiator20]

N2 - which LN were positive?

 

[bonusking]

As in pathology report :
Around falciform - hepatoduodenal ligament
3N+/6N

Thanks

 

[Radiator20]

Extrahepatic primary?

SWOG S0809 comes to mind (only enrolled GB and extrahepatic). They did adjuvant Gem+cape -> cape + RT. Per their paper (and planning constraints are kindly provided in an appendix table):

Capecitabine (1,330 mg/m2per day, in divided doses twice daily, 7 days per week) concurrent with radiotherapy (45 Gy to regional lymph nodes [retropancreaticoduodenal, celiac, and portal vein nodes] and 54 to 59.4 Gy to preoperative tumor bed). Both three-dimensional planning and intensity-modulated radiotherapy (IMRT) were allowed. In patients receiving three-dimensional radiotherapy, total dose was 54 Gy in 30 fractions (59.4 Gy in 33 fractions for R1 resection at treating physician's discretion). In patients receiving IMRT, a concurrent boost was delivered for a total dose of 52.5 Gy in 25 fractions (55 Gy in 25 fractions for R1 resection at physician's discretion)

Hopefully you have preop imaging and/or clips to guide you as to where those gross LN were?

 

[bonusking]

Unfortunately no clips.

Thanks

 

[seper]

Never treated a case like this, but I'd suggest wide nodal field to 45 Gy - portal, gastrohepatic, celiac, and SMA nodes.

 

[Palex80]

Unfortunately there is no clear survival benefit through RT in this scenario. All evidence is retrospective and subject to considerable bias. We do not really know if these patients needs RT, RT+CT or CT only.
I would only irradiate if the patient is young & fit and eager to undergo maximal treatment. And yes, unfortunately the volume you are going to have to irradiate is big, just like Seper said.

 

[Radiator20]

Also interesting to note the MDACC experience - no survival difference between R0, pN0 patients who got surgery alone, vs R1 and/or pN+ pts who got surgery + adjuvant CRT. To my mind, that does suggest a benefit to adjuvant CRT although of course does not prove it.

For what it's worth, like S0809, they also most often went higher than 45 Gy (usu ~54) and most often did concurrent 5FU. They describe their coverage as: tumor bed (usually marked with surgical clips), portahepatis, hepatoduodenal ligament, and peripancreatic and celiac lymph nodes.

 

[ramsesthenice]

Agree that the benefit is not clear but if the patient did well with adjuvant chemotherapy and is otherwise well then it is probably reasonable to try. I would encourage you to be thoughtful with how you define your tumor bed and boost volume. The whole point of a boost is to reduce the risk of local failure in the area of highest concern. This person had a right hepatectomy. If the tumor didn't penetrate the capsule or involve adjacent tissues and they had wide margins then the physical location of the tumor preoperatively is not where they are at risk of failing. Consider intrahepatic paths of spread (like vessels) and boost the residual hepatic margins you think are most at risk. You may not be able to define one. I don't universally include a boost volume. You are treating this person because they had N2 disease. If it is the nodes you are worried about, don't go crazy on the primary. No matter how big you make your fields they are at risk of satellitosis and intrahepatic failure. Its just the nature of the disease.

 

[nkmiami]

Agree that the benefit is not clear but if the patient did well with adjuvant chemotherapy and is otherwise well then it is probably reasonable to try. I would encourage you to be thoughtful with how you define your tumor bed and boost volume. The whole point of a boost is to reduce the risk of local failure in the area of highest concern. This person had a right hepatectomy. If the tumor didn't penetrate the capsule or involve adjacent tissues and they had wide margins then the physical location of the tumor preoperatively is not where they are at risk of failing. Consider intrahepatic paths of spread (like vessels) and boost the residual hepatic margins you think are most at risk. You may not be able to define one. I don't universally include a boost volume. You are treating this person because they had N2 disease. If it is the nodes you are worried about, don't go crazy on the primary. No matter how big you make your fields they are at risk of satellitosis and intrahepatic failure. Its just the nature of the disease.

Last year there was a randomized phase III trial (bilcap) that adjuvant Xeloda has a 15 month survival benefit, so it worth adding the chemo/rads after initial chemo.

 

[ramsesthenice]

Last year there was a randomized phase III trial (bilcap) that adjuvant Xeloda has a 15 month survival benefit, so it worth adding the chemo/rads after initial chemo.

Couldn't agree more. That is why I specifically said if they have done well with chemo. Start with what has a proven survival benefit. The poster already state the patient got chemo so I didn't explicitly address the point. It also biologically makes sense. Its the distant disease we are all worried about. If you can't control that then it is very unlikely you are going to make much of a difference with local therapy.

 

[Palex80]

The Bilcap trial was certainly helpful, but it included a variety of tumors and stages. This is why it‘s difficult to draw definite conclusions ob modality and intendity of adjuvant treatment. Less than 100 patients on the trial had a CCC.

 

[nguyencuong9102]

N2 - which LN were positive?