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CASE:
58-year-old
male with newly diagnosed cholangiocarcinoma.
MDExpert
- Assessment and Recommendations
First
of two opinions
Disclaimer:
This opinion is based solely on my review of those medical records
provided to MDExpert by the treating physician. I have not examined
the patient nor is it my present intent to do so in the future.
Those opinions to be rendered herein are intended for advisory
purposes only. It is within the sole discretion of the treating
physician to determine the course, scope, and extent of treatment.
It is expressly agreed and understood that my review of those
records provided and the rendering of any opinion based upon my
review of those records provided do not create a physician/patient
relationship.
MDEXPERT
TREATMENT RECOMMENDATION AND RATIONALE:
Based
on the information provided, this case represents a diagnostic
challenge that isnot unusual for biliary cancer. The presenting
symptoms are consistent with the disease process. The diagnostic
radiographs describe a biliary stricture, but this is not otherwise
specified. Without reviewing the films I cannot be certain of
the exact location, which could be critical for obtaining an optimal
result with surgery. The fact that there was gall bladder distention
on the initial CT scan suggests this is a tumor in the distal
common bile duct. Bile duct cancer has a propensity to spread
along the duct mucosa and submucosa but presumably this has not
occurred since there have been several attempts to obtain a cytologic
diagnosis from brushings of the biliary duct in several locations.
This matter may not be realized until the specimen is examined
histologically. A Whipple (pancreaticduodenectomy) is the operation
of choice for distal common bile duct cancer. The ability to preserve
to pylorus will need to be determined intraoperatively.
ADDITIONAL
INFORMATION OR TESTING THAT WILL FACILITATE OR IMPROVE TREATMENT
DECISION-MAKING:
An
MRI scan can be useful in detecting the extent of spread of the
cancer prior to surgery. The same information might be obtainable
from a thin section, helical CT scan with contrast. The intent
of these studies is to determine if there is evidence of vascular
adherence, which could lead to the inability to surgically extirpate
disease. Endoscopic ultrasound in some experienced users hands
can also be used to detect tumor spread as can intraductal ultra
sound, which has been used to look at the depth of penetration
of the cancer from the mucosa outwards. The latter procedure is
highly user dependent and I have only seen this preformed in Amsterdam
but other GI groups in this country may be using these specialized
scopes now.
TREATMENT
ALTERNATIVES AND THE ADVANTAGES OR DISADVANTAGES OF EACH:
If
the patient does not recover well enough to tolerate an operation,
the use of external beam irradiation plus 5-FU based chemotherapy
has shown some benefit in prolonging survival. Alternatively,
brachytherapy with or without external beam irradiation can also
be used to treat these cancers. After radiotherapy treatment,
an external drainage system can be converted to an internal stent
to make life more manageable for the patient by elimination of
the external catheter and drainage bag. Infectious complications
are always a risk with any form of drainage apparatus and this
does not appear to be appreciably increased by the use of irradiation.
PROGNOSIS:
Complete
resection of distal bile duct cancer yields about a 35% 5-year
survival rate for all comers in several surgical series. This
means there is a small cancer (<2-3 cm) with negative surgical
margins. This patient has a 3 to 4 cm cancer on the CT/cholangiogram
and prognosis may be worse. The median survival of patients treated
with irradiation is around 10 to 12 months and with the addition
of chemotherapy and high dose irradiation the median survival
can be extended 4 to 6 months. In the case of surgical resection
and post-operative treatment, the median survival may be the same
but this would reduce the risk of local recurrence and possibly
add to his survival.
By:
Tyvin Rich, M.D.
University
of Virginia Health Services Center
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MDExpert - Assessment and Recommendations
Second
of two opinions
Disclaimer:
This opinion is based solely on my review of those medical records
provided to MDExpert by the treating physician. I have not examined
the patient nor is it my present intent to do so in the future.
Those opinions to be rendered herein are intended for advisory
purposes only. It is within the sole discretion of the treating
physician to determine the course, scope, and extent of treatment.
It is expressly agreed and understood that my review of those
records provided and the rendering of any opinion based upon my
review of those records provided do not create a physician/patient
relationship.
MDEXPERT
TREATMENT RECOMMENDATION AND RATIONALE:
The
patient is a 58-year-old gentleman with a diagnosis of distant
common bile duct cancer. The patient has undergone exploratory
laparotomy on two occasions, but has not undergone resection because
the patient was found to have edematous pancreatitis and then
the patient subsequently had an operation for bleeding. He had
a very complicated postoperative course characterized by respiratory
failure and adult respiratory distress syndrome. He has a biopsy-proven
adenocarcinoma and radiologically this suggests that the tumor
is located at the distal common bile duct. His medical state at
this time is significant for a low serum albumin at 1.7. Of note,
there is no evidence of metastatic disease based on prior laparotomy
or radiologic imaging to date.
Regarding
treatment recommendations for this gentleman, his only opportunity
for long-term survival would be surgical resection of the disease,
which would be associated with 30 to 50 percent long-term survivorship
for patients with localized disease undergoing an initial resection.
This patient would be unlikely to have such an optimistic outlook
secondary to his previous laparotomies and the postoperative complications
from his treatment thus far. However, this remains a viable treatment
option if the patient's nutritional status can be improved so
that he would tolerate the operation itself as well as postoperative
recovery. A pancreaticoduodenectomy with resection of the distal
common bile duct is the surgical option of choice for this patient.
ADDITIONAL
INFORMATION OR TESTING THAT WILL FACILITATE OR IMPROVE TREATMENT
DECISION-MAKING:
None
noted
TREATMENT
ALTERNATIVES AND THE ADVANTAGES OR DISADVANTAGES OF EACH:
The
other treatment alternative would be primary radiation therapy;
this would be palliative therapy and is not associated with a
significant long-term cure rate. Chemotherapy is ineffective in
this disease and it would not be my recommendation. The other
alternative is palliative care if the patient is felt not to be
a surgical candidate based on his current nutritional status.
PROGNOSIS:
In
the ideal scenario, the prognosis for these patients is about
30 to 50 percent long-term survival, particularly if he is found
to have negative regional lymph nodes. However, because this patient
sounds like a relatively poor operative candidate, he would have
a high risk of perioperative mortality, which I would gauge to
be approximately 10 to 20 percent based on the history provided
to me.
Dr.
Mary Brady
Memorial
Sloan-Kettering Cancer Center
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