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NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines ®)

HepatobiliaryCancers Version 1.2014

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NCCN Guidelines IndexHepatobiliary Cancers Table of Contents

Discussion


NCCN Guidelines Version 1.2014 Panel MembersHepatobiliary Cancers

Al B. Benson, III, MD/Chair †Robert H. Lurie Comprehensive CancerCenter of Northwestern University

Michael I. D’Angelica, MD/Vice-Chair ¶Memorial Sloan-Kettering Cancer Center

Thomas A. Abrams, MD †Dana-Farber/Brigham and Women’sCancer Center

Chandrakanth Are, MD ¶Fred & Pamela Buffett Cancer Center atThe Nebraska Medical Center

P. Mark Bloomston, MD ¶The Ohio State UniversityComprehensive Cancer Center -James Cancer Hospital andSolove Research Institute

Daniel T. Chang, MD §Stanford Cancer Institute

Bryan M. Clary, MD ¶Duke Cancer Institute

Anne M. Covey, MD §Memorial Sloan-Kettering Cancer Center

William D. Ensminger, MD, PhD †University of MichiganComprehensive Cancer Center

Renuka Iyer, MDRoswell Park Cancer Institute

R. Kate Kelley, MD † ‡UCSF Helen Diller FamilyComprehensive Cancer Center

David Linehan, MD ¶Siteman Cancer Center at Barnes-Jewish Hospital and WashingtonUniversity School of Medicine

Mokenge P. Malafa, MD ¶Mof tt Cancer Center

Steven G. Meranze, MD §Vanderbilt-Ingram Cancer Center

James O. Park, MD ¶Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance

Timothy Pawlik, MD, MPH, PhD ¶The Sidney Kimmel ComprehensiveCancer Center at Johns Hopkins

James A. Posey, MD †University of Alabama at BirminghamComprehensive Cancer Center

Courtney Scaife, MD ¶Huntsman Cancer Instituteat the University of Utah

Tracey Schefter, MD §University of Colorado Cancer Center

Elin R. Sigurdson, MD, PhD ¶Fox Chase Cancer Center

G. Gary Tian, MD, PhD †St. Jude Children’sResearch Hospital/The University of Tennessee Health Science Center

Jean-Nicolas Vauthey, MD ¶The University of TexasMD Anderson Cancer Center

Alan P. Venook, MD † ‡UCSF Helen Diller FamilyComprehensive Cancer Center

Yun Yen, MD, PhD ‡City of Hope Comprehensive

Cancer Center

Andrew X. Zhu, MD, PhD †Massachusetts General HospitalCancer Center

NCCN Guidelines Panel Disclosures

† Medical oncology§ Radiotherapy/Radiation oncology/Interventional radiology¶ Surgery/Surgical oncologyÞ Internal medicine‡ Hematology/Hematology oncology*Writing committee member

NCCNLauren Gallagher, RPh, PhDKarin G. Hoffmann, RN, CCM

Nicole McMillian, MSHema Sundar, PhD

*

*

*

*

*

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Discussion


NCCN Guidelines Version 1.2014 SubcommitteesHepatobiliary Cancers

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NCCN Guidelines Panel Disclosures

Principles of Locoregional TherapyAnne M. Covey, MD §Memorial Sloan-Kettering Cancer Center

Daniel T. Chang, MD §Stanford Cancer Institute

Principles of Surgery: (Gallbladder Cancer, Intrahepatic and Extrahepatic Cholangiocarcinoma)Michael I. D’Angelica, MD ¶LeadMemorial Sloan-Kettering Cancer Center

Chandrakanth Are, MD ¶Fred & Pamela Buffett Cancer Center atThe Nebraska Medical Center

§ Radiotherapy/Radiation Oncology/Interventional radiology

¶ Surgery/Surgical oncology*Writing committee member








Clinical Trials: NCCN believes thatthe best management for any cancerpatient is in a clinical trial. Participation

in clinical trials is especiallyencouraged.

To nd clinical trials online at NCCNMember Institutions, click here:nccn.org/clinical_trials/physician.html .

NCCN Categories of Evidence andConsensus: All recommendationsare category 2A unless otherwisespeci ed.

See NCCN Categories of Evidence and Consensus.

NCCN Hepatobiliary Cancers Panel MembersSummary of the Guidelines Updates

Hepatocellular Carcinom a (HCC)• HCC Screening (HCC-1)• Diagnosis of HCC (HCC-2 )• HCC Con rmed, (HCC-4)• Potentially Resectabl e or Transplantable, Operable (HCC-5)• Unresectable (HCC-6)• Inoperable, Local Disease, Extensive Liver Tumor Burden, Metastatic Disease (HCC-7)• Child-Pugh Score (HCC-A)• Principles of Surgery (HCC-B)• Principles of Locoregional Therapy (HCC-C)

Gallbladder Cancer • Incidental Finding at Surgery (GALL-1)• Incidental Finding on Patho logic Review (GALL-2)

• Mass on Imaging ( GALL-3)• Jaundice (GALL-4)• Metastatic Disease (GAL L-4)• Post-Resection (GALL-5)• Principles of Surgery (GALL-A)

Intrahepatic Cholangiocarcinoma• Presentation, Workup, Primary Treatment (I NTRA-1)• Adjuvant Treatment, Surveillanc e (INTRA-2)• Principles of Surgery (INTRA-A)

Extrahepatic Cholangiocarcinoma• Presentation, Workup, Primary Treatment (E XTRA-1)• Adjuvant Treatment, Surveillance (EXTRA-2 )• Principles of Surgery (EXTRA-A)

Staging (ST-1)

The NCCN Guidelines ® are a statement of evidence and consensus of the authors regarding their views of currently accepted approaches to treatment. Anyclinician seeking to apply or consult the NCCN Guidelines is expected to use independent medical judgment in the context of individual clinical circumstancesto determine any patient’s care or treatment. The National Comprehensive Cancer Network ® (NCCN ®) makes no representations or warranties of any kindregarding their content, use or application and disclaims any responsibility for their application or use in any way. The NCCN Guidelines are copyrighted by

National Comprehensive Cancer Network®

. All rights reserved. The NCCN Guidelines and the illustrations herein may not be reproduced in any form withoutthe express written permission of NCCN. ©2014.

Version 1.2014 02/2814 © National Comprehensive Cancer Network, Inc. 2014, All rights reserved. The NCCN Guidelines ® and this illustration may not be reproduced in any form without the express written permission of NCCN ®.

NCCN Guidelines Version 1.2014 Table of ContentsHepatobiliary Cancers


Discussion


i d b S j S d k 3 11 201 8 8 1 l l d f di ib i C i h © 201 i l C h i C k All i h d

http://www.nccn.org/clinical_trials/clinicians.aspx









Discussion


UPDATESCONTINUE 1 OF 4

NCCN Guidelines Version 1.2014 UpdatesHepatobiliary Cancers

Hepatocellular Carcinoma:HCC-1• Patients at risk for HCC; Under Cirrhosis; fourth bullet revised:

"Non-alcoholic steatohepatitis fatty liver disease (NAFLD)" • Footnote "e" revised: "Additional risk factors include patients, HBV

carrier with family history of HCC, Asian males ≥40 y, Asian females≥50 y , and African/North American Blacks with hepatitis B."

HCC-2• Findings:"Stable" revised: "Continue imaging every 3-6 mo for 2

years using technique that rst identi ed nodule(s) returning tobasel ine surveillance schedule after 2 yrs of stability ."

HCC-3• Diagnosis of HCC: "Non-diagnostic" revised: "Non-diagnostic or

Negative for HCC" • Footnote " m" added: " A growing mass with negative biopsy

does not rule out cancer. Continual monitoring is recommended, inclu ding multidisciplinary review."

HCC-4• Workup: rst sentence revised: "Multidisciplinary evaluation

(assess liver reserve and comorbidity) and staging:" HCC-5• If ineligible for transplant; Treatment: The recommendation

"Locoregional therapy" was clari ed to include "Ablation, Arteriallydirected therapies, External-beam radiation therapy (conformal or

stereotactic) (category 2B)"• Under "Surveillance": Second bullet: revised: "AFP, if initiallyelevated, every 3-6 mo for 2 y, then every 6-12 mo"

• Footnote "w" added: " In well-selected patients with small properlylocated tumors ablation should be considered as de nitivetreatment in the context of a multidisciplinary review. (Feng K,Yan J, Li X, et al. A randomized controlled trial of radiofrequencyablation and surgical resection in the treatment of smallhepatocellular carcinoma. J Hepatol. 2012;57(4):794-802 and ChenMS, Li JQ, Zheng Y, et al. A prospective randomized trialcomparing percutaneous local ablative therapy and partialhepatectomy for small hepatocellular carcinoma. Ann Surg 2006,243(3):321-328) "

HCC-5 continued Footnote "x" added: " Case series and single-arm studies suggestsafety and possible ef cacy of radiation in selected cases . SeePrinciples of Locoregional Therapy/ra diation therapy (HCC-C) . (Also for HCC-6, HCC-7 )HCC-6• Not a transplant candidate; Treatment; Options: The

recommendations were modi ed for clarity as follows:Systemic therapy

◊ SorafenibChemotherapy◊ Systemic

◊

Intra-arterialClinical trial"Locoregional therapy" was clari ed to include "Ablation,Arterially directed therapies, External-beam radiation therapy(conformal or stereotactic) (category 2B)"Last bullet modi ed: "Best supportive care"

• Under "Surveillance": Second bullet revised: "AFP, if initiallyelevated, every 3-6 mo for 2 y, then every 6-12 mo"

• Footnote "z" revised: "Order does not indicate preference. Thechoice of treatment modality may depend on extent/location ofdisease, hepatic reserve, and institutional capabilities."

• Footnote "bb" revised: "For selected patients,

a tw o randomized phase 3 clinical trials has have demonstrated survival bene ts."• Footnote "dd" added: " There are limited data supporting the use of

systemic chemotherapy, and its use in the context of a clinical trial is preferred."

Updates in Version 1.2014 of the NCCN Guidelines for Hepatobiliary Cancer from Version 2.2013 include:


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Discussion

Version 1.2014 02/28/14 © National Comprehensive Cancer Network, Inc. 2014, All rights reserved. The NCCN Guidelines ® and this illustration may not be reproduced in any form without the express written permission of NCCN ®. CONTINUEUPDATES

2 OF 4


Hepatocellular Carcinoma---continuedHCC-7• "Options": "Locoregional therapy" revised: " Ablation, Arterially

directed therapies, External-beam radiation therapy (conformal orstereotactic) (category 2B) , Best supportive care"

• "Clinical Presentation"; "Metastatic or Extensive liver tumor burden"pathway:

"Consider biopsy to con rm metastatic disease" added priorto the treatment options.

"Best supportive care" added as treatment option• Footnote "z" revised: "Order does not indicate preference. The choice

of treatment modality may depend on extent/location of disease,hepatic reserve, and institutional capabilites."

HCC-B Principles of Surgery• Bullet six added: " The Model for End-stage Liver Disease (MELD)

score is used by UNOS to assess the severity of liver disease and prioritize the allocation of the liver transplants. Meld score can bedetermined using the MELD calculator ( http://optn.transplant.hrsa.gov/resources/MeldPeldCalculator.asp?index=98) . Additional MELD"exception points" may be granted to patients with HCC eligible forliver transplant."

HCC-C (1 of 3) Principles of Locoregional Therapy• First paragraph revised: "All patients with HCC should be evaluated for

potential curative therapies (resection, transplantation, and for smalllesions, ablative strategies )."

• Ablation; fourth bullet revised: " Ablation alone may be curative in

treating tumors ≤3 cm. In well-selected patients with small properly located tumors ablation should be considered as de nitive treatmentin the context of a multidisciplinary review . Lesions 3 to 5 cm may betreated to prolong survival using arterially directed therapies, or withcombination of an arterially directed therapy and ablation as longas tumor location is accessible for ablation. "

• "Arterially directed therapies"; Sixth bullet revised: "The safety andef cacy of the use of sorafenib concomitantly with arterially directedtherapies and/ or ablation is being investigated in ongoing clinicaltrials has not been associated with signi cant bene t in tworandomized trials; other randomized phase lll trials are ongoing tofurther investigate combination approaches. "

HCC-C (2 of 3) Principles of Locoregional Therapy• External-beam radiation therapy (EBRT)

Second bullet revised: "SBRT is an advanced technique of EBRTthat delivers large ablative doses of radiation" in 1 week or less.Fourth bullet revised: " The majority of data on radiation for HCCliver tumors arises from patients with Child-Pugh A liver disease;safety data are limited for patients with Child-Pugh B or poorerliver function. Those with Child-Pugh B cirrhosis can be safelytreated, but they may require dose modi cations and strictdose constraint adherence. Child Pugh C cirrhosis is a relativecontraindication, and these patients should be considered for aclinical trial. The safety of liver radiation for HCC in patients withChild-Pugh C cirrhosis has not been established, as there are notlikely to be clinical trials available for CP-C patients." Fifth bullet added: " Palliative EBRT is appropriate for symptomcontrol and/or prevention of complications from metastatic HCC

lesions, such as bone or brain."

Gallbladder Cancer GALL-1• Unresectable; Primary Treatment; Options: Last bullet revised:

"Best supportive care" (Also for (GALL-2 ) and (GALL-3)• Footnote "c" revised: "Order does not indicate preference. The

choice of treatment modality may depend on extent/location ofdisease and institutional capabilites." (Also for (GALL-2) , (GALL-3 ),and (GALL-4) .




http://optn.transplant.hrsa.gov/resources/MeldPeldCalculator.asp?index=98)








Discussion



UPDATES3 OF 4

Gallbladder Cancer---continuedGALL-4• Under "Unresectable" and "Metastatic disease;" Options: " Best

supportive care" revised.GALL-5• Footnote "j" added: " Adjuvant chemotherapy or chemoradiation has

been associated with survival benefit in patients with biliary tractcancer (BTC), especially in patients with lymph-node positivedisease. Horgan AM, Amir E, Walter T, Knox JJ. Adjuvant Therapy ofBiliary Tract Cancer: A Systemic Review and Meta-Analysis. J Clin Oncol 2012;30:1934-1940."

Intrahepatic CholangiocarcinomaINTRA-1

• Presentation revised: "Isolated intrahepatic mass (biopsy provenimaging characteristics consistent with adenocarcinoma )"

• WorkupNinth bullet revised: "Consider" removed from"Esophagogastroduodenoscopy (EGD) and colonscopy"Last bullet added: " Biopsy"

• "Primary Treatment": "Locoregional therapy (category 2B)" added to"Unresectable" and "Metastatic disease"

• "Best supportive care" added to "Unresectable" and "Metastaticdisease"

• Footnote deleted: "Upper/lower endscopy may not be needed ifimmnuohistochemistry/pathology is conclusive."

• Footnote "f" revised: "Order does not indicate preference. The choiceof treatment modality may depend on extent/location of disease andinstitutional capabilites."

• Footnote "g" revised: "A recent phase III trial supporting gemcitabine/cisplatin has been reported for patients with advanced or metastaticbilliary tract cancer."

• Footnote "h" revised: "Systemic or intra-arterial chemotherapy may beused in a clinical trial or at experienced centers".

Intrahepatic Cholangiocarcinoma---continuedINTRA-2 • Title: "ADDITIONAL THERAPY" replaced by " ADJUVANT

THERAPY" • "No residual local disease (R0 resection)": Fluoropyrimidine

chemoradiation removed• "Microscopic margins (R1) resection revised to include: "or

Positive regional nodes"• "Residual local disease (R2 resection)" moved to third row

as a separate pathway. Previously this group had the sametreatment options as "Microscopic margins (R1)" patients.

• "Primary treatment options for Unresectable disease fromINTRA-1 added to "Residual local disease (R2 resection)"

• Footnote "h" revised: "Systemic or intra-arterial chemotherapymay be used in a clinical trial or at experienced centers." • Footnote "i" added:" Adjuvant chemotherapy or chemoradiation

has been associated with survival benefit in patients withbiliary tract cancer (BTC), especially in patients with lymph- node positive disease. Horgan AM, Amir E, Walter T, KnoxJJ. Adjuvant Therapy of Bi liary Tract Cancer: A SystemicReview and Meta-Analysis. J Clin Oncol 2012;30:1934-1940. However, this meta-analysis included only a few patients withintrahepatic cholangiocarcinoma. There are no randomizedphase III clinical trial data to support a standard adjuvant

regimen. Clinical trial participation is encouraged. Thereare phase II trials that support the following combinations:gemcitabine/ cisplatin, gemcitabine/oxaliplatin, gemcitabine/capecitabine, capecitabine/cisplatin, capecitabine/ oxaliplatin,5- uorouracil/oxaliplatin, 5- uorouracil/cisplatin and thesingle agents gemcitabine, capecitabine, and 5- uorouracilin the unresectable or metastatic setting. (Hezel AF and ZhuAX. Systemic therapy for biliary tract cancers. The Oncologist2008;13:415-423)."

CONTINUE







NCCN Guidelines Version 1.2014Hepatobiliary Cancers


Discussion


Extrahepatic CholangiocarcinomaEXTRA-1• Footnote "b" revised: MRCP is preferred. ERCP/PTC are used more for

therapeutic intervention. "Noninvasive cholangiography with cross- sectional imaging."

• Footnote "f" revised: "Order does not indicate preference. The choiceof treatment modality may depend on extent/location of disease andinstitutional capabilities. "

• F ootnote deleted: "Highly selected patients may be transplantcandidates."EXTRA-2"Adjuvant Treatment": Footnote "j"added: " Adjuvant chemotherapy or

chemoradiation has been associated with survival benefit in patientswith biliary tract cancer (BTC), especially in patients with lymph-node

positive disease. Horgan AM, Amir E, Walter T, Knox JJ. AdjuvantTherapy of Biliary Tract Cancer: A Systemic Review and Meta-Analysis.J Clin Oncol 2012;30:1934-1940."

Updates

UPDATES4 OF 4







Note: All recommendations are category 2A unless otherwise indicated.Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.



Discussion

HEPATOCELLULAR CARCINOMA (HCC)SCREENING

Patients at risk for HCC: a

• CirrhosisHepatitis B, C b

AlcoholGenetic hemochromatosisNon-alcoholic fatty liverdisease (NAFLD) c

Stage 4 primary biliary cirrhosisAlpha1-antitrypsin de ciency

Other causes of cirrhosisd

• Without cirrhosisHepatitis B carriers e

Alfa-fetoprotein (AFP)/Ultrasound (US)every 6-12 mo

Liver mass or nodule(See HCC-2 )

Rising AFP Liver imaging

studiesf,g

Mass con rmed

No mass h

HCC con rmed(See HCC-4 )

Follow every3 mo withAFP, liverimaging

HCC-1

a Adapted with permission from Bruix J, Sherman M. Management of Hepatocellular Carcinoma: An Update. Alexandria, VA: American Association for the Study of LiverDiseases, 2010. This updates a previous version: Bruix J, Sherman M. Management of Hepatocellular Carcinoma. Hepatology 2005;42:1208-1236.(http://www.aasld.org/practiceguidelines/Documents/Bookmarked%20Practice%20Guidelines/HCCUpdate2010.pdf).

bThere is evidence suggesting improved outcomes for patients with HCC in the setting of HBV or HCV cirrhosis when the HBV/HCV is successfully treated. Referral toa hepatologist should be considered for the management of these patients.

cWhite DL, Kanwal F, El-Serag HB. Asssociation between nonalcoholic fatty liver disease and risk for hepatocellular cancer, based on systemic review. ClinGastroenterol Hepatol 2012;10:1342-1359.

dSchiff ER, Sorrell MF, and Maddrey WC. Schiff's Diseases of the Liver. Philadelphia: Lippincott Williams & Wilkins (LWW); 2007.e Additional risk factors include HBV carrier with family history of HCC, Asian males ≥40 y, Asian females ≥50 y, and African/North American Blacks with hepatitis B.f If ultrasound is negative, CT/MRI should be performed.g At least a 3-phase liver protocol CT or MRI including late arterial phase and portal venous phase to determine perfusion characteristics, extent and number of lesions,vascular anatomy, and extrahepatic disease. PET/CT is not adequate. (Bruix J, Sherman M. Management of Hepatocellular Carcinoma: An Update. Alexandria,VA:

American Association for the Study of Liver Diseases, 2010. This updates a previous version: Bruix J, Sherman M. Management of Hepatocellular Carcinoma. Hepatology 2005;42:1208-1236 [http://www.aasld.org/practiceguidelines/Documents/Bookmarked%20Practice%20Guidelines/HCCUpdate2010.pdf]) .hRule out germ cell tumor if clinically indicated.



http://www.aasld.org/practiceguidelines/Documents/Bookmarked%20Practice%20Guidelines/HCCUpdate2010.pdf









Discussion



HCC-2

CLINICALPRESENTATION i

LIVERNODULESIZE

ADDITIONALIMAGING

DIAGNOSIS OF HCC a

FINDINGS

Incidental livermass or

nodule foundduring screening

<1 cm

>1 cm

Imaging:At least a 3-phase CTor MRI g or CEUS j

every 3-6 mo

Imaging:At least a 3-phaseCT or MRI g

Stable

Enlarging

Histologicallycon rmed HCC

Continue imaging evey 3-6 mo for2 years using technique that rstidenti ed nodule(s) returning tobaseline surveillance scheduleafter 2 yrs of stability

Proceed accordingto nodule size

See livernodule size(See HCC-3 )

HCCcon rmed(See HCC-4 )

a Adapted with permission from Bruix J, Sherman M. Management of Hepatocellular Carcinoma: An Update. Alexandria, VA: American Association for the Study of LiverDiseases, 2010. This updates a previous version: Bruix J, Sherman M. Management of Hepatocellular Carcinoma. Hepatology 2005;42:1208-1236.

(http://www.aasld.org/practiceguidelines/Documents/Bookmarked%20Practice%20Guidelines/HCCUpdate2010.pdf) .g At least a 3-phase liver protocol CT or MRI including late arterial phase and portal venous phase to determine perfusion characteristics, extent and number of lesions, vascular anatomy, and extrahepatic disease. PET/CT is not adequate. (Bruix J, Sherman M. Management of Hepatocellular Carcinoma: An Update. Alexandria, VA: American Association for the Study of Liver Diseases, 2010. This updates a previous version: Bruix J, Sherman M. Management of Hepatocellular Carcinoma. Hepatology 2005;42:1208-1236 [ http://www.aasld.org/practiceguidelines/Documents/Bookmarked%20Practice%20Guidelines/HCCUpdate2010.pdf]) .iThese guidelines apply to nodules identified in cirrhotic patients. In patients without cirrhosis or known liver disease, biopsy should be strongly considered.

jContrast-enhanced ultrasound (CEUS) where available.












Discussion



HCC-3

LIVERNODULE

SIZE i

ADDITIONAL IMAGINGFINDINGS g

DIAGNOSIS OF HCC a

>1 cm

2 classic k

enhancements

0 or 1classic k

enhancement

2 classic k

enhancements

Perform 2ndtype ofcontrast-enhanced(at least3-phase) scan(CT or MRI) g 0 or 1

classic k

enhance-ment

1-2 cm

>2 cm

Core biopsy l

(preferred) orFNA k or repeatimaging (at least3-phase) in 3 moand followalgorithmaccording to sizeand image

ndings

Positivefor HCC

Non-diagnostic orNegative for HCC

RepeatimagingorFollow-up

HCCcon rmed

(See HCC-4)

Changein nodulesize

Core biopsy l

(preferred)or FNA l

Repeatimagingand/orbiopsy l

Negative m

Positive

a Adapted with permission from Bruix J, Sherman M. Management of Hepatocellular Carcinoma: An Update. Alexandria, VA: American Association for the Study of LiverDiseases, 2010. This updates a previous version: Bruix J, Sherman M. Management of Hepatocellular Carcinoma. H epatology 2005 Nov; 42(5):1208-1236.(http://www.aasld.org/practiceguidelines/Documents/Bookmarked%20Practice%20Guidelines/HCCUpdate2010.pdf) .

g At least a 3-phase liver protocol CT or MRI including late arterial phase and portal venous phase to determine perfusion characteristics, extent and number of lesions,vascular anatomy, and extrahepatic disease. PET/CT is not adequate. (Bruix J, Sherman M. Management of Hepatocellular Carcinoma: An Update. Alexandria, VA:

American Association for the Study of Liv er Diseases, 2010. This updates a previous version: Bruix J, Sherman M. Management of Hepatocellular Carcino ma.Hepatology 2005 Nov; 42(5):1208-1236 [ http://www.aasld.org/practiceguidelines/Documents/Bookmarked%20Practice%20Guidelines/HCCUpdate2010.pd f]).

iThese guidelines apply to nodules identified in cirrhotic patients. In patients without cirrhosis or known liver disease, biopsy should be strongly considered.kClassic imaging: Lesion shows arterial hyperenhancement and washes out in the venous phase. From Bruix J and Sherman M. Management of hepatocellularcarcinoma. Hepatology 2005;42(5):1208-1236.

lBefore biopsy, evaluate if patient is a surgical or transplant candidate. If patient is a potential transplant candidate, consider referral to transplant center before biopsy.m A growing mass with negative biopsy does not rule out cancer. Continual monitoring is recommended , including multidisciplinary review .















Discussion



HCC-4

CLINICALPRESENTATION

WORKUP

HCC confirmed

Multidisciplinary evaluation (assess liver reserve n and comorbidity)and staging:• H&P• Hepatitis panel o

• Bilirubin, transaminases, alkaline phosphatase

• PT or INR, albumin, BUN, creatinine• CBC, platelets• AFP• Chest CT• Bone scan if clinically indicated

Potentially resectable or transplantable,operable by performance status orcomorbidity (See HCC-5)

Unresectable(See HCC-6)

Inoperable by performance statusor comorbidity, local disease only(See HCC-7 )

Metastatic disease(See HCC-7)

nSee Child-Pugh Score (HCC-A ) and assessment of portal hypertension (eg, varices, splenomegaly, thrombocytopenia).o An appropriate hepatitis panel should preferably include:• Hepatitis B surface antigen (HBsAg). If the HBsAg is positive, check HBeAg, HBeAb, and quantitative HBV DNA and refer to hepatologist.• Hepatitis B surface antibody (for vaccine evaluation only).• Hepatitis B core antibody (HBcAb) IgG. The HBcAb IgM should only be checked in cases of acute viral hepatitis. An isolated HBcAb IgG may still be chronic HBV and

should prompt testing for a quantitative HBV DNA.• Hepatitis C antibody. If positive, check quantitative HCV RNA and HCV genotype and refer to hepatologist.








Discussion



• UNOS criteria q,s

Patient has a tumor≤5 cm in diameter or 2-3tumors ≤3 cm eachNo macrovascularinvolvementNo extrahepatic disease

HCC-5


SURGICAL ASSESSMENT p,q TREATMENT SURVEILLANCE

Potentially resectable ortransplantable, operableby performance status orcomorbidity

• Child-Pugh Class A, B r

• No portal hypertension

• Suitable tumor location• Adequate liver reserve• Suitable liver remnant

If ineligible fortransplant

If eligible fortransplant,• Refer to liver

transplantcenter q,s

• Consider bridgetherapy asindicated t

Resection, if feasible(preferred) u

or Locoregionaltherapy v

• Ablation w

• Arterially directedtherapies

• External-beamradiation therapy(conformal orstereotactic) x (category 2B)

p Di scussion of surgical treatment with patient and determination of whe ther patient is amenable to surgery.qPatients with Child-Pugh Class A liver function, who fit UNOS criteria (www.unos.org ) and are resectable could be considered for resection or transplant.There is controversy over which initial strategy is preferable to treat such patients. These patients should be evaluated by a multidisciplinary team.

r In highly selected Child-Pugh Class B patients with limited resection.s Mazzaferro V, Regalia E, Doci, R, et al. Liver transplantation for the treatment of small hepatocellular carcinomas in patients with cirrhosis.N Engl J Med 1996;334(11):693-700.tMany transplant centers consider b ridge therapy for transplant candidates. (See Discussion )uSee Principles of Surgery (HCC-B) .vSee Principles of Locoregional Therapy/radiation therapy (HCC-C ).wIn well-selected patients with small, properly located tumors ablation should be considered as definitive treatment in the context of a multidisciplinary review.

(Feng K, Yan J, Li X, et al. A randomized controlled trial of radiofrequency ablation and surgical resection in the treatment of small hepatocellular carcinoma.J Hepatol. 2012;57(4):794-802 and Chen MS, Li JQ, Zheng Y, et al. A prospective randomized trial comparing percutaneous local ablative therapy and partialhepatectomy for small hepatocellular carcinoma. Ann Surg 2006, 243(3):321-328).

xCase series and single-arm studies suggest safety and possible efficacy of radiation therapy in selected cases. yMRI or multi-phase CT scans for liver assessment are recommend ed. Consider chest imaging as clinically indicated. See Principles of Locoregional Therapy/radiation therapy (HCC-C) .

• Imaging y

every 3-6 mo for 2 y,then every 6-12 mo

• AFP, every 3-6 mo for2 y, then every 6-12 mo

• See relevant pathway(HCC-2 through HCC-7 )if disease recurs

For relapse, see initialWorkup (HCC-4 )



http://www.unos.org/








Discussion




TREATMENT SURVEILLANCE

• Inadequatehepaticreserve x

• Tumor location

Evaluate whetherpatient a candidatefor transplant(See UNOS criteriaunder SurgicalAssessment HCC-5 )s

Transplantcandidate

Not atransplantcandidate

• Refer to liver

transplantcenter

• Considerbridge therapyas indicated t

Options: z

• Systemic therapySorafenib

(Child-Pugh Class A [category 1] or B) aa,bb,cc

Chemotherapy dd

◊ Systemic ◊ Intra-arterial

• Clinical trial• Locoregional therapy v,ee

AblationArterially directed therapiesExternal-beam radiation therapy (conformal orstereotactic) x(category 2B)

• Best supportive care

• Imaging y every 3-6 mo for 2 y,then every 6-12 mo

• AFP, every 3-6 mo for2 y, then every 6-12 mo

• See relevant pathway ( HCC-2 through HCC-7 ) if disease recurs

sMazzaferro V, Regalia E, Doci, R, et al. Liver transplantation for the treatment of smallhepatocellular carcinomas in patients with cirrhosis. N Engl J Med 1996;334:693-700.

tMany transplant centers consider bridge therapy for transplant candidates.(See Discussion)

vSee Principles of Locoregional Therapy (HCC-C ).xCase series and single-arm studies suggest safety and possible efficacy of radiation

therapy in selected cases.(See Principles of Locoregional Therapy/radiation therapy (HCC-C) .yMRI or multi-phase CT scans for liver assessment are recommended. Consider chest

imaging as clinically indicated.zOrder does not indicate preference. The choice of treatment modality may depend on

extent/location of disease, hepatic reserve, and institutional capabilities.aa See Child-Pugh Score (HCC-A ).bb For selected patients, two randomized phase 3 clinical trials have demonstrated

survival benefits. (Llovet J, Ricci S, Mazzaferro V,et al. Sorafenib in advancedhepatocellular carcinoma. New Engl J Med 2008;359(4):378-390) and (Cheng A,Kang Y, Chen Z, et al. Efficacy and safety of sorafenib in patients in the Asia Pacificregion with advanced hepatocellular carcinoma: a phase III randomised, double-blind,placebo-controlled trial. Lancet Oncol 2009;10:25-34.

cc Caution: There are limited safety data available for Child-Pugh Class B or C patients and dosingis uncertain. Use with extreme caution in patients with elevated bilirubin levels. (Miller AA, MurryK, Owzar DR, et al. Phase I and pharmacokinetic study of sorafenib in patients with hepatic orrenal dysfunction:CALGB 60301. J Clin Oncol 2009;27:1800-1805).The impact of sorafenib onpatients potentially eligible for transplant is unknown.

dd There are limited data supporting the use of systemic chemotherapy, and its use in the contextof a clinical trial is preferred.

ee Use of chemoembolization has also been supported by randomized controlled trials inselected populations over best supportive care. (Lo CM, Ngan H, Tso WK, et al. Randomizedcontrolled trial of transarterial lipiodol chemoembolization for unresectable hepatocellularcarcinoma. Hepatology. 2002;35:1164-1171 and Llovet JM, Real MI, Montaña X, et al. Arterialembolisation or chemoembolisation versus symptomatic treatment in patients with unresectablehepatocellular carcinoma: a randomized controlled trial. Lancet 2002;359:1734-1739.)

HCC-6

Unresectable








Discussion



HCC-7


TREATMENT

Inoperable by performance status or comorbidity,local disease or local disease with minimalextrahepatic disease only

Metastatic diseaseor Extensive liver tumor burden

Consider biopsyto con rmmetastatic disease

Options: z

• Sorafenib(Child-Pugh Class A [category 1] or B) aa,bb,cc

• Clinical trial• Best supportive care

Options: z

• Sorafenib(Child-Pugh Class A [category 1] or B) aa,bb,cc

• Clinical trial• Locoregional therapy v

AblationArterially directed therapiesExternal-beam radiation therapy (conformal orstereotactic) y (category 2B)

• Best supportive care

v(See Principles of Locoregional Therapy/Radiation Therapy [HCC-C ]).xCase series and single-arm studies suggest saf ety and possible efficacy of radiation therapy in selected cases.(See Principles of Lo coregional Therapy/Radiation Therapy [HCC-C ]).

zOrder does not indicate preference. The choice of treatment modality may depend on extent/location of disease, hepatic reserve, and institutional capabilities.aa See Child-Pugh Score (HCC-A) .bb For selected patients, two randomized phase 3 clinical trials have demonstrated survival bene ts. (Llovet J, Ricci S, Mazzaferro V, et al. Sorafenib in advanced

hepatocellular carcinoma. New Engl J Med 2008;359(4):378-390) and (Cheng A, Kang Y, Chen Z, et al. Ef cacy and safety of sorafenib in patients in the Asia-Paci cregion with advanced hepatocellular carcinoma: a phase III randomised, double-blind, placebo-controlled trial. Lancet Oncol 2009;10:25-34.

cc Caution: There are limited safety data available for Child-Pugh Class B or C patients and dosing is uncertain. Use with extreme caution in patients with elevatedbilirubin levels. (Miller AA, Murry K, Owzar DR, et al. Phase I and pharmacokinetic study of sorafenib in patients with hepatic or renal dysfunction: CALGB 60301.J Clin Onc 2009;27:1800-1805). The impact of sorafenib on patients potentially eligible for transplant is unknown.








Discussion



HCC-A

CHILD-PUGH SCORE

Chemical and Biochemical Parameters Scores (Points) for Increasing Abnormality

Class A: Good operative riskClass B: Moderate operative riskClass C: Poor operative risk

Encephalopathy (grade) 1

Ascites

Albumin (g/dL)

Prothrombin time prolonged (sec) 2

Bilirubin (mg/dL)

• For primary biliary cirrhosis

1 2 3

None 1-2 3-4

None Slight Moderate

>3.5 2.8-3.5 <2.8

1-4 4-6 >6

<2

<4

2-3

4-10 >10

>3

1Trey C, Burns DG, Saunders SJ. Treatment of hepatic coma by exchange blood transfusion. N Engl J Med 1966;274(9):473-481. Source: Pugh R, Murray-Lyon I, Dawson J, et al: Transection of the oesophagus for bleeding oesophageal varices. Br J of Surg 1973;60(8):646-649.

©British Journal of Surgery Society Ltd. Adapted with permission. Permission is granted by John Wiley & Sons Ltd on behalf of the BJSS Ltd.2Corresponding International Normalized Ratio (INR) measurements are Score points 1: <1.7; Score points 2: 1.8 - 2.3; Score points 3: > 2.3 (van Rijn JL, Schmidt NA, Rutten WP. Correction of instrument- and reagent-based differences in determination of the International Normalized Ratio (INR)

for monitoring anticoagulant therapy. Clin Chem 1989;35(5):840-843).

Class A = 5–6 points; Class B = 7–9 points; Class C = 10–15 points.








Discussion



HCC-B

PRINCIPLES OF SURGERY

• Patients must be medically t for a major operation.

• Hepatic resection is indicated as a potentially curative option in the following circumstances:Adequate liver function (generally Child-Pugh Class A without portal hypertension)Solitary mass without major vascular invasionAdequate future liver remnant (at least 20% without cirrhosis and at least 30% to 40% with Child-Pugh Class A cirrhosis, adequatevascular and biliary in ow/out ow)

• Hepatic resection is controversial in the following circumstances, but can be considered:Limited and resectable multifocal diseaseMajor vascular invasion

• Patients with chronic liver disease being considered for major resection, preoperative portal vein embolization should beconsidered. 1

• Patients meeting the UNOS criteria ([single lesion ≤5 cm, or 2 or 3 lesions ≤3 cm], http://www.unos.org ) should be considered fortransplantation (cadaveric or living donation). More controversial are those patients whose tumor characteristics are marginallyoutside the UNOS guidelines and may be considered at some institutions for living or deceased donor.

• The Model for End-stage Liver Disease (MELD) score is used by UNOS to assess the severity of liver disease and prioritize theallocation of the liver transplants. 2 MELD score can be determined using the MELD calculator(http://optn.transplant.hrsa.gov/resources/MeldPeldCalculator.asp?index=98) . Additional MELD "exception points" may be grantedto patients with HCC eligible for liver transplant.

• Patients with Child-Pugh Class A liver function, who t UNOS criteria and are resectable could be considered for resection ortransplant. There is controversy over which initial strategy is preferable to treat such patients. These patients should be evaluatedby a multidisciplinary team.

1Farges O, Belghiti J, Kianmanesh R, et al. Portal vein embolization before right hepatectomy: prospective clinical trial. Ann Surg 2003;237:208-217.2Kamath PS, Wiesner RH, Malinchoc M, et al. A model to predict survival in patients with end-stage liver disease. Hepatology 2001; 33:464-470.




http://optn.transplant.hrsa.gov/resources/MeldPeldCalculator.asp?index=98

http://optn.transplant.hrsa.gov/resources/MeldPeldCalculator.asp?index=98








Discussion



PRINCIPLES OF LOCOREGIONAL THERAPY

All patients with HCC should be evaluated for potential curative therapies (resection, transplantation, and for small lesions, ablativestrategies). Locoregional therapy should be considered in those patients not candidates for surgical curative treatments, or as a part of astrategy to bridge patients for other curative therapies. These are broadly categorized into ablation and arterially directed therapies.

Ablation (radiofrequency, cryoablation, percutaneous alcohol injection, microwave) :• All tumors should be amenable to ablation such that the tumor and, in the case of thermal ablation, a margin of normal tissue is treated. A

margin is not expected following percutaneous ethanol injection.• Tumors should be in a location accessible for percutaneous/laparoscopic/open approaches for ablation.• Caution should be exercised when ablating lesions near major vessels, major bile ducts, diaphragm, and other intra-abdominal organs.• Ablation alone may be curative in treating tumors ≤3 cm. In well-selected patients with small properly located tumors, ablation should be

considered as de nitive treatment in the context of a multidisciplinary review. Lesions 3 to 5 cm may be treated to prolong survival usingarterially directed therapies, or with combination of an arterially directed therapy and ablation as long as tumor location is accessible forablation. 1,2,3

• Unresectable/inoperable lesions >5 cm should be considered for treatment using arterially directed or systemic therapy. 4-6• Sorafenib may be appropriate following ablative therapy in patients with adequate liver function once bilirubin returns to baseline if there

is evidence of residual/recurrent tumor not amenable to additional local therapies. The safety and ef cacy of adjuvant sorafenib followingablation is being investigated in an ongoing clinical trial. 7

Arterially directed therapies:• All tumors irrespective of location may be amenable to arterially directed therapies provided that the arterial blood supply to the tumor

may be isolated without excessive non-target treatment.• Arterially directed therapies include transarterial bland embolization (TAE), 5,6,8 chemoembolization (transarterial chemoembolization

[TACE] 9 and TACE with drug-eluting beads [DEB-TACE] 6,10 ) and radioembolization with yttrium -90 microspheres, 11,12

• All arterially directed therapies are relatively contraindicated in patients with bilirubin >3 mg/dL unless segmental injections can beperformed. 13 Radioembolization with yttrium -90 microspheres has an increased risk of radiation induced liver disease in patients withbilirubin over 2 mg/dL. 12

• Arterially directed therapies are relatively contraindicated in patients with main portal vein thrombosis and Child-Pugh Class C.• The angiographic endpoint of embolization may be chosen by the treating physician.• Sorafenib may be appropriate following arterially directed therapies in patients with adequate liver function once bilirubin returns to baseline if there is evidence of residual/recurrent tumor not amenable to additional local therapies. The safety and ef cacy of the use of sorafenib concomitantly with arterially directed therapies has not been associated with signi cant bene t in two randomized trials; other

randomized phase lll trials are ongong to further investigate combination approaches. 14,15,16

HCC-C1 of 3










Discussion




External-beam radiation therapy (EBRT)

• All tumors irrespective of the location may be amenable to EBRT (Stereotactic body radiation therapy [SBRT] or 3D-conformal radiationtherapy).

• SBRT is an advanced technique of EBRT that delivers large ablative doses of radiation.• There is growing evidence for the usefulness of SBRT in the management of patients with HCC. 17 SBRT can be considered as alternative to

the ablation/embolization techniques mentioned above or when these therapies have failed or are contraindicated.• SBRT is often used for patients with 1-3 tumors. SBRT could be considered for larger lesions or more extensive disease, if there is

suf cient uninvolved liver and liver radiation tolerance can be respected. There should be no extrahepatic disease or it should be minimaland addressed in a comprehensive management plan. The majority of data on radiation for HCC liver tumors arises from patients withChild-Pugh A liver disease; safety data are limited for patients with Child-Pugh B or poorer liver functon. Those with Child-Pugh B cirrhosiscan be safely treated, but they may require dose modi cations and strict dose constraint adherence. 18 The safety of liver radiation for HCCin patients with Child-Pugh C cirrhosis has not been established, as there are not likely to be clinical trials available for CP-C patients. 19,20

• Palliative EBRT is appropriate for symptom control and/or prevention of complications from metastatic HCC lesions, such as bone or brain.

References on next page

HCC-C2 of 3

NCCN G id li V i 1 2014 d l d










Discussion



HCC-C3 of 3


1 Peng ZW, Zhang YJ, Liang HH, et al. Recurrent hepatocellular carcinoma treated with sequential transcatheter arterial chemoembolization and RF ablation versus RFablation alone: a prospective randomized trial. Radiology 2012;262:689-700.

2Feng K, Yan J, Li X, et al. A randomized controlled trial of radiofrequency ablation and surgical resection in the treatment of small hepatocellular carcinoma. J Hepatol. 2012;57(4):794-802.3Chen MS, Li JQ, Zheng Y, et al. A prospective randomized trial comparing percutaneous local ablative therapy and partial hepatectomy for small hepatocellular

carcinoma. Ann Surg 2006, 243(3):321-328.4Yamakado, K., et al., Early-stage hepatocellular carcinoma: radiofrequency ablation combined with chemoembolization versus hepatectomy. Radiology 2008; 247:260- 266.5Maluccio, M., et al., Comparison of survival rates after bland arterial embolization and ablation versus surgical resection for treating solitary hepatocellular carcinoma up

to 7 cm. J Vasc Interv Radiol 2005;16: 955-961.6Malagari K, Pomoni M, Kelekis A, et al. Prospective randomized comparison of chemoembolization with doxorubicin-eluting beads and bland embolization with

BeadBlock for hepatocellular carcinoma. Cardiovasc Intervent Radiol 2010;33:541-551.7Printz C. Clinical trials of note. Sorafenib as adjuvant treatment in the prevention of disease recurrence in patients with hepatocellular carcinoma (HCC) (STORM).

Cancer 2009;115:46. (http://clinicaltrials.gov/show/NCT00692770)8Maluccio, M.A., et al., Transcatheter arterial embolization with only particles for the treatment of unresectable hepatocellular carcinoma. J Vasc Interv Radiol 2008;19:862-869.

9Llovet, J.M., et al., Arterial embolisation or chemoembolisation versus symptomatic treatment in patients with unresectable hepatocellular carcinoma: a randomisedcontrolled trial. Lancet 2002;359(9319):1734-1739.

10 Lammer J, Malagari K, Vogl T, et al. Prospective randomized study of doxorubicin-eluting-bead embolization in the treatment of hepatocellular carcinoma: results of the PRECISION V study. Cardiovasc Intervent Radiol 2010;33:41-52.

11Kulik, L.M., et al., Safety and ef cacy of 90Y radiotherapy for hepatocellular carcinoma with and without portal vein thrombosis. Hepatology 2008;47:71-81.12 Salem R, Lewandowski RJ, Mulcahy MF, et al. Radioembolization for hepatocellular carcinoma using Yttrium-90 microspheres: a comprehensive report of long-term

outcomes. Gastroenterology. 2010;138:52-64.13 Ramsey DE, Kernagis LY, Soulen MC, Geschwind JF. Chemoembolization of hepatocellular carcinoma. J Vasc Interv Radiol 2002;13(9 Pt 2):S211-21.14 Pawlik TM, Reyes DK, Cosgrove D, et al. Phase II trial of sorafenib combined with concurrent transarterial chemoembolization with drug-eluting beads for

hepatocellular carcinoma J Clin Oncol 2011;29:3960-3967.15 Kudo M, Imanaka K, Chida N, et al. Phase lll study of sorafenib after transarterial chemoembolization in Japanese and Korean patients with unresectable

hepatocellular carcinoma. Eur J Cancer. 2011;47:2117-2127.16 Lencioni R, Llovet JM, Han G, et al. Sorafenib or placebo in combination with transarterial chemoembolization (TACE) with doxorubicin-eluting beads (DEBDOX) for intermediate-stage hepatocellular carcinoma (HCC): Phase ll, randomized, double-blind SPACE trial [abstract]. J Clin Oncol 2012;30(4_suppl):Abstract LBA154.17 Hoffe SE, Finkelstein SE, Russell MS, Shridhar R. Nonsurgical options for hepatocellular carcinoma: evolving role of external beam radiotherapy. Cancer Control

2010;17:100-110.18 Cardenes HR, Price TR, Perkins SM, et al. Phase I feasibility trial of stereotactic body radiation therapy for primary hepatocellular carcinoma. Clin Transl Oncol

2010;12: 218-225.19 Tse RV, Hawkins M, Lockwood G, K, et al. Phase I study of individualized stereotactic body radiotherapy for hepatocellular carcinoma and intrahepatic

cholangiocarcinoma. J Clin Oncol 2008;26:657-664.20 Andolino DL, Johnson CS, Maluccio M, et al.Stereotactic body radiotherapy for primary hepatocellular carcinoma. Int J Radiat Oncol Biol Phys 2011;81:e447-453.

NCCN G id li I dNCCN G id li V i 1 2014



http://clinicaltrials.gov/show/NCT00692770

http://clinicaltrials.gov/show/NCT00692770







Discussion



NCCN Guidelines Version 1.2014Gallbladder Cancer

GALL-1

PRESENTATION POSTOPERATIVEWORKUP

PRIMARY TREATMENT

Incidentalnding at

surgery

• Intraoperativestaging

• Frozen section ofgallbladder

• Consider extendedcholecystectomy a

CT/MRI,chest CT

Cholecystectomy b + en bloc hepatic resection+ lymphadenectomy± bile duct excision

Resectable b

Options: c

• Gemcitabine/cisplatin combination therapy d (category 1)• Fluoropyrimidine-based or other gemcitabine-based

chemotherapy regimen d• Fluoropyrimidine chemoradiation e • Clinical trial• Best supportive care

See Adjuvant TreatmentandSurveillance(GALL-5)

Incidentalnding on

pathologicreview

See (GALL-2 )

aDepends on expertise of surgeon an d/or resectability. If resectability not clear, close incision.bSee Principles of Surgery (GALL-A) .cOrder does not indicate preference. The choice of treatment modality may depend on extent/location of disease and institutional capabilites .d A phase III trial supporting gemcitabine/cisplatin has been reported for patients with advanced or metastatic billiary tract cancer. Valle JW, Wasan HS, Palmer DD, et al. Cisplatin plus gemcitabine versus gemcitabine for biliary tract cancer. N Eng J Med 2010;362:1273-1281. Clinical trial participation is encouraged. There are phase II

trials that support the following combinations: gemcitabine/oxaliplatin, gemcitabine/capecitabine, capecitabine/cisplatin, capecitabine/oxaliplatin,5- uorouracil/oxaliplatin, 5- uorouracil/cisplatin and the single agents gemcitabine, capecitabine, and 5- uorouracil in the unresectable or metastatic setting.(Hezel AF and Zhu AX. Systemic therapy for biliary tract cancers. The Oncologist 2008;13:415-423).

eThere are limited clinical trial data to de ne a standard regimen or de nitive bene t. Clinical trial participation is encouraged. (Macdonald OK, Crane CH. Palliative andpostoperative radiotherapy in biliary tract cancer. Surg Oncol Clin N Am 2002;11(4):941-954) .

Other ClinicalPresentations(See GALL-3) and (GALL-4)

Unresectable

NCCN Guidelines IndexNCCN Guidelines Version 1 2014









Discussion


Note: All recommendations are category 2A unless otherwise indicated.

Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.


PRESENTATION POSTOPERATIVEWORKUP

PRIMARY TREATMENT

GALL-2

Incidentalnding on

pathologicreview

T1a(with negativemargins)

T1b or

greater

• CT/MRI,chest CT

• Considerstaginglaparoscopy f

Resectable b

Unresectable

Observe

Hepatic resection b

+ lymphadenectomy± bile duct excision

Options: c• Gemcitabine/cisplatin combination therapy d (category 1)• Fluoropyrimidine-based or other gemcitabine-based

chemotherapy regimen d

• Fluoropyrimidine chemoradiation e • Clinical trial• Best supportive care

See AdjuvantTreatmentandSurveillance(GALL-5)

bSee Principles of Surgery (GALL-A) .cOrder does not indicate preference. The choice of treatment modality may depend on extent/location of disease, and institutional capabilites .d A phase III trial supporting gemcitabine/cisplatin has been reported for patients with advanced or metastatic billiary tract cancer. Valle JW, Wasan HS, Palmer DD, et al. Cisplatin plus gemcitabine versus gemcitabine for biliary tract cancer. N Eng J Med 2010;362:1273-1281. Clinical trial participation is encouraged. There are phase IItrials that support the following combinations: gemcitabine/oxaliplatin, gemcitabine/capecitabine, capecitabine/cisplatin, capecitabine/oxaliplatin,5- uorouracil/oxaliplatin, 5- uorouracil/cisplatin and the single agents gemcitabine, capecitabine, and 5- uorouracil in the unresectable or metastatic setting.(Hezel AF and Zhu AX. Systemic therapy for biliary tract cancers. The Oncologist 2008;13:415-423).

eThere are limited clinical trial data to define a standard regimen or definitive benefit. Clinical trial participation is encouraged. (Macdonald OK, Crane CH. Palliative andpostoperative radiotherapy in biliary tract cancer. Surg Oncol Clin N Am 2002;11:941-954).

f Butte JM, Gonen M, Allen PJ, et al. The role of laparoscopic staging in patients with incidental gallbladder cancer. HPB (Oxford) 2011;13:463-472.Other ClinicalPresen tations(See GALL-3) and (GALL-4)










Discussion





PRESENTATION

GALL-3

WORKUP PRIMARY TREATMENT

Mass onimaging

• H&P• CT/MRI• Liver function tests• Chest CT• Surgical consultation• Assessment of

hepatic reserve• Consider CEA• Consider CA 19-9

• Consider staginglaparoscopy

Resectable b

Unresectable Biopsy

Cholecystectomy b

+ en bloc hepatic resection+ lymphadenectomy ± bile duct excision

See Adjuvant TreatmentandSurveillance(GALL-5)

Options: c

• Gemcitabine/cisplatin combination therapy d (category 1)• Fluoropyrimidine-based or other gemcitabine-based


• Fluoropyrimidine chemoradiation e


bSee Principles of Surgery (GALL-A ).cOrder does not indicate preference. The choice of treatment modality may depend on extent/location of disease, and institutional capabilites .d A phase III trial supporting gemcitabine/cisplatin has been reported for patients with advanced or metastatic billiary tract cancer. Valle JW, Wasan HS, Palmer DD, et al.

Cisplatin plus gemcitabine versus gemcitabine for biliary tract cancer. N Eng J Med 2010;362:1273-1281. Clinical trial participation is encouraged. There are phase IItrials that support the following combinations: gemcitabine/oxaliplatin, gemcitabine/capecitabine, capecitabine/cisplatin, capecitabine/oxaliplatin,5- uorouracil/oxaliplatin, 5- uorouracil/cisplatin and the single agents gemcitabine, capecitabine, and 5- uorouracil in the unresectable or metastatic setting.

(Hezel AF and Zhu AX. Systemic therapy for biliary tract cancers. The Oncologist 2008;13:415-423)e There are limited clinical trial data to define a standard regimen or definitive benefit. Clinical trial participation is encouraged. (Macdonald OK, Crane CH. Palliative and

postoperative radiotherapy in biliary tract cancer. Surg Oncol Clin N Am 2002;11:941-954).

Other Clinical Presentations

(See GALL-1 ), ( GALL-2 ),and ( GALL-4 )









Hepatobiliary Cancers Table of ContentsDiscussion





GALL-4

PRESENTATION WORKUP PRIMARY TREATMENT

Jaundice

• H&P• Liver function tests• Chest CT• CT/MRI• Cholangiography g

• Surgical consultation h

• Consider CEA• Consider CA 19-9• Consider staging

laparoscopy

Resectable b

Unresectable Biopsy

Cholecystectomy b + en bloc hepatic resection+ lymphadenectomy ± bile duct excision

See AdjuvantTreatmentandSurveillance(GALL-5)

Options: c

• Biliary drainage i

• Gemcitabine/cisplatin combination therapy d (category 1)• Other gemcitabine-based or uoropyrimidine-based


• Fluoropyrimidine chemoradiation e


Options: c

• Biliary drainage i

• Gemcitabine/cisplatin combination therapy d (category 1)• Other gemcitabine-based or uoropyrimidine-based



Metastatic disease

bSee Principles of Surgery (GALL-A ).cOrder does not indicate preference. The choice of treatment modality may depend on extent/location of disease, and institutional capabilites.d A phase III trial supporting gemcitabine/cisplatin has been reported for patients with advanced or metastatic billiary tract cancer. Valle JW, Wasan HS, Palmer DD, et al.Cisplatin plus gemcitabine versus gemcitabine for biliary tract cancer. N Eng J Med 2010;362:1273-1281. Clinical trial participation is encouraged. There are phase IItrials that support the following combinations: gemcitabine/oxaliplatin, gemcitabine/capecitabine, capecitabine/cisplatin, capecitabine/oxaliplatin,5- uorouracil/oxaliplatin, 5- uorouracil/cisplatin and the single agents gemcitabine, capecitabine, and 5- uorouracil in the unresectable or metastatic setting.(Hezel AF and Zhu AX. Systemic therapy for biliary tract cancers. The Oncologist 2008;13:415-423).

e There are limited clinical trial data to define a standard regimen or definitive benefit. Clinical trial participation is encouraged. (Macdonald OK, Crane CH. Palliative andpostoperative radiotherapy in biliary tract cancer. Surg Oncol Clin N Am 2002;11:941-954).

gMagnetic resonance cholangiopancreatography (MRCP) is preferred. Endoscopic retrograde cholangiopancreatography/percutaneous transhepatic Scholangiography (ERCP/PTC) are used more for therapeutic intervention.

hConsult with a multidisciplinary team.iIt is expected that patients will have biliary drainage for jaundice prior to instituting chemotherapy. Consider baseline CA 19-9 after biliary decompression.

Other ClinicalPresentationsSee (GALL-2 ) and ( GALL-3 )

NCCN Guidelines IndexNCCN Guidelines Version 1.2014













GALL-5

ADJUVANTTREATMENT j SURVEILLANCE

Postresection

Consideruoropyrimidine

chemoradiation(except T1a or T1b, N0) e

orFluoropyrimidine orgemcitabine chemotherapy

regimen korObserve

Considerimaging every6 mo for 2 y l

if clinicallyindicated

For relapse, see Workupof the following initialClinical presentations:

Mass on imaging(See GALL-3 )or Jaundice(See GALL-4 )or Metastases(See GALL-5)

eThere are limited clinical trial data to define a standard regimen or definitive benefit. Clinical trial participation is encouraged. (Macdonald OK, Crane CH. Palliativeand postoperative radiotherapy in biliary tract cancer. Surg Oncol Clin N Am 2002;11:941-954).

j Adjuvant chemotherapy or chemoradiation has been associated with survival benefit in patients with biliary tract cancer (BTC), especially in patients with lymph node-positive disease (Horgan AM, Amir E, Walter T, Knox JJ. Adjuvant Therapy of Biliary Tract Cancer: A Systemic Review and Meta-Analysis. J Clin Oncol

2012;30:1934-1940).kThere are no randomized phase III clinical trial data to support a standard adjuvant regimen. Clinical trial participation is encouraged. Single-agent fluoropyrimidine or gemcitabine is generally recommended in the adjuvant setting.lThere are no data to support aggressive surveillance. There should be a patient/physician discussion regarding appropriate follow-up schedules/imaging.

NCCN Guidelines IndexNCCN Guidelines Version 1.2014










Gallbladder Cancer

Incidental Finding at Surgery:• If expertise is unavailable, document all relevant ndings and refer the patient to a center with available expertise. If there is a suspicious

mass, a biopsy is not necessary as this can result in peritoneal dissemination.• If expertise is available and there is convincing clinical evidence of cancer, a de nitive resection should be performed as written below. Ifthe diagnosis is not clear, frozen section biopsies can be considered in selected cases before proceeding with de nitive resection.

• The principles of resection are the same as below consisting of radical cholecystectomy including segments IV B and V andlymphadenectomy and extended hepatic or biliary resection as necessary to obtain a negative margin.

Incidental Finding on Pathologic Review:• Review the operative note and/or speak to surgeon to check for completeness of cholecystectomy, signs of disseminated disease, location

of tumor, and any other pertinent information.• Review the pathology report for T stage, cystic duct margin status, and other margins.• Diagnostic laparoscopy can be performed but is of relatively low yield. Higher yields may be seen in patients with T3 or higher tumors,

poorly differentiated tumors, or with a margin-positive cholecystectomy. Diagnostic laparoscopy should also be considered in patientswith any suspicion of metastatic disease on imaging that is not amenable to percutaneous biopsy. 1

• Repeat cross-sectional imaging of the chest, abdomen, and pelvis should be performed prior to de nitive resection.• Initial exploration should rule out distant lymph node metastases in the celiac axis or aorto-caval groove as these contraindicate further

resection.• Hepatic resection should be performed to obtain clear margins, which usually consists of segments IV B and V. Extended resections

beyond segments IV B and V may be needed in some patients to obtain negative margins.• Lymphadenectomy should be performed to clear all lymph nodes in the porta hepatis.• Resection of the bile duct may be needed to obtain negative margins. Routine resection of the bile duct for lymphadenectomy has been

shown to increase morbidity without convincing evidence for improved survival. 2,3

• Port site resection has not been shown to be effective, as the presence of a port site implant is a surrogate marker of underlyingdisseminated disease and has not been shown to to improve outcomes. 4


1Butte JM, Gonen M, Allen PJ et al. The role of laparoscopic staging in patients with incidental gallbladder cancer. HPB 2011;13:463-472.2Fuks D, Regimbeau JM, Le Treut YP et al. Incidental gallbladder cancer by the AFC-GBC-2009 Study Group. W J of Surg 2011;35:1887-1897.3D'Angelica M, Dalal KM, Dematteo RP et al. Analysis of extent of resection for adenocarcinoma of gallbladder. Ann Surg Onc 2009;16: 806-8164Maker AV, Butte JM, Oxenberg J et al. Is Port site resection necessary in the surgical management of gallbladder cancer. Ann Surg Onc 2012;19: 409-417 .

GALL-A1 of 2

NCCN Guidelines IndexH bili C T bl f C

NCCN Guidelines Version 1.2014










Gallbladder Cancer

GALL-A2 of 2


Mass on Imaging: Patients presenting with gallbladder mass/disease suspicious for gallbladder cancer • Staging should be carried out with cross-sectional imaging of the chest, abdomen, and pelvis.• If there is a suspicious mass, a biopsy is not necessary and a de nitive resection should be carried out.• Diagnostic laparoscopy is recommended prior to de nitive resection.• In selected cases where the diagnosis is not clear it may be reasonable to perform a cholecystectomy (including intraoperative frozen

section) followed by the de nitive resection during the same setting if pathology con rms cancer.• The resection is carried out as per the principles described above.

Gallbladder cancer and jaundice• The presence of jaundice in gallbladder cancer usually portends a poor prognosis. 5,6 These patients need careful surgical evaluation.• Although a relative contraindication, in select patients curative intent resection can be attempted for resectable disease in centers with

available expertise.

5Hawkins WG, DeMatteo RP, Jarnagin WR, et al. Jaundice predicts advanced disease and early mortality in patients with gallbladder cancer. Ann Surg Oncol2004;11:310-315.

6Regimbeau JM, Fuks D, Bachellier P, et al. Prognostic value of jaundice in patients with gallbladder cancer by the AFC -GBC-2009 study group. Eur J Surg Oncol2011;37: 505-512.












Intrahepatic Cholangiocarcinoma

INTRA-1

PRESENTATION WORKUP PRIMARYTREATMENT

Isolated intrahepatic mass a

(imaging characteristicsconsistent with adenocarcinoma)(See NCCN Guidelines for OccultPrimary Cancers)

• H&P• CT/MRI b

• Chest CT• Consider CEA• Consider CA 19-9• Liver function tests• Surgical consultation c

• Consider laparoscopy d

• Esophagogastroduodenoscopy (EGD)

and colonoscopy• Consider viral hepatitisserologies

• Biopsy a

Resectablea

Unresectable

Metastaticdisease

Resection a

Considerlympadenectomy foraccurate staging

See Additional Therapy and Surveillance(INTRA-2)

Options: e

• Gemcitabine/cisplatin combinationtherapy f (category 1)

• Clinical trial g

• Fluoropyrimidine-based or othergemcitabine-based chemotherapyregimen f

• Fluoropyrimidine chemoradiationh

• Locoregional therapy (category 2B)• Best supportive care

Options: e





aSee Principles of Surgery (INTRA-A) .bRecommend delayed contrast-enhanced imaging.cConsult with multidisciplinary team.dLaparoscopy may be done in conjunction with surgery if no distant metastases are found.eOrder does not indicate preference. The choice of treatment modality may depend on extent/location of disease and institutional capabilites .f A phase III trial supporting gemcitabine/cisplatin has been reported for patients with advanced or metastatic billiary tract cancer. (Valle JW, Wasan HS, Palmer DD, et al. Cisplatin plus gemcitabine versus gemcitabine for biliary tract cancer. N Eng J Med 2010;362:1273-1281.) Clinical trial participation is encouraged. There arephase II trials that support the following combinations: gemcitabine/oxaliplatin, gemcitabine/capecitabine, capecitabine/cisplatin, capecitabine/oxaliplatin,5-fluorouracil/oxaliplatin, 5-fluorouracil/cisplatin, and the single agents gemcitabine, capecitabine, and 5-fluorouracil in the unresectable or metastatic setting.(Hezel AF and Zhu AX. Systemic therapy for biliary tract cancers. The Oncologist 2008;13:415-423).

gSystemic or intra-arterial chemotherapy may be used in a clinical trial or at experienced centers.hThere are limited clinical trial data to define a standard regimen or definitive benefit. Participation in clinical trials is encouraged. (Macdonald OK, Crane CH. Palliativeand postoperative radiotherapy in biliary tract cancer. Surg Oncol Clin N Am 2002;11:941-954)




http://www.nccn.org/professionals/physician_gls/pdf/occult.pdf













INTRA-2

SURVEILLANCE

Postresectionstatus

No residual

local disease(R0 resection)

Observeor

Clinical trialor Fluoropyrimidine-based or gemcitabine-basedchemotherapy i

Considerimaging every6 mo for 2 y j

if clinicallyindicatedMicroscopic

margins (R1)or Positiveregional nodes

Fluoropyrimidine chemoradiation h

or Fluoropyrimidine-based or gemcitabine-basedchemotherapy i

cConsult with multidisciplinary team.eOrder does not indicate preference. The choice of treatment modality may depend on extent/location of disease and institutional capabilites .f A phase III trial supporting gemcitabine/cisplatin has been reported for patients with advanced or metastatic billiary tract cancer. (Valle JW, Wasan HS, Palmer DD, et al. Cisplatin plus gemcitabine versus gemcitabine for biliary tract cancer. N Eng J Med 2010;362:1273-1281.) Clinical trial participation is encouraged. There arephase II trials that support the following combinations: gemcitabine/oxaliplatin, gemcitabine/capecitabine, capecitabine/cisplatin, capecitabine/oxaliplatin,5-fluorouracil/oxaliplatin, 5-fluorouracil/cisplatin, and the single agents gemcitabine, capecitabine, and 5-fluorouracil in the unresectable or metastatic setting.Hezel AF and Zhu AX. Systemic therapy for biliary tract cancers. The Oncologist 2008;13:415-423).

gSystemic or intra-arterial chemotherapy may be used in a clinical trial or at experienced centers.hThere are limited clinical trial data to de ne a standard regimen or de nitive bene t. Participation in clinical trials is encouraged. (Macdonald OK, Crane CH.Palliative and postoperative radiotherapy in biliary tract cancer. Surg Oncol Clin N Am 2002;11:941-954)

i Adjuvant chemotherapy or chemoradiation has been associated with survival benefit, in patients with biliary tract cancers, especially in patients with lymphnode-positive disease. (Horgan AM, Amir E, Walter T, Knox JJ. Adjuvant Therapy of Biliary Tract Cancer: A Systemic Review and Meta-Analysis. J Clin Oncol2012;30:1934-1940). However, this meta-analysis included only a few patients with intrahepatic cholangiocarcinoma. There are no randomized phase III clinical trialdata to support a standard adjuvant regimen. Clinical trial participation is encouraged. There are phase II trials that support the following combinations: gemcitabine/ cisplatin, gemcitabine/oxaliplatin, gemcitabine/capecitabine, capecitabine/cisplatin, capecitabine/ oxaliplatin, 5- uorouracil/oxaliplatin, 5- uorouracil/cisplatin and thesingle agents gemcitabine, capecitabine, and 5- uorouracil in the unresectable or metastatic setting. (Hezel AF and Zhu AX. Systemic therapy for biliary tract cancers. The Oncologist 2008;13:415-423).

jThere are no data to support aggressive surveillance. There should be a patient/physician discussion regarding appropriate follow-up schedules/imaging.

ADJUVANTTREATMENT i

Residuallocal disease c

(R2 resection)

Options: e

















INTRA-A

PRINCIPLES OF SURGERY 1,2

• A preoperative biopsy is not always necessary before proceeding with a de nitive, potentially curative resection. A suspicious masson imaging in the proper clinical setting should be treated as malignant.• Diagnostic laparoscopy to rule out unresectable disseminated disease should be considered• Initial exploration should assess for multifocal hepatic disease, lymph node metastases, and distant metastases. Lymph node

metastases beyond the porta hepatis and distant metastatic disease contraindicate resection.• Hepatic resection with negative margins is the goal of surgical therapy. While major resections are often necessary, wedge

resections and segmental resections are all appropriate given that a negative margin can be achieved.• A portal lymphadenectomy is reasonable as this provides relevant staging information.• Multifocal liver disease is generally representative of metastatic disease and is a contraindication to resection. In highly selected

cases with limited multifocal disease resection can be considered.• Gross lymph node metastases to the porta hepatis portend a poor prognosis and resection should only be considered in highly

selected cases.

1Endo I, Gonen M, Yopp A. Intraheptic cholangiocarcinoma: rising frequency, improved survival and determinants of outcome after resection. Ann Surg 2008;248:84-962de Jong MC, Nathan H, Sotiropoulos GC. Intrahepatic cholangiocarcinoma: an international multi-institutional analysis of prognostic factors. J Clin Oncol 2011;29:3140-

3145.


NCCN Guidelines Version 1.2014E h i Ch l i i






p yDiscussion




Extrahepatic Cholangiocarcinoma

EXTRA-1

PRESENTATION WORKUP PRIMARY TREATMENT

• Pain• Jaundice• Abnormal liver

function tests

(LFTs)• Obstruction or

abnormality onimaging

• H&P• CT/MRI (assess for

vascular invasion) a

• Chest CT• Cholangiography b

• Consider CEA• Consider CA 19-9• LFTs• Surgical consultation• Consider endoscopic

ultrasound (EUS)

Unresectable c• Biliary drainage,

if indicated• Biopsy c

Resectable d

Metastaticdisease

• Surgicalexploration e

• Considerlaparoscopicstaging

• Considerpreoperativebiliary drainage

• Biliary drainage,if indicated

• Biopsy

aRecommend delayed contrast-enhanced imaging.b Noninvasive cholangiography with cross-sectional imaging.cBefore biopsy, evaluate if patient is a surgical or transplant candidate. If patient is a potential transplant candidate, consider referral to transplant center before biopsy.dSee Principles of Surgery (EXTRA-A) .eSurgery may be performed when index of suspicion is high; biopsy not required.f Order does not indicate preference. The choice of treatment modality may depend on extent/location of disease and institutional capabilites.g A recent phase III trial supporting gemcitabine/cisplatin has been reported for patients with advanced or metastatic biliary tract cancer. (Valle JW, Wasan HS, PalmerDD, et al. Cisplatin plus gemcitabine versus gemcitabine for biliary tract cancer. N Eng J Med 2010;362:1273-1281) Clinical trial participation is encouraged. There are

phase II trials that support the following combinations: gemcitabine/oxaliplatin, gemcitabine/capecitabine, capecitabine/cisplatin, capecitabine/oxaliplatin,5- uorouracil/oxaliplatin, 5- uorouracil/cisplatin and the single agents gemcitabine, capecitabine, and 5- uorouracil in the unresectable or metastatic setting.(Hezel AF and Zhu AX. Systemic therapy for biliary tract cancers. The Oncologist 2008;13:415-423)

hThere are limited clinical trial data to de ne a standard regimen or de nitive bene t. Clinical trial participation is encouraged. (Macdonald OK, Crane CH. Palliative and postoperative radiotherapy in biliary tract cancer. Surg Oncol Clin N Am 2002; 11:941-954)

Options f :• Gemcitabine/cisplatin combination therapy g

(category 1)• Clinical trial• Fluoropyrimidine based or other

gemcitabine-based chemotherapy regimen g

• Fluoropyrimidine chemoradiation h

• Supportive care

Unresectable, see above

Resectable d Resection d

See AdjuvantTreatment and Surveillance(EXTRA-2)

Options f :• Gemcitabine/cisplatin combination therapy g

(category 1)• Clinical trial• Fluoropyrimidine-based or other

gemcitabine-based chemotherapy regimen g

• Supportive care


NCCN Guidelines Version 1.2014Extrahepatic Cholangiocarcinoma






Discussion





EXTRA-2

ADJUVANT TREATMENT jSURVEILLANCE

Postresectionstatus

Resected, negative margin (R0),Negative regional nodesor Carcinoma in situ at margin

Resected, positive margin (R1) i

or Resected gross residualdisease (R2) i

or Positive regional nodes

Observe

or Fluoropyrimidine chemoradiation h

or Fluoropyrimidine-based orgemcitabine-based chemotherapy k

or Clinical trial

Consider uoropyrimidinechemoradiation h

followed by additionaluoropyrimidine-based or

gemcitabine-based chemotherapyor Fluoropyrimidine-based orgemcitabine-based chemotherapyfor positive regional lymph nodes l

Consider imaging every6 mo for 2 y m

as clinically indicated

hThere are limited clinical trial data to define a standard regimen or definitive benefit. Clinical trial participation is encouraged. (Macdonald OK, Crane CH. Palliativeand postoperative radiotherapy in biliary tract cancer. Surg Oncol Clin N Am 2002;11:941-954).

iR1 or R2 resections should be evaluated by a multidisciplinary team. j Adjuvant chemotherapy or chemoradiation has been associated with survival benefit in patients with biliary tract cancers, especially in patients with lymph node-

positive disease (Horgan AM, Amir E, Walter T, Knox JJ. Adjuvant Therapy of Biliary Tract Cancer: A Systemic Review and Meta-Analysis. J Clin Oncol2012;30:1934-1940).

kThere are limited clinical trial data to define a standard regimen. Clinical trial participation is encouraged.lThere are no randomized phase III clinical trial data to support a standard adjuvant regimen. Clinical trial participation is encouraged. There are phase II trials thatsupport the following combinations: gemcitabine/cisplatin, gemcitabine/oxaliplatin, gemcitabine/capecitabine, capecitabine/cisplatin, capecitabine/oxaliplatin,5-fluorouracil/oxaliplatin, 5-fluorouracil/cisplatin and the single agents gemcitabine, capecitabine, and 5-fluorouracil in the unresectable or metastatic setting.(Hezel AF and Zhu AX. Systemic therapy for biliary tract cancers. The Oncologist 2008;13:415-423).

mThere are no data to support aggressive surveillance. There should be a patient/physician discussion regarding appropriate follow-up schedules/imaging.








Discussion





EXTRA-A1 of 2


• The basic principle is a complete resection with negative margins and regional lymphadenectomy. This generally requires apancreaticoduodenectomy for distal bile duct tumors and a major hepatic resection for hilar tumors. Rarely, a mid bile duct tumor can beresected with a bile duct resection and regional lymphadenectomy.

• Diagnostic laparoscopy should be considered.• Occasionally a bile duct tumor will involve the biliary tree over a long distance such that a hepatic resection and pancreaticoduodenectomy

will be necessary. These are relatively morbid procedures and should only be carried out in very healthy patients without signi cantcomorbidity. Nonetheless, these can be potentially curative procedures and should be considered in the proper clinical setting. Combinedliver and pancreatic resections performed to clear distant nodal disease are not recommended.

Hilar cholangiocarcinoma• Detailed descriptions of imaging assessment of resectability are beyond the scope of this outline. The basic principle is that the tumor will

need to be resected along with the involved biliary tree and the involved hemi-liver with a reasonable chance of a margin negative resection.

The contra-lateral liver requires intact arterial and portal in ow as well as biliary drainage.1,2,3

• Detailed descriptions of preoperative surgical planning are beyond the scope of this outline but require an assessment of the future liverremnant (FLR). This requires an assessment of biliary drainage and volumetrics of the FLR. While not necessary in all cases, the use ofpreoperative biliary drainage of the FLR and contralateral portal vein embolization should be considered in cases of a small future liverremnant. 4,5

• Initial exploration rules out distant metastatic disease to the liver, peritoneum, or distant lymph nodes beyond the porta hepatis as thesendings contraindicate resection. Further exploration must con rm local resectability.

• Since hilar tumors, by de nition, abut or invade the central portion of the liver they require major hepatic resections on the involved side toencompass the biliary con uence and generally require a caudate resection.

• Resection and reconstruction of the portal vein and/or hepatic artery may be necessary for complete resection and require expertise inthese procedures.

• Biliary reconstruction is generally through a Roux-en-Y hepaticojejunostomy.• A regional lymphadenectomy of the porta hepatis is carried out.• Frozen section assessment of proximal and distal bile duct margins are recommended if further resection can be carried out.

Distal cholangiocarcinoma• Initial assessment to rule out distant metastatic disease and local resectability.• The operation generally requires a pancreaticoduodenectomy with typical reconstruction.

References on next page


Di i







Discussion





EXTRA-A2 of 2

PRINCIPLES OF SURGERY (References)

1Nishio H, Nagino M, Nimura Y. Surgical management of hilar cholangiocarcinoma: the Nagoya experience. HPB 2005;7:259-262.2Matsuo K, Rocha FG, Ito K, et al. The Blumgart preoperative staging system for hilar cholangiocarcinoma: analysis of resectability and outcomes in 380 patients. J AmColl Surg 2012;215:343-355.

3Jarnagin WR, Fong Y, DeMatteo RP, et al. Staging, resectability and outcomes in 225 patients with hilar cholangiocarcinoma. Ann Surg 2001;234:507-517.4Nimura Y. Preoperative biliary drainage before resection for cholangiocarcinoma. HPB 2008;10:130-133.5Kennedy TJ, Yopp A, Qin Y, et al. Role of preoparative biliary drainage of live remnant prior to extended liver resection of hilar cholangiocarcinoma. HPB 2009;11:445- 451.


Discussion

NCCN Guidelines Version 1.2014 StagingHepatobiliary Cancers






Discussion


Hepatobiliary Cancers

Table 1American Joint Committee on Cancer (AJCC)TNM Staging for Liver Tumors (7th ed., 2010)*

Primary Tumor (T)TX Primary tumor cannot be assessedT0 No evidence of primary tumor T1 Solitary tumor without vascular invasionT2 Solitary tumor with vascular invasion or multiple tumors none

more than 5 cmT3a Multiple tumors more than 5 cmT3b Single tumor or multiple tumors of any size involving a major

branch of the portal vein or hepatic veinT4 Tumor(s) with direct invasion of adjacent organs other than the

gallbladder or with perforation of visceral peritoneum

Regional Lymph Nodes (N)NX Regional lymph nodes cannot be assessedN0 No regional lymph node metastasisN1 Regional lymph node metastasis

Distant Metastasis (M)M0 No distant metastasisM1 Distant metastasis

Anatomic Stage/Prognostic GroupsStage I T1 N0 M0Stage II T2 N0 M0Stage IIIA T3a N0 M0IIIB T3b N0 M0IIIC T4 N0 M0Stage IVA Any T N1 M0Stage IVB Any T Any N M1

Histologic Grade (G)G1 Well differentiatedG2 Moderately differentiatedG3 Poorly differentiatedG4 Undifferentiated

Fibrosis Score (F)The brosis score as de ned by Ishak is recommended because ofits prognostic value in overall survival. This scoring system uses a0-6 scale.F0 Fibrosis score 0-4 (none to moderate brosis)F1 Fibrosis score 5-6 (severe brosis or cirrhosis)

Used with the permission of the American Joint Committee on Cancer (AJCC), Chicago, Illinois. The original and primary source for this information is the AJCCCancer Staging Manual, Seventh Edition (2010) published by Springer Science+Business Media, LLC (SBM). (For complete information and data supportingthe staging tables, visit www.springer.com .) Any citation or quotation of this material must be credited to the AJCC as its primary source. The inclusion of this

information herein does not authorize any reuse or further distribution without the expressed, written permission of Springer SBM, on behalf of the AJCC.ST-1


Discussion



http://www.springer.com/?SGWID=0-102-0-0-0






Discussion


p y

ST-2

Table 2 American Joint Committee on Cancer (AJCC)TNM Staging for Gallbladder Cancer (7th ed., 2010)*

Primary Tumor (T)TX Primary tumor cannot be assessedT0 No evidence of primary tumor Tis Carcinoma in situ

T1 Tumor invades lamina propria or muscular layer T1a Tumor invades lamina propriaT1b Tumor invades muscle layer T2 Tumor invades perimuscular connective tissue; no extension

beyond serosa or into liver T3 Tumor perforates the serosa (visceral peritoneum) and/or

directly invades the liver and/or one other adjacent organ orstructure, such as the stomach, duodenum, colon,pancreas, omentum, or extrahepatic bile ducts

T4 Tumor invades main portal vein or hepatic artery or invadestwo or more extrahepatic organs or structures

Regional Lymph Nodes (N)NX Regional lymph nodes cannot be assessedN0 No regional lymph node metastasisN1 Metastases to nodes along the cystic duct, common bile duct, hepatic artery, and/or portal veinN2 Metastases to periaortic, pericaval, superior mesenteric

artery, and/or celiac artery lymph nodes


Anatomic Stage/Prognostic GroupsStage 0 Tis N0 M0Stage I T1 N0 M0Stage II T2 N0 M0Stage IIIA T3 N0 M0Stage IIIB T1-3 N1 M0Stage IVA T4 N0-1 M0Stage IVB Any T N2 M0 Any T Any N M1

Histologic Grade (G )GX Grade cannot be assessedG1 Well differentiatedG2 Moderately differentiatedG3 Poorly differentiatedG4 Undifferentiated

Used with the permission of the American Joint Committee on Cancer (AJCC), Chicago, Illinois. The original and primary source for this information is the AJCCCancer Staging Manual, Seventh Edition (2010) published by Springer Science+Business Media, LLC (SBM). (For complete information and data supportingthe staging tables, visit www.springer.com .) Any citation or quotation of this material must be credited to the AJCC as its primary source. The inclusion of thisinformation herein does not authorize any reuse or further distribution without the expressed, written permission of Springer SBM, on behalf of the AJCC.


Discussion











p y


ST-3

Table 3American Joint Committee on Cancer (AJCC)TNM Staging for Intrahepatic Bile Duct Tumors (7th ed.,2010)*

Primary Tumor (T)TX Primary tumor cannot be assessedT0 No evidence of primary tumor Tis Carcinoma in situ (intraductal tumor)T1 Solitary tumor without vascular invasionT2a Solitary tumor with vascular invasionT2b Multiple tumors, with or without vascular invasionT3 Tumor perforating the visceral peritoneum or involving the

local extra hepatic structures by direct invasion

T4 Tumor with periductal invasion

Regional Lymph Nodes (N)NX Regional lymph nodes cannot be assessedN0 No regional lymph node metastasisN1 Regional lymph node metastasis present

Distant Metastasis (M)M0 No distant metastasisM1 Distant metastasis present

Anatomic Stage/Prognostic GroupsStage 0 Tis N0 M0Stage I T1 N0 M0Stage II T2 N0 M0Stage III T3 N0 M0Stage IVA T4 N0 M0 Any T N1 M0Stage IVB Any T Any N M1

Histologic Grade (G )G1 Well differentiatedG2 Moderately differentiatedG3 Poorly differentiatedG4 Undifferentiated


Discussion










Version 1.2014 01/30/14 © National Comprehensive Cancer Network, Inc. 2014, All rights reserved. The NCCN Guidelines ® and this illustration may not be reproduced in any form without the express written permission of NCCN ®. ST-4

Table 4American Joint Committee on Cancer (AJCC)TNM Staging for Perihilar Bile Duct Tumors (7th ed., 2010)*

Primary Tumor (T)TX Primary tumor cannot be assessedT0 No evidence of primary tumor Tis Carcinoma in situ

T1 Tumor con ned to the bile duct, with extension up to the muscle layer or brous tissueT2a Tumor invades beyond the wall of the bile duct to surrounding

adipose tissueT2b Tumor invades adjacent hepatic parenchymaT3 Tumor invades unilateral branches of the portal vein or

hepatic arteryT4 Tumor invades main portal vein or its branches bilaterally; or

the common hepatic artery; or the second-order biliaryradicals bilaterally; or unilateral second-order biliary radicalswith contralateral portal vein or hepatic artery involvement

Regional Lymph Nodes (N)NX Regional lymph nodes cannot be assessedN0 No regional lymph node metastasisN1 Regional lymph node metastasis (including nodes along the

cystic duct, common bile duct, hepatic artery, and portal vein)N2 Metastasis to periaortic, pericaval, superior mesenteric artery, and/or

celiac artery lymph nodes


Anatomic Stage/Prognostic GroupsStage 0 Tis N0 M0Stage I T1 N0 M0Stage II T2a-b N0 M0Stage IIIA T3 N0 M0Stage IIIB T1-3 N1 M0Stage IVA T4 N0-1 M0Stage IVB Any T N2 M0 Any T Any N M1

Histologic Grade (G)GX Grade cannot be assessedG1 Well differentiatedG2 Moderately differentiatedG3 Poorly differentiatedG4 Undifferentiated

Used with the permission of the American Joint Committee on Cancer (AJCC), Chicago, Illinois. The original and primary source for this information is the AJCCCancer Staging Manual, Seventh Edition (2010) published by Springer Science+Business Media, LLC (SBM). (For complete information and data supportingthe staging tables, visit www.springer.com .) Any citation or quotation of this material must be credited to the AJCC as its primary source. The inclusion of this

information herein does not authorize any reuse or further distribution without the expressed, written permission of Springer SBM, on behalf of the AJCC.


Discussion









Version 1.2014 02/28/14 © National Comprehensive Cancer Network, Inc. 2014, All rights reserved. The NCCN Guidelines ® and this illustration may not be reproduced in any form without the express written permission of NCCN ®. ST-5


Table 5American Joint Committee on Cancer (AJCC)TNM Staging for Distal Bile Ducts Tumors (7th ed., 2010)*

Primary Tumor (T)TX Primary tumor cannot be assessedT0 No evidence of primary tumor Tis Carcinoma in situT1 Tumor con ned to the bile duct histologicallyT2 Tumor invades beyond the wall of the bile ductT3 Tumor invades the gallbladder, pancreas, duodenum, or other

adjacent organs without involvement of the celiac axis, or thesuperior mesenteric artery

T4 Tumor involves the celiac axis, or the superior mesenteric

artery

Regional Lymph Nodes (N)N0 No regional lymph node metastasisN1 Regional lymph node metastasis


Anatomic Stage/Prognostic GroupsStage 0 Tis N0 M0Stage IA T1 N0 M0Stage IB T2 N0 M0Stage IIA T3 N0 M0Stage IIB T1 N1 M0 T2 N1 M0 T3 N1 M0Stage III T4 Any N M0Stage IV Any T Any N M1

Histologic Grade (G)GX Grade cannot be assessedG1 Well differentiated

G2 Moderately differentiatedG3 Poorly differentiatedG4 Undifferentiated







Discussion







Version 1.2014, 02/28/14 © National Comprehensive Cancer Network, I nc. 2014, All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®. MS-40

Figure 1: Classification of Cholangiocarcinoma

Reproduced with permission from Patel T. Cholangiocarcinoma, Nat Clin Pract Gastroenterol Hepatol.2006;3:33-42.




http://www.aasld.org/practiceguidelines/Pages/SortablePracticeGuidelinesAlpha.aspx

http://www.aasld.org/practiceguidelines/Documents/HCCUpdate2010.pdf
