Biliary Tract Cancer Flashcards

Biliary Tract Cancer

Biliary Tract Cancer Part 2

What percentage of patients with advanced cholangiocarcinoma have mutations in IDH ?

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25%

Biliary Tract Cancer Part 2
Biliary Tract Cancer Part 1

What are some available agents in the second line setting for advanced cholangiocarcinoma?

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5-FU-based regimens including FOLFOX FOLFIRI

Targeted therapy if next generation sequencing data is available

Immunotherapy for patients that have mismatch repair deficiency or PDL1 overexpression

Biliary Tract Cancer Part 1
Biliary Tract Cancer Part 1

Is there phase 3 data to support the use of combination gemcitabine and capecitabine in advance cholangiocarcinoma?

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No

Biliary Tract Cancer Part 1
Biliary Tract Cancer Part 1

Are there randomized phase 3 data supporting the use of Bevacizumab for advanced cholangiocarcinoma ?

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No only phase 2

Biliary Tract Cancer Part 1
Biliary Tract Cancer Part 1

Is there randomized non-inferiority data comparing GEMOX and CAPOX for advanced cholangiocarcinoma ?

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Yes both are equally efficacious

Biliary Tract Cancer Part 1
Biliary Tract Cancer Part 1

Is there randomized data comparing the combination of gemcitabine and cis-platinum versus another gemcitabine combination for advanced cholangiocarcinoma ?

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Only with S-1 but that is not available in the US

Biliary Tract Cancer Part 1
Biliary Tract Cancers Part 1

If there meta-analyses data to support the use of gemcitabine and cis-platinum in the first-line setting for advanced cholangiocarcinoma?

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Yes

Biliary Tract Cancers Part 1
Biliary Tract Cancers Part 1

What is the significance of the BILCAP trial ?

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Showed a survival advantage of adjuvant capecitabine 1250mg/m2

Biliary Tract Cancers Part 1
Biliary Tract Cancers Part 1

What are some of the challenges with interpreting adjuvant chemotherapy trials in the context of cholangiocarcinoma?

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Heterogeneity of underlying patients including R1 resection rates

Biliary Tract Cancers Part 1
Biliary Tract Cancers Part 1

Was there a survival advantage in the PRODIGE-2 ACCORD 18 UNICANCER GI trial with bile duct tumors ?

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No

Biliary Tract Cancers Part 1
Biliary Tract Cancers Part 1

Which agents were used in the adjuvant setting in the PRODIGE-2 ACCORD 18 UNICANCER GI trial ?

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Gemcitabine and oxaliplatin

Biliary Tract Cancers Part 1
Biliary Tract Cancer Part 1

What were the treatment arms in theESPAC-3 trial ?

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Observation 6 months of 5-FU / leucovorin and 6 months of single agent gemcitabine

Biliary Tract Cancer Part 1
Biliary Tract Cancers Part 1

Which European trials assessed the utility of adjuvant chemotherapy in patients with resected bile duct tumors?

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ESPAC- 3 also included ampullary tumors

Biliary Tract Cancers Part 1
Biliary Tract Cancer Part 1

Have radomized clinical trials demonstrated a survival benefit in the adjuvant setting for resected or incompletely resected cholangiocarcinoma with chemotherapy?

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No

Biliary Tract Cancer Part 1
Biliary Tract Cancer Part 1

Are there randomized clinical trials supporting the use of neoadjuvant chemotherapy prior to resection of cholangiocarcinoma?

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No, only limited case series

Biliary Tract Cancer Part 1
Biliary Tract Cancer Part 1

Which patients with cholangiocarcinoma can be considered for a liver transplant?

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Those with underlying primary sclerosing cholangitis or those with small, up to 3 cm but unresectable hilar cholangiocarcinoma

Biliary Tract Cancer Part 1
Biliary Tract Cancer Part 1

Which patients appears to derive the most benefit from adjuvant radiotherapy?

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Those having positive lymph nodes or margins

Biliary Tract Cancer Part 1
Biliary Tract Cancer Part 1

What are the 2 common sites of metastatic recurrence for cholangiocarcinoma?

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Hepatic and peritoneal

Biliary Tract Cancer Part 1
Biliary Tract Cancer Part 1

Which concurrent chemoradiotherapy regimens have been employed in the adjuvant setting for cholangiocarcinoma?

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Infusion 5-FU, oral capecitabine, and gemcitabine

Biliary Tract Cancer Part 1
Biliary Tract Cancer Part 1

Under what conditions should patients with resected cholangiocarcinoma be considered for adjuvant chemoradiotherapy?

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Positive lymph nodes and / or positive margins

Biliary Tract Cancer Part 1
Biliary Tract Cancer Part 1

If there are any utility in alpha-fetoprotein in diagnosing cholangiocarcinoma?

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No, it is much more suggestive of hepatocellular carcinoma

Biliary Tract Cancer Part 1
Biliary Tract Cancer Part 1

A combination of which 2 tumor markers may be useful as a screening tool for cholangiocarcinoma in patients with underlying primary sclerosing cholangitis?

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CEA and CA-19-9

Biliary Tract Cancer Part 1
Biliary Tract Cancer Part 1

Is there data to support the use of CA-19-9 screening in patients with underlying primary sclerosing cholangitis?

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No, studies have not proven this to be useful strategy

Biliary Tract Cancer Part 1
Biliary Tract Cancer Part 1

Is the tumor marker CA-19-9 specific for cholangiocarcinoma?

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No, unfortunately, can also be seen with pancreatic cancer cholangitis, and other malignancies

Biliary Tract Cancer Part 1
Biliary Tract Cancer Part 1

Which of the 2 tumor growth patterns for cholangiocarcinoma are most common in the intrahepatic setting?

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Mass forming type, roughly 60%

Biliary Tract Cancer Part 1
Biliary Tract Cancer Part 1

What are the 2 growth patterns with intrahepatic cholangiocarcinoma?

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The mass forming type and periductal infiltrating type with associated intrahepatic ductal dilation

Biliary Tract Cancer Part 1
Biliary Tract Cancer Part 1

A ductal dilation greater than how many millimeters is suggestive of an obstructive malignancy?

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6 mm

Biliary Tract Cancer Part 1
Biliary Tract Cancer Part 1

Is weight loss a common symptom with cholangiocarcinoma?

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Yes, and can be seen in up to 50% of patients

Biliary Tract Cancer Part 1
biliary tract cholangio

Which fusion protein is required to utilize pemigatinib in metastatic cholangiocarcinoma?

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FGFR2

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biliary tract cholangio

Which VEGFR targeting TKI has shown activity in advanced cholangiocarcinoma ?

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Regorafenib

biliary tract cholangio
biliary tract cholangio

Is there randomized phase 3 data to support the addition of bevacizumab to gemcitabine/oxaliplatin for metastatic cholangiocarcinoma ?

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No, only phase II

biliary tract cholangio
biliary tract cholangio

Can capecitabine be substituted for gemcitabine in addition to oxaliplatin in advanced cholangiocarcinoma ?

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Yes, there is non-inferiority randomized data

biliary tract cholangio
biliary tract cholangio

Is there efficacy with ivosidenib in IDH1 mutated cholangiocarcinoma ?

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Yes, mostly stable disease

biliary tract cholangio
Biliary Tract Cancer

What surgical procedure can be considered prior to resection of an intrahepatic
cholangiocarcinoma?

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Staging laparotomy

Biliary Tract Cancer
Biliary Tract Cancer

Which tumor markers are useful for gallbladder cancer?

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CEA and CA 19-9 , though they are nondiagnostic

Biliary Tract Cancer
Biliary Tract Cancer

How do you manage gallbladder cancer postresection?

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Negative lymph nodes or R0 resection or Carcinoma in situ = observation or 5FU/XRT

R1/R2/+LN = 5FU/XRT + adjuvant 5FU/Gemcitabine

Biliary Tract Cancer
Biliary Tract Cancer

How do you manage gallbladder cancer postresection?

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Negative lymph nodes or R0 resection or Carcinoma in situ = observation or 5FU/XRT
R1/R2/+LN = 5FU/XRT + adjuvant 5FU/Gemcitabine

Biliary Tract Cancer
Biliary Tract Cancer

What is the difference between the treatment of gallbladder cancer who presents with
jaundice rather than one detected incidentally during surgery or diagnostic imaging?

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Patients with jaundice likely require biliary drainage and neoadjuvant chemotherapy prior to resection

Biliary Tract Cancer
Biliary Tract Cancer

Which chemotherapy regimens are available for metastatic gallbladder cancer besides
gemcitabine and cisplatin?

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Gem/Ox, 5FU/Cis, 5FU/Oxaliplatin, Capecitabine/Cisplatin and capecitabine/Oxaliplatin

Biliary Tract Cancer
Biliary Tract Cancer

How would you manage an incidental gallbladder cancer that also has an involved cystic duct lymph node ?

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Neoadjuvant chemotherapy followed by surgery

Biliary Tract Cancer
Biliary Tract Cancer

What TNM status for incidentally discovered gallbladder cancer is adjuvant observation an acceptable option?

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T1aN0M0

Biliary Tract Cancer
Biliary Tract Cancer

What NCCN Category 1 recommendation for chemotherapy is there were metastatic
cholangiocarcinoma?

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Gemcitabine and cisplatin

Biliary Tract Cancer
Biliary Tract Cancer

Which surgical procedure is favored for incidentally discovered gallbladder cancers ?

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Cholecystectomy plus en bloc liver resection plus lymph node dissection with or without bile duct
excision

Biliary Tract Cancer
Biliary Tract Cancer Part 2

What is an advantage of giving chemotherapy first before chemoradiotherapy in the adjuvant setting for resected gallbladder cancer ?

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If patients have chemotherapy resistant disease and develop distant metastases then radiotherapy can be deferred

Biliary Tract Cancer Part 2
Biliary Tract Cancer Part 2

Which 2 large clinical trials support the use of adjuvant chemotherapy in patients with resected gallbladder cancer?

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BILCAP and PRODIGE 12 ACCORD 18-UNICANCER GI Each had approximately 20% gallbladder cancer patients BILCAP – single agent capecitabine PRODIGE 12 ACCORD 18-UNICANCER GI – gemcitabine plus oxaliplatin

Biliary Tract Cancer Part 2
Biliary Tract Cancer Part 2

Is there are randomized data to support chemotherapy versus concurrent chemoradiotherapy in the adjuvant setting for resected gallbladder cancer?

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No

Biliary Tract Cancer Part 2
Biliary Tract Cancer Part 2

What is a common adjuvant modality for patients with resected gallbladder cancer?

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Several months of single agent chemotherapy either 5-FU or capecitabine followed by chemoradiotherapy

Biliary Tract Cancer Part 2
Biliary Tract Cancer Part 2

Which patients with gallbladder cancer can be spared adjuvant chemotherapy and/or radiotherapy?

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T1a only

Biliary Tract Cancer Part 2
Biliary Tract Cancer Part 2

Which subsets of patients with resected gallbladder cancer derive the most benefit from adjuvant chemotherapy and/or radiotherapy or combination?

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Those with positive margins and those with positive lymph nodes

Biliary Tract Cancer Part 2
Biliary Tract Cancer Part 2

Is there a statistically significant improvements in a survival advantage with adjuvant chemotherapy in patients with resected gallbladder cancer?

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No since only a trend has been observed

Biliary Tract Cancer Part 2
Biliary Tract Cancer Part 2

Is there randomized data to support the use of adjuvant radiotherapy in patients with resected gallbladder cancer?

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No there are only retrospective data

Biliary Tract Cancer Part 2
Biliary Tract Cancer Part 2

What are some other histologies that can be seen in gallbladder cancer decides adenocarcinoma?

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Squamous cell carcinoma & lymphoma & small cell carcinoma

Biliary Tract Cancer Part 2
Biliary Tract Cancer Part 2

What is the most common histology for newly diagnosed gallbladder cancer?

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Adenocarcinoma which is seen in 90%.

Biliary Tract Cancer Part 2
Biliary Tract Cancer Part 2

Is routine PET scan required during the staging of newly diagnosed gallbladder cancer?

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No

Biliary Tract Cancer Part 2
Biliary Tract Cancer Part 2

Has endoscopic ultrasound proven to be more sensitive then transabdominal ultrasound for gallbladder cancer?

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Yes

Biliary Tract Cancer Part 2
Biliary Tract Cancer Part 2

Which lymph node regions designate N1 versus N2 for gallbladder cancer?

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N1 nodes are cystic duct hepatic artery / portal vein and common bile duct N2 nodes are aortic superior mesenteric artery celiac and caval nodes – hence they are not resectable

Biliary Tract Cancer Part 2
Biliary Tract Cancer Part 2

What distinguishes between a T3 and a T4 lesion in gallbladder cancer?

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T3 invades the liver while T4 invades main portal vein hepatic artery or to extrahepatic structures

Biliary Tract Cancer Part 2
Biliary Tract Cancer Part 2

What anatomic features

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can predispose patients to gallbladder cancer?

Biliary Tract Cancer Part 2
Biliary Tract Cancer Part 2

Which 2 modifiable risk factors have been associated with an increased risk of gallbladder cancer?

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Obesity and hyperglycemia

Biliary Tract Cancer Part 2
Biliary Tract Cancer Part 2

Which medications have been implicated but not fully proven to be associated with gallbladder cancer?

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Oral contraceptive pills and isoniazid and methyldopa

Biliary Tract Cancer Part 2
Biliary Tract Cancer Part 2

patients with which underlying disease should be screened for gallbladder cancer annually with ultrasound?

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Primary sclerosing cholangitis

Biliary Tract Cancer Part 2
Biliary Tract Cancer Part 2

What is the incidence of gallbladder cancer in patients with porcelain gallbladder?

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Approximately 2%

Biliary Tract Cancer Part 2
Biliary Tract Cancer Part 2

What common feature of gallstones can lead to a nearly a 10-fold increase in the development of gallbladder cancer?

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Very large stones in particular those that are larger than 3 cm

Biliary Tract Cancer Part 2
Biliary Tract Cancer Part 2

What is the strongest risk factor for developing gallbladder cancer?

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Gallstones wichh are seen in 70-80% of patients

Biliary Tract Cancer Part 2
Biliary Tract Cancer Part 2

Which geographic regions in the world have a higher incidence of gallbladder cancer?

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South America in particular Bolivia

Biliary Tract Cancer Part 2
Biliary Tract Cancer Part 2

What percentage of routine cholecystectomies will result in an incidental finding of gallbladder cancer?

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Less than 2%

Biliary Tract Cancer Part 2
Biliary Tract Cancer Part 2

How many gallbladder cancer cases are diagnosed in the United States every your?

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Approximately 5000

Biliary Tract Cancer Part 2
Biliary Tract Cancer Part 2

What are some treatment options for patients with advanced cholangiocarcinoma but poor performance status?

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Capecitabine and 5FU/Lv and single agent gemcitabine

Biliary Tract Cancer Part 2
Biliary Tract Cancer Part 2

Was there a survival advantage shown in the ClarIDHy trial ?

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No because crossover was allowed

Biliary Tract Cancer Part 2
Biliary Tract Cancer Part 2

What was the purpose of the ClarIDHy trial ?

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Phase 3 trial assessing the utility of ivosidenib in patients with IDH1 mutated advanced cholangiocarcinoma

Biliary Tract Cancer Part 2
Biliary Tract Cancer Part 2

Which IDH mutation is more common in cholangiocarcinoma ?

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Type 1 while type 2 is seen in less than 5%

Biliary Tract Cancer Part 2
Biliary Tract Cancer Part 2

Where are the majority of extrahepatic cholangiocarcinoma found?

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Perihilar region

Biliary Tract Cancer Part 2
Biliary Tract Cancer Part 2

Approximately what percentage of cholangiocarcinoma are intrahepatic?

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5-10%

Biliary Tract Cancer Part 2
Biliary Tract Cancer Part 2

Is an ampulla of vater carcinoma considered a cholangiocarcinoma?

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No

Biliary Tract Cancer Part 2
Biliary Tract Cancer Part 2

Patients with which autoimmune disease are at an elevated risk of cholangiocarcinoma?

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Primary sclerosing cholangitis

Biliary Tract Cancer Part 2
Biliary Tract Cancer Part 2

What formally defines a Klatskin tumor?

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Cholangiocarcinoma that involves the hepatic duct bifurcation

Biliary Tract Cancer Part 2
Biliary Tract Cancer Part 2

Is an ampulla of vater carcinoma considered a cholangiocarcinoma?

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No

Biliary Tract Cancer Part 2
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