The Oncologist US

ONC_17.12 Dec 2012

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The Oncologist Challenging Cases �� Adjuvant Therapy for Intrahepatic Cholangiocarcinoma: The Debate Continues PRESENTATION OF THE CASE A 37-year-old woman presented at 35 weeks of gestation with her third child with failure to adequately gain weight and was noted by her obstetrician to have delay in the growth of her baby. Ultrasound of the abdomen incidentally revealed the presence of a liver lesion. After additional evaluation, she ultimately delivered her daughter at 36 weeks uneventfully. She subsequently underwent additional evaluation. Liver magnetic resonance imaging (MRI) revealed a 5-cm solitary solid mass in segment 4A of the liver, concerning for malignancy. Serum ���-fetoprotein, carcinoembryonic antigen, cancer antigen (CA)19 ���9, CA15���3, and CA125 were all normal. Liver biopsy was positive for adenocarcinoma. The tumor cells demonstrated a phenotype suggesting a possible breast primary, although the immunohistochemistry did not support that diagnosis and the tumor was negative for mammaglobin, gross cystic disease fluid protein (GCDFP)-15, estrogen receptor (ER), and progesterone receptor (PR) (Table 1). The tumor was also CDX2 and cardiotrophin-1 negative, but cytokeratin (CK) 19 positive. Her endoscopic retrograde cholangiopancreatography, upper endoscopy, colonoscopy, breast mammogram, and breast MRI were completely normal. A positron emission tomography��� computed tomography scan showed a fluorodeoxyglucose-avid 5.8-cm �� 6.0-cm hypoattenuating lesion with peripheral enhancement involving segment 4 and segment 8 at the dome. In addition, central necrosis within the lesion was noted. The left main portal vein was Table 1. Immunohistochemistry staining pattern mildly attenuated by the mass. She eventually underwent a Surgical resection left hepatectomy en bloc with caudate resection, portal Initial biopsy specimen lymphadenectomy, cholecystectomy, and omental pedicle Negative: TTF-1, CDX-2, Negative: CK20, CDX-2, flap. On exploration of the abdomen, no additional disease ER, PR, mammoglobin, CA125, ER, PR, GCDFPwas noted. The final pathology revealed a 9.4-cm moderGCDFP-15, CK20, 15, synaptophysin, and ately to poorly differentiated adenocarcinoma of the intraPAX8, and WT-1 chromogranin hepatic bile ducts. Venous invasion was present. Perineural Positive: CK7, CK19, and Positive: CK7, CK19, and invasion was absent. The margins were negative. Thirteen SMAD4 (intact) CA19���9 lymph nodes were obtained, all of which were negative, consistent with a stage T2, N0, MX intrahepatic cholangiocarciAbbreviations: CA, cancer antigen; CK, cytokeratin; noma. The tumor was positive for CK7, CK19, and CA19 ���9 ER, estrogen receptor; GCDFP, gross cystic disease and negative for CK20, CDX2, CA125, ER, PR, GCDFP-15, fluid protein; PAX, paired box; PR, progesterone receptor; TTF, thyroid transcription factor; WT, synaptophysin, and chromogranin (Table 1). The uninvolved Wilms��� tumor. liver was unremarkable and a trichrome stain showed no fibrosis. Following an uneventful postoperative recovery, she was referred for consideration of adjuvant therapy. PRO CON By Andrew X. Zhu Massachusetts General Hospital Cancer Center, Harvard Medical School By Jennifer J. Knox Princess Margaret Hospital, University of Toronto Biliary tract cancers (BTCs) encompass a spectrum of invasive adenocarcinomas including both cholangiocarcinoma (CC), which has been used to refer to The strongest arguments against recommending adjuvant therapy for this case are both the lack of evidence supporting clear benefit for such a patient and the Andrew X. Zhu Jennifer J. Knox Correspondence: Andrew Zhu, M.D., Ph.D., Massachusetts General Hospital, 55 Fruit Street, Cancer Center POB Room 232, Boston, Massachusetts 02114, USA. Telephone: 617-724-3853; Fax: 617-724-3166; e-mail: azhu@partners.org. Jennifer J. Knox, M.D., M.Sc., FRCPC, Princess Margaret Hospital, 5th Floor Room 218, 610 University Avenue, Toronto, Ontario, Canada M5G 2M9. Telephone: 416-946-2399; Fax: 416-946-6546; e-mail: jennifer.knox@uhn.ca Received November 8, 2012; accepted for publication November 9, 2012; first published online in The Oncologist Express on December 7, 2012. ��AlphaMed Press 1083-7159/2012/$20.00/0 http://dx.doi.org/10.1634/theoncologist.2012-0432 The Oncologist 2012;17:1504 ���1507 www.TheOncologist.com

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