Apullary Adeno Case

[Haybrant]

I have a pretty old guy, 85 who was referred with ampullary carcinoma. Initial presentation was ICU w ascending cholangitis. He underwent sphincterotomy and edematous ampulla was noted and a periampullary diverticulum, no stent was placed. Path was poorly diff amullary ca, imaging doesn't really show much, no nodes, perhaps a 1.5 cm lesion of the ampulla with biliary ductal dilatation extending up to the gallbladder.

That was 2.5 months ago. He been doing well since, has not had any clinical issues. TBili is normal. Too old for a whipple. Curious your thoughts here. I suspect this will grow again and cause issues at some point bc they are calling it poorly differentiated. His preference is to be aggressive. If you would offer RT what would you treat? Thank you

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[Neuronix]

Whipple is his only chance of cure. You sure he's "too old for a whipple" ? If he's in good shape, I'd still get a good pancreas surgeon's opinion from a high volume center.

Otherwise everything you're doing is palliative. Treat it like you would a locally advanced pancreas cancer. Several right answers there. I'd probably SBRT it, but you could also do gem + 50.4 Gy with concurrent 5-FU or any of several dose escalation or hypofractionation protocols that exist out there.

 

[medgator]

If there isn't a clear dominant mass, I'd probably offer 50.4 to a generous field (if there was a mass, would just treat that with no ENI) with IMRT + xeloda/5-FU, assuming he is not a surgical candidate after eval at a high-volume center.

 

[evilbooyaa]

Could just send him for Gemcitabine alone per an extrapolation of LAP07 (without RT) before putting him through the side effects of even focal GI radiation, and radiate him palliatively whenever he recurs and has local symptoms. I would personally avoid palliative radiation of a 'wide field' in somebody of his age. He may look good but his intestines are still 85 years old.

Agree with the consensus that he should be sent to a high-volume Surg Onc to determine medical operability.

 

[nkmiami]

for what its worth, if pt goes on to have a whipple, I dont think the ampullary cancers benefited from adjuvant chemo in the espac trial.

 

[Palex80]

I'd only treat if he's symptomatic again. 12 x 3 Gy sound reasonable.
Gemcitabine is fairly easy treatmemt even in older patients.

 

[BobbyHeenan]

I'd only treat if he's symptomatic again. 12 x 3 Gy sound reasonable.
Gemcitabine is fairly easy treatmemt even in older patients.

I think this is very reasonable, but my concern would be once symptomatic, he's going to need more than just palliative XRT. You may be looking at an inpatient admission with stent placement (unless he already has a stent, but original post suggested he doesn't have a stent) and then further XRT.

If you're just going to watch this and treat later then I think he may want to consider a stent if GI thinks this is doable.

For me personally I'd probably treat now after surg onc says no to Whipple. I'd do similar to what medgator said and just treat his primary tumor, no elective nodes. It sounds like target/tumor delineation would be challenging, so I wouldn't use SBRT.

 

[nkmiami]

I am really starting to sour on (low dose 6 Gy x 5 etc) stereo for pancreas. I havent been impressed by the results, and you can really injure the patient and it is not that convenient to implant a fiducial. I think hypofractionation like chris crane has described is much more appealing.

 

[evilbooyaa]

I am really starting to sour on (low dose 6 Gy x 5 etc) stereo for pancreas. I havent been impressed by the results, and you can really injure the patient and it is not that convenient to implant a fiducial. I think hypofractionation like Craig Stevens has described is much more appealing.

Is that a similar technique to the Chris Crane papers on BED 70 or bust for definitive control? 67.5/15 IIRC, using stereotactic technique? Can't find a paper on a quick search.

 

[Neuronix]

You have to do it right to do SBRT. If you can't put in fiducials or don't have a Viewray, then not doing SBRT is the right move.

 

[seper]

In terms of local control and side effects, "extracranial SBRT" of 6 Gy X 5 is not superior to simple 35 Gy/14 fx with reasonable margins. Great RVU source though.

 

[nkmiami]

Is that a similar technique to the Chris Crane papers on BED 70 or bust for definitive control? 67.5/15 IIRC, using stereotactic technique? Can't find a paper on a quick search.

sorry meant chris crane/mdacc- basically, like palex says 12/13 x 3 etc is a good option and I dont think any less convenient than stereo when all is said and done, and you wont have to worry about an ulcer for a tumor that must be really close to the duodenum.

 

[Neuronix]

In terms of local control and side effects, "extracranial SBRT" of 6 Gy X 5 is not superior to simple 35 Gy/14 fx with reasonable margins. Great RVU source though.

With SBRT pancreas the institution where I trained had 78% locoregional control at 1 year and 7% Grade 3+ toxicity at any point with ~160 patients.

We have phase II multi-institutional prospective data for it as well in 49 patients, which oddly enough also had 78% locoreigonal control at one year, 2% acute grade 2+ toxicity and 11% late grade 2+ toxicity.

Conventional palliative regimens do not get that degree of control.

Ampullary tumors tend to met less which to me emphasizes local control even further.

There's no pressure on me to generate RVUs here in academics. I do it because I believe in it.

Whether it's any better than other hypofractionated regimens is to be determined. I stand by my earlier statement though. You need to know what you're doing and have a well coordinated setup to do SBRT in the biliary system. Without excellent IGRT and motion management, control and toxicity are much worse.

 

[evilbooyaa]

Can you post a link or two to the studies you're referencing, @Neuronix ? Much appreciated.

 

[Neuronix]

Long-term outcomes of induction chemotherapy and neoadjuvant stereotactic body radiotherapy for borderline resectable and locally advanced pancreat... - PubMed - NCBI
Phase 2 multi-institutional trial evaluating gemcitabine and stereotactic body radiotherapy for patients with locally advanced unresectable pancrea... - PubMed - NCBI

 

[seper]

Reasonable data, thanks. Perhaps dose painting to 8 Gy X 5 is a good idea. But, please, do not insinuate that Moffitt does not have RVU targets for faculty

 

[Neuronix]

I'm sure you meant it tongue in cheek, but don't take me the wrong way. I wrote: "There's no pressure on me to generate RVUs here in academics. I do it because I believe in it." I don't work at Moffitt.

I will stand by that I don't think there's a financial reason for people doing this where I've been. There is an academic reason--we do need to find what's new, what's next, what's possible, and publish or perish in academics. But we're trying not to hurt people also and be at least as good as standard of care.

I don't want to write about the financial/RVU side of things. If you want to discuss that verbally at some point, happy to talk at ASTRO.

 

[nkmiami]

Regarding stereo vs hypofractionation- what intrigued me about hypofractionation was reporting 18% 5 year survival in the MDACC series. Obviously, these are selected pts, but I have never heard of any 5 year survivors from stereo or anything else for that matter (without surgery)

 

[Neuronix]

Agree. Guys in academics I know that do SBRT make 700+. But yeah, RVUs don't matter.'

Are they hiring?

 

[Neuronix]

That's not exactly same same there.

Such is my baseline rule. Whenever someone tells me about some amazing position, I ask if they're hiring. The answer is always no or at least not for as good of a position.