Bile Duct Adenoma with Oncocytic Features

Bile duct adenomas are benign bile duct proliferations usually encountered as an incidental finding. Oncocytic bile duct neoplasms are rare and the majority are malignant. A 61-year-old male with a diagnosis of colorectal adenocarcinoma was undergoing surgery when a small white nodule was discovered on the surface of the right lobe of his liver. This lesion was composed of cytologically bland cells arranged in tightly packed glands. These cells were immunopositive for cytokeratin 7, negative for Hep Par 1, contained mucin, and had a Ki67 proliferation index of 8%. The morphology, immunophenotype, presence of mucin, and normal appearing bile ducts, as well as the increased Ki67 proliferation rate, were consistent with a bile duct adenoma with oxyphilic (oncocytic) change. Oncocytic tumors in the liver are rare; the first described in 1992. Only two bile duct adenomas with oncocytic change have been reported and neither of them had reported mucin production or the presence of normal appearing bile ducts within the lesion.

Image-guided intensity modulated radiation therapy (IG-IMRT) affords increased survival for biliary tract tumors: Results from preliminary analysis

4131 Background: The purpose of this study is to determine the effect of image-guided radiotherapy on survival in adenocarcinoma of the biliary tract. Methods: Between 1995 and 2005, 43 pts with primary biliary tract (gallbladder or bile duct) neoplasms were treated with radiotherapy. 26 of the pts were female and 17 were male. Their average age at registration was 64, and ranged from 25 to 86. Twenty-five pts (58%) were Hispanic, while 18 (42%) were white. 31 pts (72%) underwent surgical treatment, most having cholecystecomy (50%). 29 pts (67%) had chemotherapy: 21 (72%) were given fluorouracil-based drugs, 2 (7%) received gemcitabine, and 6 (21%) received other agents. 23 pts (53%) received conventional radiation treatment using AP/PA, AP/PA with opposing lateral, or AP with opposing lateral fields. 20 pts (47%) received IG-IMRT using Nomos Peacock and daily ultrasound image guidance (BAT, Nomos, Cranberry, PA). For daily ultrasound-based image-guidance, sagittal and axial ultrasound images were acquired, and used to align pt anatomy through superimposition of CT derived organ and vascular guidance structures. Pts were treated using a boost technique to a reduced volume at gross disease after an initial dose to gross tumor and clinically evident microscopic disease. Results: Median dose to target was 54 Gy, with median conventional and IG-IMRT total doses of 48.6 and 60 Gy respectively (p=0.05). Treatment was well tolerated, with only two patients reporting RTOG grade 3 toxicity. All other patients exhibited Grade ≤2, with 23/43 reporting Grade ≤1 The median survival time from the date of registration for all patients was 8.7 months; conventional RT pts had a median survival of 6.1 months, while the IG-IMRT cohort had a median survival of 11.4 months (p = .02). Conclusions: Ultrasound-based image-guided IMRT is a feasible mechanism of delivering moderate dose escalation in conjunction with tighter safety margins, resulting in acceptable acute toxicities. Early survival data with this novel technique are encouraging and demonstrate a notable survival differential using image guided radiotherapy as component of multi-modaility regimens. No significant financial relationships to disclose.

Chemotherapy in advanced biliary tract carcinoma (BTC): A comprehensive analysis

14036 Background: BTC are uncommon but highly fatal malignancies in the United States and Europe. Unfortunately, most BTC are diagnosed at advanced stages when the tumor is unresectable. Due to the lack of phase III studies there is no standard regimen for palliative chemotherapy of BTC. The aim of this study was to analyze existing data of published clinical trials, even small and non-randomized, and identify superior regimens, which may represent a quasi standard of care of palliative chemotherapy in this disease. Methods: Data for this analysis were identified by searches of PubMed and references from relevant articles using the search terms “biliary tract neoplasms”, “bile duct neoplasms”, “cholangiocarcinoma”, and “gallbladder neoplasms”. Only papers published in English since 1985 were included. Additionally abstracts from ASCO meetings presented since 1999 were included. Results: 88 trials were analyzed. The overall response rates (OR) of this trials were in the range of 0–83%. There were 497 responders out of 2137 patients corresponding to a pooled OR of 23.3% (95%CI 21.5–25.2%). The median progression free survival (PFS) and overall survival (OS) for all patients was 4.1 and 8.0 months, respectively. There was a significant correlation between OR and PFS (r=0.49; p=0.001) and PFS and OS (r=0.76; p=0.000) but not between OR and OS. Gemcitabine (GEM) and platinum analogs (P) had a significant positive impact on OR, whereas the impact of taxanes and irinotecan was negative. OR of subgroups defined by 5-FU, GEM, and P were analyzed in detail. There was only a trend of an increased OR between 5-FU and GEM without P (17 vs 22%). Combination with P increased significantly the OR of 5-FU by 10% (17 vs 27%) and of GEM by 20% (22 vs 42%). Conclusions: The pooled OR of mostly small trials of palliative chemotherapy in BTC is about 23%. With GEM alone no significant improvement could be achieved compared to 5-FU or capecitabine. However, doublets of GEM in combination with P synergistically increased OR. Results of GEM plus P are promising and should be further evaluated by large RCT. In the meantime GEM plus P may represent at least a good option for patients in good general condition. No significant financial relationships to disclose.