Precision Medicine: A New Frontier for Advanced Cholangiocarcinoma - Episode 1

Diagnosing CCA


Ghassan Abou-Alfa, MD, MBA: Hello, and thank you for joining this OncLive Peer Exchange® titled “Precision Medicine: A New Frontier for Advanced Cholangiocarcinoma.”

Despite aggressive therapeutic interventions, the prognosis for cholangiocarcinoma remains poor, with a high recurrence rate even in the majority of the patients who are eligible for surgery. However, better understanding of the mutational landscape of cholangiocarcinoma has led to emerging landscape surrounding the use of novel therapeutic agents.

In this OncLive® Peer Exchange discussion, my colleagues and I are going to be discussing the current treatment options and strategies for cholangiocarcinoma.

I am Ghassan Abou-Alfa, an attending physician at Memorial Sloan Kettering Cancer Center in New York, New York, a professor of medicine at Weill Cornell Medical College in New York, New York, and the chair of the National Cancer Institute (NCI) Hepatobiliary Task Force.

Participating today on our distinguished panel are: Dr Martin Gutierrez, a medical oncologist, the director of the phase I program, and a co-chief for oncology and gastrointestinal oncology at Hackensack University Medical Center in Hackensack, New Jersey; Dr Teresa Macarulla, a principal investigator in gastrointestinal oncology and endocrine tumor group at Vall d’Hebron Institute of Oncology in Barcelona, Spain; Dr Andrea Wang-Gillam, an associate professor of medicine in the division of oncology, section of medical oncology, at Washington University School of Medicine in St. Louis, Missouri; and Dr Andrew Zhu, a professor of medicine at Harvard Medical School and Massachusetts General Hospital in Boston, Massachusetts.

Thank you so much for joining us. Let’s begin. We’re here to talk about cholangiocarcinoma today, and I have to admit that many of our colleagues do not necessarily have the familiarity with the disease per se. I’ll start with you, Andrew. If I’m not mistaken, cholangiocarcinoma was the unknown primary.

Andrew Zhu, MD, PhD: Ghassan, as you know, we definitely have the entity of the so-called unknown primary. But then on the other hand, I think as we’re doing better with our diagnostic tools, we realize at least a portion of those are actually not classified as true unknown primaries. Actually, we have very sophisticated molecular tools pinning down that this may truly represent the intrahepatic cholangiocarcinoma entity. Obviously, we have quite a lot of molecular technology to do this. For example, our center developed a very interesting sophisticated in situ hybridization [ISH] technique, looking at expression of the albumen ISH-based assay. Basically, we can tell that if you have that gene expression, you actually have a very good confidence the adenocarcinoma is coming from the intrahepatic origin. So we can actually make the diagnosis for cholangiocarcinoma.

Ghassan Abou-Alfa, MD, MBA: Fair enough. It’s definitely nice to see this very advanced work in that regard. But Teresa, a cholangiocarcinoma is just another carcinoma in the community. How would a pathologist, from your perspective, define what is cholangiocarcinoma? What are the basic needs for the pathologist there?

Teresa Macarulla, MD, PhD: Of course the first thing is that we need a core biopsy. You need a good pathology tissue in order to do some immunohistochemical test in order to define that this is not another kind of tumor, and this is not a metastasis. This is intrahepatic cholangiocarcinoma. I think we have to change our mentality. We always need this core biopsy in order to have enough tissue to do it. I also agree that molecular characterization of this tissue can help us say, “Yeah, this is characteristic of intrahepatic cholangiocarcinoma.” But it is true that this is only possible to do in a highly specific unit or high-volume centers. In the community, in the hospitals in my country, Spain, it’s not possible to do it. So you have to have this good tissue and a good pathologist, and also the specialized pathologist. This is because if you have a pathologist who is looking for breast cancer, also intrahepatic, it’s more difficult to define it.

Ghassan Abou-Alfa, MD, MBA: Fair enough.

Transcript Edited for Clarity