"Doctor Lu, I came to Tianjin today for a review, and the indicators are very good in all aspects!"
"Great, it just so happens that the peach blossoms in Tianjin have bloomed a lot, I recommend you to go to the Peach Blossom Embankment to enjoy the flowers!"
It's hard to imagine that this was a conversation between a patient with an advanced cancer and a doctor, but it really happened between Professor Lu Wei, Secretary of the Party Committee of Tianjin Medical University Cancer Hospital and Director of the Liver Cancer Prevention and Treatment Research Center, and a middle-aged patient who was diagnosed with advanced cholangiocarcinoma with multiple metastases by a local hospital more than a year ago, which undoubtedly caused a huge blow to the patient's life. But now, this patient has not only returned to normal life, but also has an uplifted and comfortable mood, and has even become a local anti-cancer star.
In a short period of time, why did this patient undergo such a big change, and how did he establish a deep relationship with the doctor? China Medical Tribune specially invited the team from the Department of Hepatobiliary Oncology of Tianjin Medical University Cancer Hospital to share the highlights of this patient's disease diagnosis and treatment and team development experience.
Patients with poor curative effect and easy recurrence have hope and go to Tiansema to seek medical treatment
Case profile
Background of the disease
Intrahepatic cholangiocarcinoma (ICC) is a primary liver malignancy between the bile duct and the secondary bile duct, according to the World Health Organization and Pan American Health Organization databases of 32 selected sites in Europe, the Americas, Asia and Oceania, the 5-year survival rate of ICC patients is expected to be about 8%. It has a high recurrence rate, poor chemotherapy efficacy, and easy drug resistance.
Individualized multidisciplinary first-line and second-line optimization of treatment selection and efficacy prediction are the problems that clinical individualization is imperative to solve. In the process of diagnosing and treating a case of advanced cholangiocarcinoma in the Department of Hepatobiliary Oncology of Tianjin Cancer Hospital, it fully reflects the individualized, precise, multidisciplinary and whole-process management and diagnosis and treatment characteristics of tumor treatment.
Case data
The patient was a 59-year-old woman who underwent an MRI examination of the upper abdomen in a local hospital in August 2022 due to fever and fatigue and found a huge liver mass, and a liver biopsy showed adenocarcinoma, and the largest mass in the right lobe of the liver was about 8.8×6.0×11.1cm, and cholangiocarcinoma was considered to be cholangiocarcinoma, with multiple metastases in the adjacent liver and multiple lymph node metastases in the abdominal cavity.
Due to the poor prognosis of cholangiocarcinoma, most experts recommend a non-invasive, conservative treatment strategy. The patient learned that the Liver Cancer Center of Tianjin Medical University Cancer Hospital is characterized by multidisciplinary and individualized precision diagnosis and treatment, and has rich experience in the diagnosis and treatment of bile duct cancer.
At the time of admission, the patient had a palpable 10cm mass in the right upper abdomen, and his previous history was not special, and he was clearly diagnosed with intrahepatic cholangiocarcinoma (cT2bN1M1 stage IVB) through abdominal CT, angiography, pathology and other examinations
Difficult to treat
The ABC-02 study, the TOPAZ-1 study, and the KEYNOTE-966 study suggest that the median overall survival (OS) period of first-line standard chemotherapy regimens (GC, XELOX, etc.) in the treatment of advanced biliary tract tumors is about 11 months, and the median progression-free survival (PFS) is about 5 to 8 months. In this case, advanced cholangiocarcinoma has a large tumor burden and a worse prognosis, so how to formulate an individualized and precise treatment plan has become a difficult point in treatment.
Patient-centered, whole-process management and joint efforts to create individualized diagnosis and treatment plans
Diagnosis and treatment process sharing
Multidisciplinary Characteristics (MDT) program development
After MDT consultation with the Department of Interventional Medicine, the Department of Nuclear Medicine, the Department of Interventional Ultrasound, the Department of Imaging, and the Department of Pathology, the team of the Department of Hepatobiliary Medical Oncology integrated the knowledge and technology of multiple disciplines to formulate a detailed treatment plan for this patient: based on chemotherapy combined with immunotherapy, combined with yttrium-90 microsphere selective internal radiation therapy (SIRT), microwave ablation and other local treatment methods to quickly reduce the tumor burden, and at the same time, genetic testing actively sought precise targets to effectively control the tumor and prolong survival.
New Technology – Yttrium-90 Microspheres Selective Internal Radiation Therapy (SIRT)
The patient's liver tumors, predominantly located in the right lobe, were evaluated by the Tc-99m MAA test with a lung shunt fraction of 6.1% and a tumor-to-normal hepatic nuclide uptake ratio (TNR) of 6.2. After mapping to develop a personalized and accurate radiotherapy dose, yttrium-90 resin microspheres were implanted and 0.9GBq of yttrium-90 microspheres were injected.
Yttrium-90 microspheres prior to selective internal radiation therapy (SIRT) treatment
Yttrium-90 microspheres after selective internal radiation therapy (SIRT) treatment
Multidisciplinary local combination therapy - ultrasound-guided microwave ablation
After the giant mass in the right lobe of the liver is rapidly controlled, the active site and adjacent small intrahepatic metastases will be treated with thermal ablation and tumor reduction.
Individualized and precise treatment plan management throughout the process
XELOX combined with PD-1 antibody toripalimab was given as a first-line systemic treatment regimen to control systemic tumors. A total of 5 individual cell variants were detected by simultaneous liver aspiration tissue genetic testing, including 3 variants with definite or potential clinical significance, IDH1, ARID1A, PIK3CA, and ERCC2. The presence of mutations in IDH1 suggests that the IDH1 inhibitor ivosidenib may be a follow-up targeted therapy option.
After 8 months of first-line therapy, the disease was under stable control, and maintenance therapy was performed with Ivosidenib in combination with capecitabine.
Eighteen months after the diagnosis, the patient returned to the hospital again for reexamination, and the Eastern Cooperative Oncology Group (ECOG PS) physical strength score (ECOG PS) was 0 points, and PET-CT showed that the liver tumor activity was inhibited, and the metastatic lymph nodes were significantly reduced and reduced. By the end of the last follow-up, patients had an 18-month PFS period and a high quality of life.
With the blessing of new therapies, multidisciplinary precision cancer treatment is on the move
HighlightsExpert reviews
Application of new technologies
The application of yttrium-90 technology made the tumor shrink rapidly, and combined with local thermal ablation technology, the patient was able to quickly control the tumor and create an opportunity for follow-up treatment. The introduction of yttrium-90 resin microsphere therapy has provided patients with a more diverse range of options.
Application of individualized precision medicine
Advanced tumors are accompanied by extrahepatic metastases, and local treatment alone is not sufficient. Based on evidence-based medical evidence, standard first-line chemotherapy combined with immunotherapy was selected to further control systemic tumors. Based on precision medicine evidence, genetic testing suggests IDH-1 mutations, which provides a better treatment option for patients.
Application of multidisciplinary characteristic models
In the treatment of advanced biliary tract tumors, the patient-centered, hepatobiliary oncology, interventional medicine, nuclear medicine, imaging, hepatobiliary oncology, ultrasound, radiotherapy, pathology and other disciplines have developed a combined treatment plan, which improves the efficiency of treatment and strives for more survival opportunities for cholangiocarcinoma patients.
Using the concept of precision medicine integrated medicine, we can find the most suitable and individualized best solution for patients, and only in this way can the desired results be achieved.
Application of the whole process management mode
The "doctor-patient partner" model involves regular follow-up with the patient to evaluate the treatment effect and the patient's recovery. Through feedback, we continuously optimize treatment options to ensure the best possible outcomes for our patients.
The three new models have repeatedly broken through the treatment problems, and the "national team" continues to open up the road of characteristic development
Summary of team development
A new concept of patient-centered multidisciplinary diagnosis and treatment
In the process of treating each patient, the team of hepatobiliary oncology has always implemented the concept of precise diagnosis and treatment of single-disease multidisciplinary individualized whole-process management, and formulated an individualized treatment plan for patients through comprehensive MDT discussions in hepatobiliary oncology, hepatobiliary oncology, interventional therapy, ultrasound diagnosis and treatment, radiotherapy, radiology, pathology and other disciplines, combined with the professional characteristics and advantages of each discipline.
Under the MDT model, each specialist can give full play to their professional advantages, conduct an in-depth analysis of the patient's condition from different perspectives, and discuss the best treatment plan together. This model breaks the boundaries between traditional disciplines, realizes resource integration and complementary advantages, and provides patients with more comprehensive and accurate diagnosis and treatment suggestions.
Our patient-centered approach is also reflected in our respect and care for our patients. In the process of diagnosis and treatment, we fully understand the needs and psychological state of patients, respect patients' wishes and choices, and encourage patients to actively participate in treatment decisions. Through good communication and exchanges, we have established trust and cooperation between doctors and patients to jointly address the challenges of the disease.
New technologies for precision medicine-oriented treatment
In the Department of Hepatobiliary Medical Oncology, we actively introduce and practice new precision medicine-oriented treatment technologies to improve treatment outcomes and patient outcomes. We use minimally invasive surgery and interventional techniques, such as yttrium-90, microwave ablation, etc., to precisely destroy tumors. These technologies have the advantages of less trauma and faster recovery, improving safety and efficacy.
In particular, the new technology, Yttrium-90 Microsphere Selective Internal Radiation Therapy (SIRT), can directly deliver yttrium-90 resin microspheres with reasonable radiation directly to the inside of the tumor through interventional means, and quickly kill tumor cells by releasing β rays, accurately locate the tumor, and have no impact on the surrounding healthy tissues. Yttrium [90Y] resin microspheres can also be used in combination with comprehensive treatment methods such as tumor surgery, immunity, and targeting, which will not only enrich the treatment methods for liver cancer, but also improve the treatment effect of patients with advanced liver cancer to a certain extent.
In addition, with the popularization of gene detection technology and the understanding of molecular typing of biliary system tumors, more and more tumor heterogeneous gene variants have been detected, and studies have shown that about 43% of cholangiocarcinoma has potential targeted mutations, and targeted drugs targeting mutant genes provide more individualized treatment options for cholangiocarcinoma patients.
A new mode of communication with "doctor-patient partners" as the culture
In the Department of Hepatobiliary Medical Oncology, we adopt a new communication model of "doctor-patient partner" culture, aiming to establish a more equal, collaborative and transparent doctor-patient relationship. This model emphasizes the partnership between physicians and patients, aiming to face the challenges of disease together through effective communication and collaboration. In the process of practicing the "doctor-patient partner" model, we focused on the following aspects.
01Respect, listen, communicate
We respect our patients' opinions and choices and listen to their needs and concerns. With clear explanations and communication, patients are better able to participate in treatment decisions.
Develop a treatment plan together
Patients are encouraged to be actively involved in decision-making throughout the treatment process, including the selection of treatment options, adjustments during treatment, and the development of rehabilitation plans.
03Ongoing support and education
We provide ongoing support and guidance to our patients to help them navigate the challenges of their treatment. Through education, we help patients understand the importance of disease management, lifestyle modifications, and psychological support.
03Regular follow-up and feedback
We conduct regular follow-up visits with patients to assess the effectiveness of treatment and their recovery. Through feedback, we continuously optimize treatment options to ensure the best possible outcomes for our patients.
The "doctor-patient partner" model not only reflects the doctor's sense of responsibility, but also enhances support for the patient. Through this model, we are able to better understand the needs of our patients and provide more personalized care. At the same time, patients feel more respected and involved in the treatment process, which enhances their confidence and willingness to cooperate in the treatment. This model helps to improve the treatment outcomes and improve the quality of life of patients.
Department Introduction
Under the leadership of Professor Lu Wei, Secretary of the Party Committee of Tianjin Medical University Cancer Hospital, Director of the Liver Cancer Prevention and Research Center, and Zhang Ningning, Director of the Department of Hepatobiliary Oncology of Tianjin Medical University Cancer Hospital, the Department of Hepatobiliary Oncology of Tianjin Medical University Cancer Hospital is committed to integrating the latest treatment options for hepatobiliary tumors in China and abroad, and is a demonstration unit for the diagnosis and treatment of liver tumors integrating medical teaching and research. It is a clinical department featuring individualized comprehensive evaluation of liver cancer patients and corresponding non-surgical treatment, including yttrium-90 treatment, interventional therapy, microwave ablation therapy, targeted immunotherapy, international and domestic clinical trials and multidisciplinary comprehensive treatment.
"Degao Medical Excellence, New and Perfect" is the motto of Tianjin Medical University Cancer Hospital, which means "noble medical ethics, exquisite medical skills, advocating innovation, and perfection". The "three new" concepts explored by the hepatobiliary medical oncology team are new interpretations of the hospital motto, including "new patient-centered multidisciplinary diagnosis and treatment", "new treatment technology oriented by precision medicine", and "new communication model with 'doctor-patient partner' as the culture".
Finally, with the poem "The Peach Blossoms of Dalin Temple" rewritten from the famous poet Bai Juyi of the Tang Dynasty, "Mo Dao is full of fragrant flowers in the world, and the peach blossoms are in full bloom on the road ahead", I hope that the team of the Department of Hepatobiliary Oncology of Tianjin Medical University Cancer Hospital will insist on innovation and carry forward the characteristics, and hope that more cancer patients can regain hope and feel the "perfection and beauty" of the world with the help of doctors!
Source: Hepatobiliary Medical Oncology Team, Tianjin Medical University Cancer Hospital
Correspondent: Zhou Yan, Cancer Hospital of Tianjin Medical University
Editor: Hu Yue, China Medical Tribune