Refers to article:
Case Presentation: A Man with Two Synchronous and Symptomatic Malignancies Related to Smoking
1. Clinical features
This patient apparently suffers from two synchronous and symptomatic malignancies. Otherwise, he appears fit, with few comorbidities, but is a heavy smoker and so is likely to have occult cardiovascular and pulmonary diseases. The biliary neoplasm is the cause of abdominal pain, weight loss, and jaundice. The tumour in the renal pelvis is the source of gross haematuria.
The acute jaundice has been relieved by biliary tract drainage and stent placement. As for the tiny lung nodule, no firm conclusions as to the presence of distant metastases are possible. So far, only radiologic diagnoses have been obtained; histologic diagnosis is still missing for both malignancies.
Most intrahepatic cholangiocarcinomas are adenocarcinomas with variable desmoplastic reaction. After histology has been secured, the treatment of choice for locally advanced, inoperable, or metastasized biliary tract neoplasms is systemic chemotherapy. Objective response rates with gemcitabine alone range from 7% to 27%, and palliation can clearly be achieved; however, median survival is rarely >8 mo .
The combination of gemcitabine plus cisplatin is active and was well tolerated in most studies. The superiority of gemcitabine plus cisplatin over gemcitabine alone was shown in the multicentre ABC-02 trial, with a significant overall survival benefit with combination therapy versus gemcitabine alone (11.7 vs 8.1 mo), as was median progression-free survival (8 vs 5 mo). Toxicity was comparable in both groups with the exception of some more haematologic toxicity with the combination .
Treatment of choice for urothelial cancer in the locally advanced, perioperative, and metastatic settings is cisplatin-based chemotherapy. The gemcitabine and cisplatin combination is generally the preferred standard option in most centres around the world.
3. Treatment strategy
From the oncologic point of view, histology should be secured before any firm conclusions are drawn and further treatment decisions made. In particular, the biliary neoplasm apparently is not amenable to complete surgery. Consequently, a biopsy should be sought before further decisions can be made.
As for the tumour in the renal pelvis, in which urothelial cancer is suspected and, indeed, is the most probable histology, complete surgery seems possible and like a reasonable way to proceed, even in a palliative situation with regard to the biliary neoplasm. Surgery of the tumour in the renal pelvis would secure the histology and remove the source of symptoms (gross haematuria, pain in later stage) and might stop local and distant spread.
In this particular patient case, gemcitabine and cisplatin combination chemotherapy would fit for both malignancies, apart from slight variations in the published schedules. If cisplatin were not feasible, gemcitabine and carboplatin combinations would be alternative options for both malignancies, the biliary tract cancer and the urothelial cancer of the renal pelvis.
Conflicts of interest
The author has nothing to disclose.
-  J.S. Park, S.Y. Oh, S.H. Kim, et al. Single-agent gemcitabine in the treatment of advanced biliary tract cancers: a phase II study. Jpn J Clin Oncol. 2005;35:68-73 Crossref
-  J.W. Valle, H. Wasan, P. Johnson, et al. Gemcitabine alone or in combination with cisplatin in patients with advanced or metastatic cholangiocarcinomas or other biliary tract tumours: a multicentre randomised phase II study - The UK ABC-01 Study. Br J Cancer. 2009;101:621-627 Crossref
© 2015 European Association of Urology, Published by Elsevier B.V.