WEBVTT

NOTE duration: "01:21:50.379"


NOTE Confidence: 1

00:00:01.520 --> 00:00:02.259
Good evening.

NOTE Confidence: 0.99523926

00:00:02.879 --> 00:00:04.500
Today is April sixteenth,

NOTE Confidence: 0.93481445

00:00:04.960 --> 00:00:06.399
and welcome to our two

NOTE Confidence: 0.93481445

00:00:06.399 --> 00:00:08.320
thousand twenty six Center for

NOTE Confidence: 0.93481445

00:00:08.320 --> 00:00:10.420
GI Cancers CME series.

NOTE Confidence: 0.98098415

00:00:11.119 --> 00:00:12.559
Tonight, we will focus on

NOTE Confidence: 0.98098415

00:00:12.559 --> 00:00:14.420
biliary tract cancer specifically.

NOTE Confidence: 0.9817019

00:00:15.684 --> 00:00:17.445
My name is Jacqueline Gaddy,

NOTE Confidence: 0.9817019

00:00:17.445 --> 00:00:18.564
and I am an assistant

NOTE Confidence: 0.9817019

00:00:18.564 --> 00:00:19.704
professor of medicine

NOTE Confidence: 0.9850586

00:00:20.085 --> 00:00:21.765
and GI medical oncology at

NOTE Confidence: 0.9850586

00:00:21.765 --> 00:00:23.685
Yale. Thank you so much

NOTE Confidence: 0.9850586

00:00:23.685 --> 00:00:25.305
for joining us this evening.

NOTE Confidence: 0.99943036

00:00:26.805 --> 00:00:28.244
I have no disclosures to

NOTE Confidence: 0.99943036

00:00:28.244 --> 00:00:28.744
review.

NOTE Confidence: 0.9837302

00:00:31.330 --> 00:00:33.329
I most importantly, besides thanking

NOTE Confidence: 0.9837302

00:00:33.329 --> 00:00:34.290
all of you for joining

NOTE Confidence: 0.9837302

00:00:34.290 --> 00:00:35.570
us this evening and those

NOTE Confidence: 0.9837302

00:00:35.570 --> 00:00:36.370
that may join at a

NOTE Confidence: 0.9837302

00:00:36.370 --> 00:00:38.050
later date, I also want

NOTE Confidence: 0.9837302

00:00:38.050 --> 00:00:39.409
to thank my colleagues that

NOTE Confidence: 0.9837302

00:00:39.409 --> 00:00:40.930
have taken the time to

NOTE Confidence: 0.9837302

00:00:40.930 --> 00:00:42.150
join us this evening.

NOTE Confidence: 0.9968533

00:00:43.185 --> 00:00:45.284
Tonight, we will review perioperative

NOTE Confidence: 0.9968533

00:00:45.585 --> 00:00:46.085
management,

NOTE Confidence: 0.99975586

00:00:46.625 --> 00:00:47.604
surgical management,

NOTE Confidence: 0.9909831

00:00:48.385 --> 00:00:49.925
the critical role of hepatology,

NOTE Confidence: 0.9990886

00:00:50.545 --> 00:00:52.085
and the management of unresectable

NOTE Confidence: 0.9980469

00:00:52.545 --> 00:00:53.845
and metastatic disease.

NOTE Confidence: 0.96663785

00:00:54.385 --> 00:00:55.665
I am joined by doctor

NOTE Confidence: 0.96663785

00:00:55.665 --> 00:00:57.585
Yifei Zhang, a GI medical

NOTE Confidence: 0.96663785

00:00:57.585 --> 00:00:58.085
oncologist,

NOTE Confidence: 0.93950194

00:00:58.990 --> 00:01:01.170
doctor Straza Bosco, a hepatologist

NOTE Confidence: 0.94300133

00:01:01.710 --> 00:01:02.990
and leader of the liver

NOTE Confidence: 0.94300133

00:01:02.990 --> 00:01:05.150
cancer program and co director

NOTE Confidence: 0.94300133

00:01:05.150 --> 00:01:06.850
of the Yale Liver Center,

NOTE Confidence: 0.9062093

00:01:07.709 --> 00:01:08.690
and doctor Sogawa,

NOTE Confidence: 0.99864364

00:01:09.069 --> 00:01:11.069
the surgical director of liver

NOTE Confidence: 0.99864364

00:01:11.069 --> 00:01:11.569
transplantation.

NOTE Confidence: 0.9860073

00:01:14.744 --> 00:01:15.944
I also want to give

NOTE Confidence: 0.9860073

00:01:15.944 --> 00:01:17.145
a plug for our last

NOTE Confidence: 0.9860073

00:01:17.145 --> 00:01:18.424
session of the year, which

NOTE Confidence: 0.9860073

00:01:18.424 --> 00:01:19.805
will be held next month

NOTE Confidence: 0.9860073

00:01:19.865 --> 00:01:21.625
on May twenty first, which

NOTE Confidence: 0.9860073

00:01:21.625 --> 00:01:23.225
will be led by doctor

NOTE Confidence: 0.9860073

00:01:23.225 --> 00:01:25.965
Jill Lacey reviewing pancreatic cancer.

NOTE Confidence: 0.9970259

00:01:30.200 --> 00:01:31.319
I will get us started

NOTE Confidence: 0.9970259

00:01:31.319 --> 00:01:33.100
by first providing a simple

NOTE Confidence: 0.9970259

00:01:33.159 --> 00:01:33.659
background

NOTE Confidence: 0.970676

00:01:33.959 --> 00:01:35.799
on biliary tract cancers, which

NOTE Confidence: 0.970676

00:01:35.799 --> 00:01:37.240
as I have diagrammed and

NOTE Confidence: 0.970676

00:01:37.240 --> 00:01:39.399
pictured here, includes tumor within

NOTE Confidence: 0.970676

00:01:39.399 --> 00:01:40.815
the liver and outside of

NOTE Confidence: 0.970676

00:01:40.815 --> 00:01:41.935
the liver, which are known

NOTE Confidence: 0.970676

00:01:41.935 --> 00:01:42.595
as intrahepatic

NOTE Confidence: 0.98377824

00:01:42.895 --> 00:01:44.275
and extrahepatic cholangiocarcinoma,

NOTE Confidence: 0.99694824

00:01:45.455 --> 00:01:47.075
along with gallbladder cancer.

NOTE Confidence: 0.9647064

00:01:48.335 --> 00:01:50.675
Doctor Straza Bosco will additionally

NOTE Confidence: 0.9647064

00:01:50.735 --> 00:01:52.495
further discuss the background of

NOTE Confidence: 0.9647064

00:01:52.495 --> 00:01:54.415
biliary tract cancers, including the

NOTE Confidence: 0.9647064

00:01:54.415 --> 00:01:54.915
heterogeneity,

NOTE Confidence: 0.9925537

00:01:55.900 --> 00:01:57.040
mutational profile,

NOTE Confidence: 0.99853516

00:01:57.659 --> 00:01:59.119
and diagnostic evaluation.

NOTE Confidence: 0.9794529

00:02:02.939 --> 00:02:04.460
When compared to other GI

NOTE Confidence: 0.9794529

00:02:04.460 --> 00:02:06.460
tumors, such as colon cancer,

NOTE Confidence: 0.9794529

00:02:06.460 --> 00:02:09.075
which we often also treat,

NOTE Confidence: 0.9794529

00:02:09.155 --> 00:02:11.075
Biliary tract cancers are certainly

NOTE Confidence: 0.9794529

00:02:11.075 --> 00:02:12.834
rare with approximately twelve to

NOTE Confidence: 0.9794529

00:02:12.834 --> 00:02:14.194
thirteen thousand new cases in

NOTE Confidence: 0.9794529

00:02:14.194 --> 00:02:15.715
the US per year, with

NOTE Confidence: 0.9794529

00:02:15.715 --> 00:02:17.334
majority of these being cholangiocarcinoma,

NOTE Confidence: 0.993042

00:02:18.355 --> 00:02:19.175
with intrahepatic

NOTE Confidence: 0.82714844

00:02:19.635 --> 00:02:20.135
specifically

NOTE Confidence: 0.9536743

00:02:20.514 --> 00:02:21.875
being the most common form

NOTE Confidence: 0.9536743

00:02:21.875 --> 00:02:23.014
in Western countries.

NOTE Confidence: 0.980896

00:02:24.680 --> 00:02:26.780
More specifically, intrahepatic cholangiocarcinoma

NOTE Confidence: 0.9763997

00:02:27.480 --> 00:02:29.080
has a rising incidence and

NOTE Confidence: 0.9763997

00:02:29.080 --> 00:02:29.580
mortality.

NOTE Confidence: 0.9491954

00:02:30.200 --> 00:02:31.800
I have known risk factors

NOTE Confidence: 0.9491954

00:02:31.800 --> 00:02:33.080
here that are listed, which

NOTE Confidence: 0.9491954

00:02:33.080 --> 00:02:34.760
again doctor Straza Bosco may

NOTE Confidence: 0.9491954

00:02:34.760 --> 00:02:36.135
further review. But I think

NOTE Confidence: 0.9491954

00:02:36.135 --> 00:02:37.834
what it's also really important

NOTE Confidence: 0.9491954

00:02:37.975 --> 00:02:39.415
to know is that many

NOTE Confidence: 0.9491954

00:02:39.415 --> 00:02:41.495
patients actually present without any

NOTE Confidence: 0.9491954

00:02:41.495 --> 00:02:43.095
established risk factor, and they

NOTE Confidence: 0.9491954

00:02:43.095 --> 00:02:45.514
often, unfortunately, present with advanced

NOTE Confidence: 0.9491954

00:02:45.575 --> 00:02:46.555
stage disease.

NOTE Confidence: 0.9696917

00:02:50.580 --> 00:02:52.420
As stated previously, most patients

NOTE Confidence: 0.9696917

00:02:52.420 --> 00:02:54.100
present with advanced stage disease

NOTE Confidence: 0.9696917

00:02:54.100 --> 00:02:55.540
with only about twenty five

NOTE Confidence: 0.9696917

00:02:55.540 --> 00:02:57.320
percent of patients actually presenting

NOTE Confidence: 0.9696917

00:02:57.540 --> 00:02:59.540
with resectable disease, which doctor

NOTE Confidence: 0.9696917

00:02:59.540 --> 00:03:00.840
Sobo will review

NOTE Confidence: 0.99853516

00:03:01.300 --> 00:03:01.800
momentarily.

NOTE Confidence: 0.99918616

00:03:03.135 --> 00:03:04.115
Despite resection,

NOTE Confidence: 0.99975586

00:03:05.055 --> 00:03:06.255
up to sixty percent of

NOTE Confidence: 0.99975586

00:03:06.255 --> 00:03:07.635
patients also recur.

NOTE Confidence: 0.9885356

00:03:08.415 --> 00:03:10.014
The overall survival rates can

NOTE Confidence: 0.9885356

00:03:10.014 --> 00:03:11.615
vary by tumor type with

NOTE Confidence: 0.9885356

00:03:11.615 --> 00:03:12.834
intrahepatic cholangiocarcinoma

NOTE Confidence: 0.9860026

00:03:13.535 --> 00:03:14.755
having porous prognosis.

NOTE Confidence: 0.99316406

00:03:16.720 --> 00:03:17.700
Picture here

NOTE Confidence: 0.9633789

00:03:18.080 --> 00:03:18.580
are

NOTE Confidence: 0.99853516

00:03:18.880 --> 00:03:19.620
the prognostic

NOTE Confidence: 0.990332

00:03:19.919 --> 00:03:21.280
factors that we consider in

NOTE Confidence: 0.990332

00:03:21.280 --> 00:03:22.800
biliary tract cancers. And if

NOTE Confidence: 0.990332

00:03:22.800 --> 00:03:24.720
you keep these prognostic factors

NOTE Confidence: 0.990332

00:03:24.720 --> 00:03:26.320
in mind, these are often

NOTE Confidence: 0.990332

00:03:26.320 --> 00:03:27.919
the prognostic factors and the

NOTE Confidence: 0.990332

00:03:27.919 --> 00:03:30.240
eligibility criteria that are considered

NOTE Confidence: 0.990332

00:03:30.240 --> 00:03:32.055
for high risk clinical trials,

NOTE Confidence: 0.99921876

00:03:32.454 --> 00:03:34.314
but they include performance status,

NOTE Confidence: 0.94140625

00:03:35.015 --> 00:03:36.875
resection margins being positive,

NOTE Confidence: 0.8414062

00:03:37.655 --> 00:03:38.155
lymphometastases,

NOTE Confidence: 0.99975586

00:03:39.814 --> 00:03:40.875
vascular invasion,

NOTE Confidence: 0.92822266

00:03:41.575 --> 00:03:42.075
increased

NOTE Confidence: 0.8803711

00:03:42.534 --> 00:03:43.834
CA ninety nine,

NOTE Confidence: 0.99780273

00:03:44.215 --> 00:03:45.034
poor histological

NOTE Confidence: 0.8039551

00:03:45.495 --> 00:03:45.995
differentiation,

NOTE Confidence: 0.9963379

00:03:47.220 --> 00:03:48.840
along with advanced stage.

NOTE Confidence: 0.9996202

00:03:50.900 --> 00:03:52.739
As mentioned earlier, my colleagues

NOTE Confidence: 0.9996202

00:03:52.739 --> 00:03:53.720
and I will discuss

NOTE Confidence: 0.99816895

00:03:54.260 --> 00:03:56.019
different forms of management depending

NOTE Confidence: 0.99816895

00:03:56.019 --> 00:03:56.840
on the stage

NOTE Confidence: 0.99645996

00:03:57.220 --> 00:03:58.760
of biliary tract cancers.

NOTE Confidence: 0.959046

00:04:00.095 --> 00:04:02.095
I will now transition to

NOTE Confidence: 0.959046

00:04:02.095 --> 00:04:03.615
doctor Straza Bosco, who will

NOTE Confidence: 0.959046

00:04:03.615 --> 00:04:04.915
review the role of hepatology

NOTE Confidence: 0.959046

00:04:05.135 --> 00:04:07.315
in biliary tract cancer management,

NOTE Confidence: 0.959046

00:04:07.535 --> 00:04:08.575
who will then be followed

NOTE Confidence: 0.959046

00:04:08.575 --> 00:04:10.175
by doctor Sogawa, who will

NOTE Confidence: 0.959046

00:04:10.175 --> 00:04:12.015
discuss the surgical management of

NOTE Confidence: 0.959046

00:04:12.015 --> 00:04:13.235
biliary tract cancers.

NOTE Confidence: 0.98524475

00:04:13.890 --> 00:04:15.250
I encourage each of you

NOTE Confidence: 0.98524475

00:04:15.250 --> 00:04:16.449
to put any questions in

NOTE Confidence: 0.98524475

00:04:16.449 --> 00:04:17.889
the chat or enter them

NOTE Confidence: 0.98524475

00:04:17.889 --> 00:04:19.169
in the question and answer

NOTE Confidence: 0.98524475

00:04:19.169 --> 00:04:20.690
format. And we will try

NOTE Confidence: 0.98524475

00:04:20.690 --> 00:04:22.289
to answer them possibly during

NOTE Confidence: 0.98524475

00:04:22.289 --> 00:04:22.949
the presentation,

NOTE Confidence: 0.99982244

00:04:23.330 --> 00:04:24.850
but may also save them

NOTE Confidence: 0.99982244

00:04:24.850 --> 00:04:26.210
for the conclusion of our

NOTE Confidence: 0.99982244

00:04:26.210 --> 00:04:26.710
session.

NOTE Confidence: 0.9984131

00:04:30.535 --> 00:04:31.755
Thank you very much,

NOTE Confidence: 0.9894043

00:04:32.214 --> 00:04:34.635
Jackie, for this beautiful introduction.

NOTE Confidence: 0.9893329

00:04:36.455 --> 00:04:37.835
Bear with me a second

NOTE Confidence: 0.9893329

00:04:37.895 --> 00:04:39.835
while I try and fail

NOTE Confidence: 0.9893329

00:04:40.055 --> 00:04:41.675
to share my

NOTE Confidence: 0.98358625

00:04:42.180 --> 00:04:43.779
screen? No problem at all,

NOTE Confidence: 0.98358625

00:04:43.779 --> 00:04:44.740
and I'll let you know

NOTE Confidence: 0.98358625

00:04:44.740 --> 00:04:45.640
when it's showing.

NOTE Confidence: 0.99902344

00:04:46.339 --> 00:04:46.839
Okay.

NOTE Confidence: 0.91845703

00:04:49.860 --> 00:04:51.220
So it should be this

NOTE Confidence: 0.91845703

00:04:51.220 --> 00:04:51.720
one.

NOTE Confidence: 0.9995117

00:04:53.060 --> 00:04:53.560
Okay.

NOTE Confidence: 0.9982422

00:04:55.785 --> 00:04:57.805
Is it showing? It's perfect.

NOTE Confidence: 0.9998372

00:04:58.345 --> 00:04:59.705
Okay. Thank you very much.

NOTE Confidence: 0.9998372

00:04:59.705 --> 00:05:00.205
So

NOTE Confidence: 0.99902344

00:05:00.665 --> 00:05:01.404
my task

NOTE Confidence: 0.8943359

00:05:01.705 --> 00:05:03.565
tonight is to try to,

NOTE Confidence: 0.9482422

00:05:04.505 --> 00:05:05.005
refresh,

NOTE Confidence: 1

00:05:05.465 --> 00:05:05.965
what

NOTE Confidence: 0.7976074

00:05:06.345 --> 00:05:07.005
a hepatologist

NOTE Confidence: 0.925

00:05:07.385 --> 00:05:09.485
should know about this, rare,

NOTE Confidence: 0.8477783

00:05:10.550 --> 00:05:11.270
and yet,

NOTE Confidence: 0.9194336

00:05:13.110 --> 00:05:13.610
difficult

NOTE Confidence: 0.745752

00:05:14.630 --> 00:05:15.370
and prognostically,

NOTE Confidence: 0.50097656

00:05:17.270 --> 00:05:17.770
unfortunate

NOTE Confidence: 0.9465332

00:05:18.229 --> 00:05:18.729
cancer.

NOTE Confidence: 0.96191406

00:05:19.190 --> 00:05:20.789
Okay? And I this is

NOTE Confidence: 0.96191406

00:05:20.789 --> 00:05:21.529
my disclosure.

NOTE Confidence: 0.9921875

00:05:22.550 --> 00:05:23.050
So

NOTE Confidence: 0.74766034

00:05:25.135 --> 00:05:26.915
BERI tract cancer in cholangiocarcinoma

NOTE Confidence: 0.8308919

00:05:27.695 --> 00:05:28.755
is a heterogeneous

NOTE Confidence: 0.9394531

00:05:29.294 --> 00:05:30.195
under several,

NOTE Confidence: 0.840768

00:05:31.695 --> 00:05:33.854
different categories. So first of

NOTE Confidence: 0.840768

00:05:33.854 --> 00:05:35.455
all, is heterogeneous in terms

NOTE Confidence: 0.840768

00:05:35.455 --> 00:05:36.514
of cell of origin,

NOTE Confidence: 1

00:05:37.375 --> 00:05:37.875
location,

NOTE Confidence: 0.9909668

00:05:38.970 --> 00:05:39.710
pattern of

NOTE Confidence: 0.9951172

00:05:40.250 --> 00:05:41.070
growth, morphology,

NOTE Confidence: 0.97540283

00:05:41.610 --> 00:05:44.270
mutational landscape, and clinical manifestation.

NOTE Confidence: 0.97540283

00:05:44.410 --> 00:05:45.310
And this cartoon

NOTE Confidence: 0.94817245

00:05:46.170 --> 00:05:47.450
kind of make the point.

NOTE Confidence: 0.94817245

00:05:47.610 --> 00:05:48.430
Only recently,

NOTE Confidence: 0.9362305

00:05:49.450 --> 00:05:51.150
the different tumor have been

NOTE Confidence: 0.9654134

00:05:51.824 --> 00:05:53.444
classified in a more homogeneous

NOTE Confidence: 0.9654134

00:05:53.505 --> 00:05:54.005
way.

NOTE Confidence: 0.9938965

00:05:54.544 --> 00:05:56.705
And so according to the

NOTE Confidence: 0.9938965

00:05:56.705 --> 00:05:58.245
order of the

NOTE Confidence: 0.83713317

00:05:59.025 --> 00:06:00.865
the bile ducts, that are

NOTE Confidence: 0.83713317

00:06:00.865 --> 00:06:02.224
affected by the cancer, we

NOTE Confidence: 0.83713317

00:06:02.224 --> 00:06:03.604
distinguish the intraepartic

NOTE Confidence: 0.970459

00:06:03.904 --> 00:06:04.404
cancer,

NOTE Confidence: 0.92371964

00:06:05.080 --> 00:06:05.580
cholangiocarcinoma,

NOTE Confidence: 0.8734131

00:06:06.360 --> 00:06:07.100
the perihealer

NOTE Confidence: 0.9851888

00:06:07.560 --> 00:06:08.060
cholangiocarcinoma,

NOTE Confidence: 0.8800083

00:06:09.800 --> 00:06:11.420
and the distal cholangiocarcinoma.

NOTE Confidence: 0.9746094

00:06:12.200 --> 00:06:13.180
These are,

NOTE Confidence: 0.83325195

00:06:15.000 --> 00:06:15.500
also,

NOTE Confidence: 0.9941406

00:06:17.800 --> 00:06:18.860
different histologically

NOTE Confidence: 0.9243978

00:06:20.225 --> 00:06:21.285
And mutationally,

NOTE Confidence: 0.9938151

00:06:21.665 --> 00:06:22.885
so, for example,

NOTE Confidence: 0.8544922

00:06:23.505 --> 00:06:24.005
the.

NOTE Confidence: 0.6997477

00:06:25.505 --> 00:06:26.725
Intrepatic cholangiocarcinoma

NOTE Confidence: 0.57714844

00:06:28.065 --> 00:06:29.044
is generated.

NOTE Confidence: 0.84319514

00:06:30.065 --> 00:06:32.065
From the small interpathic bile

NOTE Confidence: 0.84319514

00:06:32.065 --> 00:06:33.825
duct and may have different

NOTE Confidence: 0.84319514

00:06:33.825 --> 00:06:34.325
histological

NOTE Confidence: 0.9001698

00:06:36.000 --> 00:06:38.180
feature. You see here the

NOTE Confidence: 0.9001698

00:06:38.240 --> 00:06:38.740
cholangiocellular,

NOTE Confidence: 0.9261882

00:06:39.599 --> 00:06:40.500
so the smaller,

NOTE Confidence: 0.9875488

00:06:41.039 --> 00:06:42.819
branches of the bile duct

NOTE Confidence: 0.9875488

00:06:42.879 --> 00:06:43.779
from the small

NOTE Confidence: 0.9445801

00:06:44.159 --> 00:06:44.659
type.

NOTE Confidence: 0.9038086

00:06:45.520 --> 00:06:47.039
And, here you see an

NOTE Confidence: 0.9038086

00:06:47.039 --> 00:06:47.539
example

NOTE Confidence: 0.96606445

00:06:47.839 --> 00:06:48.580
of the,

NOTE Confidence: 1

00:06:49.120 --> 00:06:49.620
cancer

NOTE Confidence: 0.9323012

00:06:50.235 --> 00:06:51.755
arising from the large bile

NOTE Confidence: 0.9323012

00:06:51.755 --> 00:06:53.595
ducts and from the distal

NOTE Confidence: 0.9323012

00:06:53.595 --> 00:06:55.514
bile duct. But, also, they

NOTE Confidence: 0.9323012

00:06:55.514 --> 00:06:56.175
are heterogeneous

NOTE Confidence: 0.97490233

00:06:56.475 --> 00:06:57.915
in terms of type of

NOTE Confidence: 0.97490233

00:06:57.915 --> 00:06:59.435
growth. So you may have,

NOTE Confidence: 0.9995117

00:07:00.635 --> 00:07:01.294
the classic

NOTE Confidence: 0.97753906

00:07:01.595 --> 00:07:02.574
mass forming

NOTE Confidence: 0.95391846

00:07:04.159 --> 00:07:04.659
cholangiocarcinoma

NOTE Confidence: 0.9439591

00:07:05.680 --> 00:07:07.759
or the periductal one, but

NOTE Confidence: 0.9439591

00:07:07.759 --> 00:07:08.879
you may also have the

NOTE Confidence: 0.9439591

00:07:08.879 --> 00:07:10.560
one that is introductory, and

NOTE Confidence: 0.9439591

00:07:10.560 --> 00:07:11.840
this is more difficult to

NOTE Confidence: 0.9439591

00:07:11.840 --> 00:07:13.139
diagnose. Of course.

NOTE Confidence: 0.99609375

00:07:15.120 --> 00:07:15.615
So

NOTE Confidence: 0.84073895

00:07:16.014 --> 00:07:17.294
I I briefly mentioned and

NOTE Confidence: 0.84073895

00:07:17.294 --> 00:07:19.315
also Jack is told that

NOTE Confidence: 0.84073895

00:07:19.455 --> 00:07:20.115
they are,

NOTE Confidence: 0.9793812

00:07:20.735 --> 00:07:22.835
their mutational landscape is different

NOTE Confidence: 0.9793812

00:07:22.895 --> 00:07:24.574
according to their location and

NOTE Confidence: 0.9793812

00:07:24.574 --> 00:07:25.074
type.

NOTE Confidence: 0.89241534

00:07:26.175 --> 00:07:27.055
Here, I have,

NOTE Confidence: 0.953125

00:07:28.014 --> 00:07:28.835
only show

NOTE Confidence: 0.97735596

00:07:29.140 --> 00:07:30.820
some of the different,

NOTE Confidence: 0.9521179

00:07:32.260 --> 00:07:33.860
mutations that are present, but

NOTE Confidence: 0.9521179

00:07:33.860 --> 00:07:34.680
I want to

NOTE Confidence: 0.92996216

00:07:35.140 --> 00:07:36.980
draw your attention to the

NOTE Confidence: 0.92996216

00:07:36.980 --> 00:07:37.480
IDH12,

NOTE Confidence: 0.94189453

00:07:38.260 --> 00:07:38.760
the

NOTE Confidence: 0.4296875

00:07:39.140 --> 00:07:40.280
in the.

NOTE Confidence: 0.95062584

00:07:40.820 --> 00:07:42.945
That can happen in twenty,

NOTE Confidence: 0.95062584

00:07:42.945 --> 00:07:44.305
twenty two percent of the

NOTE Confidence: 0.95062584

00:07:44.305 --> 00:07:44.805
intrahepatic,

NOTE Confidence: 0.99432373

00:07:45.425 --> 00:07:45.925
cholangiocarcinoma

NOTE Confidence: 0.8267909

00:07:47.505 --> 00:07:49.585
together with other. Whereas in

NOTE Confidence: 0.8267909

00:07:49.585 --> 00:07:50.405
the periheolar

NOTE Confidence: 0.99142796

00:07:51.025 --> 00:07:51.525
cholangiocarcinoma,

NOTE Confidence: 0.85221356

00:07:52.305 --> 00:07:53.685
the b the KRAS,

NOTE Confidence: 0.74542236

00:07:54.625 --> 00:07:56.005
and have two, three,

NOTE Confidence: 0.84155273

00:07:56.385 --> 00:07:56.544
and,

NOTE Confidence: 0.88216144

00:07:59.150 --> 00:08:01.470
TP53 becomes more frequent and

NOTE Confidence: 0.88216144

00:08:01.470 --> 00:08:01.970
this

NOTE Confidence: 0.9016062

00:08:02.830 --> 00:08:04.030
is more or less also

NOTE Confidence: 0.9016062

00:08:04.030 --> 00:08:05.330
the case in the distal,

NOTE Confidence: 0.9016062

00:08:05.630 --> 00:08:07.230
whereas the IDH12 and the

NOTE Confidence: 0.9016062

00:08:07.230 --> 00:08:07.730
FTR2

NOTE Confidence: 0.8508417

00:08:08.510 --> 00:08:10.350
are more classic, really on

NOTE Confidence: 0.8508417

00:08:10.350 --> 00:08:11.570
the intrepatic

NOTE Confidence: 0.9189911

00:08:12.350 --> 00:08:14.445
thing. Is this relevant? Yes.

NOTE Confidence: 0.9189911

00:08:14.445 --> 00:08:15.345
It is. Because,

NOTE Confidence: 0.9824219

00:08:16.205 --> 00:08:17.185
of the many,

NOTE Confidence: 0.8947754

00:08:18.125 --> 00:08:18.625
different,

NOTE Confidence: 0.923584

00:08:19.565 --> 00:08:21.265
mutations that have been associated

NOTE Confidence: 0.923584

00:08:21.485 --> 00:08:21.805
with,

NOTE Confidence: 0.9697808

00:08:23.085 --> 00:08:23.585
cholangiocarcinoma,

NOTE Confidence: 0.93806964

00:08:25.165 --> 00:08:26.845
many of them, and they're

NOTE Confidence: 0.93806964

00:08:26.845 --> 00:08:28.785
just briefly listed here,

NOTE Confidence: 0.9996745

00:08:29.840 --> 00:08:31.539
can be targeted.

NOTE Confidence: 0.9877116

00:08:32.800 --> 00:08:33.679
So the first,

NOTE Confidence: 0.97940063

00:08:36.320 --> 00:08:38.000
the first message here is

NOTE Confidence: 0.97940063

00:08:38.000 --> 00:08:38.980
that it's always

NOTE Confidence: 0.9995117

00:08:39.360 --> 00:08:40.820
mandatory, I think,

NOTE Confidence: 0.7565918

00:08:41.360 --> 00:08:41.839
to,

NOTE Confidence: 1

00:08:42.320 --> 00:08:42.820
genotype

NOTE Confidence: 0.9145064

00:08:44.415 --> 00:08:46.735
this, cancer from from from

NOTE Confidence: 0.9145064

00:08:46.735 --> 00:08:48.654
the biopsy because it may

NOTE Confidence: 0.9145064

00:08:48.654 --> 00:08:49.154
have

NOTE Confidence: 0.7449951

00:08:51.695 --> 00:08:52.355
a treatment.

NOTE Confidence: 0.9640625

00:08:53.695 --> 00:08:55.075
It may guide the treatment.

NOTE Confidence: 0.97143555

00:08:55.455 --> 00:08:55.955
Okay?

NOTE Confidence: 0.99523926

00:08:56.495 --> 00:08:58.355
Now in terms of

NOTE Confidence: 0.95410156

00:08:59.790 --> 00:09:00.610
risk factor,

NOTE Confidence: 0.673584

00:09:01.150 --> 00:09:01.890
as Jackie

NOTE Confidence: 0.9692383

00:09:02.350 --> 00:09:04.050
said, most cases are sporadic,

NOTE Confidence: 0.9692383

00:09:04.190 --> 00:09:05.230
so we are not able

NOTE Confidence: 0.9692383

00:09:05.230 --> 00:09:05.470
to,

NOTE Confidence: 0.99902344

00:09:06.670 --> 00:09:07.170
find

NOTE Confidence: 0.83987087

00:09:09.390 --> 00:09:10.510
a cause or a risk

NOTE Confidence: 0.83987087

00:09:10.510 --> 00:09:12.370
factor. But there are

NOTE Confidence: 0.9906006

00:09:13.605 --> 00:09:16.184
some condition that are

NOTE Confidence: 0.9690552

00:09:17.365 --> 00:09:18.804
low that are rare with

NOTE Confidence: 0.9690552

00:09:18.804 --> 00:09:20.105
low prevalence, like

NOTE Confidence: 0.70979816

00:09:20.725 --> 00:09:22.184
primary sclerosis, cholangitis,

NOTE Confidence: 0.74576825

00:09:23.125 --> 00:09:24.184
choroidal disease,

NOTE Confidence: 0.81933594

00:09:24.725 --> 00:09:25.945
cholestical cyst,

NOTE Confidence: 0.7416382

00:09:26.529 --> 00:09:28.130
presence of large stones in

NOTE Confidence: 0.7416382

00:09:28.130 --> 00:09:28.710
the bladder,

NOTE Confidence: 0.95841473

00:09:29.330 --> 00:09:31.010
and but also chronic liver

NOTE Confidence: 0.95841473

00:09:31.010 --> 00:09:31.510
disease,

NOTE Confidence: 0.82543945

00:09:32.050 --> 00:09:33.350
inflammatory, like,

NOTE Confidence: 0.97021484

00:09:34.130 --> 00:09:34.630
hepatitis,

NOTE Confidence: 0.83251953

00:09:35.570 --> 00:09:36.390
and HBV,

NOTE Confidence: 0.8819987

00:09:39.245 --> 00:09:40.625
in which that

NOTE Confidence: 0.75857204

00:09:42.925 --> 00:09:44.125
that that these condition are

NOTE Confidence: 0.75857204

00:09:44.125 --> 00:09:45.665
associated with a higher

NOTE Confidence: 0.973196

00:09:46.045 --> 00:09:47.964
possibility of of liver cancer.

NOTE Confidence: 0.973196

00:09:47.964 --> 00:09:49.404
For example, in the primary

NOTE Confidence: 0.973196

00:09:49.404 --> 00:09:50.384
sclerosing cholangitis,

NOTE Confidence: 0.9522095

00:09:50.845 --> 00:09:52.285
up to fifteen percent of

NOTE Confidence: 0.9522095

00:09:52.285 --> 00:09:53.824
this patient developed

NOTE Confidence: 0.93006766

00:09:54.449 --> 00:09:55.410
in the course of their

NOTE Confidence: 0.93006766

00:09:55.410 --> 00:09:56.709
life, echolangiocarcinoma.

NOTE Confidence: 0.97382814

00:09:57.809 --> 00:09:59.750
So these are condition that

NOTE Confidence: 0.9891968

00:10:01.329 --> 00:10:02.709
are not very prevalent,

NOTE Confidence: 0.9797526

00:10:03.649 --> 00:10:04.870
but they have a significant

NOTE Confidence: 0.9797526

00:10:05.170 --> 00:10:06.610
risk. So if you look

NOTE Confidence: 0.9797526

00:10:06.610 --> 00:10:08.709
here into this this plot,

NOTE Confidence: 0.96051025

00:10:09.545 --> 00:10:10.985
so the risk of,

NOTE Confidence: 0.99095243

00:10:12.505 --> 00:10:13.385
this is the risk of

NOTE Confidence: 0.99095243

00:10:13.385 --> 00:10:14.985
having the cancer, and this

NOTE Confidence: 0.99095243

00:10:14.985 --> 00:10:17.225
is instead the prevalence. So

NOTE Confidence: 0.99095243

00:10:17.225 --> 00:10:17.885
there are

NOTE Confidence: 0.9770101

00:10:18.745 --> 00:10:20.105
some condition that have a

NOTE Confidence: 0.9770101

00:10:20.105 --> 00:10:21.545
high prevalence, but they are

NOTE Confidence: 0.9770101

00:10:21.545 --> 00:10:23.210
not, but they are rare.

NOTE Confidence: 0.9770101

00:10:23.210 --> 00:10:24.490
On the other hand, there

NOTE Confidence: 0.9770101

00:10:24.490 --> 00:10:26.350
are high prevalence factor

NOTE Confidence: 0.9213379

00:10:26.890 --> 00:10:28.750
that confer a moderate risk.

NOTE Confidence: 0.97869873

00:10:29.690 --> 00:10:30.970
And we should be aware

NOTE Confidence: 0.97869873

00:10:30.970 --> 00:10:32.110
of this because

NOTE Confidence: 0.99142796

00:10:32.730 --> 00:10:34.910
we think to this condition

NOTE Confidence: 0.99142796

00:10:35.050 --> 00:10:36.589
mostly in terms of

NOTE Confidence: 0.9911499

00:10:37.125 --> 00:10:38.745
risk factor for hepatocellular

NOTE Confidence: 0.95670575

00:10:39.125 --> 00:10:39.625
carcinoma,

NOTE Confidence: 0.953125

00:10:40.325 --> 00:10:41.705
but that's not the case.

NOTE Confidence: 0.953125

00:10:41.845 --> 00:10:43.365
Some of these patient, and

NOTE Confidence: 0.953125

00:10:43.365 --> 00:10:44.425
we will see that,

NOTE Confidence: 0.93671876

00:10:44.804 --> 00:10:46.745
may actually have a cholangiocarcinoma.

NOTE Confidence: 0.9333801

00:10:47.684 --> 00:10:49.845
Among that, there are alcohol

NOTE Confidence: 0.9333801

00:10:49.845 --> 00:10:51.225
use disorder, diabetes,

NOTE Confidence: 0.99934894

00:10:52.580 --> 00:10:53.640
and I will

NOTE Confidence: 0.97324914

00:10:54.100 --> 00:10:57.060
underlie also the metabolic associated

NOTE Confidence: 0.97324914

00:10:57.060 --> 00:10:57.960
liver disease,

NOTE Confidence: 0.9980469

00:10:59.620 --> 00:11:00.840
in his inflammatory

NOTE Confidence: 0.95997727

00:11:01.380 --> 00:11:02.840
form, which is called MASH.

NOTE Confidence: 0.9574788

00:11:04.035 --> 00:11:05.975
Some of these patient, particularly

NOTE Confidence: 0.9574788

00:11:06.115 --> 00:11:07.795
if they are not fully

NOTE Confidence: 0.9574788

00:11:07.795 --> 00:11:09.714
cirrhotic, may actually have a

NOTE Confidence: 0.9574788

00:11:09.714 --> 00:11:10.855
intrepartic cholangiocarcinoma.

NOTE Confidence: 0.9434291

00:11:11.475 --> 00:11:12.355
So this is a very

NOTE Confidence: 0.9434291

00:11:12.355 --> 00:11:13.954
important second method that you

NOTE Confidence: 0.9434291

00:11:13.954 --> 00:11:15.095
should bear in mind.

NOTE Confidence: 0.9794922

00:11:15.890 --> 00:11:17.250
So what happens in,

NOTE Confidence: 0.9591797

00:11:17.650 --> 00:11:19.830
in primary sclerosing cholangitis?

NOTE Confidence: 0.946696

00:11:21.809 --> 00:11:22.550
There is a,

NOTE Confidence: 0.862386

00:11:23.970 --> 00:11:26.130
presence of multifocal stricture. In

NOTE Confidence: 0.862386

00:11:26.130 --> 00:11:28.390
this multifocal stricture, we harbor

NOTE Confidence: 0.862386

00:11:28.529 --> 00:11:29.029
infections,

NOTE Confidence: 0.9769176

00:11:30.045 --> 00:11:32.765
and chronic infection infection will

NOTE Confidence: 0.9769176

00:11:32.765 --> 00:11:34.785
end up causing DNA damage,

NOTE Confidence: 0.9769176

00:11:34.845 --> 00:11:35.345
metaplasia,

NOTE Confidence: 0.963437

00:11:36.125 --> 00:11:37.804
low grade dysplasia, high grade,

NOTE Confidence: 0.963437

00:11:37.804 --> 00:11:38.545
and cholangiocarcinoma.

NOTE Confidence: 0.9886249

00:11:40.045 --> 00:11:41.245
And as I said, up

NOTE Confidence: 0.9886249

00:11:41.245 --> 00:11:42.445
to fifteen percent of the

NOTE Confidence: 0.9886249

00:11:42.445 --> 00:11:43.885
patient will sooner or later

NOTE Confidence: 0.9886249

00:11:43.885 --> 00:11:45.280
develop that. So what do

NOTE Confidence: 0.9886249

00:11:45.280 --> 00:11:46.400
we do in this case?

NOTE Confidence: 0.9886249

00:11:46.400 --> 00:11:46.980
I mean,

NOTE Confidence: 0.9114583

00:11:49.040 --> 00:11:49.940
in this case,

NOTE Confidence: 0.90625

00:11:50.480 --> 00:11:51.360
we will have it. We'll

NOTE Confidence: 0.90625

00:11:51.360 --> 00:11:52.660
discuss that after.

NOTE Confidence: 0.9348958

00:11:53.200 --> 00:11:54.420
There are surveillance,

NOTE Confidence: 0.98742676

00:11:55.200 --> 00:11:56.500
protocols. However,

NOTE Confidence: 0.9490289

00:11:57.065 --> 00:11:58.605
they are not that established

NOTE Confidence: 0.9490289

00:11:58.904 --> 00:12:00.184
as in the case of

NOTE Confidence: 0.9490289

00:12:00.184 --> 00:12:01.404
hepatocellular carcinoma.

NOTE Confidence: 0.9797712

00:12:02.825 --> 00:12:04.425
As I said before, a

NOTE Confidence: 0.9797712

00:12:04.425 --> 00:12:05.704
condition in which we need

NOTE Confidence: 0.9797712

00:12:05.704 --> 00:12:06.765
to be very careful

NOTE Confidence: 0.9970703

00:12:07.144 --> 00:12:07.644
is

NOTE Confidence: 0.9704294

00:12:08.985 --> 00:12:11.160
steptotic liver disease. In this

NOTE Confidence: 0.9704294

00:12:11.160 --> 00:12:12.440
case, this is a still

NOTE Confidence: 0.9704294

00:12:12.440 --> 00:12:12.940
unpublished

NOTE Confidence: 0.86897784

00:12:14.040 --> 00:12:15.740
series from from Padova,

NOTE Confidence: 0.9986328

00:12:16.520 --> 00:12:18.460
but it was found that

NOTE Confidence: 0.8695243

00:12:21.880 --> 00:12:23.320
that in thirty percent of

NOTE Confidence: 0.8695243

00:12:23.320 --> 00:12:23.899
the cases,

NOTE Confidence: 0.995636

00:12:24.965 --> 00:12:26.184
there was a cholangiocarcinoma

NOTE Confidence: 0.9663519

00:12:26.885 --> 00:12:28.485
in the resected sample rather

NOTE Confidence: 0.9663519

00:12:28.485 --> 00:12:29.684
than an HCC. And you

NOTE Confidence: 0.9663519

00:12:29.684 --> 00:12:30.905
can see in this beautiful

NOTE Confidence: 0.93566895

00:12:31.285 --> 00:12:33.285
slide, the border between the

NOTE Confidence: 0.93566895

00:12:33.285 --> 00:12:33.785
steatotic,

NOTE Confidence: 0.97998047

00:12:34.485 --> 00:12:34.985
liver

NOTE Confidence: 0.8619032

00:12:35.525 --> 00:12:36.665
and and and the cholangiocarcinoma.

NOTE Confidence: 0.9500263

00:12:38.110 --> 00:12:39.630
So be very careful, and

NOTE Confidence: 0.9500263

00:12:39.630 --> 00:12:40.510
this is a case that

NOTE Confidence: 0.9500263

00:12:40.510 --> 00:12:41.490
we had here.

NOTE Confidence: 0.9289202

00:12:42.510 --> 00:12:44.350
This patient, seventy nine years

NOTE Confidence: 0.9289202

00:12:44.350 --> 00:12:45.170
old, female,

NOTE Confidence: 0.85009766

00:12:45.710 --> 00:12:46.770
known to have

NOTE Confidence: 0.81363934

00:12:47.150 --> 00:12:48.530
a metabolic associated

NOTE Confidence: 0.9767456

00:12:49.230 --> 00:12:51.090
liver disease related cirrhosis,

NOTE Confidence: 0.9465332

00:12:52.054 --> 00:12:54.375
overweight with diabetes, high blood

NOTE Confidence: 0.9465332

00:12:54.375 --> 00:12:56.954
pressure. So all the classic,

NOTE Confidence: 0.7955322

00:12:58.535 --> 00:12:59.834
science of a potential,

NOTE Confidence: 0.48327637

00:13:02.295 --> 00:13:03.035
mass holder

NOTE Confidence: 0.9862305

00:13:03.415 --> 00:13:05.355
shows in the clinic with

NOTE Confidence: 0.98553467

00:13:07.149 --> 00:13:08.450
with the liver lesion

NOTE Confidence: 0.9347018

00:13:09.390 --> 00:13:11.010
that might have been classified

NOTE Confidence: 0.9347018

00:13:11.230 --> 00:13:12.830
as l r five, but

NOTE Confidence: 0.9347018

00:13:12.830 --> 00:13:14.370
not everything was

NOTE Confidence: 0.9182617

00:13:15.309 --> 00:13:16.929
consistent with l r five.

NOTE Confidence: 0.9519314

00:13:19.070 --> 00:13:20.429
And in particular, you see

NOTE Confidence: 0.9519314

00:13:20.429 --> 00:13:22.370
this this incision here,

NOTE Confidence: 0.980399

00:13:22.975 --> 00:13:25.295
this capsule retraction, which were

NOTE Confidence: 0.980399

00:13:25.295 --> 00:13:26.275
very suspicious

NOTE Confidence: 0.9827474

00:13:26.735 --> 00:13:27.554
at the time.

NOTE Confidence: 0.9348736

00:13:27.855 --> 00:13:29.135
So we decided to do

NOTE Confidence: 0.9348736

00:13:29.135 --> 00:13:30.895
a biopsy. And and in

NOTE Confidence: 0.9348736

00:13:30.895 --> 00:13:31.395
fact,

NOTE Confidence: 0.989917

00:13:31.775 --> 00:13:33.235
you can see the background

NOTE Confidence: 0.989917

00:13:33.455 --> 00:13:35.795
liver, which is classic for

NOTE Confidence: 0.8003743

00:13:37.130 --> 00:13:38.270
a metabolic associated,

NOTE Confidence: 0.8527832

00:13:39.130 --> 00:13:39.630
cirrhosis.

NOTE Confidence: 0.8998447

00:13:40.330 --> 00:13:41.929
And here, the the tumor

NOTE Confidence: 0.8998447

00:13:41.929 --> 00:13:42.830
was a cholangiocarcinoma.

NOTE Confidence: 0.914917

00:13:44.410 --> 00:13:45.150
This patient,

NOTE Confidence: 0.94592285

00:13:46.250 --> 00:13:47.390
underwent surgery.

NOTE Confidence: 0.8581543

00:13:48.970 --> 00:13:49.770
Sorry. And,

NOTE Confidence: 0.99401855

00:13:50.334 --> 00:13:51.955
she's actually doing fine,

NOTE Confidence: 0.9737956

00:13:52.334 --> 00:13:53.475
four years after,

NOTE Confidence: 0.97298175

00:13:54.815 --> 00:13:55.795
after the treatment.

NOTE Confidence: 0.94226074

00:13:56.255 --> 00:13:56.995
So, again,

NOTE Confidence: 0.96742755

00:13:58.654 --> 00:13:59.695
we need to be very,

NOTE Confidence: 0.96742755

00:14:00.095 --> 00:14:02.255
cognizant that a lesion in

NOTE Confidence: 0.96742755

00:14:02.255 --> 00:14:04.495
a, steatotic liver may actually

NOTE Confidence: 0.96742755

00:14:04.495 --> 00:14:04.995
be

NOTE Confidence: 0.9651693

00:14:05.379 --> 00:14:05.959
a cholangiocarcinoma.

NOTE Confidence: 0.8774414

00:14:06.980 --> 00:14:07.480
Okay.

NOTE Confidence: 0.93829346

00:14:07.860 --> 00:14:08.920
This is a series,

NOTE Confidence: 1

00:14:09.379 --> 00:14:09.879
of

NOTE Confidence: 0.8987793

00:14:10.819 --> 00:14:12.420
more than two thousand patient,

NOTE Confidence: 0.8895019

00:14:12.899 --> 00:14:15.319
followed by a European registry.

NOTE Confidence: 0.9980469

00:14:16.579 --> 00:14:17.079
And

NOTE Confidence: 0.73217773

00:14:17.459 --> 00:14:18.360
you see there,

NOTE Confidence: 0.9369532

00:14:19.205 --> 00:14:20.905
these are divided in intrahepatic,

NOTE Confidence: 0.900293

00:14:23.125 --> 00:14:23.625
perihealer,

NOTE Confidence: 0.9995117

00:14:23.925 --> 00:14:24.665
and distal.

NOTE Confidence: 0.9815674

00:14:25.605 --> 00:14:27.385
The risk factor associated

NOTE Confidence: 0.90871936

00:14:27.925 --> 00:14:29.765
again are in the case

NOTE Confidence: 0.90871936

00:14:29.765 --> 00:14:30.585
of intrahepatic,

NOTE Confidence: 1

00:14:30.965 --> 00:14:31.465
obesity,

NOTE Confidence: 1

00:14:32.245 --> 00:14:32.745
diabetes,

NOTE Confidence: 0.99438477

00:14:33.750 --> 00:14:35.530
viral hepatitis, and cirrhosis.

NOTE Confidence: 0.9867676

00:14:37.750 --> 00:14:39.210
In the case of the,

NOTE Confidence: 0.69348145

00:14:39.670 --> 00:14:40.170
perihela

NOTE Confidence: 0.9510091

00:14:41.590 --> 00:14:42.090
cholangiocarcinoma,

NOTE Confidence: 0.9820499

00:14:42.790 --> 00:14:44.470
the main factor is actually

NOTE Confidence: 0.9820499

00:14:44.470 --> 00:14:45.210
the PSC.

NOTE Confidence: 0.8886715

00:14:46.705 --> 00:14:48.145
Whereas in in the case

NOTE Confidence: 0.8886715

00:14:48.145 --> 00:14:49.825
of the distal, we have

NOTE Confidence: 0.8886715

00:14:49.825 --> 00:14:52.245
a metabolic condition like hyperthritillary

NOTE Confidence: 0.8886715

00:14:52.465 --> 00:14:52.965
terendemia

NOTE Confidence: 0.92962646

00:14:53.345 --> 00:14:55.685
and and, gastron disease.

NOTE Confidence: 0.8288574

00:14:56.625 --> 00:14:58.165
So this again confirmed

NOTE Confidence: 0.9941406

00:14:58.705 --> 00:14:59.445
that the

NOTE Confidence: 0.8112793

00:14:59.905 --> 00:15:00.805
risk factor

NOTE Confidence: 0.953125

00:15:02.080 --> 00:15:02.660
are similar

NOTE Confidence: 0.97216797

00:15:03.520 --> 00:15:05.060
to those of the hepatocellular

NOTE Confidence: 0.97216797

00:15:05.280 --> 00:15:06.500
carcinoma somehow.

NOTE Confidence: 0.9699519

00:15:07.280 --> 00:15:08.480
So how do we go

NOTE Confidence: 0.9699519

00:15:08.480 --> 00:15:10.400
about the diagnosis? Of course,

NOTE Confidence: 0.9699519

00:15:10.400 --> 00:15:11.860
we the MRI

NOTE Confidence: 0.93896484

00:15:12.480 --> 00:15:13.200
is our,

NOTE Confidence: 0.8730469

00:15:13.600 --> 00:15:14.100
principal

NOTE Confidence: 1

00:15:14.560 --> 00:15:15.060
instrument

NOTE Confidence: 0.8987902

00:15:15.825 --> 00:15:17.825
and the MRCP that is

NOTE Confidence: 0.8987902

00:15:17.825 --> 00:15:18.325
always,

NOTE Confidence: 0.9497884

00:15:19.105 --> 00:15:20.005
to be done,

NOTE Confidence: 0.9926758

00:15:21.185 --> 00:15:21.925
even before

NOTE Confidence: 0.7753906

00:15:24.465 --> 00:15:24.965
the

NOTE Confidence: 0.9909668

00:15:26.225 --> 00:15:26.725
ERCP.

NOTE Confidence: 0.94247586

00:15:27.759 --> 00:15:29.360
Actually, the ERCP now is

NOTE Confidence: 0.94247586

00:15:29.360 --> 00:15:29.940
is never,

NOTE Confidence: 0.90356445

00:15:30.880 --> 00:15:31.380
indicated,

NOTE Confidence: 0.94402206

00:15:32.079 --> 00:15:33.199
if you don't do an

NOTE Confidence: 0.94402206

00:15:33.199 --> 00:15:34.420
MRCP before.

NOTE Confidence: 0.9810791

00:15:35.040 --> 00:15:35.940
But the MRCP,

NOTE Confidence: 0.9781087

00:15:36.399 --> 00:15:37.380
you can do,

NOTE Confidence: 0.9353747

00:15:38.000 --> 00:15:40.000
either biopsies and lesion that

NOTE Confidence: 0.9353747

00:15:40.000 --> 00:15:41.600
that that you can see

NOTE Confidence: 0.9353747

00:15:41.600 --> 00:15:42.500
with a spyglass

NOTE Confidence: 0.76342773

00:15:42.880 --> 00:15:43.380
or,

NOTE Confidence: 0.99934894

00:15:44.385 --> 00:15:45.285
do a brush.

NOTE Confidence: 0.9799072

00:15:46.305 --> 00:15:47.584
We'll talk more about the

NOTE Confidence: 0.9799072

00:15:47.584 --> 00:15:49.765
brushing. If you see something,

NOTE Confidence: 0.945282

00:15:50.464 --> 00:15:51.745
that is suspect, you can

NOTE Confidence: 0.945282

00:15:51.745 --> 00:15:52.885
use a endoscopic

NOTE Confidence: 0.95458984

00:15:53.345 --> 00:15:53.845
ultrasound.

NOTE Confidence: 0.96655273

00:15:55.265 --> 00:15:55.765
And,

NOTE Confidence: 0.9699707

00:15:56.545 --> 00:15:57.045
hopefully,

NOTE Confidence: 0.970459

00:15:57.959 --> 00:15:58.459
soon,

NOTE Confidence: 0.965861

00:15:58.839 --> 00:16:00.519
we will also be able

NOTE Confidence: 0.965861

00:16:00.519 --> 00:16:02.759
to use liquid biopsy in

NOTE Confidence: 0.965861

00:16:02.759 --> 00:16:03.399
terms of,

NOTE Confidence: 0.94177246

00:16:05.800 --> 00:16:06.300
ctDNA.

NOTE Confidence: 0.96728516

00:16:14.894 --> 00:16:17.154
So this is you usually,

NOTE Confidence: 0.96309406

00:16:17.615 --> 00:16:19.935
the the diagnosis in the

NOTE Confidence: 0.96309406

00:16:19.935 --> 00:16:20.435
PSC

NOTE Confidence: 0.99348956

00:16:20.815 --> 00:16:21.714
was done by

NOTE Confidence: 0.8535344

00:16:22.029 --> 00:16:23.390
brushing. Brushing can give you

NOTE Confidence: 0.8535344

00:16:23.390 --> 00:16:25.710
a cytological reading. Brushwing can

NOTE Confidence: 0.8535344

00:16:25.710 --> 00:16:26.690
give you a,

NOTE Confidence: 0.88395184

00:16:29.070 --> 00:16:30.690
more genetically determined

NOTE Confidence: 0.84665525

00:16:31.150 --> 00:16:33.070
fish, for example, for certain,

NOTE Confidence: 0.78564453

00:16:36.885 --> 00:16:37.925
expression of,

NOTE Confidence: 0.9561244

00:16:39.125 --> 00:16:41.285
genomic expression, but this is

NOTE Confidence: 0.9561244

00:16:41.285 --> 00:16:42.185
never really,

NOTE Confidence: 0.9133301

00:16:43.045 --> 00:16:43.545
very,

NOTE Confidence: 0.9470757

00:16:44.084 --> 00:16:45.685
sensitive. For example, see the

NOTE Confidence: 0.9470757

00:16:45.685 --> 00:16:46.904
fish is only fifty,

NOTE Confidence: 0.9445801

00:16:48.325 --> 00:16:49.760
fifty five percent,

NOTE Confidence: 0.9263599

00:16:50.160 --> 00:16:52.000
of of positivity. So now

NOTE Confidence: 0.9263599

00:16:52.000 --> 00:16:53.380
there is this new,

NOTE Confidence: 0.8186035

00:16:53.760 --> 00:16:55.520
technology, which is called Billy

NOTE Confidence: 0.8186035

00:16:55.520 --> 00:16:56.820
Sack on brushing.

NOTE Confidence: 0.95703125

00:16:57.280 --> 00:16:58.660
It looks for a certain

NOTE Confidence: 0.95703125

00:16:58.720 --> 00:17:01.060
sector of a potential mutation

NOTE Confidence: 0.95703125

00:17:01.280 --> 00:17:03.140
that are most frequent in

NOTE Confidence: 0.91541886

00:17:03.805 --> 00:17:04.465
in cholangiocarcinoma.

NOTE Confidence: 0.80615234

00:17:05.725 --> 00:17:06.045
And,

NOTE Confidence: 0.9134766

00:17:06.925 --> 00:17:08.625
here you can see that,

NOTE Confidence: 0.97314453

00:17:09.645 --> 00:17:09.885
they

NOTE Confidence: 0.9537964

00:17:10.525 --> 00:17:12.205
this approach is able to

NOTE Confidence: 0.9537964

00:17:12.205 --> 00:17:13.345
find a mutation

NOTE Confidence: 0.96698

00:17:14.045 --> 00:17:15.565
in patient that would be

NOTE Confidence: 0.96698

00:17:15.565 --> 00:17:17.345
otherwise considered negative.

NOTE Confidence: 1

00:17:18.260 --> 00:17:18.760
So

NOTE Confidence: 0.99902344

00:17:19.060 --> 00:17:19.880
the combination

NOTE Confidence: 0.8378906

00:17:20.260 --> 00:17:20.580
of,

NOTE Confidence: 0.6175842

00:17:22.980 --> 00:17:23.480
PSYTOLOGY

NOTE Confidence: 0.98828125

00:17:24.020 --> 00:17:25.000
during the brushing

NOTE Confidence: 0.86206055

00:17:25.619 --> 00:17:25.940
can,

NOTE Confidence: 0.9970703

00:17:26.420 --> 00:17:27.640
bring our diagnostic

NOTE Confidence: 0.91955566

00:17:30.020 --> 00:17:31.560
precision and and sensitivity

NOTE Confidence: 0.94574654

00:17:31.940 --> 00:17:33.605
up to eighty five percent.

NOTE Confidence: 0.94574654

00:17:33.665 --> 00:17:34.984
So that is the the

NOTE Confidence: 0.94574654

00:17:34.984 --> 00:17:36.225
the future in the follow-up

NOTE Confidence: 0.94574654

00:17:36.225 --> 00:17:37.125
of these patients.

NOTE Confidence: 0.9707031

00:17:38.545 --> 00:17:39.045
So,

NOTE Confidence: 0.95755005

00:17:40.225 --> 00:17:41.744
the good thing is that

NOTE Confidence: 0.95755005

00:17:41.744 --> 00:17:43.125
also the treatment,

NOTE Confidence: 0.9039714

00:17:45.505 --> 00:17:46.725
prospect are increasing.

NOTE Confidence: 0.94736326

00:17:48.390 --> 00:17:50.070
Doctor Sugawa will talk about

NOTE Confidence: 0.94736326

00:17:50.070 --> 00:17:51.610
the resection and the transplant,

NOTE Confidence: 0.9331462

00:17:52.230 --> 00:17:54.410
and, I think our medical

NOTE Confidence: 0.9331462

00:17:54.470 --> 00:17:54.970
oncology,

NOTE Confidence: 0.97382814

00:17:56.470 --> 00:17:58.090
colleague will talk about chemotherapy

NOTE Confidence: 0.87540686

00:17:58.630 --> 00:17:59.850
and, immunotherapy.

NOTE Confidence: 0.9404109

00:18:01.365 --> 00:18:02.405
There are more and more,

NOTE Confidence: 0.9404109

00:18:02.805 --> 00:18:04.725
example of the use of

NOTE Confidence: 0.9404109

00:18:04.725 --> 00:18:05.865
local regional treatment

NOTE Confidence: 0.8707824

00:18:06.405 --> 00:18:08.085
for for the treatment of

NOTE Confidence: 0.8707824

00:18:08.085 --> 00:18:09.225
intraepartic angiocarcinoma.

NOTE Confidence: 0.8792572

00:18:09.925 --> 00:18:11.525
They can be ablation or

NOTE Confidence: 0.8792572

00:18:11.525 --> 00:18:12.905
y ninety preferentially.

NOTE Confidence: 0.9337158

00:18:14.549 --> 00:18:15.049
Stereotactic

NOTE Confidence: 0.9836077

00:18:15.350 --> 00:18:17.350
body radiation therapy is also

NOTE Confidence: 0.9836077

00:18:17.350 --> 00:18:18.169
is also

NOTE Confidence: 0.93535906

00:18:18.950 --> 00:18:20.869
a good alternative for patients

NOTE Confidence: 0.93535906

00:18:20.869 --> 00:18:22.549
that are otherwise unable to

NOTE Confidence: 0.93535906

00:18:22.549 --> 00:18:23.450
be treated differently.

NOTE Confidence: 0.92451614

00:18:25.350 --> 00:18:26.710
I think that as Milo,

NOTE Confidence: 0.92451614

00:18:26.710 --> 00:18:28.169
we also have a protocol

NOTE Confidence: 0.92451614

00:18:28.230 --> 00:18:28.484
of

NOTE Confidence: 0.6915283

00:18:29.285 --> 00:18:30.265
of a particular infusion.

NOTE Confidence: 0.9765625

00:18:31.445 --> 00:18:31.765
And,

NOTE Confidence: 0.89453125

00:18:32.405 --> 00:18:33.865
if nothing else work,

NOTE Confidence: 0.8659668

00:18:35.445 --> 00:18:36.744
you can put a positive

NOTE Confidence: 0.8659668

00:18:36.804 --> 00:18:37.304
standing.

NOTE Confidence: 0.91223145

00:18:40.405 --> 00:18:41.065
A little,

NOTE Confidence: 0.89857703

00:18:42.005 --> 00:18:44.080
intro to what doctor Sugawa

NOTE Confidence: 0.89857703

00:18:44.140 --> 00:18:44.800
would say,

NOTE Confidence: 0.9105399

00:18:45.340 --> 00:18:47.500
and, from the US National

NOTE Confidence: 0.9105399

00:18:47.500 --> 00:18:48.480
Cancer Database

NOTE Confidence: 0.71728516

00:18:49.260 --> 00:18:50.640
comes for his retrospective

NOTE Confidence: 0.9242859

00:18:50.940 --> 00:18:52.400
study that shows that,

NOTE Confidence: 0.92822266

00:18:53.900 --> 00:18:56.000
transplant for early stage intrahepatic

NOTE Confidence: 0.99108887

00:18:56.619 --> 00:18:57.119
cholangiocarcinoma

NOTE Confidence: 0.8975307

00:18:58.140 --> 00:19:00.185
is actually actually has a

NOTE Confidence: 0.8975307

00:19:00.185 --> 00:19:01.165
very good

NOTE Confidence: 0.85180664

00:19:02.025 --> 00:19:02.765
very good

NOTE Confidence: 0.8388672

00:19:03.385 --> 00:19:03.885
survival

NOTE Confidence: 0.8144531

00:19:04.185 --> 00:19:05.484
as respect to other

NOTE Confidence: 0.78125

00:19:06.105 --> 00:19:06.605
approaches.

NOTE Confidence: 0.9663086

00:19:07.385 --> 00:19:08.925
And now the

NOTE Confidence: 0.9773298

00:19:09.305 --> 00:19:11.065
UNOS also has set up

NOTE Confidence: 0.9773298

00:19:11.065 --> 00:19:11.965
certain criteria

NOTE Confidence: 0.9920044

00:19:13.160 --> 00:19:14.440
so that you can actually

NOTE Confidence: 0.9920044

00:19:14.440 --> 00:19:15.660
transfer this patient.

NOTE Confidence: 0.9812012

00:19:16.359 --> 00:19:16.859
So,

NOTE Confidence: 0.9983724

00:19:17.480 --> 00:19:18.940
just to end

NOTE Confidence: 0.8717256

00:19:20.119 --> 00:19:23.160
and to summarize, so, chronic

NOTE Confidence: 0.8717256

00:19:23.160 --> 00:19:25.080
carcinoma is a diverse group

NOTE Confidence: 0.8717256

00:19:25.080 --> 00:19:26.919
of cancer. It's with specific

NOTE Confidence: 0.8717256

00:19:26.919 --> 00:19:27.900
clinical manifestation.

NOTE Confidence: 0.94187236

00:19:29.105 --> 00:19:30.945
It's more frequent in a

NOTE Confidence: 0.94187236

00:19:30.945 --> 00:19:32.145
condition in which there is

NOTE Confidence: 0.94187236

00:19:32.145 --> 00:19:32.645
chronic

NOTE Confidence: 0.8996582

00:19:33.105 --> 00:19:34.645
inflammation in the liver.

NOTE Confidence: 0.86865234

00:19:34.945 --> 00:19:35.445
Their

NOTE Confidence: 0.9890137

00:19:35.825 --> 00:19:36.645
main characteristic

NOTE Confidence: 0.79052734

00:19:36.945 --> 00:19:37.445
histologically

NOTE Confidence: 0.84225464

00:19:37.825 --> 00:19:39.105
is to have a stronger,

NOTE Confidence: 0.84225464

00:19:39.265 --> 00:19:40.244
there's more plastic

NOTE Confidence: 0.88065964

00:19:40.545 --> 00:19:42.465
reaction. So the tumor reactive

NOTE Confidence: 0.88065964

00:19:42.465 --> 00:19:43.984
stroma is very important and

NOTE Confidence: 0.88065964

00:19:43.984 --> 00:19:44.250
is

NOTE Confidence: 0.92423505

00:19:45.609 --> 00:19:46.910
believed to be,

NOTE Confidence: 0.9296468

00:19:47.770 --> 00:19:49.450
one of the condition that

NOTE Confidence: 0.9296468

00:19:49.450 --> 00:19:50.750
facilitates the metastasis.

NOTE Confidence: 0.84277344

00:19:52.090 --> 00:19:53.310
They are, in fact,

NOTE Confidence: 0.83740234

00:19:54.330 --> 00:19:54.830
very

NOTE Confidence: 0.91259766

00:19:55.210 --> 00:19:56.030
high invasiveness.

NOTE Confidence: 0.9789388

00:19:56.570 --> 00:19:58.945
And in several cases, unfortunately,

NOTE Confidence: 0.9789388

00:19:59.085 --> 00:20:00.045
by the time you do

NOTE Confidence: 0.9789388

00:20:00.045 --> 00:20:01.744
the diagnosis, there is already

NOTE Confidence: 0.8543701

00:20:02.045 --> 00:20:03.185
a lymph node metastaticization.

NOTE Confidence: 0.9908447

00:20:04.845 --> 00:20:05.505
The epidemiology

NOTE Confidence: 0.9913737

00:20:05.805 --> 00:20:07.025
is changing because

NOTE Confidence: 0.9364421

00:20:07.325 --> 00:20:08.785
of the actual,

NOTE Confidence: 0.940825

00:20:10.390 --> 00:20:12.809
very high prevalence of, steatotic

NOTE Confidence: 0.940825

00:20:12.869 --> 00:20:13.770
liver disease.

NOTE Confidence: 0.9226074

00:20:14.470 --> 00:20:14.790
And,

NOTE Confidence: 0.9055278

00:20:15.270 --> 00:20:17.690
surgery is potentially correlative,

NOTE Confidence: 0.9730903

00:20:18.150 --> 00:20:19.830
but, can be offered usually

NOTE Confidence: 0.9730903

00:20:19.830 --> 00:20:20.790
to less than twenty five

NOTE Confidence: 0.9730903

00:20:20.790 --> 00:20:22.230
percent of the cases. But

NOTE Confidence: 0.9730903

00:20:22.230 --> 00:20:23.130
we do have

NOTE Confidence: 0.9007162

00:20:23.669 --> 00:20:24.570
liver transplantation,

NOTE Confidence: 0.97477216

00:20:25.725 --> 00:20:27.804
And I stop here because

NOTE Confidence: 0.97477216

00:20:27.804 --> 00:20:29.105
I don't want to enter

NOTE Confidence: 0.97477216

00:20:29.244 --> 00:20:31.184
the domain of my colleagues.

NOTE Confidence: 0.92871094

00:20:32.045 --> 00:20:33.825
So finally, this is the,

NOTE Confidence: 0.8335475

00:20:34.365 --> 00:20:35.725
telephone number of entry of

NOTE Confidence: 0.8335475

00:20:35.725 --> 00:20:37.424
the Yale liver cancer. And

NOTE Confidence: 0.8335475

00:20:37.484 --> 00:20:39.299
if I can draw the

NOTE Confidence: 0.8335475

00:20:39.299 --> 00:20:40.840
attention, whoever is interested,

NOTE Confidence: 0.7279663

00:20:41.700 --> 00:20:42.520
the FASB,

NOTE Confidence: 0.92944336

00:20:43.059 --> 00:20:45.140
will have, in August in

NOTE Confidence: 0.92944336

00:20:45.140 --> 00:20:45.640
Washington,

NOTE Confidence: 0.95425415

00:20:48.260 --> 00:20:49.400
meeting on the biocomplexity

NOTE Confidence: 0.87416995

00:20:49.859 --> 00:20:51.960
and molecular medicine liver cancer.

NOTE Confidence: 0.9547038

00:20:52.915 --> 00:20:54.695
And with that, I unshare.

NOTE Confidence: 0.9459076

00:20:55.234 --> 00:20:56.595
Thank you. Thank you so

NOTE Confidence: 0.9459076

00:20:56.595 --> 00:20:57.734
much, doctor Strazzavasco.

NOTE Confidence: 0.99975586

00:20:58.035 --> 00:20:59.015
That was a great

NOTE Confidence: 0.99668884

00:20:59.795 --> 00:21:01.875
presentation and overview of how

NOTE Confidence: 0.99668884

00:21:01.875 --> 00:21:02.855
to approach cholangiocarcinoma

NOTE Confidence: 0.9970703

00:21:03.635 --> 00:21:05.335
and other biliary tract cancers

NOTE Confidence: 0.9676758

00:21:05.960 --> 00:21:07.260
in the space of hepatology,

NOTE Confidence: 0.9998915

00:21:08.040 --> 00:21:09.160
and you also did an

NOTE Confidence: 0.9998915

00:21:09.160 --> 00:21:10.540
amazing job of transitioning

NOTE Confidence: 0.9906413

00:21:11.000 --> 00:21:12.460
it over to doctor Sogawa.

NOTE Confidence: 0.9906413

00:21:12.600 --> 00:21:14.359
So doctor Sogawa will now

NOTE Confidence: 0.9906413

00:21:14.359 --> 00:21:16.380
spend some time discussing transplant

NOTE Confidence: 0.9996745

00:21:16.760 --> 00:21:18.840
and resection options for patients

NOTE Confidence: 0.9996745

00:21:18.840 --> 00:21:20.380
with biliary tract cancers.

NOTE Confidence: 1

00:21:21.475 --> 00:21:22.774
Awesome. Thank you.

NOTE Confidence: 0.9832519

00:21:24.034 --> 00:21:25.575
Let's see. I can share.

NOTE Confidence: 0.96665734

00:21:27.475 --> 00:21:29.014
Are you able to see?

NOTE Confidence: 0.96665734

00:21:29.154 --> 00:21:29.894
That's perfect.

NOTE Confidence: 1

00:21:31.715 --> 00:21:32.215
Okay.

NOTE Confidence: 0.97558594

00:21:35.789 --> 00:21:37.090
Just one second.

NOTE Confidence: 0.99658203

00:21:48.645 --> 00:21:49.285
Okay. So,

NOTE Confidence: 0.9715169

00:21:49.925 --> 00:21:51.145
good evening, everyone.

NOTE Confidence: 0.70861816

00:21:51.445 --> 00:21:51.945
Thank,

NOTE Confidence: 0.8072917

00:21:53.125 --> 00:21:53.845
thank you for,

NOTE Confidence: 0.916626

00:21:55.525 --> 00:21:57.605
invitation, and, I'm happy to

NOTE Confidence: 0.916626

00:21:57.605 --> 00:21:59.445
talk about surgical management over

NOTE Confidence: 0.916626

00:21:59.445 --> 00:21:59.945
chorangiocarcinoma

NOTE Confidence: 0.8262126

00:22:00.645 --> 00:22:02.185
resection and antibody transplantation.

NOTE Confidence: 0.82830256

00:22:08.859 --> 00:22:11.020
So it's already, doctor Strauss

NOTE Confidence: 0.82830256

00:22:11.020 --> 00:22:12.859
Vasco showed us that stem

NOTE Confidence: 0.82830256

00:22:12.859 --> 00:22:13.359
diagram.

NOTE Confidence: 0.9572483

00:22:14.140 --> 00:22:15.500
This is very important. In

NOTE Confidence: 0.9572483

00:22:15.500 --> 00:22:17.040
terms of surgical treatment,

NOTE Confidence: 0.9415458

00:22:17.565 --> 00:22:19.404
the location dictate what kind

NOTE Confidence: 0.9415458

00:22:19.404 --> 00:22:20.144
of treatment,

NOTE Confidence: 0.99853516

00:22:21.164 --> 00:22:21.984
is appropriate.

NOTE Confidence: 0.9819336

00:22:22.605 --> 00:22:23.484
So the,

NOTE Confidence: 0.9581299

00:22:24.205 --> 00:22:24.705
intracellular,

NOTE Confidence: 0.94649255

00:22:25.484 --> 00:22:26.784
intrahepatic cholangiocarcinoma,

NOTE Confidence: 0.96415204

00:22:27.325 --> 00:22:28.365
which is ten to twenty

NOTE Confidence: 0.96415204

00:22:28.365 --> 00:22:28.865
percent,

NOTE Confidence: 0.96845704

00:22:29.244 --> 00:22:30.945
essentially, you wanna do resection,

NOTE Confidence: 0.6472473

00:22:31.549 --> 00:22:32.049
prostaglandin

NOTE Confidence: 0.9270833

00:22:32.350 --> 00:22:33.410
lymph node dissection,

NOTE Confidence: 0.6630804

00:22:34.030 --> 00:22:35.710
or very selective case, the

NOTE Confidence: 0.6630804

00:22:35.710 --> 00:22:37.150
difference for transplantation is a

NOTE Confidence: 0.6630804

00:22:37.150 --> 00:22:37.650
indication.

NOTE Confidence: 0.5941569

00:22:38.030 --> 00:22:38.270
Indicated.

NOTE Confidence: 0.99826884

00:22:39.070 --> 00:22:40.910
Are you advancing your slides?

NOTE Confidence: 0.99826884

00:22:40.910 --> 00:22:42.030
We still see the title

NOTE Confidence: 0.99826884

00:22:42.030 --> 00:22:42.530
slide.

NOTE Confidence: 0.9890137

00:22:43.150 --> 00:22:43.650
Oh,

NOTE Confidence: 0.9904785

00:22:45.710 --> 00:22:46.210
okay.

NOTE Confidence: 0.8744141

00:22:59.380 --> 00:23:01.000
K. Sorry. I am advancing,

NOTE Confidence: 0.9864366

00:23:01.940 --> 00:23:03.700
from end, but seems like

NOTE Confidence: 0.9864366

00:23:03.700 --> 00:23:04.840
it's not the case.

NOTE Confidence: 0.9917436

00:23:05.220 --> 00:23:06.740
Just one second, please. Let

NOTE Confidence: 0.9917436

00:23:06.740 --> 00:23:08.580
me just stop share. No

NOTE Confidence: 0.9917436

00:23:08.580 --> 00:23:09.080
problem.

NOTE Confidence: 0.9782715

00:23:17.975 --> 00:23:19.195
Let me try again.

NOTE Confidence: 0.8605957

00:23:31.630 --> 00:23:32.130
Okay.

NOTE Confidence: 0.9912923

00:23:32.990 --> 00:23:34.830
I guess okay. Alright. So

NOTE Confidence: 0.9912923

00:23:34.830 --> 00:23:36.050
let me let me try

NOTE Confidence: 0.9912923

00:23:36.110 --> 00:23:36.430
a little

NOTE Confidence: 0.8451022

00:23:41.734 --> 00:23:42.775
so, again, so I was

NOTE Confidence: 0.8451022

00:23:42.775 --> 00:23:44.455
talking about the location of

NOTE Confidence: 0.8451022

00:23:44.455 --> 00:23:45.515
a chorangial carcinoma

NOTE Confidence: 0.98095703

00:23:46.215 --> 00:23:46.715
dictate

NOTE Confidence: 0.964495

00:23:47.095 --> 00:23:48.695
what kind of surgical treatment

NOTE Confidence: 0.964495

00:23:48.695 --> 00:23:49.515
is necessary.

NOTE Confidence: 0.5428874

00:23:51.095 --> 00:23:51.595
Intercepter

NOTE Confidence: 0.9481201

00:23:51.895 --> 00:23:52.395
interhepatic

NOTE Confidence: 0.87492883

00:23:53.015 --> 00:23:54.075
chorangial carcinoma,

NOTE Confidence: 0.8106428

00:23:54.375 --> 00:23:56.720
usually liver resection plus minus

NOTE Confidence: 0.8106428

00:23:56.720 --> 00:23:57.299
the inflamydinectomy.

NOTE Confidence: 0.9894206

00:23:58.960 --> 00:24:01.200
Some case, liver transplantation is

NOTE Confidence: 0.9894206

00:24:01.200 --> 00:24:01.700
indicated.

NOTE Confidence: 0.98981124

00:24:02.639 --> 00:24:04.179
And if it's a perihilar

NOTE Confidence: 0.90759283

00:24:04.639 --> 00:24:06.559
chorangial carcinoma, which is people

NOTE Confidence: 0.90759283

00:24:06.559 --> 00:24:07.940
call Krebskin tumor,

NOTE Confidence: 0.7972412

00:24:08.639 --> 00:24:10.259
which is required frequently

NOTE Confidence: 0.9892334

00:24:10.955 --> 00:24:12.734
right hepatectomy, left hepatectomy,

NOTE Confidence: 0.9753418

00:24:13.115 --> 00:24:13.615
sometimes,

NOTE Confidence: 0.53275555

00:24:14.315 --> 00:24:15.375
right price segmentectomy

NOTE Confidence: 0.8347168

00:24:15.835 --> 00:24:16.975
or left right segmentectomy.

NOTE Confidence: 0.7696708

00:24:17.275 --> 00:24:18.575
Usually, you need a coded

NOTE Confidence: 0.7696708

00:24:18.635 --> 00:24:19.375
role resection.

NOTE Confidence: 0.8041992

00:24:20.795 --> 00:24:22.075
Some of the cracked skin

NOTE Confidence: 0.8041992

00:24:22.075 --> 00:24:22.575
tumor,

NOTE Confidence: 0.89939374

00:24:25.083 --> 00:24:25.950
the the particularly Mayo Mayo

NOTE Confidence: 0.89939374

00:24:25.950 --> 00:24:27.490
protocol, liver transplantation,

NOTE Confidence: 0.8778076

00:24:27.950 --> 00:24:29.490
has a good outcome.

NOTE Confidence: 0.9941329

00:24:30.909 --> 00:24:32.190
And when you have a

NOTE Confidence: 0.9941329

00:24:32.190 --> 00:24:33.250
distal cholangiocarcinoma,

NOTE Confidence: 0.71051025

00:24:34.590 --> 00:24:36.539
the the the the

NOTE Confidence: 0.92475045

00:24:37.012 --> 00:24:37.957
that cholangiocarcinoma,

NOTE Confidence: 0.92215985

00:24:38.429 --> 00:24:40.792
is a little bit better

NOTE Confidence: 0.92215985

00:24:40.792 --> 00:24:43.155
outcome generally speaking, but it's

NOTE Confidence: 0.92215985

00:24:43.155 --> 00:24:44.100
a distal,

NOTE Confidence: 0.96657985

00:24:44.572 --> 00:24:45.045
cholangiocarcinoma.

NOTE Confidence: 0.9246419

00:24:45.517 --> 00:24:46.935
The treatment option,

NOTE Confidence: 0.945166

00:24:47.407 --> 00:24:49.770
treatment choice is a Whipple,

NOTE Confidence: 0.8496094

00:24:50.410 --> 00:24:50.910
pancreaticulodenectomy.

NOTE Confidence: 0.883903

00:24:58.730 --> 00:25:00.010
Do you see a distal

NOTE Confidence: 0.883903

00:25:00.010 --> 00:25:00.510
chorangial?

NOTE Confidence: 0.8178711

00:25:00.890 --> 00:25:02.170
Yes. We do. You still.

NOTE Confidence: 0.8178711

00:25:02.170 --> 00:25:02.670
Yeah.

NOTE Confidence: 0.9793261

00:25:03.115 --> 00:25:04.794
So the I'm just briefly

NOTE Confidence: 0.9793261

00:25:04.794 --> 00:25:06.414
talking about the distal chorangial.

NOTE Confidence: 0.9269307

00:25:07.595 --> 00:25:08.975
As I mentioned in prior

NOTE Confidence: 0.9269307

00:25:09.195 --> 00:25:10.894
slide, it's, Whipple.

NOTE Confidence: 0.97074383

00:25:11.274 --> 00:25:13.034
So the workup and also

NOTE Confidence: 0.97074383

00:25:13.034 --> 00:25:13.534
treatment

NOTE Confidence: 0.9269206

00:25:13.994 --> 00:25:16.015
is is similar to Whipple's

NOTE Confidence: 0.9269206

00:25:16.075 --> 00:25:16.575
procedure.

NOTE Confidence: 0.83728606

00:25:17.859 --> 00:25:19.539
Outcome is still even r

NOTE Confidence: 0.83728606

00:25:19.539 --> 00:25:20.280
zero resection.

NOTE Confidence: 0.93594795

00:25:20.900 --> 00:25:22.419
It's better than the pancreas

NOTE Confidence: 0.93594795

00:25:22.419 --> 00:25:24.260
cancer, generally speaking, by twenty

NOTE Confidence: 0.93594795

00:25:24.260 --> 00:25:25.640
five to thirty percent.

NOTE Confidence: 0.9708252

00:25:26.340 --> 00:25:27.960
It's important to have,

NOTE Confidence: 0.9658068

00:25:28.740 --> 00:25:30.419
r zero resection, if it's

NOTE Confidence: 0.9658068

00:25:30.419 --> 00:25:30.919
possible.

NOTE Confidence: 0.87027997

00:25:31.465 --> 00:25:33.145
And then portal vein recon

NOTE Confidence: 0.87027997

00:25:33.545 --> 00:25:34.045
reconstruction

NOTE Confidence: 0.9697673

00:25:34.585 --> 00:25:35.885
and lymph node dissection,

NOTE Confidence: 0.9436035

00:25:36.185 --> 00:25:36.925
these are,

NOTE Confidence: 0.9498291

00:25:37.465 --> 00:25:39.485
also doesn't change outcomes.

NOTE Confidence: 0.95626396

00:25:45.289 --> 00:25:46.330
So let me talk about

NOTE Confidence: 0.95626396

00:25:46.330 --> 00:25:46.990
the surgical,

NOTE Confidence: 0.81225586

00:25:48.090 --> 00:25:48.590
liver,

NOTE Confidence: 0.96313477

00:25:49.210 --> 00:25:51.049
resection option for cracked skin

NOTE Confidence: 0.96313477

00:25:51.049 --> 00:25:51.549
tumor.

NOTE Confidence: 0.8864464

00:25:52.330 --> 00:25:54.190
Cracked skin tumor is classified

NOTE Confidence: 0.8864464

00:25:54.409 --> 00:25:55.450
is a biz it is

NOTE Confidence: 0.8864464

00:25:55.450 --> 00:25:56.669
called bismuth classification.

NOTE Confidence: 0.9557757

00:25:58.195 --> 00:25:59.955
When you see, type one,

NOTE Confidence: 0.9557757

00:25:59.955 --> 00:26:00.774
it's mainly,

NOTE Confidence: 0.86976457

00:26:01.234 --> 00:26:03.315
common hepatic duct and the

NOTE Confidence: 0.86976457

00:26:03.315 --> 00:26:05.414
type two including hilum.

NOTE Confidence: 0.90841675

00:26:06.115 --> 00:26:08.034
And type three a, three

NOTE Confidence: 0.90841675

00:26:08.034 --> 00:26:09.955
three b is is on

NOTE Confidence: 0.90841675

00:26:09.955 --> 00:26:11.554
the right side or left

NOTE Confidence: 0.90841675

00:26:11.554 --> 00:26:11.940
side.

NOTE Confidence: 0.9909668

00:26:12.580 --> 00:26:13.080
And,

NOTE Confidence: 0.9367676

00:26:14.419 --> 00:26:16.980
bismuth four including both right

NOTE Confidence: 0.9367676

00:26:16.980 --> 00:26:18.980
and left hepatic duct. So

NOTE Confidence: 0.9367676

00:26:18.980 --> 00:26:20.500
what does that means, from

NOTE Confidence: 0.9367676

00:26:20.500 --> 00:26:22.820
the surgical standpoint? And type

NOTE Confidence: 0.9367676

00:26:22.820 --> 00:26:24.279
one and type two,

NOTE Confidence: 0.88216144

00:26:24.615 --> 00:26:25.975
generally speaking, you wanna take

NOTE Confidence: 0.88216144

00:26:25.975 --> 00:26:27.035
a you know, remove,

NOTE Confidence: 0.81396484

00:26:27.655 --> 00:26:29.275
excise the bile duct

NOTE Confidence: 0.87065125

00:26:29.655 --> 00:26:31.015
and then plus minus if

NOTE Confidence: 0.87065125

00:26:31.015 --> 00:26:31.895
you need to have a

NOTE Confidence: 0.87065125

00:26:31.895 --> 00:26:33.575
hepatic artery and the motor

NOTE Confidence: 0.87065125

00:26:33.575 --> 00:26:34.075
vein.

NOTE Confidence: 0.9710938

00:26:34.455 --> 00:26:35.175
You need to have a,

NOTE Confidence: 0.9297665

00:26:36.455 --> 00:26:38.500
resection if it's needed. But

NOTE Confidence: 0.9297665

00:26:38.500 --> 00:26:39.940
generally speaking, you need to

NOTE Confidence: 0.9297665

00:26:39.940 --> 00:26:41.380
have a reconstruction and who

NOTE Confidence: 0.9297665

00:26:41.380 --> 00:26:42.200
and why.

NOTE Confidence: 0.90112305

00:26:42.820 --> 00:26:43.720
But relatively,

NOTE Confidence: 0.9751383

00:26:44.660 --> 00:26:45.780
you don't need to have

NOTE Confidence: 0.9751383

00:26:45.780 --> 00:26:47.400
a liver resection, not necessarily.

NOTE Confidence: 0.94845146

00:26:48.179 --> 00:26:50.260
However, type three a or

NOTE Confidence: 0.94845146

00:26:50.260 --> 00:26:51.080
three b

NOTE Confidence: 0.9630127

00:26:51.380 --> 00:26:53.320
require major liver resection.

NOTE Confidence: 0.9885254

00:26:53.925 --> 00:26:54.425
And,

NOTE Confidence: 0.79821324

00:26:55.365 --> 00:26:56.805
and also the same way

NOTE Confidence: 0.79821324

00:26:56.805 --> 00:26:58.585
hepatocar three portal vein,

NOTE Confidence: 0.9702846

00:26:59.205 --> 00:27:00.485
involvement, you need to have

NOTE Confidence: 0.9702846

00:27:00.485 --> 00:27:01.145
a reconstruction.

NOTE Confidence: 0.93464005

00:27:02.885 --> 00:27:04.585
That's that's a bigger operation,

NOTE Confidence: 0.93464005

00:27:04.725 --> 00:27:06.645
generally speaking. And also, you

NOTE Confidence: 0.93464005

00:27:06.645 --> 00:27:07.625
need to have reconstruction

NOTE Confidence: 0.9535319

00:27:07.925 --> 00:27:09.300
of bile duct.

NOTE Confidence: 0.96986216

00:27:10.260 --> 00:27:11.940
Now bismuth four is more

NOTE Confidence: 0.96986216

00:27:11.940 --> 00:27:12.440
troublesome

NOTE Confidence: 0.9159831

00:27:12.980 --> 00:27:14.660
because you you have some

NOTE Confidence: 0.9159831

00:27:14.740 --> 00:27:16.180
both of the hepatic duct

NOTE Confidence: 0.9159831

00:27:16.180 --> 00:27:17.720
right and left are involved.

NOTE Confidence: 0.942749

00:27:18.180 --> 00:27:19.460
So what is that means?

NOTE Confidence: 0.942749

00:27:19.460 --> 00:27:20.920
You do need to have

NOTE Confidence: 0.942749

00:27:20.980 --> 00:27:21.975
right trisegmentectomy.

NOTE Confidence: 0.9615304

00:27:22.754 --> 00:27:24.034
So if you have this

NOTE Confidence: 0.9615304

00:27:24.034 --> 00:27:25.875
only left lateral segment, twenty

NOTE Confidence: 0.9615304

00:27:25.875 --> 00:27:27.634
percent is left over, which

NOTE Confidence: 0.9615304

00:27:27.634 --> 00:27:29.715
is generally it's it's too

NOTE Confidence: 0.9615304

00:27:29.715 --> 00:27:30.215
small

NOTE Confidence: 0.9455915

00:27:30.595 --> 00:27:31.875
as a remnant. You would

NOTE Confidence: 0.9455915

00:27:31.875 --> 00:27:32.754
like to have a thirty

NOTE Confidence: 0.9455915

00:27:32.754 --> 00:27:34.375
to forty percent. So,

NOTE Confidence: 0.9744466

00:27:35.040 --> 00:27:36.240
in that case, you do

NOTE Confidence: 0.9744466

00:27:36.240 --> 00:27:37.460
need to have a portal

NOTE Confidence: 0.9744466

00:27:37.600 --> 00:27:38.820
portal vein embolization

NOTE Confidence: 0.98046875

00:27:39.280 --> 00:27:40.640
to make a left lateral

NOTE Confidence: 0.98046875

00:27:40.640 --> 00:27:41.620
segment bigger.

NOTE Confidence: 0.95842487

00:27:42.800 --> 00:27:44.640
And then, if it's the

NOTE Confidence: 0.95842487

00:27:44.640 --> 00:27:45.840
other side, it's you might

NOTE Confidence: 0.95842487

00:27:45.840 --> 00:27:46.720
need to have a left

NOTE Confidence: 0.95842487

00:27:46.720 --> 00:27:47.220
trisemantectomy.

NOTE Confidence: 0.94718426

00:27:48.935 --> 00:27:49.835
So these are,

NOTE Confidence: 0.923584

00:27:50.775 --> 00:27:51.275
surgery,

NOTE Confidence: 0.8414917

00:27:52.055 --> 00:27:52.955
outcome, particularly,

NOTE Confidence: 0.7776151

00:27:55.575 --> 00:27:57.015
like in Nagoya's group, they

NOTE Confidence: 0.7776151

00:27:57.015 --> 00:27:57.515
have

NOTE Confidence: 0.6230469

00:27:57.975 --> 00:27:58.475
extraordinary

NOTE Confidence: 0.95458984

00:27:58.855 --> 00:27:59.355
outcomes.

NOTE Confidence: 0.9902344

00:28:00.135 --> 00:28:00.630
But

NOTE Confidence: 0.95481133

00:28:00.950 --> 00:28:02.390
the aim is try to

NOTE Confidence: 0.95481133

00:28:02.390 --> 00:28:04.310
get r zero resection. It's

NOTE Confidence: 0.95481133

00:28:04.310 --> 00:28:05.510
r you know, compared to

NOTE Confidence: 0.95481133

00:28:05.510 --> 00:28:06.490
r one resection,

NOTE Confidence: 0.87996423

00:28:06.950 --> 00:28:08.790
outcome is, is a is

NOTE Confidence: 0.87996423

00:28:08.790 --> 00:28:10.310
a different overall five year

NOTE Confidence: 0.87996423

00:28:10.310 --> 00:28:12.170
survival, thirty to forty percent

NOTE Confidence: 0.87996423

00:28:12.310 --> 00:28:13.510
if you have r zero

NOTE Confidence: 0.87996423

00:28:13.510 --> 00:28:15.174
resection. Resection, but r one's

NOTE Confidence: 0.87996423

00:28:15.174 --> 00:28:15.674
microscopic

NOTE Confidence: 0.55163574

00:28:16.054 --> 00:28:16.794
is leftover,

NOTE Confidence: 0.9375

00:28:17.815 --> 00:28:19.195
is only ten percent.

NOTE Confidence: 0.9597168

00:28:24.294 --> 00:28:24.794
Preoperative

NOTE Confidence: 0.9389038

00:28:25.174 --> 00:28:25.994
and adjuvant,

NOTE Confidence: 0.91918945

00:28:26.890 --> 00:28:27.390
consideration,

NOTE Confidence: 0.84223634

00:28:28.730 --> 00:28:30.669
is I've already kinda mentioned,

NOTE Confidence: 0.88742405

00:28:33.290 --> 00:28:34.429
portal vein embolization

NOTE Confidence: 0.9765625

00:28:34.730 --> 00:28:35.630
to increase,

NOTE Confidence: 0.9246419

00:28:36.730 --> 00:28:38.030
remnant of liver.

NOTE Confidence: 0.8944417

00:28:38.890 --> 00:28:40.755
That's a key. And, you

NOTE Confidence: 0.8944417

00:28:40.995 --> 00:28:42.375
used to be a PTBD,

NOTE Confidence: 0.9759567

00:28:43.315 --> 00:28:44.835
drainage of a bile duct.

NOTE Confidence: 0.9759567

00:28:45.075 --> 00:28:46.215
When you have obstructing,

NOTE Confidence: 0.9413249

00:28:46.995 --> 00:28:48.135
it doesn't function.

NOTE Confidence: 0.9514974

00:28:48.915 --> 00:28:49.975
But we prefer,

NOTE Confidence: 0.9954427

00:28:50.675 --> 00:28:51.175
ERCP

NOTE Confidence: 0.9941406

00:28:51.555 --> 00:28:52.455
to decompress

NOTE Confidence: 0.7420044

00:28:52.755 --> 00:28:53.575
bile duct,

NOTE Confidence: 0.8405462

00:28:55.130 --> 00:28:56.350
in terms of a tumor

NOTE Confidence: 0.8405462

00:28:56.410 --> 00:28:58.169
outcomes. And then, I'm done

NOTE Confidence: 0.8405462

00:28:58.169 --> 00:28:59.789
going for Azovant and systemic

NOTE Confidence: 0.8405462

00:28:59.850 --> 00:29:01.470
treatment, but these are,

NOTE Confidence: 0.936084

00:29:03.450 --> 00:29:05.470
very important, in the preoperative

NOTE Confidence: 0.93025714

00:29:05.929 --> 00:29:08.110
treatment of surgical treat, surgical

NOTE Confidence: 0.93025714

00:29:08.169 --> 00:29:08.669
therapy.

NOTE Confidence: 0.92743754

00:29:11.375 --> 00:29:13.395
And so there's two landmark

NOTE Confidence: 0.92743754

00:29:13.455 --> 00:29:15.375
studies. One is from Sloan

NOTE Confidence: 0.92743754

00:29:15.375 --> 00:29:16.815
Kettering, and one is from

NOTE Confidence: 0.92743754

00:29:16.815 --> 00:29:18.015
Nagano's group.

NOTE Confidence: 0.9763997

00:29:18.735 --> 00:29:19.235
Nagino,

NOTE Confidence: 0.91015625

00:29:19.775 --> 00:29:21.955
and numerous, they have tremendous

NOTE Confidence: 0.91015625

00:29:22.015 --> 00:29:22.515
outcomes.

NOTE Confidence: 0.8569336

00:29:23.570 --> 00:29:24.230
But, overall,

NOTE Confidence: 0.91967773

00:29:24.690 --> 00:29:25.170
the,

NOTE Confidence: 0.88427734

00:29:25.490 --> 00:29:26.690
when you have a good

NOTE Confidence: 0.88427734

00:29:26.690 --> 00:29:27.590
liver resection,

NOTE Confidence: 0.9978841

00:29:28.290 --> 00:29:29.270
you could achieve,

NOTE Confidence: 0.98598635

00:29:30.450 --> 00:29:32.710
thirty to fifty percent of,

NOTE Confidence: 0.8621419

00:29:33.090 --> 00:29:33.590
survivals,

NOTE Confidence: 0.9986328

00:29:34.530 --> 00:29:36.309
but these are selected cases.

NOTE Confidence: 0.9005805

00:29:39.185 --> 00:29:40.465
Now I just wanna mention

NOTE Confidence: 0.9005805

00:29:40.465 --> 00:29:41.925
about cracked skin tumor,

NOTE Confidence: 0.9752197

00:29:42.465 --> 00:29:43.285
Mayo protocol.

NOTE Confidence: 0.93927

00:29:43.905 --> 00:29:45.505
Mayo group has been,

NOTE Confidence: 0.9992676

00:29:45.985 --> 00:29:48.165
advocating for liver transplantation

NOTE Confidence: 0.92441404

00:29:48.465 --> 00:29:50.085
for this cracked skin tumor.

NOTE Confidence: 0.88946533

00:29:51.345 --> 00:29:52.725
They are very, very,

NOTE Confidence: 0.98095703

00:29:53.880 --> 00:29:55.020
extensive protocol,

NOTE Confidence: 0.8848766

00:29:56.040 --> 00:29:58.220
prior to transplant and also

NOTE Confidence: 0.8848766

00:29:58.280 --> 00:29:59.960
before, when you're listing a

NOTE Confidence: 0.8848766

00:29:59.960 --> 00:30:00.460
patient.

NOTE Confidence: 0.93725586

00:30:01.560 --> 00:30:02.060
Then,

NOTE Confidence: 0.9350586

00:30:03.960 --> 00:30:05.240
it's it's by all means,

NOTE Confidence: 0.9350586

00:30:05.240 --> 00:30:06.220
it's very selected

NOTE Confidence: 0.8739828

00:30:07.000 --> 00:30:09.455
cases. The original study was

NOTE Confidence: 0.8739828

00:30:09.455 --> 00:30:10.274
from PSC.

NOTE Confidence: 0.8846261

00:30:10.654 --> 00:30:11.534
And then when you have

NOTE Confidence: 0.8846261

00:30:11.534 --> 00:30:12.674
the, cholangiocarcinoma,

NOTE Confidence: 0.86198676

00:30:13.215 --> 00:30:14.735
they find out. They're going

NOTE Confidence: 0.86198676

00:30:14.735 --> 00:30:16.735
for transplant. But even that,

NOTE Confidence: 0.86198676

00:30:16.735 --> 00:30:18.335
the de novo, without the

NOTE Confidence: 0.86198676

00:30:18.335 --> 00:30:18.835
PSC,

NOTE Confidence: 0.8884522

00:30:19.855 --> 00:30:21.394
they apply the same methodology,

NOTE Confidence: 0.9285753

00:30:21.774 --> 00:30:22.800
and it seems like it's

NOTE Confidence: 0.9285753

00:30:23.120 --> 00:30:24.740
achieving the same outcomes.

NOTE Confidence: 0.86690265

00:30:25.200 --> 00:30:26.900
However, because of,

NOTE Confidence: 0.91967773

00:30:27.440 --> 00:30:28.260
lots of,

NOTE Confidence: 0.8397136

00:30:28.800 --> 00:30:30.660
this is truly multi multidisciplinary

NOTE Confidence: 0.9770508

00:30:31.920 --> 00:30:32.420
preparations

NOTE Confidence: 0.9083534

00:30:32.720 --> 00:30:34.500
needed. Not too many transplant

NOTE Confidence: 0.9083534

00:30:34.560 --> 00:30:36.820
centers, not necessarily be support

NOTE Confidence: 0.9083534

00:30:36.880 --> 00:30:38.205
that treatment. However,

NOTE Confidence: 0.97106934

00:30:41.145 --> 00:30:41.885
the outcomes,

NOTE Confidence: 0.9970703

00:30:42.825 --> 00:30:43.325
are

NOTE Confidence: 0.83942205

00:30:45.305 --> 00:30:46.745
very good outcomes. Five years

NOTE Confidence: 0.83942205

00:30:46.745 --> 00:30:48.665
fibro is about sixty five

NOTE Confidence: 0.83942205

00:30:48.665 --> 00:30:49.165
percent,

NOTE Confidence: 0.95857745

00:30:49.865 --> 00:30:51.725
both PSC and non PSC.

NOTE Confidence: 0.8295085

00:30:52.900 --> 00:30:54.280
The UNOS actually,

NOTE Confidence: 0.8891392

00:30:54.740 --> 00:30:57.140
will give, exception point if

NOTE Confidence: 0.8891392

00:30:57.140 --> 00:30:58.740
it's a meet criteria for

NOTE Confidence: 0.8891392

00:30:58.740 --> 00:31:00.660
this Kratzkin tumor liver transplant

NOTE Confidence: 0.8891392

00:31:00.660 --> 00:31:01.160
case.

NOTE Confidence: 0.8084542

00:31:04.340 --> 00:31:06.625
The original studies, is a

NOTE Confidence: 0.8084542

00:31:06.625 --> 00:31:07.445
Mayo studies.

NOTE Confidence: 0.95825195

00:31:07.905 --> 00:31:09.925
That was confirmed by,

NOTE Confidence: 0.2662964

00:31:10.545 --> 00:31:11.045
worldwide,

NOTE Confidence: 0.8169678

00:31:11.905 --> 00:31:13.765
unit studies and also international,

NOTE Confidence: 0.8413086

00:31:16.145 --> 00:31:16.645
studies

NOTE Confidence: 0.99902344

00:31:17.185 --> 00:31:18.005
as well.

NOTE Confidence: 0.99658203

00:31:20.660 --> 00:31:21.160
Now,

NOTE Confidence: 0.9463072

00:31:22.180 --> 00:31:23.220
I think this is more

NOTE Confidence: 0.9463072

00:31:23.220 --> 00:31:25.160
focusing on for intracellular

NOTE Confidence: 0.96416014

00:31:25.700 --> 00:31:26.200
intrahepatic,

NOTE Confidence: 0.93641496

00:31:27.300 --> 00:31:27.800
cholangiocarcinoma.

NOTE Confidence: 0.97998047

00:31:30.020 --> 00:31:31.220
The reason why being,

NOTE Confidence: 0.91160077

00:31:32.195 --> 00:31:33.635
it seems like incidence of

NOTE Confidence: 0.91160077

00:31:33.635 --> 00:31:34.135
intrahepatic

NOTE Confidence: 0.9126587

00:31:34.835 --> 00:31:35.335
cholangiocarcinoma

NOTE Confidence: 0.89868164

00:31:36.035 --> 00:31:36.855
has increasing,

NOTE Confidence: 0.98624676

00:31:38.195 --> 00:31:39.255
as well as,

NOTE Confidence: 0.8453776

00:31:40.195 --> 00:31:41.575
trans liver transplantation

NOTE Confidence: 0.9980469

00:31:41.875 --> 00:31:42.934
for intrahepatic

NOTE Confidence: 0.9707031

00:31:43.315 --> 00:31:43.795
liver,

NOTE Confidence: 0.99676514

00:31:44.355 --> 00:31:44.855
cholangiocarcinoma

NOTE Confidence: 0.99039716

00:31:45.795 --> 00:31:47.175
has progressed tremendously.

NOTE Confidence: 0.9401611

00:31:49.450 --> 00:31:51.929
But overall, the PRINCEPRO is,

NOTE Confidence: 0.9001465

00:31:52.250 --> 00:31:52.750
something,

NOTE Confidence: 0.98950195

00:31:53.210 --> 00:31:53.710
similar.

NOTE Confidence: 0.98547363

00:31:54.730 --> 00:31:55.950
However, resection,

NOTE Confidence: 0.93826294

00:31:56.650 --> 00:31:58.510
is almost like a hepacillary

NOTE Confidence: 0.93826294

00:31:58.570 --> 00:31:59.950
carcinoma liver resection.

NOTE Confidence: 0.8805176

00:32:00.650 --> 00:32:02.669
Maybe only difference would be,

NOTE Confidence: 0.97822267

00:32:03.655 --> 00:32:05.835
would be ideal to obtain,

NOTE Confidence: 0.9555664

00:32:06.695 --> 00:32:07.755
lymph node dissection,

NOTE Confidence: 0.93326825

00:32:08.535 --> 00:32:10.055
to have a more, lymph

NOTE Confidence: 0.93326825

00:32:10.055 --> 00:32:11.255
node is that will be

NOTE Confidence: 0.93326825

00:32:11.255 --> 00:32:13.035
a prognostic and also therapeutic.

NOTE Confidence: 0.9301758

00:32:15.255 --> 00:32:15.755
However,

NOTE Confidence: 0.8376465

00:32:16.055 --> 00:32:16.795
five year,

NOTE Confidence: 0.9621582

00:32:17.800 --> 00:32:18.300
survival,

NOTE Confidence: 0.83569336

00:32:18.760 --> 00:32:20.600
r zero resection steroids twenty

NOTE Confidence: 0.83569336

00:32:20.600 --> 00:32:21.980
five to thirty five percent,

NOTE Confidence: 0.73602295

00:32:22.920 --> 00:32:24.220
of, interest,

NOTE Confidence: 0.948249

00:32:25.080 --> 00:32:26.380
intrahepatic cholangiocarcinoma.

NOTE Confidence: 0.9622803

00:32:30.634 --> 00:32:32.715
And landmark studies is,

NOTE Confidence: 0.9124756

00:32:33.274 --> 00:32:34.414
Hopkins and,

NOTE Confidence: 0.80181885

00:32:35.195 --> 00:32:36.174
Sloan's group.

NOTE Confidence: 0.9230957

00:32:37.914 --> 00:32:39.534
Its outcome is something similar.

NOTE Confidence: 0.9995117

00:32:39.914 --> 00:32:40.894
Generally speaking,

NOTE Confidence: 0.9024251

00:32:41.355 --> 00:32:42.254
it's the importance

NOTE Confidence: 0.92303467

00:32:42.554 --> 00:32:44.095
of r zero section,

NOTE Confidence: 0.9956868

00:32:44.850 --> 00:32:46.150
for surgical cases.

NOTE Confidence: 0.8638238

00:32:47.570 --> 00:32:49.090
And the challenge is sometimes

NOTE Confidence: 0.8638238

00:32:49.090 --> 00:32:50.690
is, do you have,

NOTE Confidence: 0.9822591

00:32:51.250 --> 00:32:52.790
enough remnant volume

NOTE Confidence: 0.93258023

00:32:53.250 --> 00:32:55.010
after resection? That's that's a

NOTE Confidence: 0.93258023

00:32:55.010 --> 00:32:57.110
challenge in cases, particularly cirrhotic

NOTE Confidence: 0.93258023

00:32:57.170 --> 00:32:57.670
patient.

NOTE Confidence: 0.9970703

00:33:02.075 --> 00:33:02.975
So now,

NOTE Confidence: 0.986084

00:33:03.995 --> 00:33:05.375
maybe last, particularly,

NOTE Confidence: 0.99912107

00:33:06.715 --> 00:33:08.414
last five years or so,

NOTE Confidence: 0.858846

00:33:09.595 --> 00:33:11.375
the this, you know, transplant

NOTE Confidence: 0.858846

00:33:11.514 --> 00:33:12.014
community,

NOTE Confidence: 0.9563488

00:33:12.440 --> 00:33:14.040
we are more focusing on

NOTE Confidence: 0.9563488

00:33:14.120 --> 00:33:15.640
it is called transplant on

NOTE Confidence: 0.9563488

00:33:15.640 --> 00:33:16.140
colosy.

NOTE Confidence: 0.95816714

00:33:16.760 --> 00:33:19.340
So the hepatocellular carcinoma, obviously,

NOTE Confidence: 0.95816714

00:33:19.559 --> 00:33:21.559
we've been transplanting for many,

NOTE Confidence: 0.95816714

00:33:21.559 --> 00:33:22.299
many years.

NOTE Confidence: 1

00:33:22.600 --> 00:33:23.100
However,

NOTE Confidence: 0.9488874

00:33:23.799 --> 00:33:25.640
we we start focusing on

NOTE Confidence: 0.9488874

00:33:25.640 --> 00:33:26.460
for cholangiocarcinoma

NOTE Confidence: 0.97665405

00:33:27.635 --> 00:33:29.495
and also colorectal metastasis

NOTE Confidence: 0.8748474

00:33:29.795 --> 00:33:31.635
to the liver. Some selected

NOTE Confidence: 0.8748474

00:33:31.635 --> 00:33:32.855
cases is. And,

NOTE Confidence: 0.9654541

00:33:35.075 --> 00:33:36.855
particularly opening up idea

NOTE Confidence: 0.94754463

00:33:37.315 --> 00:33:38.995
of, and also people pay

NOTE Confidence: 0.94754463

00:33:38.995 --> 00:33:40.135
attention to,

NOTE Confidence: 0.9566345

00:33:41.410 --> 00:33:42.070
this, chorangiocarcinoma

NOTE Confidence: 0.99560547

00:33:42.690 --> 00:33:43.430
liver transplantation

NOTE Confidence: 0.9831543

00:33:43.890 --> 00:33:44.390
is,

NOTE Confidence: 0.98232424

00:33:45.010 --> 00:33:47.270
in two thousand fourteen, sixteen,

NOTE Confidence: 0.8993688

00:33:48.690 --> 00:33:51.270
Spanish studies and, which shows

NOTE Confidence: 0.8993688

00:33:51.330 --> 00:33:53.350
about, below two centimeter,

NOTE Confidence: 0.93115234

00:33:53.985 --> 00:33:54.485
chorangiocarcinoma.

NOTE Confidence: 0.9191546

00:33:55.184 --> 00:33:56.785
And the transplant outcome is

NOTE Confidence: 0.9191546

00:33:56.785 --> 00:33:57.765
essentially fantastic,

NOTE Confidence: 0.8017578

00:33:58.545 --> 00:33:59.025
almost,

NOTE Confidence: 0.8789673

00:33:59.505 --> 00:34:01.205
a hundred percent, survival,

NOTE Confidence: 0.8464966

00:34:02.065 --> 00:34:02.965
for very,

NOTE Confidence: 0.90856934

00:34:04.305 --> 00:34:05.605
small number of cases.

NOTE Confidence: 0.9243164

00:34:06.520 --> 00:34:08.840
And that's also confirmed in

NOTE Confidence: 0.9243164

00:34:08.840 --> 00:34:09.820
multiple studies.

NOTE Confidence: 0.99560547

00:34:10.120 --> 00:34:10.620
And,

NOTE Confidence: 0.74026924

00:34:11.719 --> 00:34:13.719
as doctor Suresh Vasco had

NOTE Confidence: 0.74026924

00:34:13.719 --> 00:34:14.620
showed, actually,

NOTE Confidence: 0.9141188

00:34:16.040 --> 00:34:17.719
you know, three centimeter cut

NOTE Confidence: 0.9141188

00:34:17.719 --> 00:34:20.120
off. It depends on, studies,

NOTE Confidence: 0.9141188

00:34:20.120 --> 00:34:21.500
but that was,

NOTE Confidence: 0.8618164

00:34:23.135 --> 00:34:23.875
made into

NOTE Confidence: 0.7864583

00:34:24.575 --> 00:34:25.075
UNOS,

NOTE Confidence: 0.9695638

00:34:26.175 --> 00:34:28.094
create a policy for UNOS

NOTE Confidence: 0.9695638

00:34:28.094 --> 00:34:28.594
exception.

NOTE Confidence: 0.92595565

00:34:29.614 --> 00:34:31.155
It's smaller than three centimeter

NOTE Confidence: 0.92595565

00:34:31.215 --> 00:34:31.875
of cholangiocarcinoma

NOTE Confidence: 0.95670575

00:34:32.895 --> 00:34:34.175
with six months,

NOTE Confidence: 0.9440918

00:34:34.815 --> 00:34:35.315
observation.

NOTE Confidence: 0.94799805

00:34:35.855 --> 00:34:37.055
As far as this doesn't

NOTE Confidence: 0.94799805

00:34:37.055 --> 00:34:37.555
progress,

NOTE Confidence: 0.8999837

00:34:39.110 --> 00:34:40.310
UNOS will give,

NOTE Confidence: 0.8701477

00:34:40.710 --> 00:34:42.630
it is called MMT minus

NOTE Confidence: 0.8701477

00:34:42.630 --> 00:34:43.830
three, which is like a

NOTE Confidence: 0.8701477

00:34:43.830 --> 00:34:45.670
MER score twenty eight, the

NOTE Confidence: 0.8701477

00:34:45.670 --> 00:34:47.850
same as a hepatocellular carcinoma

NOTE Confidence: 0.97402346

00:34:48.150 --> 00:34:49.770
when you have exception point.

NOTE Confidence: 0.89560544

00:34:50.085 --> 00:34:51.685
So that will open up,

NOTE Confidence: 0.9983724

00:34:52.165 --> 00:34:53.145
the big paradigm

NOTE Confidence: 0.97631836

00:34:53.525 --> 00:34:54.025
for,

NOTE Confidence: 0.9942627

00:34:55.285 --> 00:34:57.545
liver transplantation for intrahepatic

NOTE Confidence: 0.7607422

00:34:58.005 --> 00:34:58.505
liver,

NOTE Confidence: 0.8625488

00:34:59.125 --> 00:34:59.625
cholangiocarcinoma.

NOTE Confidence: 0.9963379

00:35:02.730 --> 00:35:03.630
So the,

NOTE Confidence: 0.76958007

00:35:04.330 --> 00:35:06.510
so rational array is still

NOTE Confidence: 0.7922363

00:35:06.969 --> 00:35:07.469
even,

NOTE Confidence: 0.6897583

00:35:08.170 --> 00:35:09.550
r zero resection case.

NOTE Confidence: 0.93721515

00:35:09.930 --> 00:35:11.930
Liver resection does not give

NOTE Confidence: 0.93721515

00:35:11.930 --> 00:35:12.430
you,

NOTE Confidence: 0.71569824

00:35:14.010 --> 00:35:14.910
great outcome.

NOTE Confidence: 0.9951172

00:35:15.770 --> 00:35:17.230
And then the small

NOTE Confidence: 0.9633789

00:35:18.435 --> 00:35:18.935
size

NOTE Confidence: 0.27954102

00:35:19.395 --> 00:35:19.895
or

NOTE Confidence: 0.79681396

00:35:20.355 --> 00:35:20.855
intrahepatic

NOTE Confidence: 0.39086914

00:35:21.155 --> 00:35:21.395
liver

NOTE Confidence: 0.8491821

00:35:21.955 --> 00:35:22.455
chorangiocarcinoma

NOTE Confidence: 0.8798828

00:35:23.315 --> 00:35:23.815
outcome

NOTE Confidence: 0.9176636

00:35:24.195 --> 00:35:25.415
seems to be promising.

NOTE Confidence: 0.81103516

00:35:27.715 --> 00:35:28.215
Therefore,

NOTE Confidence: 0.65914714

00:35:28.995 --> 00:35:30.455
and ours and the unit's,

NOTE Confidence: 0.99044365

00:35:30.835 --> 00:35:32.275
change of policy. So the

NOTE Confidence: 0.99044365

00:35:32.275 --> 00:35:33.094
last year,

NOTE Confidence: 0.96484375

00:35:33.890 --> 00:35:34.550
I asked,

NOTE Confidence: 0.9023031

00:35:35.810 --> 00:35:36.710
doctor Jaffe,

NOTE Confidence: 0.8803045

00:35:37.010 --> 00:35:38.850
you know, our hepatologist, and

NOTE Confidence: 0.8803045

00:35:38.850 --> 00:35:40.450
then working with all the

NOTE Confidence: 0.8803045

00:35:40.450 --> 00:35:40.950
SMILOs,

NOTE Confidence: 0.7702637

00:35:41.890 --> 00:35:42.390
group,

NOTE Confidence: 0.9875488

00:35:42.930 --> 00:35:43.750
we create,

NOTE Confidence: 0.9941406

00:35:44.290 --> 00:35:44.790
Yale's,

NOTE Confidence: 0.94989014

00:35:45.170 --> 00:35:45.670
chorangiocarcinoma

NOTE Confidence: 0.90600586

00:35:46.290 --> 00:35:46.790
protocol,

NOTE Confidence: 0.9896721

00:35:47.325 --> 00:35:49.005
for liver transplantation. I would

NOTE Confidence: 0.9896721

00:35:49.005 --> 00:35:49.805
like to show it to

NOTE Confidence: 0.9896721

00:35:49.805 --> 00:35:50.305
you.

NOTE Confidence: 0.93046874

00:35:52.605 --> 00:35:54.525
So the inclusion this is

NOTE Confidence: 0.93046874

00:35:54.525 --> 00:35:56.385
the inclusion criteria and exclusion

NOTE Confidence: 0.9951172

00:35:56.685 --> 00:35:57.185
criteria.

NOTE Confidence: 0.99121094

00:35:57.645 --> 00:36:00.065
Inclusion criteria is, is adult

NOTE Confidence: 0.98657227

00:36:00.480 --> 00:36:01.540
and, either,

NOTE Confidence: 0.9716797

00:36:02.880 --> 00:36:03.380
cholangiocarcinoma,

NOTE Confidence: 0.9983724

00:36:04.480 --> 00:36:05.619
by tissue diagnosis

NOTE Confidence: 0.878323

00:36:06.000 --> 00:36:07.619
or mixed tumor, cholangiocarcinoma,

NOTE Confidence: 0.99121094

00:36:10.320 --> 00:36:11.540
that can be included.

NOTE Confidence: 0.8856201

00:36:13.175 --> 00:36:13.915
And, obviously,

NOTE Confidence: 0.991333

00:36:14.375 --> 00:36:15.195
there's no

NOTE Confidence: 0.93641883

00:36:15.495 --> 00:36:17.435
lymph node or some distance

NOTE Confidence: 0.93641883

00:36:17.495 --> 00:36:18.155
of metathesis,

NOTE Confidence: 0.86120605

00:36:18.775 --> 00:36:19.915
that would be excluded,

NOTE Confidence: 0.99820966

00:36:20.375 --> 00:36:21.275
from the criteria.

NOTE Confidence: 0.93965656

00:36:25.329 --> 00:36:27.250
And and, obviously, there's,

NOTE Confidence: 0.9207001

00:36:27.890 --> 00:36:29.650
patient need to tolerate the

NOTE Confidence: 0.9207001

00:36:29.650 --> 00:36:30.849
transplant, so the,

NOTE Confidence: 0.96655273

00:36:32.130 --> 00:36:32.630
cardiopulmonary

NOTE Confidence: 0.99609375

00:36:33.650 --> 00:36:35.430
function need to be appropriate.

NOTE Confidence: 0.9662737

00:36:38.385 --> 00:36:40.705
Workup and staging is, something

NOTE Confidence: 0.9662737

00:36:40.705 --> 00:36:41.605
similar to,

NOTE Confidence: 0.59472656

00:36:43.505 --> 00:36:44.005
as

NOTE Confidence: 0.5105591

00:36:44.305 --> 00:36:44.805
a,

NOTE Confidence: 0.9012587

00:36:45.905 --> 00:36:47.364
workup for, cholangiocarcinoma,

NOTE Confidence: 0.99210614

00:36:48.065 --> 00:36:49.445
MRI, CT scan,

NOTE Confidence: 0.9121582

00:36:50.385 --> 00:36:52.085
and then also PET scan.

NOTE Confidence: 0.9088745

00:36:54.420 --> 00:36:55.140
And we do need to

NOTE Confidence: 0.9088745

00:36:55.140 --> 00:36:56.200
have tissue diagnosis.

NOTE Confidence: 0.95544434

00:36:59.780 --> 00:37:01.080
So this is a major,

NOTE Confidence: 0.95544434

00:37:01.140 --> 00:37:01.640
probably,

NOTE Confidence: 0.97802734

00:37:01.940 --> 00:37:03.160
takeaway from,

NOTE Confidence: 0.99658203

00:37:03.620 --> 00:37:04.440
our protocol.

NOTE Confidence: 0.9198134

00:37:06.425 --> 00:37:07.325
So we don't,

NOTE Confidence: 0.9655762

00:37:08.505 --> 00:37:09.005
exclude,

NOTE Confidence: 0.90498734

00:37:09.705 --> 00:37:11.545
the size. If we let's

NOTE Confidence: 0.90498734

00:37:11.545 --> 00:37:13.085
say, even, like, ten centimeter

NOTE Confidence: 0.90498734

00:37:13.305 --> 00:37:13.805
cholangiocarcinoma,

NOTE Confidence: 0.83808595

00:37:14.744 --> 00:37:16.765
that's not necessarily the automatic,

NOTE Confidence: 0.9592285

00:37:17.385 --> 00:37:18.364
no for,

NOTE Confidence: 0.9992676

00:37:18.905 --> 00:37:19.724
that protocol.

NOTE Confidence: 0.7999573

00:37:21.660 --> 00:37:23.220
It's more important would be

NOTE Confidence: 0.7999573

00:37:23.220 --> 00:37:24.180
a tumor biology,

NOTE Confidence: 0.8883464

00:37:24.739 --> 00:37:26.440
has a response to neoadjuvant

NOTE Confidence: 0.8883464

00:37:26.660 --> 00:37:27.160
treatment.

NOTE Confidence: 0.94833994

00:37:28.180 --> 00:37:29.620
But we do we cut

NOTE Confidence: 0.94833994

00:37:29.700 --> 00:37:30.739
we make a cut with

NOTE Confidence: 0.94833994

00:37:30.739 --> 00:37:32.739
two centimeter versus above two

NOTE Confidence: 0.94833994

00:37:32.739 --> 00:37:34.600
centimeter. Below the two centimeter,

NOTE Confidence: 0.8910598

00:37:36.114 --> 00:37:37.395
the patient will go, like,

NOTE Confidence: 0.8910598

00:37:37.395 --> 00:37:38.535
hypocerebral carcinoma,

NOTE Confidence: 0.83999026

00:37:39.075 --> 00:37:40.695
going to have a neoadsibone

NOTE Confidence: 0.8408203

00:37:40.995 --> 00:37:42.995
treatment such as particularly for

NOTE Confidence: 0.8408203

00:37:42.995 --> 00:37:44.515
this is, like, Y ninety

NOTE Confidence: 0.8408203

00:37:44.515 --> 00:37:45.015
or,

NOTE Confidence: 0.83297294

00:37:45.635 --> 00:37:47.475
radiation based, that'd be better.

NOTE Confidence: 0.83297294

00:37:47.475 --> 00:37:48.690
But, abrasion,

NOTE Confidence: 0.98738605

00:37:49.870 --> 00:37:50.850
try to maintain,

NOTE Confidence: 0.98945314

00:37:51.469 --> 00:37:52.930
for the next six months.

NOTE Confidence: 0.9921875

00:37:53.870 --> 00:37:54.370
Then,

NOTE Confidence: 0.6899007

00:37:56.830 --> 00:37:58.130
the, patient may,

NOTE Confidence: 0.9428362

00:37:59.150 --> 00:38:00.684
have a MET score. So

NOTE Confidence: 0.9428362

00:38:00.684 --> 00:38:01.505
the transplantation,

NOTE Confidence: 0.9444755

00:38:02.605 --> 00:38:04.285
from deceased donor is a

NOTE Confidence: 0.9444755

00:38:04.285 --> 00:38:05.265
feasible option.

NOTE Confidence: 0.8315633

00:38:05.805 --> 00:38:08.224
Now if above two centimeter

NOTE Confidence: 0.8315633

00:38:08.444 --> 00:38:09.665
or mars multifocal,

NOTE Confidence: 0.89801025

00:38:11.964 --> 00:38:12.464
cholangiocarcinoma

NOTE Confidence: 0.987854

00:38:13.910 --> 00:38:16.010
And then, we mandated,

NOTE Confidence: 0.76447755

00:38:16.950 --> 00:38:19.370
neosporin the chemo treatment, essentially,

NOTE Confidence: 0.9980469

00:38:20.390 --> 00:38:21.430
and then to see the

NOTE Confidence: 0.9980469

00:38:21.430 --> 00:38:21.930
response.

NOTE Confidence: 0.9904785

00:38:22.870 --> 00:38:24.250
The issue is,

NOTE Confidence: 0.9740668

00:38:25.590 --> 00:38:26.890
above three centimeter,

NOTE Confidence: 0.90789115

00:38:29.435 --> 00:38:30.875
the UNOS does not give

NOTE Confidence: 0.90789115

00:38:30.875 --> 00:38:33.195
you exception point. So so

NOTE Confidence: 0.90789115

00:38:33.195 --> 00:38:34.635
that means if you have

NOTE Confidence: 0.90789115

00:38:34.635 --> 00:38:35.935
a multiple multifocal,

NOTE Confidence: 0.9776001

00:38:37.594 --> 00:38:38.094
cholangiocarcinoma

NOTE Confidence: 0.9338379

00:38:38.875 --> 00:38:39.375
or,

NOTE Confidence: 0.98657227

00:38:40.235 --> 00:38:40.735
if,

NOTE Confidence: 0.8564453

00:38:41.515 --> 00:38:42.015
above,

NOTE Confidence: 0.9605306

00:38:43.520 --> 00:38:44.660
above three centimeter

NOTE Confidence: 0.984375

00:38:45.280 --> 00:38:45.780
tumor,

NOTE Confidence: 0.9909668

00:38:46.400 --> 00:38:46.900
then,

NOTE Confidence: 0.9225098

00:38:47.440 --> 00:38:48.800
the only option will be

NOTE Confidence: 0.9225098

00:38:48.800 --> 00:38:50.339
a living donor liver transplant.

NOTE Confidence: 0.902771

00:38:50.800 --> 00:38:51.839
So that's the only,

NOTE Confidence: 0.95477295

00:38:52.239 --> 00:38:53.520
the problem is. But,

NOTE Confidence: 0.55371094

00:38:54.319 --> 00:38:55.219
none of this,

NOTE Confidence: 0.9417307

00:38:57.165 --> 00:38:59.085
We will be able to

NOTE Confidence: 0.9417307

00:38:59.085 --> 00:39:01.085
see the tumor biology. So

NOTE Confidence: 0.9417307

00:39:01.085 --> 00:39:02.364
if it's have a response

NOTE Confidence: 0.9417307

00:39:02.364 --> 00:39:03.405
to it, even to, like,

NOTE Confidence: 0.9417307

00:39:03.405 --> 00:39:05.265
say, ten centimeter chorangiocarcinoma,

NOTE Confidence: 0.9770508

00:39:06.844 --> 00:39:08.605
if you, if the patient

NOTE Confidence: 0.9770508

00:39:08.605 --> 00:39:10.305
have a good tumor response,

NOTE Confidence: 0.92458767

00:39:10.685 --> 00:39:11.745
to a chemo,

NOTE Confidence: 0.9784953

00:39:12.660 --> 00:39:13.619
as far as the living

NOTE Confidence: 0.9784953

00:39:13.619 --> 00:39:15.780
donor is available, then, we

NOTE Confidence: 0.9784953

00:39:15.780 --> 00:39:16.520
we will,

NOTE Confidence: 0.9445801

00:39:17.460 --> 00:39:19.079
after we discuss in,

NOTE Confidence: 0.88916016

00:39:20.660 --> 00:39:22.339
tumor board and also, the

NOTE Confidence: 0.88916016

00:39:22.339 --> 00:39:22.839
meeting,

NOTE Confidence: 0.8964844

00:39:23.140 --> 00:39:23.800
we will,

NOTE Confidence: 0.8439331

00:39:25.219 --> 00:39:26.739
trying to go for live

NOTE Confidence: 0.8439331

00:39:26.739 --> 00:39:27.800
donor liver transplant.

NOTE Confidence: 0.8569336

00:39:32.475 --> 00:39:33.995
So, again, this is something

NOTE Confidence: 0.8569336

00:39:34.075 --> 00:39:35.435
it's it's the same,

NOTE Confidence: 0.9758301

00:39:35.755 --> 00:39:36.655
same same,

NOTE Confidence: 0.98095703

00:39:37.195 --> 00:39:38.335
same in a different,

NOTE Confidence: 0.786499

00:39:39.755 --> 00:39:40.900
color, but,

NOTE Confidence: 0.9318472

00:39:41.380 --> 00:39:43.060
so two centimeter and above

NOTE Confidence: 0.9318472

00:39:43.060 --> 00:39:44.340
two centimeter. This is a

NOTE Confidence: 0.9318472

00:39:44.340 --> 00:39:45.719
year year's protocol.

NOTE Confidence: 0.95458984

00:39:46.660 --> 00:39:48.500
Each institution have a different

NOTE Confidence: 0.95458984

00:39:48.500 --> 00:39:49.140
protocol, but,

NOTE Confidence: 0.9946289

00:39:50.580 --> 00:39:52.200
we are open to,

NOTE Confidence: 0.93025714

00:39:52.980 --> 00:39:54.520
have this, patient,

NOTE Confidence: 0.9252581

00:39:56.424 --> 00:39:57.944
coming to this protocol. We

NOTE Confidence: 0.9252581

00:39:57.944 --> 00:39:58.605
we just,

NOTE Confidence: 0.7426758

00:39:59.065 --> 00:39:59.964
kind of finalized

NOTE Confidence: 0.9038086

00:40:00.505 --> 00:40:01.565
few months ago.

NOTE Confidence: 0.9753418

00:40:04.025 --> 00:40:04.525
And,

NOTE Confidence: 0.9896918

00:40:05.785 --> 00:40:07.625
it's important to have a

NOTE Confidence: 0.9896918

00:40:07.625 --> 00:40:08.125
postoperative,

NOTE Confidence: 0.661499

00:40:09.704 --> 00:40:10.924
tree surveillance.

NOTE Confidence: 0.982666

00:40:11.589 --> 00:40:12.089
So,

NOTE Confidence: 0.8898926

00:40:13.589 --> 00:40:14.089
MRI,

NOTE Confidence: 0.90112305

00:40:14.790 --> 00:40:16.790
over abdomen and also the

NOTE Confidence: 0.90112305

00:40:16.790 --> 00:40:18.730
CT scan of chest. That's

NOTE Confidence: 0.90112305

00:40:18.869 --> 00:40:20.309
every three months, every six

NOTE Confidence: 0.90112305

00:40:20.309 --> 00:40:20.809
months,

NOTE Confidence: 0.9326172

00:40:21.510 --> 00:40:21.989
and then,

NOTE Confidence: 0.8383179

00:40:23.685 --> 00:40:24.885
so creating tumor DNA,

NOTE Confidence: 0.9940796

00:40:26.245 --> 00:40:27.445
and then we will,

NOTE Confidence: 0.90427655

00:40:27.844 --> 00:40:29.285
do a surveillance like a

NOTE Confidence: 0.90427655

00:40:29.285 --> 00:40:31.625
hepatocellular carcinoma post reverse transplantation.

NOTE Confidence: 0.8314073

00:40:37.489 --> 00:40:38.690
I think because we missed

NOTE Confidence: 0.8314073

00:40:38.690 --> 00:40:40.070
one one side maybe.

NOTE Confidence: 0.8656616

00:40:42.130 --> 00:40:42.770
Oh, here.

NOTE Confidence: 0.853418

00:40:43.650 --> 00:40:45.430
After the transplant, email suppression,

NOTE Confidence: 0.7809601

00:40:47.250 --> 00:40:48.930
user reusing attack or emails

NOTE Confidence: 0.7809601

00:40:48.930 --> 00:40:49.750
in the beginning,

NOTE Confidence: 0.90709734

00:40:50.975 --> 00:40:52.415
but at least from a

NOTE Confidence: 0.90709734

00:40:52.415 --> 00:40:54.575
certain point or earlier or

NOTE Confidence: 0.90709734

00:40:54.575 --> 00:40:56.175
some selected case even from

NOTE Confidence: 0.90709734

00:40:56.175 --> 00:40:56.835
the beginning,

NOTE Confidence: 0.84903973

00:40:57.295 --> 00:40:58.114
we were using,

NOTE Confidence: 0.97229004

00:40:58.495 --> 00:40:58.995
rapamycin.

NOTE Confidence: 0.94661456

00:41:00.015 --> 00:41:00.515
That's,

NOTE Confidence: 0.9783203

00:41:01.614 --> 00:41:03.549
that'd be a potential benefit,

NOTE Confidence: 0.92195636

00:41:04.030 --> 00:41:05.730
for antitumor effect,

NOTE Confidence: 0.9796956

00:41:06.829 --> 00:41:07.809
and then corticosteroid

NOTE Confidence: 0.9996745

00:41:08.349 --> 00:41:09.489
for three months.

NOTE Confidence: 0.9990932

00:41:13.150 --> 00:41:14.510
And back to in terms

NOTE Confidence: 0.9990932

00:41:14.510 --> 00:41:15.170
of surgery,

NOTE Confidence: 0.82336426

00:41:15.469 --> 00:41:16.190
there's some,

NOTE Confidence: 0.8515625

00:41:17.135 --> 00:41:17.635
things,

NOTE Confidence: 0.89664716

00:41:18.255 --> 00:41:19.315
it's important. We

NOTE Confidence: 0.85805935

00:41:20.815 --> 00:41:22.255
actually, generally speaking, it's a,

NOTE Confidence: 0.85805935

00:41:22.255 --> 00:41:24.094
you know, liver transplant program

NOTE Confidence: 0.85805935

00:41:24.094 --> 00:41:25.555
we're using in machine perfusion.

NOTE Confidence: 0.9069073

00:41:26.575 --> 00:41:27.934
So once the liver is

NOTE Confidence: 0.9069073

00:41:27.934 --> 00:41:29.775
out, from deceased donor, we

NOTE Confidence: 0.9069073

00:41:29.775 --> 00:41:30.915
put into the

NOTE Confidence: 0.8893636

00:41:31.219 --> 00:41:32.920
normal thermic machine perfusion.

NOTE Confidence: 0.9637357

00:41:33.380 --> 00:41:35.539
You know, normal, oxygenated blood

NOTE Confidence: 0.9637357

00:41:35.539 --> 00:41:37.140
is coming in. So you

NOTE Confidence: 0.9637357

00:41:37.140 --> 00:41:38.119
don't have to,

NOTE Confidence: 0.93742293

00:41:39.140 --> 00:41:41.219
rushing into the transplant within

NOTE Confidence: 0.93742293

00:41:41.219 --> 00:41:42.920
eight hours or twelve hours.

NOTE Confidence: 0.93742293

00:41:43.059 --> 00:41:44.864
We can wait. So what

NOTE Confidence: 0.93742293

00:41:44.864 --> 00:41:46.085
does that means is

NOTE Confidence: 0.8244955

00:41:46.465 --> 00:41:47.685
this case, hepatectomy,

NOTE Confidence: 0.8015137

00:41:48.625 --> 00:41:49.125
maybe,

NOTE Confidence: 0.9659424

00:41:49.585 --> 00:41:50.785
a little bit tricky because

NOTE Confidence: 0.9659424

00:41:50.785 --> 00:41:52.165
of radiation, chemotherapy.

NOTE Confidence: 0.9541728

00:41:54.864 --> 00:41:56.545
So but we we can

NOTE Confidence: 0.9541728

00:41:56.545 --> 00:41:57.870
take a time to do

NOTE Confidence: 0.9541728

00:41:57.870 --> 00:41:58.489
a hepatectomy

NOTE Confidence: 0.9399414

00:41:58.870 --> 00:42:00.790
about removing the liver and

NOTE Confidence: 0.9399414

00:42:00.790 --> 00:42:02.090
put the livers in.

NOTE Confidence: 0.74975586

00:42:03.270 --> 00:42:04.090
And particularly

NOTE Confidence: 0.875746

00:42:04.790 --> 00:42:05.910
radiation, we have to be

NOTE Confidence: 0.875746

00:42:05.910 --> 00:42:07.590
careful about, tilia and the

NOTE Confidence: 0.875746

00:42:07.590 --> 00:42:08.810
biliary reconstructions.

NOTE Confidence: 0.87124026

00:42:09.605 --> 00:42:11.224
And living donor is certainly,

NOTE Confidence: 0.976237

00:42:12.164 --> 00:42:13.145
could be a,

NOTE Confidence: 0.9935303

00:42:13.605 --> 00:42:14.424
very important,

NOTE Confidence: 0.9447266

00:42:15.045 --> 00:42:16.825
role, particularly for the patient,

NOTE Confidence: 0.9855686

00:42:17.444 --> 00:42:18.664
above three centimeter,

NOTE Confidence: 0.94744194

00:42:19.045 --> 00:42:21.145
chorangio or multiple chorangiocarcinoma.

NOTE Confidence: 0.9677192

00:42:21.844 --> 00:42:22.984
As far as they have

NOTE Confidence: 0.9677192

00:42:23.250 --> 00:42:24.790
good response to chemotherapy,

NOTE Confidence: 0.98779297

00:42:26.610 --> 00:42:27.350
these are,

NOTE Confidence: 0.9459961

00:42:27.969 --> 00:42:30.070
good candidates for liver transplantation.

NOTE Confidence: 0.9963379

00:42:34.130 --> 00:42:36.070
So my key, key takeaway

NOTE Confidence: 0.90625

00:42:36.370 --> 00:42:36.870
is,

NOTE Confidence: 0.9049072

00:42:37.875 --> 00:42:39.715
always r zero resection is,

NOTE Confidence: 0.9049072

00:42:39.955 --> 00:42:42.135
most important from surgical standpoint.

NOTE Confidence: 0.9970703

00:42:43.555 --> 00:42:44.055
Anatomy

NOTE Confidence: 0.9206543

00:42:44.355 --> 00:42:45.895
where the location is,

NOTE Confidence: 0.9923706

00:42:46.355 --> 00:42:48.614
that dictates surgical treatment.

NOTE Confidence: 0.99072266

00:42:49.875 --> 00:42:50.775
Liver transplant

NOTE Confidence: 0.9460449

00:42:51.150 --> 00:42:51.549
patient,

NOTE Confidence: 0.8856201

00:42:51.950 --> 00:42:53.489
outcome seems like transformative

NOTE Confidence: 0.9082031

00:42:54.109 --> 00:42:54.930
for selected,

NOTE Confidence: 0.756709

00:42:56.190 --> 00:42:58.289
CT scan tumor or intrahepatic,

NOTE Confidence: 0.876988

00:42:59.469 --> 00:42:59.969
craniocarcinoma.

NOTE Confidence: 0.9827474

00:43:02.109 --> 00:43:02.609
Multidisciplinary

NOTE Confidence: 0.9458008

00:43:03.309 --> 00:43:04.770
management is essential,

NOTE Confidence: 0.9472656

00:43:05.390 --> 00:43:05.890
and,

NOTE Confidence: 0.94555664

00:43:06.875 --> 00:43:07.375
obviously,

NOTE Confidence: 0.90220135

00:43:08.234 --> 00:43:10.895
hepatologist and medical oncologist, radiation

NOTE Confidence: 0.90220135

00:43:11.114 --> 00:43:11.614
oncologist,

NOTE Confidence: 0.84399414

00:43:12.474 --> 00:43:13.694
intervention radiologist.

NOTE Confidence: 0.9855957

00:43:13.994 --> 00:43:14.395
And,

NOTE Confidence: 0.6873779

00:43:14.875 --> 00:43:15.375
so,

NOTE Confidence: 0.86816406

00:43:15.835 --> 00:43:17.114
you know, it's a cancer

NOTE Confidence: 0.86816406

00:43:17.114 --> 00:43:18.974
treatment is generally speaking,

NOTE Confidence: 0.9720628

00:43:20.030 --> 00:43:21.650
we do this, but particularly

NOTE Confidence: 0.9720628

00:43:21.869 --> 00:43:23.089
so for chorangiocarcinoma,

NOTE Confidence: 0.6085205

00:43:24.510 --> 00:43:25.550
in very,

NOTE Confidence: 0.99401855

00:43:26.030 --> 00:43:27.089
surgical treatment.

NOTE Confidence: 0.99121094

00:43:28.750 --> 00:43:29.469
And then,

NOTE Confidence: 0.8713379

00:43:29.790 --> 00:43:31.010
emerging therapies,

NOTE Confidence: 0.84609985

00:43:31.390 --> 00:43:32.989
changing the landscape including a

NOTE Confidence: 0.84609985

00:43:32.989 --> 00:43:34.290
transplant, but immunotherapies,

NOTE Confidence: 0.86794025

00:43:35.825 --> 00:43:37.025
I I think that's be

NOTE Confidence: 0.86794025

00:43:37.025 --> 00:43:37.525
a

NOTE Confidence: 0.9326172

00:43:37.905 --> 00:43:38.405
good,

NOTE Confidence: 0.9029948

00:43:39.025 --> 00:43:40.945
transition to next speaker, I

NOTE Confidence: 0.9029948

00:43:40.945 --> 00:43:41.445
believe.

NOTE Confidence: 0.9814453

00:43:42.945 --> 00:43:44.645
Doctor Sogoa, that was amazing.

NOTE Confidence: 0.9814453

00:43:44.705 --> 00:43:45.745
Thank you so much. It

NOTE Confidence: 0.9814453

00:43:45.745 --> 00:43:47.045
really shows that

NOTE Confidence: 0.98483783

00:43:47.345 --> 00:43:48.625
so much has changed and

NOTE Confidence: 0.98483783

00:43:48.625 --> 00:43:50.225
evolved in the space of

NOTE Confidence: 0.98483783

00:43:50.225 --> 00:43:51.125
managing cholangiocarcinoma

NOTE Confidence: 0.99438477

00:43:52.109 --> 00:43:53.309
and allowing for more hope

NOTE Confidence: 0.99438477

00:43:53.309 --> 00:43:54.589
and better options for our

NOTE Confidence: 0.99438477

00:43:54.589 --> 00:43:56.190
patients. So thank you so

NOTE Confidence: 0.99438477

00:43:56.190 --> 00:43:57.410
much. I will

NOTE Confidence: 1

00:43:57.710 --> 00:43:59.329
now begin to discuss

NOTE Confidence: 0.9391276

00:43:59.950 --> 00:44:01.809
systemic therapy in the perioperative

NOTE Confidence: 0.9751994

00:44:02.269 --> 00:44:03.710
setting. If you wanna just

NOTE Confidence: 0.9751994

00:44:03.710 --> 00:44:05.069
stop sharing screen, and I

NOTE Confidence: 0.9751994

00:44:05.069 --> 00:44:06.049
will hopefully

NOTE Confidence: 0.99991864

00:44:06.585 --> 00:44:07.305
be able to do the

NOTE Confidence: 0.99991864

00:44:07.305 --> 00:44:07.805
same.

NOTE Confidence: 0.9970703

00:44:08.984 --> 00:44:09.484
Yep.

NOTE Confidence: 0.99975586

00:44:10.344 --> 00:44:11.964
Thank you. Thank you.

NOTE Confidence: 0.8974067

00:44:21.339 --> 00:44:22.380
I think as you said,

NOTE Confidence: 0.8974067

00:44:22.380 --> 00:44:23.359
that was a great

NOTE Confidence: 0.9713826

00:44:23.900 --> 00:44:26.640
transition to discussing systemic therapy.

NOTE Confidence: 0.9713826

00:44:26.780 --> 00:44:27.980
When we think about all

NOTE Confidence: 0.9713826

00:44:27.980 --> 00:44:29.980
that doctor Sogawa, doctor Straza

NOTE Confidence: 0.9713826

00:44:29.980 --> 00:44:31.420
Bosco has shared this evening

NOTE Confidence: 0.9713826

00:44:31.420 --> 00:44:33.020
so far, I think that

NOTE Confidence: 0.9713826

00:44:33.020 --> 00:44:34.219
it's now a good time

NOTE Confidence: 0.9713826

00:44:34.219 --> 00:44:35.420
to discuss, well, what do

NOTE Confidence: 0.9713826

00:44:35.420 --> 00:44:37.094
we do in the perioperative

NOTE Confidence: 0.9840698

00:44:37.395 --> 00:44:38.755
setting? So I will spend

NOTE Confidence: 0.9840698

00:44:38.755 --> 00:44:39.895
some time discussing

NOTE Confidence: 0.99720985

00:44:40.435 --> 00:44:42.035
options for patients in the

NOTE Confidence: 0.99720985

00:44:42.035 --> 00:44:43.335
neoadjuvant setting.

NOTE Confidence: 0.9627475

00:44:43.955 --> 00:44:45.315
I will review a couple

NOTE Confidence: 0.9627475

00:44:45.315 --> 00:44:46.835
of studies, but also keep

NOTE Confidence: 0.9627475

00:44:46.835 --> 00:44:48.435
our time, in mind as

NOTE Confidence: 0.9627475

00:44:48.435 --> 00:44:50.160
well. But I'll also discuss

NOTE Confidence: 0.9627475

00:44:50.219 --> 00:44:52.080
adjuvant therapy as doctor Sogawa

NOTE Confidence: 0.9627475

00:44:52.140 --> 00:44:53.760
very briefly alluded to.

NOTE Confidence: 0.96632165

00:44:54.140 --> 00:44:56.380
I will discuss hepatic arterial

NOTE Confidence: 0.96632165

00:44:56.380 --> 00:44:58.060
infusion therapy, but save a

NOTE Confidence: 0.96632165

00:44:58.060 --> 00:44:58.940
little bit of time for

NOTE Confidence: 0.96632165

00:44:58.940 --> 00:45:00.300
my colleague, doctor Zeng, to

NOTE Confidence: 0.96632165

00:45:00.300 --> 00:45:01.760
discuss that as well briefly.

NOTE Confidence: 0.99986047

00:45:02.125 --> 00:45:03.485
And then we will end

NOTE Confidence: 0.99986047

00:45:03.485 --> 00:45:04.385
with discussing

NOTE Confidence: 0.99858946

00:45:04.685 --> 00:45:06.225
metastatic and unresectable

NOTE Confidence: 1

00:45:06.685 --> 00:45:07.185
management.

NOTE Confidence: 0.9945571

00:45:09.405 --> 00:45:11.885
For biliary tract cancers, there's

NOTE Confidence: 0.9945571

00:45:11.885 --> 00:45:13.165
evidence that the use of

NOTE Confidence: 0.9945571

00:45:13.165 --> 00:45:15.425
chemotherapy is appropriate in nearly

NOTE Confidence: 0.9945571

00:45:15.485 --> 00:45:16.305
all settings,

NOTE Confidence: 0.96655273

00:45:16.809 --> 00:45:17.309
especially,

NOTE Confidence: 0.9513463

00:45:17.849 --> 00:45:19.289
in the adjuvant setting, but

NOTE Confidence: 0.9513463

00:45:19.289 --> 00:45:20.030
most importantly,

NOTE Confidence: 0.94577366

00:45:20.569 --> 00:45:22.089
as doctor Zhang will discuss,

NOTE Confidence: 0.94577366

00:45:22.089 --> 00:45:23.630
in the metastatic setting.

NOTE Confidence: 0.9940314

00:45:24.410 --> 00:45:25.690
But there has been recent

NOTE Confidence: 0.9940314

00:45:25.690 --> 00:45:28.089
data that further supports what

NOTE Confidence: 0.9940314

00:45:28.089 --> 00:45:29.369
are options that we can

NOTE Confidence: 0.9940314

00:45:29.369 --> 00:45:31.230
consider in the neoadjuvant

NOTE Confidence: 0.9980469

00:45:31.770 --> 00:45:32.175
setting.

NOTE Confidence: 0.98520505

00:45:32.735 --> 00:45:33.855
I'm going to spend some

NOTE Confidence: 0.98520505

00:45:33.855 --> 00:45:35.455
time first discussing what our

NOTE Confidence: 0.98520505

00:45:35.455 --> 00:45:37.295
options are currently that are

NOTE Confidence: 0.98520505

00:45:37.295 --> 00:45:39.315
evolving in the neoadjuvant setting.

NOTE Confidence: 0.9016113

00:45:39.855 --> 00:45:40.995
And that particularly,

NOTE Confidence: 0.94699246

00:45:41.535 --> 00:45:43.055
as I have listed here,

NOTE Confidence: 0.94699246

00:45:43.055 --> 00:45:44.975
is the ZsaB NEOGOLD study,

NOTE Confidence: 0.94699246

00:45:44.975 --> 00:45:46.114
which was just published,

NOTE Confidence: 0.91355544

00:45:46.460 --> 00:45:47.580
I think, maybe less than

NOTE Confidence: 0.91355544

00:45:47.580 --> 00:45:48.940
a couple months ago but

NOTE Confidence: 0.91355544

00:45:48.940 --> 00:45:50.079
earlier this year.

NOTE Confidence: 0.93698955

00:45:50.619 --> 00:45:51.900
And there is an open

NOTE Confidence: 0.93698955

00:45:51.900 --> 00:45:53.259
clinical trial, which I will

NOTE Confidence: 0.93698955

00:45:53.259 --> 00:45:53.759
discuss,

NOTE Confidence: 0.8557129

00:45:54.539 --> 00:45:56.160
also the BILCAP study,

NOTE Confidence: 0.9817592

00:45:56.779 --> 00:45:57.900
and then, as I said,

NOTE Confidence: 0.9817592

00:45:57.900 --> 00:45:58.960
HAI therapy.

NOTE Confidence: 0.98502606

00:46:04.135 --> 00:46:05.675
I now will briefly discuss

NOTE Confidence: 0.98502606

00:46:05.735 --> 00:46:07.515
the neoadjuvant gulp study.

NOTE Confidence: 0.9903041

00:46:08.855 --> 00:46:10.695
The neoadjuvant gulp study was

NOTE Confidence: 0.9903041

00:46:10.695 --> 00:46:12.695
recently published, and what that

NOTE Confidence: 0.9903041

00:46:12.695 --> 00:46:14.075
study looked at ultimately

NOTE Confidence: 0.99455565

00:46:14.375 --> 00:46:15.830
was the role of neoadjuvant

NOTE Confidence: 0.9980469

00:46:16.290 --> 00:46:16.790
chemotherapy

NOTE Confidence: 0.8713379

00:46:17.570 --> 00:46:18.390
plus immunotherapy

NOTE Confidence: 0.9751465

00:46:18.770 --> 00:46:21.010
plus targeted therapy for patients,

NOTE Confidence: 0.9921875

00:46:21.330 --> 00:46:22.310
using specifically

NOTE Confidence: 0.58251953

00:46:22.770 --> 00:46:23.270
GemOx

NOTE Confidence: 0.88964844

00:46:23.970 --> 00:46:24.790
plus lenvatinib

NOTE Confidence: 0.9430746

00:46:25.650 --> 00:46:26.470
and torapalumab.

NOTE Confidence: 0.9984976

00:46:27.455 --> 00:46:28.735
This is not a commonly

NOTE Confidence: 0.9984976

00:46:28.735 --> 00:46:30.015
used regimen when we think

NOTE Confidence: 0.9984976

00:46:30.015 --> 00:46:30.915
about the combination

NOTE Confidence: 0.94889325

00:46:31.375 --> 00:46:32.895
of this particular regimen, but,

NOTE Confidence: 0.94889325

00:46:32.895 --> 00:46:33.395
certainly,

NOTE Confidence: 0.9690959

00:46:33.775 --> 00:46:35.695
GemOx is a very known

NOTE Confidence: 0.9690959

00:46:35.775 --> 00:46:37.135
well known regimen in the

NOTE Confidence: 0.9690959

00:46:37.135 --> 00:46:38.035
setting of

NOTE Confidence: 0.9995117

00:46:38.655 --> 00:46:39.155
metastatic

NOTE Confidence: 0.98657227

00:46:39.880 --> 00:46:41.239
therapy in the biliary tract

NOTE Confidence: 0.98657227

00:46:41.239 --> 00:46:43.000
setting. And then we also,

NOTE Confidence: 0.98657227

00:46:43.000 --> 00:46:44.359
as we know, have evidence

NOTE Confidence: 0.98657227

00:46:44.359 --> 00:46:45.099
for immunotherapy

NOTE Confidence: 0.98462987

00:46:45.400 --> 00:46:46.700
in this setting as well.

NOTE Confidence: 0.98462987

00:46:46.920 --> 00:46:48.040
And furthermore, just to give

NOTE Confidence: 0.98462987

00:46:48.040 --> 00:46:48.920
you a little bit of

NOTE Confidence: 0.98462987

00:46:48.920 --> 00:46:50.359
history, it builds upon prior

NOTE Confidence: 0.98462987

00:46:50.359 --> 00:46:51.640
work that this team had

NOTE Confidence: 0.98462987

00:46:51.640 --> 00:46:53.340
established looking at this regimen

NOTE Confidence: 0.98462987

00:46:53.480 --> 00:46:54.885
for patients, but more so

NOTE Confidence: 0.98462987

00:46:54.885 --> 00:46:55.945
in the unresectable

NOTE Confidence: 0.88582355

00:46:56.325 --> 00:46:58.565
setting trying to convert these

NOTE Confidence: 0.88582355

00:46:58.565 --> 00:46:59.065
patients.

NOTE Confidence: 0.9898953

00:47:00.005 --> 00:47:02.085
This particular study, however, it

NOTE Confidence: 0.9898953

00:47:02.085 --> 00:47:03.605
enrolled one hundred and seventy

NOTE Confidence: 0.9898953

00:47:03.605 --> 00:47:04.645
eight patients as I have

NOTE Confidence: 0.9898953

00:47:04.645 --> 00:47:06.185
listed here, specifically

NOTE Confidence: 0.9880744

00:47:06.485 --> 00:47:07.925
looking at patients with high

NOTE Confidence: 0.9880744

00:47:07.925 --> 00:47:09.619
risk intrahepatic cholangiocarcinoma.

NOTE Confidence: 0.940258

00:47:10.960 --> 00:47:12.799
And patients or, actually, those

NOTE Confidence: 0.940258

00:47:12.799 --> 00:47:14.000
in the audience may consider,

NOTE Confidence: 0.940258

00:47:14.000 --> 00:47:15.119
well, what is high risk?

NOTE Confidence: 0.940258

00:47:15.119 --> 00:47:16.559
And that has been in

NOTE Confidence: 0.940258

00:47:16.559 --> 00:47:18.400
this study and oftentimes other

NOTE Confidence: 0.940258

00:47:18.400 --> 00:47:19.760
studies defined as a large

NOTE Confidence: 0.940258

00:47:19.760 --> 00:47:20.660
tumor size,

NOTE Confidence: 0.99560547

00:47:21.965 --> 00:47:23.185
multifocal disease,

NOTE Confidence: 0.99975586

00:47:23.485 --> 00:47:24.705
vascular invasion,

NOTE Confidence: 0.97276473

00:47:25.325 --> 00:47:26.705
hepatic portal lymphadenopathy

NOTE Confidence: 0.9312744

00:47:27.085 --> 00:47:28.125
or lymph nodes, I should

NOTE Confidence: 0.9312744

00:47:28.125 --> 00:47:28.625
say,

NOTE Confidence: 0.9025391

00:47:29.005 --> 00:47:31.265
or increased CA nineteen nine,

NOTE Confidence: 0.9883355

00:47:32.525 --> 00:47:34.285
which I previously reviewed when

NOTE Confidence: 0.9883355

00:47:34.285 --> 00:47:35.985
I first started discussing prognostic

NOTE Confidence: 0.9883355

00:47:36.205 --> 00:47:37.380
factors. So you can certainly

NOTE Confidence: 0.9883355

00:47:37.380 --> 00:47:38.599
see the overlap.

NOTE Confidence: 0.9918213

00:47:39.380 --> 00:47:41.380
Patients were randomized to receive

NOTE Confidence: 0.9918213

00:47:41.380 --> 00:47:41.880
neoadjuvant

NOTE Confidence: 0.93494236

00:47:42.259 --> 00:47:43.539
gulp, which I just reviewed

NOTE Confidence: 0.93494236

00:47:43.539 --> 00:47:44.279
that regimen,

NOTE Confidence: 0.93847656

00:47:44.660 --> 00:47:46.739
versus upfront surgery. And all

NOTE Confidence: 0.93847656

00:47:46.739 --> 00:47:48.039
of the patients enrolled

NOTE Confidence: 0.9996745

00:47:48.420 --> 00:47:49.700
were then treated with eight

NOTE Confidence: 0.9996745

00:47:49.700 --> 00:47:51.400
cycles of adjuvant capecitabine.

NOTE Confidence: 0.9685547

00:47:52.415 --> 00:47:54.015
The primary endpoint for this

NOTE Confidence: 0.9685547

00:47:54.015 --> 00:47:55.955
study was event free survival.

NOTE Confidence: 0.9949463

00:47:56.655 --> 00:47:57.855
And I think what's really

NOTE Confidence: 0.9949463

00:47:57.855 --> 00:47:59.214
important is that it's the

NOTE Confidence: 0.9949463

00:47:59.214 --> 00:48:00.974
first randomized study to show

NOTE Confidence: 0.9949463

00:48:00.974 --> 00:48:02.835
evidence for new adjuvant therapy

NOTE Confidence: 1

00:48:03.135 --> 00:48:05.234
in this particular clinical space.

NOTE Confidence: 0.96985286

00:48:09.270 --> 00:48:10.630
The results are shown here,

NOTE Confidence: 0.96985286

00:48:10.870 --> 00:48:12.150
sharing the Kaplan Meier as

NOTE Confidence: 0.96985286

00:48:12.150 --> 00:48:12.790
you can see in the

NOTE Confidence: 0.96985286

00:48:12.790 --> 00:48:13.989
bottom right, but a hundred

NOTE Confidence: 0.96985286

00:48:13.989 --> 00:48:15.110
and seventy eight patients were

NOTE Confidence: 0.96985286

00:48:15.110 --> 00:48:16.330
randomized as I mentioned,

NOTE Confidence: 0.99541557

00:48:16.710 --> 00:48:18.310
and eighty eight patients were

NOTE Confidence: 0.99541557

00:48:18.310 --> 00:48:19.530
randomized to the neoadjuvant

NOTE Confidence: 0.9925842

00:48:19.910 --> 00:48:21.525
group. Important to know when

NOTE Confidence: 0.9925842

00:48:21.525 --> 00:48:22.964
reviewing the table one that

NOTE Confidence: 0.9925842

00:48:22.964 --> 00:48:24.565
there was an overall even

NOTE Confidence: 0.9925842

00:48:24.565 --> 00:48:25.065
distribution

NOTE Confidence: 0.9996745

00:48:25.605 --> 00:48:26.505
of the characteristics

NOTE Confidence: 0.97585225

00:48:26.805 --> 00:48:28.165
in each of the arms

NOTE Confidence: 0.97585225

00:48:28.165 --> 00:48:29.464
as far as the characteristics

NOTE Confidence: 0.97585225

00:48:29.685 --> 00:48:30.185
specifically

NOTE Confidence: 0.98010254

00:48:30.724 --> 00:48:31.864
considering stage,

NOTE Confidence: 0.9301758

00:48:32.325 --> 00:48:34.739
CA ninety nine, performance status,

NOTE Confidence: 0.9921875

00:48:35.219 --> 00:48:36.600
and tumor characteristics.

NOTE Confidence: 0.9954625

00:48:38.020 --> 00:48:39.219
One may ask, well, how

NOTE Confidence: 0.9954625

00:48:39.219 --> 00:48:40.580
many of the patients actually

NOTE Confidence: 0.9954625

00:48:40.580 --> 00:48:42.660
completed the neoadjuvant therapy? And

NOTE Confidence: 0.9954625

00:48:42.660 --> 00:48:43.780
it's important to note that

NOTE Confidence: 0.9954625

00:48:43.780 --> 00:48:44.820
ninety four percent of the

NOTE Confidence: 0.9954625

00:48:44.820 --> 00:48:47.219
neoadjuvant group actually did complete

NOTE Confidence: 0.9954625

00:48:47.219 --> 00:48:48.600
all of the planned cycles.

NOTE Confidence: 0.9499381

00:48:49.805 --> 00:48:52.045
The median event for event

NOTE Confidence: 0.9499381

00:48:52.045 --> 00:48:53.645
free survival or EFS was

NOTE Confidence: 0.9499381

00:48:53.645 --> 00:48:55.025
eighteen months in the neoadjuvant

NOTE Confidence: 0.9499381

00:48:55.245 --> 00:48:56.445
group compared to eight point

NOTE Confidence: 0.9499381

00:48:56.445 --> 00:48:58.045
seven in the patients that

NOTE Confidence: 0.9499381

00:48:58.045 --> 00:48:59.345
had upfront surgery,

NOTE Confidence: 0.9545186

00:48:59.805 --> 00:49:01.245
and the overall survival was

NOTE Confidence: 0.9545186

00:49:01.245 --> 00:49:02.365
seventy nine percent in the

NOTE Confidence: 0.9545186

00:49:02.365 --> 00:49:04.170
neoadjuvant group compared to sixty

NOTE Confidence: 0.9545186

00:49:04.250 --> 00:49:05.690
one percent of those that

NOTE Confidence: 0.9545186

00:49:05.690 --> 00:49:07.069
went to upfront resection.

NOTE Confidence: 0.9997395

00:49:08.170 --> 00:49:09.309
So what are the takeaways?

NOTE Confidence: 1

00:49:09.930 --> 00:49:10.430
Ultimately,

NOTE Confidence: 0.99820554

00:49:11.210 --> 00:49:12.170
I think that we are

NOTE Confidence: 0.99820554

00:49:12.170 --> 00:49:13.530
now starting to see data

NOTE Confidence: 0.99820554

00:49:13.530 --> 00:49:14.809
that there certainly can be

NOTE Confidence: 0.99820554

00:49:14.809 --> 00:49:16.910
a role for considering neoadjuvant

NOTE Confidence: 0.97090656

00:49:17.210 --> 00:49:18.730
therapy for patients with high

NOTE Confidence: 0.97090656

00:49:18.730 --> 00:49:20.165
risk intrahepatic cholangiocarcinoma,

NOTE Confidence: 0.98201495

00:49:21.825 --> 00:49:23.985
and, ultimately, further studies are

NOTE Confidence: 0.98201495

00:49:23.985 --> 00:49:24.485
needed.

NOTE Confidence: 0.9998779

00:49:26.305 --> 00:49:27.605
With that being said,

NOTE Confidence: 0.99240804

00:49:27.905 --> 00:49:29.105
for those that are here

NOTE Confidence: 0.99240804

00:49:29.105 --> 00:49:30.385
practicing in our area, we

NOTE Confidence: 0.99240804

00:49:30.385 --> 00:49:31.825
certainly have an open clinical

NOTE Confidence: 0.99240804

00:49:31.825 --> 00:49:33.105
trial that I would encourage

NOTE Confidence: 0.99240804

00:49:33.105 --> 00:49:34.320
you that if you have

NOTE Confidence: 0.99240804

00:49:34.320 --> 00:49:35.840
any patients that meet these

NOTE Confidence: 0.99240804

00:49:35.840 --> 00:49:36.340
criteria,

NOTE Confidence: 0.9503466

00:49:36.800 --> 00:49:38.080
that we do have a

NOTE Confidence: 0.9503466

00:49:38.080 --> 00:49:39.600
open study, which is under

NOTE Confidence: 0.9503466

00:49:39.600 --> 00:49:41.040
the PI of doctor Raghav

NOTE Confidence: 0.9503466

00:49:41.040 --> 00:49:42.239
Sundar, one of our medical

NOTE Confidence: 0.9503466

00:49:42.239 --> 00:49:44.160
oncologists and experts here, which

NOTE Confidence: 0.9503466

00:49:44.160 --> 00:49:45.440
is a phase two trial

NOTE Confidence: 0.9503466

00:49:45.440 --> 00:49:47.040
that evaluates the role of

NOTE Confidence: 0.9503466

00:49:47.040 --> 00:49:47.780
JEM Systerva

NOTE Confidence: 0.9794922

00:49:48.364 --> 00:49:49.265
as neoadjuvant

NOTE Confidence: 0.94204104

00:49:49.565 --> 00:49:51.184
therapy for high risk intra,

NOTE Confidence: 0.87597656

00:49:52.285 --> 00:49:53.344
intra intrahepatic

NOTE Confidence: 0.9893663

00:49:53.645 --> 00:49:54.145
cholangiocarcinoma.

NOTE Confidence: 0.9840929

00:49:55.565 --> 00:49:57.344
And similar to the overlap

NOTE Confidence: 0.9840929

00:49:57.405 --> 00:49:58.364
of what I reviewed for

NOTE Confidence: 0.9840929

00:49:58.364 --> 00:50:00.224
the NEOGOLD study when considering

NOTE Confidence: 0.9949254

00:50:00.525 --> 00:50:01.910
the high risk features, In

NOTE Confidence: 0.9949254

00:50:01.910 --> 00:50:03.270
this study, high risk is

NOTE Confidence: 0.9949254

00:50:03.270 --> 00:50:04.810
considered as greater than

NOTE Confidence: 0.99811196

00:50:05.590 --> 00:50:07.110
five centimeters greater than or

NOTE Confidence: 0.99811196

00:50:07.110 --> 00:50:08.390
equal to five centimeters as

NOTE Confidence: 0.99811196

00:50:08.390 --> 00:50:09.610
far as the tumor size.

NOTE Confidence: 0.9963786

00:50:09.989 --> 00:50:11.290
Is there any multifocality

NOTE Confidence: 0.96940106

00:50:11.750 --> 00:50:12.489
of the disease,

NOTE Confidence: 0.99902344

00:50:13.030 --> 00:50:14.090
vascular invasion,

NOTE Confidence: 0.99008787

00:50:14.710 --> 00:50:16.730
suspected or confirmed lymph nodes,

NOTE Confidence: 0.98083496

00:50:17.085 --> 00:50:18.685
a CA nineteen nine greater

NOTE Confidence: 0.98083496

00:50:18.685 --> 00:50:19.505
than two hundred.

NOTE Confidence: 0.9359575

00:50:21.805 --> 00:50:22.685
And here I have the

NOTE Confidence: 0.9359575

00:50:22.685 --> 00:50:24.205
study schema really just showing

NOTE Confidence: 0.9359575

00:50:24.205 --> 00:50:25.565
that the role of the

NOTE Confidence: 0.9359575

00:50:25.565 --> 00:50:26.685
near or how it is

NOTE Confidence: 0.9359575

00:50:26.685 --> 00:50:27.825
actually operationalized

NOTE Confidence: 0.99820966

00:50:28.205 --> 00:50:30.125
with four cycles prior to

NOTE Confidence: 0.99820966

00:50:30.125 --> 00:50:31.585
and four cycles after.

NOTE Confidence: 0.99975586

00:50:36.570 --> 00:50:37.310
In addition,

NOTE Confidence: 0.99429685

00:50:38.090 --> 00:50:40.750
we've besides talking about neoadjuvant,

NOTE Confidence: 0.99375

00:50:41.369 --> 00:50:42.650
there is certainly the role

NOTE Confidence: 0.99375

00:50:42.650 --> 00:50:44.110
that has been further explored

NOTE Confidence: 0.9996338

00:50:44.489 --> 00:50:45.770
of what the role of

NOTE Confidence: 0.9996338

00:50:45.770 --> 00:50:47.230
adjuvant therapy is.

NOTE Confidence: 0.995752

00:50:47.724 --> 00:50:49.325
As mentioned by probably all

NOTE Confidence: 0.995752

00:50:49.325 --> 00:50:50.625
of us at this point,

NOTE Confidence: 0.9653386

00:50:50.925 --> 00:50:52.765
biliary tract cancer certainly are

NOTE Confidence: 0.9653386

00:50:52.765 --> 00:50:54.224
associated with a poor prognosis,

NOTE Confidence: 0.9653386

00:50:54.285 --> 00:50:55.425
and the rate of recurrence

NOTE Confidence: 0.9653386

00:50:55.484 --> 00:50:56.844
is rather high up to

NOTE Confidence: 0.9653386

00:50:56.844 --> 00:50:58.464
or greater than fifty percent.

NOTE Confidence: 0.9956744

00:50:59.005 --> 00:51:00.765
So adjuvant therapy certainly has

NOTE Confidence: 0.9956744

00:51:00.765 --> 00:51:02.285
been recommended, which is really

NOTE Confidence: 0.9956744

00:51:02.285 --> 00:51:04.030
guided by patient

NOTE Confidence: 0.99785155

00:51:04.410 --> 00:51:04.910
comorbidities,

NOTE Confidence: 0.99450684

00:51:05.290 --> 00:51:06.989
their preference, and then also

NOTE Confidence: 0.99450684

00:51:07.050 --> 00:51:08.349
recovery from surgery.

NOTE Confidence: 0.9701322

00:51:12.570 --> 00:51:14.089
There have been few adjuvant

NOTE Confidence: 0.9701322

00:51:14.089 --> 00:51:15.690
studies evaluating the role of

NOTE Confidence: 0.9701322

00:51:15.690 --> 00:51:17.655
adjuvant therapy for biliary tract

NOTE Confidence: 0.9701322

00:51:17.655 --> 00:51:19.175
cancer. Many of these studies,

NOTE Confidence: 0.9701322

00:51:19.175 --> 00:51:20.695
however, we should note have

NOTE Confidence: 0.9701322

00:51:20.695 --> 00:51:22.295
been small. They've also been

NOTE Confidence: 0.9701322

00:51:22.295 --> 00:51:22.795
nonrandomized,

NOTE Confidence: 0.99527997

00:51:23.415 --> 00:51:24.535
and many have also been

NOTE Confidence: 0.99527997

00:51:24.535 --> 00:51:25.035
retrospective.

NOTE Confidence: 0.99975586

00:51:25.975 --> 00:51:27.575
But our clinical decision for

NOTE Confidence: 0.99975586

00:51:27.575 --> 00:51:28.475
using capecitabine

NOTE Confidence: 0.9837477

00:51:28.775 --> 00:51:30.135
in the adjuvant setting is

NOTE Confidence: 0.9837477

00:51:30.135 --> 00:51:31.839
really largely guided by the

NOTE Confidence: 0.9837477

00:51:31.839 --> 00:51:32.819
BILCAP study.

NOTE Confidence: 0.9550293

00:51:34.800 --> 00:51:36.099
As you can see here,

NOTE Confidence: 0.9513672

00:51:36.560 --> 00:51:38.660
within the e NCCN guidelines,

NOTE Confidence: 0.9791666

00:51:40.319 --> 00:51:41.300
adjuvant capecitabine

NOTE Confidence: 0.98809135

00:51:41.680 --> 00:51:43.359
is recommended and is considered

NOTE Confidence: 0.98809135

00:51:43.359 --> 00:51:44.900
a category one recommendation,

NOTE Confidence: 0.9978841

00:51:45.359 --> 00:51:47.094
and this is an ultimate

NOTE Confidence: 0.9978841

00:51:47.094 --> 00:51:47.594
decision

NOTE Confidence: 0.9940103

00:51:47.975 --> 00:51:49.515
from the data from BILCap.

NOTE Confidence: 0.9940103

00:51:49.575 --> 00:51:50.695
And I will review that

NOTE Confidence: 0.9940103

00:51:50.695 --> 00:51:51.735
because many in the room

NOTE Confidence: 0.9940103

00:51:51.735 --> 00:51:53.415
may say, well, the results

NOTE Confidence: 0.9940103

00:51:53.415 --> 00:51:55.255
from BILCap were limited as

NOTE Confidence: 0.9940103

00:51:55.255 --> 00:51:56.455
far as what the actual

NOTE Confidence: 0.9940103

00:51:56.455 --> 00:51:58.135
intention to treat results were,

NOTE Confidence: 0.9940103

00:51:58.135 --> 00:51:59.435
and I will review that.

NOTE Confidence: 0.96242046

00:52:03.089 --> 00:52:04.849
Described here, the BILCAP study

NOTE Confidence: 0.96242046

00:52:04.849 --> 00:52:06.450
was a phase three randomized

NOTE Confidence: 0.96242046

00:52:06.450 --> 00:52:08.529
study ultimately evaluating the role

NOTE Confidence: 0.96242046

00:52:08.529 --> 00:52:09.829
of adjuvant capecitabine

NOTE Confidence: 0.96358234

00:52:10.450 --> 00:52:12.210
versus observation in patients that

NOTE Confidence: 0.96358234

00:52:12.210 --> 00:52:14.049
had undergone resection for biliary

NOTE Confidence: 0.96358234

00:52:14.049 --> 00:52:14.789
tract cancers.

NOTE Confidence: 0.9384837

00:52:15.815 --> 00:52:17.335
Foraging forty three patients were

NOTE Confidence: 0.9384837

00:52:17.335 --> 00:52:18.295
part of this study, and

NOTE Confidence: 0.9384837

00:52:18.295 --> 00:52:20.055
they ultimately were randomized to

NOTE Confidence: 0.9384837

00:52:20.055 --> 00:52:21.035
either adjuvant

NOTE Confidence: 0.9487508

00:52:21.414 --> 00:52:23.414
capecitabine with eight cycles versus

NOTE Confidence: 0.9487508

00:52:23.414 --> 00:52:23.914
observation,

NOTE Confidence: 0.9916295

00:52:24.375 --> 00:52:26.134
and the primary endpoint was

NOTE Confidence: 0.9916295

00:52:26.134 --> 00:52:27.114
overall survival.

NOTE Confidence: 0.8833146

00:52:30.390 --> 00:52:31.589
The takeaway is, which is

NOTE Confidence: 0.8833146

00:52:31.589 --> 00:52:32.969
what leads to the controversy

NOTE Confidence: 0.8833146

00:52:33.109 --> 00:52:34.469
as far as do we

NOTE Confidence: 0.8833146

00:52:34.469 --> 00:52:36.489
recommend adjuvant case, cytobine,

NOTE Confidence: 0.9383545

00:52:36.869 --> 00:52:37.930
or do we not?

NOTE Confidence: 0.95989686

00:52:38.630 --> 00:52:40.710
I've listed the amount of

NOTE Confidence: 0.95989686

00:52:40.710 --> 00:52:42.070
patients randomized as I just

NOTE Confidence: 0.95989686

00:52:42.070 --> 00:52:44.234
recently reviewed, And I also

NOTE Confidence: 0.95989686

00:52:44.295 --> 00:52:45.895
want to note similarly to

NOTE Confidence: 0.95989686

00:52:45.895 --> 00:52:47.255
the NeoGOLD study that the

NOTE Confidence: 0.95989686

00:52:47.255 --> 00:52:48.935
patients were overall matched in

NOTE Confidence: 0.95989686

00:52:48.935 --> 00:52:50.075
regards to ECOD

NOTE Confidence: 0.9758301

00:52:50.455 --> 00:52:51.275
tumor characteristics.

NOTE Confidence: 0.97748274

00:52:53.175 --> 00:52:54.375
A little bit over half

NOTE Confidence: 0.97748274

00:52:54.375 --> 00:52:55.974
of the patients completed all

NOTE Confidence: 0.97748274

00:52:55.974 --> 00:52:57.035
the planned cycles.

NOTE Confidence: 0.9750824

00:52:58.820 --> 00:53:00.980
The recurrence free survival did

NOTE Confidence: 0.9750824

00:53:00.980 --> 00:53:02.500
favor the treatment group, which

NOTE Confidence: 0.9750824

00:53:02.500 --> 00:53:03.540
I think is important to

NOTE Confidence: 0.9750824

00:53:03.540 --> 00:53:04.040
know.

NOTE Confidence: 0.96608806

00:53:04.820 --> 00:53:06.660
But the endpoint, again, which

NOTE Confidence: 0.96608806

00:53:06.660 --> 00:53:08.180
was overall survival, did not

NOTE Confidence: 0.96608806

00:53:08.180 --> 00:53:10.180
reach statistical significance in the

NOTE Confidence: 0.96608806

00:53:10.180 --> 00:53:12.045
patients for the inpatient to

NOTE Confidence: 0.96608806

00:53:12.045 --> 00:53:13.085
treat, which I have noted

NOTE Confidence: 0.96608806

00:53:13.085 --> 00:53:13.885
here as far as the

NOTE Confidence: 0.96608806

00:53:13.885 --> 00:53:14.385
data.

NOTE Confidence: 0.96346027

00:53:15.085 --> 00:53:16.525
But the endpoint for overall

NOTE Confidence: 0.96346027

00:53:16.525 --> 00:53:17.025
survival

NOTE Confidence: 0.83121747

00:53:17.484 --> 00:53:18.465
and the protocol

NOTE Confidence: 0.9511205

00:53:19.165 --> 00:53:21.085
actually did. So I think

NOTE Confidence: 0.9511205

00:53:21.085 --> 00:53:22.045
as far as when we

NOTE Confidence: 0.9511205

00:53:22.045 --> 00:53:23.244
were thinking about this for

NOTE Confidence: 0.9511205

00:53:23.244 --> 00:53:24.705
the per protocol analysis,

NOTE Confidence: 0.99902344

00:53:25.219 --> 00:53:26.839
this is what ultimately contributes

NOTE Confidence: 0.99902344

00:53:27.059 --> 00:53:27.559
to

NOTE Confidence: 0.92285156

00:53:27.859 --> 00:53:29.000
us still recommending

NOTE Confidence: 0.99328613

00:53:29.539 --> 00:53:30.599
adjuvant capecitabine

NOTE Confidence: 0.96680975

00:53:31.059 --> 00:53:32.819
and also understanding that, again,

NOTE Confidence: 0.96680975

00:53:32.819 --> 00:53:34.599
these patients have high recurrence

NOTE Confidence: 0.96680975

00:53:34.739 --> 00:53:36.339
risk, and we have limited

NOTE Confidence: 0.96680975

00:53:36.339 --> 00:53:38.440
data for alternative therapies.

NOTE Confidence: 1

00:53:41.895 --> 00:53:42.715
When discussing

NOTE Confidence: 0.97874576

00:53:43.015 --> 00:53:44.135
with our patients, I think

NOTE Confidence: 0.97874576

00:53:44.135 --> 00:53:45.015
it should be a shared

NOTE Confidence: 0.97874576

00:53:45.015 --> 00:53:46.935
decision making, really thinking about,

NOTE Confidence: 0.97874576

00:53:46.935 --> 00:53:47.895
do they have any other

NOTE Confidence: 0.97874576

00:53:47.895 --> 00:53:48.395
comorbidities,

NOTE Confidence: 0.9873047

00:53:49.175 --> 00:53:49.675
DPD,

NOTE Confidence: 0.99954927

00:53:50.295 --> 00:53:51.335
and all of the things

NOTE Confidence: 0.99954927

00:53:51.335 --> 00:53:53.255
that will ultimately guide our

NOTE Confidence: 0.99954927

00:53:53.255 --> 00:53:54.475
decision to recommend

NOTE Confidence: 0.9616862

00:53:54.775 --> 00:53:55.755
adjuvant capecitabine.

NOTE Confidence: 0.93367827

00:54:00.400 --> 00:54:02.819
I'll briefly review chemo radiation

NOTE Confidence: 0.93367827

00:54:02.880 --> 00:54:04.079
because some may say, well,

NOTE Confidence: 0.93367827

00:54:04.079 --> 00:54:06.079
what happens if after surgery,

NOTE Confidence: 0.93367827

00:54:06.079 --> 00:54:08.339
after doctor Sogawa discussed surgery

NOTE Confidence: 0.93367827

00:54:08.480 --> 00:54:09.859
that there's an r one

NOTE Confidence: 0.93367827

00:54:10.000 --> 00:54:10.500
resection,

NOTE Confidence: 0.9773809

00:54:11.015 --> 00:54:12.775
so positive resection margin. So

NOTE Confidence: 0.9773809

00:54:12.775 --> 00:54:13.975
there are some patients that

NOTE Confidence: 0.9773809

00:54:13.975 --> 00:54:15.415
we may have a shared

NOTE Confidence: 0.9773809

00:54:15.415 --> 00:54:16.875
decision making, multidisciplinary

NOTE Confidence: 0.98829204

00:54:17.415 --> 00:54:18.855
tumor board to discuss the

NOTE Confidence: 0.98829204

00:54:18.855 --> 00:54:20.715
role of adjuvant chemoradiation.

NOTE Confidence: 0.9883525

00:54:21.655 --> 00:54:22.614
For the sake of time,

NOTE Confidence: 0.9883525

00:54:22.614 --> 00:54:23.415
I won't go into the

NOTE Confidence: 0.9883525

00:54:23.415 --> 00:54:25.080
greatest detail, but I think

NOTE Confidence: 0.9883525

00:54:25.080 --> 00:54:26.440
things to consider for your

NOTE Confidence: 0.9883525

00:54:26.440 --> 00:54:28.220
patient population when considering,

NOTE Confidence: 1

00:54:28.760 --> 00:54:29.580
should I

NOTE Confidence: 0.99853516

00:54:29.880 --> 00:54:30.780
actually recommend

NOTE Confidence: 0.97021484

00:54:31.480 --> 00:54:31.980
chemoradiation

NOTE Confidence: 0.84318036

00:54:32.440 --> 00:54:33.980
is is there no positivity?

NOTE Confidence: 0.9272239

00:54:34.520 --> 00:54:36.460
Is there positive resection margin?

NOTE Confidence: 0.9272239

00:54:36.520 --> 00:54:38.440
And then ultimately, shared decision

NOTE Confidence: 0.9272239

00:54:38.440 --> 00:54:38.940
making.

NOTE Confidence: 0.9875488

00:54:42.455 --> 00:54:42.955
Additionally,

NOTE Confidence: 0.8916504

00:54:43.895 --> 00:54:45.515
earlier, I believe doctor Strazzabasco

NOTE Confidence: 0.98502606

00:54:46.055 --> 00:54:47.035
may have mentioned,

NOTE Confidence: 0.96899414

00:54:47.495 --> 00:54:49.035
hepatic arterial infusion.

NOTE Confidence: 0.94744873

00:54:49.735 --> 00:54:50.955
And I think, ultimately,

NOTE Confidence: 0.99960935

00:54:51.495 --> 00:54:53.595
for this particular patient population,

NOTE Confidence: 0.99849445

00:54:54.780 --> 00:54:56.000
high risk of recurrence,

NOTE Confidence: 0.9729492

00:54:56.940 --> 00:54:59.040
poor prognosis, it's really important

NOTE Confidence: 0.99370116

00:54:59.340 --> 00:55:00.780
to consider what are the

NOTE Confidence: 0.99370116

00:55:00.780 --> 00:55:02.140
other therapies that we can

NOTE Confidence: 0.99370116

00:55:02.140 --> 00:55:04.239
consider in this particular setting,

NOTE Confidence: 0.9837564

00:55:04.540 --> 00:55:06.480
especially in the perioperative management.

NOTE Confidence: 0.9824663

00:55:06.915 --> 00:55:08.114
And I'll make sure to

NOTE Confidence: 0.9824663

00:55:08.114 --> 00:55:08.915
save a little bit of

NOTE Confidence: 0.9824663

00:55:08.915 --> 00:55:10.035
time because I know doctor

NOTE Confidence: 0.9824663

00:55:10.035 --> 00:55:11.475
Zhang will also discuss this

NOTE Confidence: 0.9824663

00:55:11.475 --> 00:55:12.135
as well.

NOTE Confidence: 0.9938616

00:55:13.235 --> 00:55:14.594
But when we think about

NOTE Confidence: 0.9938616

00:55:14.594 --> 00:55:15.735
HAI specifically,

NOTE Confidence: 0.9852865

00:55:16.275 --> 00:55:18.114
we ultimately think about what

NOTE Confidence: 0.9852865

00:55:18.114 --> 00:55:19.235
the role of this is.

NOTE Confidence: 0.9852865

00:55:19.235 --> 00:55:20.455
So when we think about,

NOTE Confidence: 0.6014404

00:55:21.130 --> 00:55:21.630
floxiridine

NOTE Confidence: 0.83776855

00:55:21.930 --> 00:55:22.750
or FUDR,

NOTE Confidence: 0.969561

00:55:23.130 --> 00:55:25.070
which is a metabolic intermediate

NOTE Confidence: 0.969561

00:55:25.290 --> 00:55:26.810
of five f u, it's

NOTE Confidence: 0.969561

00:55:26.810 --> 00:55:29.050
infused through the hepatic arterio,

NOTE Confidence: 0.969561

00:55:29.050 --> 00:55:30.010
and it has a ninety

NOTE Confidence: 0.969561

00:55:30.010 --> 00:55:32.250
percent first pass hepatic extraction

NOTE Confidence: 0.969561

00:55:32.250 --> 00:55:33.450
rate. That's really important when

NOTE Confidence: 0.969561

00:55:33.450 --> 00:55:35.585
we're thinking about intrahepatic cholangiocarcinoma,

NOTE Confidence: 0.95288986

00:55:36.205 --> 00:55:37.665
which which is why this

NOTE Confidence: 0.95288986

00:55:37.725 --> 00:55:39.344
is used in HAI.

NOTE Confidence: 0.9846191

00:55:39.885 --> 00:55:41.244
And this is possibly what

NOTE Confidence: 0.9846191

00:55:41.244 --> 00:55:43.025
contributes to the overall potential

NOTE Confidence: 0.9846191

00:55:43.085 --> 00:55:44.864
to convert patients to resectable

NOTE Confidence: 0.9846191

00:55:44.925 --> 00:55:45.885
status so we can get

NOTE Confidence: 0.9846191

00:55:45.885 --> 00:55:46.945
them to doctor Sogawa

NOTE Confidence: 0.977417

00:55:47.390 --> 00:55:49.150
and also to ultimately contribute

NOTE Confidence: 0.977417

00:55:49.150 --> 00:55:50.450
to improving survival.

NOTE Confidence: 0.9851733

00:55:51.150 --> 00:55:52.510
The limitations of the current

NOTE Confidence: 0.9851733

00:55:52.510 --> 00:55:54.830
data ultimately do, they're limited

NOTE Confidence: 0.9851733

00:55:54.830 --> 00:55:55.550
in the space of the

NOTE Confidence: 0.9851733

00:55:55.550 --> 00:55:56.430
fact that we don't have

NOTE Confidence: 0.9851733

00:55:56.430 --> 00:55:56.930
nonrandomized

NOTE Confidence: 0.9604492

00:55:57.310 --> 00:55:57.810
studies,

NOTE Confidence: 0.99708664

00:55:58.190 --> 00:55:59.870
which really could strengthen our

NOTE Confidence: 0.99708664

00:55:59.870 --> 00:56:02.370
overall recommendation for considering HAI.

NOTE Confidence: 0.9993652

00:56:02.775 --> 00:56:04.055
But despite this, this is

NOTE Confidence: 0.9993652

00:56:04.055 --> 00:56:05.674
certainly an option to consider

NOTE Confidence: 0.99423826

00:56:05.974 --> 00:56:07.414
for your patients that could

NOTE Confidence: 0.99423826

00:56:07.414 --> 00:56:09.515
potentially be considered for resection

NOTE Confidence: 0.97469074

00:56:10.214 --> 00:56:11.835
through ultimate conversion.

NOTE Confidence: 0.9773393

00:56:13.174 --> 00:56:14.135
And these are the patients

NOTE Confidence: 0.9773393

00:56:14.135 --> 00:56:14.934
that you would want to

NOTE Confidence: 0.9773393

00:56:14.934 --> 00:56:16.135
think about as long as

NOTE Confidence: 0.9773393

00:56:16.135 --> 00:56:17.335
they don't have any extra

NOTE Confidence: 0.9773393

00:56:17.335 --> 00:56:18.395
hepatic disease,

NOTE Confidence: 0.97957355

00:56:18.830 --> 00:56:20.350
if they have preserved functional

NOTE Confidence: 0.97957355

00:56:20.350 --> 00:56:22.350
status, of course, and preserved

NOTE Confidence: 0.97957355

00:56:22.350 --> 00:56:23.170
liver function.

NOTE Confidence: 0.9995117

00:56:26.430 --> 00:56:27.250
In summary,

NOTE Confidence: 0.9995117

00:56:27.550 --> 00:56:28.670
which many of us have

NOTE Confidence: 0.9995117

00:56:28.670 --> 00:56:29.570
already said,

NOTE Confidence: 0.9864638

00:56:29.870 --> 00:56:31.630
biliary tract cancers are certainly

NOTE Confidence: 0.9864638

00:56:31.630 --> 00:56:32.130
heterogeneous,

NOTE Confidence: 0.9972331

00:56:32.435 --> 00:56:33.815
and they require multidisciplinary

NOTE Confidence: 0.8613281

00:56:34.355 --> 00:56:34.855
management,

NOTE Confidence: 0.92614746

00:56:35.315 --> 00:56:36.775
hence our panel tonight.

NOTE Confidence: 0.9648263

00:56:37.155 --> 00:56:38.755
There's growing data to support

NOTE Confidence: 0.9648263

00:56:38.755 --> 00:56:40.994
neoadjuvant therapy, especially for our

NOTE Confidence: 0.9648263

00:56:40.994 --> 00:56:42.135
our high risk patients.

NOTE Confidence: 0.9837144

00:56:42.675 --> 00:56:44.275
It's really important to explore

NOTE Confidence: 0.9837144

00:56:44.275 --> 00:56:46.580
clinical trial patients, and, ultimately,

NOTE Confidence: 0.9837144

00:56:46.800 --> 00:56:48.239
further work is needed in

NOTE Confidence: 0.9837144

00:56:48.239 --> 00:56:48.900
this space.

NOTE Confidence: 0.9261649

00:56:49.360 --> 00:56:50.800
I now will transition to

NOTE Confidence: 0.9261649

00:56:50.800 --> 00:56:52.400
doctor Zhang who will end

NOTE Confidence: 0.9261649

00:56:52.400 --> 00:56:53.860
our discussion this evening

NOTE Confidence: 0.98361546

00:56:54.160 --> 00:56:56.180
discussing the role of metastatic

NOTE Confidence: 0.98361546

00:56:56.400 --> 00:56:58.260
disease and unresectable disease.

NOTE Confidence: 0.98046875

00:57:02.095 --> 00:57:03.055
Alright. Thank you so much,

NOTE Confidence: 0.98046875

00:57:03.055 --> 00:57:04.015
Jackie. Let me try to

NOTE Confidence: 0.98046875

00:57:04.015 --> 00:57:05.715
share my slides. Of course.

NOTE Confidence: 0.99316406

00:57:10.415 --> 00:57:10.915
Alright.

NOTE Confidence: 0.9069632

00:57:20.760 --> 00:57:21.960
Does that all look okay?

NOTE Confidence: 0.9069632

00:57:21.960 --> 00:57:23.960
That's perfect, doctor Dang. Okay.

NOTE Confidence: 0.9069632

00:57:23.960 --> 00:57:25.000
Great. Thank you so much,

NOTE Confidence: 0.9069632

00:57:25.000 --> 00:57:25.900
Jackie, for,

NOTE Confidence: 0.958432

00:57:26.760 --> 00:57:28.440
that great transition. And, also,

NOTE Confidence: 0.958432

00:57:28.440 --> 00:57:29.720
I'm very grateful to have

NOTE Confidence: 0.958432

00:57:29.720 --> 00:57:31.340
the opportunity to speak tonight.

NOTE Confidence: 0.958432

00:57:31.560 --> 00:57:32.735
Thank you for everybody for

NOTE Confidence: 0.958432

00:57:32.735 --> 00:57:34.655
staying fit as well. So

NOTE Confidence: 0.958432

00:57:34.655 --> 00:57:35.935
I'll be focusing on the

NOTE Confidence: 0.958432

00:57:35.935 --> 00:57:38.015
management of metastatic biliary tract

NOTE Confidence: 0.958432

00:57:38.015 --> 00:57:40.195
cancer from medical oncology perspective

NOTE Confidence: 0.95636857

00:57:40.655 --> 00:57:43.075
with emphasis on systemic therapy,

NOTE Confidence: 0.95636857

00:57:43.295 --> 00:57:44.515
molecular profiling,

NOTE Confidence: 0.9842285

00:57:45.230 --> 00:57:46.930
as well as treatment sequencing.

NOTE Confidence: 0.999483

00:57:47.230 --> 00:57:48.349
And then we'll also talk

NOTE Confidence: 0.999483

00:57:48.349 --> 00:57:49.950
about a few practical issues

NOTE Confidence: 0.999483

00:57:49.950 --> 00:57:50.910
that come up in real

NOTE Confidence: 0.999483

00:57:50.910 --> 00:57:51.809
world care.

NOTE Confidence: 0.9902344

00:57:53.549 --> 00:57:55.170
I have no relevant disclosures.

NOTE Confidence: 0.9966196

00:57:57.995 --> 00:57:59.035
So this is a brief

NOTE Confidence: 0.9966196

00:57:59.035 --> 00:58:00.395
outline of how we're gonna

NOTE Confidence: 0.9966196

00:58:00.395 --> 00:58:01.535
approach the talk.

NOTE Confidence: 0.9947754

00:58:01.995 --> 00:58:03.195
I'll start with a brief

NOTE Confidence: 0.9947754

00:58:03.195 --> 00:58:04.575
case to frame the discussion,

NOTE Confidence: 0.97417533

00:58:05.035 --> 00:58:06.235
and then we'll review the

NOTE Confidence: 0.97417533

00:58:06.235 --> 00:58:08.015
molecular's landscape and biomarkers

NOTE Confidence: 0.9407959

00:58:08.475 --> 00:58:10.255
relevant to advanced disease.

NOTE Confidence: 0.9794778

00:58:10.800 --> 00:58:12.160
From there, I'll move through

NOTE Confidence: 0.9794778

00:58:12.160 --> 00:58:14.000
first and second line therapy

NOTE Confidence: 0.9794778

00:58:14.000 --> 00:58:16.080
and then discuss targeted therapy

NOTE Confidence: 0.9794778

00:58:16.080 --> 00:58:16.740
and sequencing.

NOTE Confidence: 0.95218915

00:58:17.360 --> 00:58:18.720
And we'll briefly touch on

NOTE Confidence: 0.95218915

00:58:18.720 --> 00:58:20.240
a selective role of hepatic

NOTE Confidence: 0.95218915

00:58:20.240 --> 00:58:21.140
arterial infusion,

NOTE Confidence: 0.9866699

00:58:21.600 --> 00:58:22.880
like Jackie did, and then

NOTE Confidence: 0.9866699

00:58:22.880 --> 00:58:24.500
close with some practical considerations

NOTE Confidence: 0.9485677

00:58:24.800 --> 00:58:25.940
and future directions.

NOTE Confidence: 0.9054362

00:58:27.895 --> 00:58:29.095
So ground to ground the

NOTE Confidence: 0.9054362

00:58:29.095 --> 00:58:29.595
discussion,

NOTE Confidence: 0.9716131

00:58:29.974 --> 00:58:31.095
I'll start with a patient

NOTE Confidence: 0.9716131

00:58:31.095 --> 00:58:32.535
of mine. This is the

NOTE Confidence: 0.9716131

00:58:32.535 --> 00:58:33.815
eighty three year old woman

NOTE Confidence: 0.9716131

00:58:33.815 --> 00:58:35.095
who came to me with

NOTE Confidence: 0.9716131

00:58:35.095 --> 00:58:36.075
advanced cholangiocarcinoma.

NOTE Confidence: 0.9639855

00:58:37.255 --> 00:58:39.095
Genomic profiling was obtained at

NOTE Confidence: 0.9639855

00:58:39.095 --> 00:58:41.434
diagnosis and identified an IDH1

NOTE Confidence: 0.9639855

00:58:41.655 --> 00:58:42.155
mutation.

NOTE Confidence: 0.84606934

00:58:42.869 --> 00:58:43.529
She started,

NOTE Confidence: 0.9918132

00:58:44.150 --> 00:58:45.670
standard first line therapy with

NOTE Confidence: 0.9918132

00:58:45.670 --> 00:58:46.170
gemcitabine,

NOTE Confidence: 0.9686279

00:58:46.549 --> 00:58:47.049
cisplatin,

NOTE Confidence: 0.93831384

00:58:47.349 --> 00:58:48.010
and darvalumab.

NOTE Confidence: 0.975296

00:58:48.789 --> 00:58:49.750
I'll come back to her

NOTE Confidence: 0.975296

00:58:49.750 --> 00:58:51.109
later, but first, I wanna

NOTE Confidence: 0.975296

00:58:51.109 --> 00:58:52.869
review why that genomic result

NOTE Confidence: 0.975296

00:58:52.869 --> 00:58:53.369
mattered.

NOTE Confidence: 0.99373937

00:58:55.315 --> 00:58:56.515
So we have seen this

NOTE Confidence: 0.99373937

00:58:56.515 --> 00:58:58.435
previously tonight, but one of

NOTE Confidence: 0.99373937

00:58:58.435 --> 00:58:59.875
the key concepts in advanced

NOTE Confidence: 0.99373937

00:58:59.875 --> 00:59:01.395
biliary tract cancer is that

NOTE Confidence: 0.99373937

00:59:01.395 --> 00:59:03.495
these tumors are molecularly heterogeneous

NOTE Confidence: 0.99373937

00:59:03.635 --> 00:59:04.775
and differ by subtype.

NOTE Confidence: 0.9959744

00:59:05.475 --> 00:59:06.695
Intrahepatic cholangiocarcinoma,

NOTE Confidence: 0.9716057

00:59:07.555 --> 00:59:08.935
which can be further classified

NOTE Confidence: 0.9716057

00:59:08.995 --> 00:59:10.350
into small duct and large

NOTE Confidence: 0.9716057

00:59:10.350 --> 00:59:10.850
ducts,

NOTE Confidence: 0.86210126

00:59:11.310 --> 00:59:13.250
is enriched before actionable alterations

NOTE Confidence: 0.86210126

00:59:13.310 --> 00:59:14.930
such as IDH one mutations

NOTE Confidence: 0.86210126

00:59:15.070 --> 00:59:15.730
and FGFR

NOTE Confidence: 0.8630371

00:59:16.030 --> 00:59:16.770
two fusions,

NOTE Confidence: 0.9925537

00:59:17.230 --> 00:59:18.210
whereas extrahepatic

NOTE Confidence: 0.83926296

00:59:18.670 --> 00:59:20.770
disease, more often, Harper KRAS,

NOTE Confidence: 0.83926296

00:59:20.830 --> 00:59:22.830
TP fifty three, and HER2

NOTE Confidence: 0.83926296

00:59:22.830 --> 00:59:23.330
alterations.

NOTE Confidence: 0.8880615

00:59:24.234 --> 00:59:25.275
So the importance of this

NOTE Confidence: 0.8880615

00:59:25.275 --> 00:59:27.215
is not just biologic classification.

NOTE Confidence: 0.9777832

00:59:27.994 --> 00:59:29.835
In the metastatic setting, it

NOTE Confidence: 0.9777832

00:59:29.835 --> 00:59:32.415
directly influences the molecular testing

NOTE Confidence: 0.8767578

00:59:32.715 --> 00:59:34.734
and ultimately the treatment options.

NOTE Confidence: 0.99851704

00:59:35.480 --> 00:59:36.920
So once we recognize that

NOTE Confidence: 0.99851704

00:59:36.920 --> 00:59:38.460
these tumors differ molecularly,

NOTE Confidence: 0.97694904

00:59:39.160 --> 00:59:40.599
the next practical question is

NOTE Confidence: 0.97694904

00:59:40.599 --> 00:59:42.279
how we identify those differences

NOTE Confidence: 0.97694904

00:59:42.279 --> 00:59:43.020
in clinic.

NOTE Confidence: 0.9660121

00:59:44.920 --> 00:59:46.920
So in practice, c ninety

NOTE Confidence: 0.9660121

00:59:46.920 --> 00:59:48.599
nine is commonly followed, but

NOTE Confidence: 0.9660121

00:59:48.599 --> 00:59:49.980
it has important limitations.

NOTE Confidence: 0.983134

00:59:50.805 --> 00:59:52.165
It is not useful for

NOTE Confidence: 0.983134

00:59:52.165 --> 00:59:53.684
screening, and its role is

NOTE Confidence: 0.983134

00:59:53.684 --> 00:59:54.585
mainly prognostic

NOTE Confidence: 0.986084

00:59:55.125 --> 00:59:56.405
and in following trends over

NOTE Confidence: 0.986084

00:59:56.405 --> 00:59:56.905
time.

NOTE Confidence: 0.98271483

00:59:57.285 --> 00:59:59.385
An important limitation for CA99

NOTE Confidence: 0.9980469

00:59:59.765 --> 01:00:00.265
diagnosis

NOTE Confidence: 0.98657227

01:00:00.565 --> 01:00:01.765
is that it's absent in

NOTE Confidence: 0.98657227

01:00:01.765 --> 01:00:03.224
about ten percent of individuals

NOTE Confidence: 0.98657227

01:00:03.365 --> 01:00:04.825
who lack the Lewis antigen.

NOTE Confidence: 0.9995117

01:00:05.760 --> 01:00:06.260
Additionally,

NOTE Confidence: 0.99894637

01:00:06.560 --> 01:00:08.340
elevated levels of these proteins

NOTE Confidence: 0.99894637

01:00:08.400 --> 01:00:10.000
may also be detected in

NOTE Confidence: 0.99894637

01:00:10.000 --> 01:00:12.080
individuals with biliary obstruction or

NOTE Confidence: 0.99894637

01:00:12.080 --> 01:00:13.700
other benign biliary disease.

NOTE Confidence: 0.9505697

01:00:14.880 --> 01:00:16.000
There's a lot of interest

NOTE Confidence: 0.9505697

01:00:16.000 --> 01:00:17.760
in emergent biomarkers such as

NOTE Confidence: 0.9505697

01:00:17.760 --> 01:00:20.020
cell free DNA, circulating RNA,

NOTE Confidence: 0.9980469

01:00:20.515 --> 01:00:21.015
extracellular

NOTE Confidence: 0.9465739

01:00:21.315 --> 01:00:22.615
vesicles, and metabolomics.

NOTE Confidence: 0.9690407

01:00:24.115 --> 01:00:25.155
But at this point, those

NOTE Confidence: 0.9690407

01:00:25.155 --> 01:00:26.135
remain investigational.

NOTE Confidence: 0.96313477

01:00:26.835 --> 01:00:28.695
So for treatment decisions today,

NOTE Confidence: 0.96313477

01:00:28.755 --> 01:00:30.835
tissue based NGS remains the

NOTE Confidence: 0.96313477

01:00:30.835 --> 01:00:32.515
standard, and ideally, it should

NOTE Confidence: 0.96313477

01:00:32.515 --> 01:00:34.215
be obtained early in metastatic

NOTE Confidence: 0.96313477

01:00:34.435 --> 01:00:34.935
disease.

NOTE Confidence: 0.97352666

01:00:35.820 --> 01:00:37.260
So with that framework in

NOTE Confidence: 0.97352666

01:00:37.260 --> 01:00:38.540
mind, I'll move into first

NOTE Confidence: 0.97352666

01:00:38.540 --> 01:00:40.300
line treatment where the standard

NOTE Confidence: 0.97352666

01:00:40.300 --> 01:00:41.820
has changed meaningfully in the

NOTE Confidence: 0.97352666

01:00:41.820 --> 01:00:42.880
last few years.

NOTE Confidence: 0.9353353

01:00:45.340 --> 01:00:46.540
So for more than a

NOTE Confidence: 0.9353353

01:00:46.540 --> 01:00:48.780
decade, cisplatin and gencitabine remain

NOTE Confidence: 0.9353353

01:00:48.780 --> 01:00:50.060
the backbone of first line

NOTE Confidence: 0.9353353

01:00:50.060 --> 01:00:52.375
therapy after ABC zero two.

NOTE Confidence: 0.96357423

01:00:52.835 --> 01:00:54.275
The major recent advance has

NOTE Confidence: 0.96357423

01:00:54.275 --> 01:00:55.655
been the addition of immunotherapy.

NOTE Confidence: 0.9009776

01:00:56.515 --> 01:00:57.555
So here we talk about

NOTE Confidence: 0.9009776

01:00:57.555 --> 01:00:59.155
the TOPAS one trial, which

NOTE Confidence: 0.9009776

01:00:59.155 --> 01:01:01.555
established darvelumab plus gemcitabine and

NOTE Confidence: 0.9009776

01:01:01.555 --> 01:01:02.055
cisplatin

NOTE Confidence: 0.89538574

01:01:02.595 --> 01:01:03.795
as the new first line

NOTE Confidence: 0.89538574

01:01:03.795 --> 01:01:04.295
standard,

NOTE Confidence: 0.9711702

01:01:04.750 --> 01:01:06.270
with a median overall survival

NOTE Confidence: 0.9711702

01:01:06.270 --> 01:01:07.550
of twelve point nine months

NOTE Confidence: 0.9711702

01:01:07.550 --> 01:01:09.330
versus eleven point three months

NOTE Confidence: 0.9711702

01:01:09.390 --> 01:01:10.670
and a hazard ratio of

NOTE Confidence: 0.9711702

01:01:10.670 --> 01:01:11.730
point seven six.

NOTE Confidence: 0.96520996

01:01:12.350 --> 01:01:14.370
The absolute benefit is modest,

NOTE Confidence: 0.96520996

01:01:14.430 --> 01:01:15.570
but it is meaningful,

NOTE Confidence: 0.8742327

01:01:15.950 --> 01:01:17.070
and it moved the field

NOTE Confidence: 0.8742327

01:01:17.070 --> 01:01:18.130
beyond chemotherapy

NOTE Confidence: 1

01:01:18.430 --> 01:01:18.930
alone.

NOTE Confidence: 0.93144345

01:01:19.645 --> 01:01:20.765
So not shown on this

NOTE Confidence: 0.93144345

01:01:20.765 --> 01:01:21.885
slide here is a second

NOTE Confidence: 0.93144345

01:01:21.885 --> 01:01:23.725
randomized phase three clinical trial,

NOTE Confidence: 0.93144345

01:01:23.725 --> 01:01:24.845
which is the Kino nine

NOTE Confidence: 0.93144345

01:01:24.845 --> 01:01:26.865
six six, which also supports

NOTE Confidence: 0.93144345

01:01:26.925 --> 01:01:27.425
additional

NOTE Confidence: 0.88911134

01:01:27.885 --> 01:01:30.045
addition of immune checkpoint inhibitor

NOTE Confidence: 0.88911134

01:01:30.045 --> 01:01:30.705
to Cisgene.

NOTE Confidence: 0.99348956

01:01:31.325 --> 01:01:32.625
In that trial, pembrolizumab

NOTE Confidence: 0.9780041

01:01:33.410 --> 01:01:34.930
or placebo was added to

NOTE Confidence: 0.9780041

01:01:34.930 --> 01:01:37.010
cisgene, which also improved overall

NOTE Confidence: 0.9780041

01:01:37.010 --> 01:01:38.470
survival in the pembrolizumab

NOTE Confidence: 0.9490777

01:01:38.930 --> 01:01:40.850
arm. So in practice, for

NOTE Confidence: 0.9490777

01:01:40.850 --> 01:01:42.390
most FIT patients, chemoimmunotherapy

NOTE Confidence: 0.9951172

01:01:43.090 --> 01:01:44.530
is now the default first

NOTE Confidence: 0.9951172

01:01:44.530 --> 01:01:45.270
line approach.

NOTE Confidence: 0.9338989

01:01:46.585 --> 01:01:48.205
But even with that advanced,

NOTE Confidence: 0.9338989

01:01:48.265 --> 01:01:49.645
outcomes remain limited,

NOTE Confidence: 0.9966708

01:01:49.945 --> 01:01:52.025
and many patients eventually require

NOTE Confidence: 0.9966708

01:01:52.025 --> 01:01:53.465
or consider for second line

NOTE Confidence: 0.9966708

01:01:53.465 --> 01:01:53.965
therapy.

NOTE Confidence: 0.9740014

01:01:55.865 --> 01:01:57.065
So in the second line

NOTE Confidence: 0.9740014

01:01:57.065 --> 01:01:59.250
setting, the ABC zero six

NOTE Confidence: 0.9740014

01:01:59.330 --> 01:02:01.250
trial established Fofox as a

NOTE Confidence: 0.9740014

01:02:01.250 --> 01:02:02.070
standard cytotoxic

NOTE Confidence: 0.99902344

01:02:02.450 --> 01:02:02.950
option

NOTE Confidence: 0.9951172

01:02:03.250 --> 01:02:04.070
after progression

NOTE Confidence: 0.9921875

01:02:04.610 --> 01:02:05.830
on first line therapy.

NOTE Confidence: 0.95937407

01:02:06.370 --> 01:02:07.890
The benefit again is modest

NOTE Confidence: 0.95937407

01:02:07.890 --> 01:02:09.570
with median overall survival of

NOTE Confidence: 0.95937407

01:02:09.570 --> 01:02:10.770
six point two months in

NOTE Confidence: 0.95937407

01:02:10.770 --> 01:02:12.930
the Fofox and active symptom

NOTE Confidence: 0.95937407

01:02:12.930 --> 01:02:14.805
control arm versus five point

NOTE Confidence: 0.95937407

01:02:14.805 --> 01:02:15.925
three months in the active

NOTE Confidence: 0.95937407

01:02:15.925 --> 01:02:17.224
symptom control only.

NOTE Confidence: 0.9843614

01:02:17.765 --> 01:02:18.885
So this is a practice

NOTE Confidence: 0.9843614

01:02:18.885 --> 01:02:20.645
defining study, but it also

NOTE Confidence: 0.9843614

01:02:20.645 --> 01:02:22.165
highlights a major unmet need

NOTE Confidence: 0.9843614

01:02:22.165 --> 01:02:22.984
in the disease.

NOTE Confidence: 0.95371383

01:02:23.845 --> 01:02:25.285
In real world practice, second

NOTE Confidence: 0.95371383

01:02:25.285 --> 01:02:26.805
line treatment is often more

NOTE Confidence: 0.95371383

01:02:26.805 --> 01:02:28.405
constrained than the trial setting

NOTE Confidence: 0.95371383

01:02:28.405 --> 01:02:29.224
was just.

NOTE Confidence: 0.8993598

01:02:32.300 --> 01:02:34.460
So clinically, Fofax remains the

NOTE Confidence: 0.8993598

01:02:34.460 --> 01:02:36.240
standard second line regimen.

NOTE Confidence: 0.99902344

01:02:36.860 --> 01:02:37.360
Liposomal

NOTE Confidence: 0.8923828

01:02:37.660 --> 01:02:38.160
irinotecan

NOTE Confidence: 0.8975157

01:02:38.540 --> 01:02:39.580
and five of you is

NOTE Confidence: 0.8975157

01:02:39.580 --> 01:02:41.500
also using some settings, but

NOTE Confidence: 0.8975157

01:02:41.500 --> 01:02:43.055
the data are mixed, as

NOTE Confidence: 0.8975157

01:02:43.055 --> 01:02:44.495
reflected by the NIFTI and

NOTE Confidence: 0.8975157

01:02:44.495 --> 01:02:46.515
NELIRIC trial, which show contradictory

NOTE Confidence: 0.8975157

01:02:46.655 --> 01:02:47.155
results.

NOTE Confidence: 1

01:02:48.175 --> 01:02:48.675
Importantly,

NOTE Confidence: 0.93833005

01:02:48.975 --> 01:02:50.655
only about half the patients

NOTE Confidence: 0.93833005

01:02:50.655 --> 01:02:52.275
ever reach second line therapy,

NOTE Confidence: 0.9808594

01:02:52.575 --> 01:02:53.935
which is one reason early

NOTE Confidence: 0.9808594

01:02:53.935 --> 01:02:56.195
molecular profiling matters so much.

NOTE Confidence: 1

01:02:56.570 --> 01:02:57.390
If actionable

NOTE Confidence: 0.9672309

01:02:57.770 --> 01:03:00.010
alterations identify upfront, they can

NOTE Confidence: 0.9672309

01:03:00.010 --> 01:03:01.790
create options at progression.

NOTE Confidence: 0.9794922

01:03:02.970 --> 01:03:04.010
And that leads to the

NOTE Confidence: 0.9794922

01:03:04.010 --> 01:03:05.050
next slide, which is that

NOTE Confidence: 0.9794922

01:03:05.050 --> 01:03:06.030
standard chemotherapy

NOTE Confidence: 0.9474284

01:03:06.330 --> 01:03:08.430
still leaves us with substantial

NOTE Confidence: 0.9474284

01:03:08.490 --> 01:03:08.990
limitations.

NOTE Confidence: 0.9556152

01:03:10.325 --> 01:03:11.924
So despite the progress we

NOTE Confidence: 0.9556152

01:03:11.924 --> 01:03:13.605
have made, the median overall

NOTE Confidence: 0.9556152

01:03:13.605 --> 01:03:15.845
survival for metastatic biliary tract

NOTE Confidence: 0.9556152

01:03:15.845 --> 01:03:17.625
cancer remains around a year.

NOTE Confidence: 0.9980469

01:03:18.085 --> 01:03:19.224
Second line chemotherapy

NOTE Confidence: 0.9269206

01:03:19.605 --> 01:03:20.984
offers limited benefit,

NOTE Confidence: 0.98323566

01:03:21.285 --> 01:03:22.825
and we still lack reliable

NOTE Confidence: 0.98323566

01:03:22.885 --> 01:03:25.065
benefit biomarkers for immunotherapy

NOTE Confidence: 0.95458984

01:03:25.365 --> 01:03:25.740
response.

NOTE Confidence: 0.9919922

01:03:26.780 --> 01:03:28.140
The majority of patients do

NOTE Confidence: 0.9919922

01:03:28.140 --> 01:03:30.080
not have currently actionable targets.

NOTE Confidence: 0.9929289

01:03:30.619 --> 01:03:31.900
So what this field needs

NOTE Confidence: 0.9929289

01:03:31.900 --> 01:03:33.520
is better predictive biomarkers,

NOTE Confidence: 0.8564453

01:03:33.820 --> 01:03:34.640
better sequencing

NOTE Confidence: 0.65808105

01:03:34.940 --> 01:03:35.440
strategies,

NOTE Confidence: 0.99934894

01:03:35.820 --> 01:03:37.840
and broader access to molecular

NOTE Confidence: 0.99934894

01:03:37.900 --> 01:03:39.520
testing and targeted therapies.

NOTE Confidence: 0.9852702

01:03:40.795 --> 01:03:42.075
So to show how early

NOTE Confidence: 0.9852702

01:03:42.075 --> 01:03:44.095
molecular profiling can change management,

NOTE Confidence: 0.9852702

01:03:44.235 --> 01:03:45.355
I'll return to the patient

NOTE Confidence: 0.9852702

01:03:45.355 --> 01:03:46.575
I introduced earlier.

NOTE Confidence: 0.9116391

01:03:47.915 --> 01:03:50.155
This patient initially responded to

NOTE Confidence: 0.9116391

01:03:50.155 --> 01:03:52.175
gemcitabine cisplatin and durvalumab,

NOTE Confidence: 0.9778239

01:03:53.400 --> 01:03:55.000
And this lasted for about

NOTE Confidence: 0.9778239

01:03:55.000 --> 01:03:56.680
six months. But then she

NOTE Confidence: 0.9778239

01:03:56.680 --> 01:03:58.520
developed progression with enlargement of

NOTE Confidence: 0.9778239

01:03:58.520 --> 01:04:00.359
the primary lesion and new

NOTE Confidence: 0.9778239

01:04:00.359 --> 01:04:00.859
intrahepatic

NOTE Confidence: 0.9532878

01:04:01.240 --> 01:04:01.740
metastasis.

NOTE Confidence: 0.9953206

01:04:02.760 --> 01:04:04.140
This is where the molecular

NOTE Confidence: 0.9953206

01:04:04.280 --> 01:04:06.520
result identified at diagnosis becomes

NOTE Confidence: 0.9953206

01:04:06.520 --> 01:04:07.500
clinically important.

NOTE Confidence: 0.9881592

01:04:08.205 --> 01:04:09.405
Because she had a known

NOTE Confidence: 0.9881592

01:04:09.405 --> 01:04:10.545
IDH one mutation,

NOTE Confidence: 0.99278426

01:04:11.005 --> 01:04:12.525
she had a rational targeted

NOTE Confidence: 0.99278426

01:04:12.525 --> 01:04:14.145
option available at progression.

NOTE Confidence: 0.9722261

01:04:17.325 --> 01:04:18.365
So now we'll take a

NOTE Confidence: 0.9722261

01:04:18.365 --> 01:04:19.965
look at targeted therapy and

NOTE Confidence: 0.9722261

01:04:19.965 --> 01:04:21.490
how it it fits into

NOTE Confidence: 0.9722261

01:04:21.490 --> 01:04:23.410
treatment sequencing in biliary tract

NOTE Confidence: 0.9722261

01:04:23.410 --> 01:04:23.910
cancer.

NOTE Confidence: 0.9955706

01:04:24.930 --> 01:04:26.530
About thirty to forty percent

NOTE Confidence: 0.9955706

01:04:26.530 --> 01:04:28.130
of patients with biliary tract

NOTE Confidence: 0.9955706

01:04:28.130 --> 01:04:30.070
cancer harbor actionable alterations.

NOTE Confidence: 0.88507485

01:04:30.850 --> 01:04:32.770
The two best established examples

NOTE Confidence: 0.88507485

01:04:32.770 --> 01:04:34.455
in intrahepatic disease disease or

NOTE Confidence: 0.88507485

01:04:34.455 --> 01:04:36.635
IDH one mutations and FGFR

NOTE Confidence: 0.9788412

01:04:37.095 --> 01:04:37.835
two fusions.

NOTE Confidence: 0.9372864

01:04:38.615 --> 01:04:40.395
For IDH one mutant disease,

NOTE Confidence: 0.9372864

01:04:40.455 --> 01:04:40.955
ivositanib

NOTE Confidence: 0.8932373

01:04:41.415 --> 01:04:43.015
is a approved targeted option

NOTE Confidence: 0.8932373

01:04:43.015 --> 01:04:44.955
and showed overall survival benefit

NOTE Confidence: 0.98046875

01:04:45.255 --> 01:04:46.955
despite substantial crossover.

NOTE Confidence: 0.9941406

01:04:47.780 --> 01:04:48.280
FGFR

NOTE Confidence: 0.85662436

01:04:48.580 --> 01:04:50.580
inhibitors such as pemigatinib and

NOTE Confidence: 0.85662436

01:04:50.580 --> 01:04:51.080
fudimbatimab

NOTE Confidence: 0.93528646

01:04:51.540 --> 01:04:53.619
have shown meaningful activity, and

NOTE Confidence: 0.93528646

01:04:53.619 --> 01:04:55.720
in selected patients, compared favorably

NOTE Confidence: 0.93528646

01:04:55.859 --> 01:04:57.640
with traditional second line chemotherapy.

NOTE Confidence: 0.99243164

01:04:58.900 --> 01:05:00.980
HER2 is particularly relevant in

NOTE Confidence: 0.99243164

01:05:00.980 --> 01:05:01.480
extrahepatic

NOTE Confidence: 0.99245876

01:05:01.780 --> 01:05:03.080
and gallbladder cancers.

NOTE Confidence: 0.8904785

01:05:03.795 --> 01:05:05.234
A very recent study from

NOTE Confidence: 0.8904785

01:05:05.234 --> 01:05:07.494
the Horizon BTC one study

NOTE Confidence: 0.964388

01:05:07.795 --> 01:05:09.815
showed durable activity with zenidetimab

NOTE Confidence: 0.9682129

01:05:10.515 --> 01:05:12.454
in previously treated HER2 positive

NOTE Confidence: 0.9402669

01:05:12.755 --> 01:05:14.454
metastatic biliary cancer,

NOTE Confidence: 0.9896973

01:05:14.835 --> 01:05:16.595
with a confirmed response rate

NOTE Confidence: 0.9896973

01:05:16.595 --> 01:05:18.135
of about forty one percent

NOTE Confidence: 0.98413086

01:05:18.440 --> 01:05:20.060
and a median overall survival

NOTE Confidence: 0.98413086

01:05:20.280 --> 01:05:21.260
of fifteen months,

NOTE Confidence: 0.9970259

01:05:21.560 --> 01:05:23.320
which further supports HER2 as

NOTE Confidence: 0.9970259

01:05:23.320 --> 01:05:24.760
a meaningful target in this

NOTE Confidence: 0.9970259

01:05:24.760 --> 01:05:25.260
disease.

NOTE Confidence: 0.94254553

01:05:26.280 --> 01:05:27.180
BRAF V600E

NOTE Confidence: 0.9718192

01:05:27.560 --> 01:05:29.320
is another important, though less

NOTE Confidence: 0.9718192

01:05:29.320 --> 01:05:30.300
common target.

NOTE Confidence: 0.99178797

01:05:30.965 --> 01:05:32.485
So target therapy has become

NOTE Confidence: 0.99178797

01:05:32.485 --> 01:05:34.005
an important part of modern

NOTE Confidence: 0.99178797

01:05:34.005 --> 01:05:34.505
sequencing,

NOTE Confidence: 0.92975724

01:05:35.045 --> 01:05:36.165
not just an as a

NOTE Confidence: 0.92975724

01:05:36.165 --> 01:05:37.065
niche consideration.

NOTE Confidence: 0.9801218

01:05:38.805 --> 01:05:40.325
So in addition to the

NOTE Confidence: 0.9801218

01:05:40.325 --> 01:05:41.845
currently approved targets, there are

NOTE Confidence: 0.9801218

01:05:41.845 --> 01:05:43.785
also rare but actionable alterations

NOTE Confidence: 0.9801218

01:05:43.925 --> 01:05:45.625
and broader precision strategies

NOTE Confidence: 0.9368164

01:05:45.930 --> 01:05:47.530
that are beginning to shape

NOTE Confidence: 0.9368164

01:05:47.530 --> 01:05:48.910
how we think about sequencing.

NOTE Confidence: 0.97325844

01:05:50.569 --> 01:05:52.490
So these are the, rare

NOTE Confidence: 0.97325844

01:05:52.490 --> 01:05:54.810
but clinically relevant alterations, such

NOTE Confidence: 0.97325844

01:05:54.810 --> 01:05:57.069
as MSI high disease, NTRK

NOTE Confidence: 0.925114

01:05:57.369 --> 01:05:59.369
fusions, and in selected cases,

NOTE Confidence: 0.925114

01:05:59.369 --> 01:06:01.310
RET or NRG one fusions.

NOTE Confidence: 0.99601233

01:06:02.035 --> 01:06:03.795
In fact, patients with MSI

NOTE Confidence: 0.99601233

01:06:03.795 --> 01:06:06.035
high may greatly benefit from

NOTE Confidence: 0.99601233

01:06:06.035 --> 01:06:06.535
pembrolizumab

NOTE Confidence: 0.8088379

01:06:06.835 --> 01:06:07.335
treatment,

NOTE Confidence: 0.91023135

01:06:07.715 --> 01:06:08.675
as they are shown to

NOTE Confidence: 0.91023135

01:06:08.675 --> 01:06:10.035
have an oral response rate

NOTE Confidence: 0.91023135

01:06:10.035 --> 01:06:10.855
in the seventies,

NOTE Confidence: 0.95780945

01:06:11.635 --> 01:06:13.075
which is significantly higher than

NOTE Confidence: 0.95780945

01:06:13.075 --> 01:06:14.835
the response rates that are

NOTE Confidence: 0.95780945

01:06:14.835 --> 01:06:16.375
observed in patients with pancreatic

NOTE Confidence: 0.95780945

01:06:16.595 --> 01:06:17.095
cancer.

NOTE Confidence: 0.99578303

01:06:17.890 --> 01:06:19.810
Higher PD L1 expression may

NOTE Confidence: 0.99578303

01:06:19.810 --> 01:06:21.490
also correlate with slightly better

NOTE Confidence: 0.99578303

01:06:21.490 --> 01:06:21.990
outcomes,

NOTE Confidence: 0.999783

01:06:22.290 --> 01:06:23.650
but this measure is not

NOTE Confidence: 0.999783

01:06:23.650 --> 01:06:25.350
suitable to select patients.

NOTE Confidence: 0.98916626

01:06:26.290 --> 01:06:27.890
More broadly, we're moving beyond

NOTE Confidence: 0.98916626

01:06:27.890 --> 01:06:29.650
one mutation, one drug thinking,

NOTE Confidence: 0.98916626

01:06:29.650 --> 01:06:31.510
and more toward precision sequencing

NOTE Confidence: 0.98916626

01:06:31.570 --> 01:06:32.070
concepts,

NOTE Confidence: 0.9965007

01:06:32.655 --> 01:06:34.195
including sequential FGFR

NOTE Confidence: 0.9995117

01:06:34.495 --> 01:06:34.995
inhibition,

NOTE Confidence: 0.99738955

01:06:35.695 --> 01:06:37.775
resistance monitoring, and the possible

NOTE Confidence: 0.99738955

01:06:37.775 --> 01:06:39.295
use of liquid biopsy to

NOTE Confidence: 0.99738955

01:06:39.295 --> 01:06:40.755
guide subsequent therapy.

NOTE Confidence: 0.98191035

01:06:41.455 --> 01:06:42.575
The main point is that

NOTE Confidence: 0.98191035

01:06:42.575 --> 01:06:44.095
molecular testing will not just

NOTE Confidence: 0.98191035

01:06:44.095 --> 01:06:46.175
inform one treatment option, but

NOTE Confidence: 0.98191035

01:06:46.175 --> 01:06:47.535
the sequence of care over

NOTE Confidence: 0.98191035

01:06:47.535 --> 01:06:48.035
time.

NOTE Confidence: 0.95061034

01:06:50.470 --> 01:06:51.930
So this is the algorithm

NOTE Confidence: 0.95061034

01:06:51.990 --> 01:06:53.190
that I adapted from the

NOTE Confidence: 0.95061034

01:06:53.190 --> 01:06:55.029
recent nature review that provides

NOTE Confidence: 0.95061034

01:06:55.029 --> 01:06:56.809
a simplified overview of management.

NOTE Confidence: 0.9940796

01:06:57.349 --> 01:06:58.549
I'll focus on the right

NOTE Confidence: 0.9940796

01:06:58.549 --> 01:07:00.150
hand side, which pertains to

NOTE Confidence: 0.9940796

01:07:00.150 --> 01:07:01.049
advanced endometastatic

NOTE Confidence: 1

01:07:01.589 --> 01:07:02.089
disease.

NOTE Confidence: 0.9998779

01:07:02.685 --> 01:07:04.045
The first key step is

NOTE Confidence: 0.9998779

01:07:04.045 --> 01:07:05.665
comprehensive molecular profiling.

NOTE Confidence: 0.94415283

01:07:06.605 --> 01:07:08.125
Most FIT patients start with

NOTE Confidence: 0.94415283

01:07:08.125 --> 01:07:09.105
first line chemoimmunotherapy,

NOTE Confidence: 0.9251709

01:07:10.125 --> 01:07:11.185
and then at progression,

NOTE Confidence: 0.990625

01:07:11.725 --> 01:07:13.985
management branches based on whether

NOTE Confidence: 0.990625

01:07:14.125 --> 01:07:16.065
an actionable alteration is present.

NOTE Confidence: 0.863739

01:07:16.640 --> 01:07:18.160
If it is, our target

NOTE Confidence: 0.863739

01:07:18.160 --> 01:07:19.920
this therapy becomes the preferred

NOTE Confidence: 0.863739

01:07:19.920 --> 01:07:20.660
next step.

NOTE Confidence: 0.9969727

01:07:21.040 --> 01:07:22.740
If not, second line chemotherapy

NOTE Confidence: 0.99438477

01:07:23.120 --> 01:07:24.740
remains a reasonable option.

NOTE Confidence: 0.96186966

01:07:25.200 --> 01:07:26.960
So this algorithm really highlights

NOTE Confidence: 0.96186966

01:07:26.960 --> 01:07:28.420
a central role of molecular

NOTE Confidence: 0.96186966

01:07:28.480 --> 01:07:28.980
profiling,

NOTE Confidence: 0.9913737

01:07:29.360 --> 01:07:30.660
not just as a diagnostic

NOTE Confidence: 0.9913737

01:07:30.800 --> 01:07:31.300
exercise,

NOTE Confidence: 0.99578303

01:07:31.925 --> 01:07:33.205
but as a decision point

NOTE Confidence: 0.99578303

01:07:33.205 --> 01:07:34.965
that determines subsequent lines of

NOTE Confidence: 0.99578303

01:07:34.965 --> 01:07:35.465
therapy.

NOTE Confidence: 0.96017337

01:07:38.005 --> 01:07:39.365
So although my focus is

NOTE Confidence: 0.96017337

01:07:39.365 --> 01:07:41.765
on systemic therapy, hepatic arterial

NOTE Confidence: 0.96017337

01:07:41.765 --> 01:07:43.765
infusions worth mentioning in selected

NOTE Confidence: 0.96017337

01:07:43.765 --> 01:07:45.065
patients with unresectable

NOTE Confidence: 0.9913228

01:07:45.819 --> 01:07:47.760
liver confined intrahepatic cholangiocarcinoma.

NOTE Confidence: 0.9819336

01:07:48.940 --> 01:07:51.099
In a systemic review, response

NOTE Confidence: 0.9819336

01:07:51.099 --> 01:07:52.780
rates were about forty one

NOTE Confidence: 0.9819336

01:07:52.780 --> 01:07:54.720
percent with a median PFS

NOTE Confidence: 0.9819336

01:07:54.780 --> 01:07:56.059
of ten months and OS

NOTE Confidence: 0.9819336

01:07:56.059 --> 01:07:57.339
of just over twenty one

NOTE Confidence: 0.9819336

01:07:57.339 --> 01:07:57.839
months.

NOTE Confidence: 0.9873047

01:07:58.755 --> 01:07:59.494
Most recently,

NOTE Confidence: 0.9166938

01:07:59.875 --> 01:08:01.394
the Dutch pump two phase

NOTE Confidence: 0.9166938

01:08:01.394 --> 01:08:03.095
two study in JCO

NOTE Confidence: 0.98291016

01:08:03.635 --> 01:08:04.135
evaluated

NOTE Confidence: 0.99902344

01:08:04.595 --> 01:08:05.095
the

NOTE Confidence: 0.8811442

01:08:05.635 --> 01:08:07.474
HAI HAE pump with concurrent

NOTE Confidence: 0.8811442

01:08:07.474 --> 01:08:08.855
gemcitabine and cisplatin

NOTE Confidence: 0.9707031

01:08:09.394 --> 01:08:10.755
and asked support for this

NOTE Confidence: 0.9707031

01:08:10.755 --> 01:08:12.694
approach in carefully selected patients.

NOTE Confidence: 0.98273677

01:08:13.490 --> 01:08:14.690
This is not a routine

NOTE Confidence: 0.98273677

01:08:14.690 --> 01:08:16.630
option for most patients with

NOTE Confidence: 0.98273677

01:08:16.689 --> 01:08:18.770
metastatic disease, but it is

NOTE Confidence: 0.98273677

01:08:18.770 --> 01:08:20.870
reasonable to consider at experience

NOTE Confidence: 0.98273677

01:08:20.929 --> 01:08:22.070
centers with multidisciplinary

NOTE Confidence: 1

01:08:22.689 --> 01:08:23.189
review.

NOTE Confidence: 0.9423131

01:08:27.165 --> 01:08:29.265
So in practice, treatment decisions

NOTE Confidence: 0.9423131

01:08:29.405 --> 01:08:30.305
in metastatic

NOTE Confidence: 0.9904948

01:08:31.085 --> 01:08:33.245
biliary tract cancers are shaped

NOTE Confidence: 0.9904948

01:08:33.245 --> 01:08:34.925
not only by biology, but

NOTE Confidence: 0.9904948

01:08:34.925 --> 01:08:36.545
also by real world factors.

NOTE Confidence: 0.99658203

01:08:37.005 --> 01:08:39.005
Candidate selection depends on performance

NOTE Confidence: 0.99658203

01:08:39.005 --> 01:08:40.705
status, organ function,

NOTE Confidence: 0.9959717

01:08:41.280 --> 01:08:42.020
disease distribution,

NOTE Confidence: 1

01:08:42.400 --> 01:08:43.700
and molecular profile.

NOTE Confidence: 0.99902344

01:08:44.479 --> 01:08:46.080
Access barriers are also very

NOTE Confidence: 0.99902344

01:08:46.080 --> 01:08:48.340
real, including delays in referral,

NOTE Confidence: 0.99902344

01:08:48.479 --> 01:08:51.060
limited availability of comprehensive NGS,

NOTE Confidence: 0.99761283

01:08:51.520 --> 01:08:53.380
and unequal access to targeted

NOTE Confidence: 0.99761283

01:08:53.439 --> 01:08:54.900
or liver directed therapies.

NOTE Confidence: 0.99934894

01:08:55.845 --> 01:08:56.505
Because benefit is

NOTE Confidence: 0.9886126

01:08:56.805 --> 01:08:58.665
often modest beyond first line,

NOTE Confidence: 0.9886126

01:08:58.805 --> 01:09:00.165
quality of life and patient

NOTE Confidence: 0.9886126

01:09:00.165 --> 01:09:01.625
goals should remain central.

NOTE Confidence: 0.9720459

01:09:02.165 --> 01:09:02.905
And finally,

NOTE Confidence: 0.9666341

01:09:03.205 --> 01:09:03.705
multidisciplinary

NOTE Confidence: 0.9975586

01:09:04.325 --> 01:09:05.785
care and patient advocacy

NOTE Confidence: 0.9674072

01:09:06.245 --> 01:09:08.104
are often essential in navigating

NOTE Confidence: 0.9674072

01:09:08.165 --> 01:09:09.545
these complex decisions.

NOTE Confidence: 0.98030597

01:09:10.645 --> 01:09:11.870
So So looking ahead, the

NOTE Confidence: 0.98030597

01:09:11.870 --> 01:09:13.390
field is continuing to evolve

NOTE Confidence: 0.98030597

01:09:13.390 --> 01:09:15.090
beyond the current approved targets.

NOTE Confidence: 0.97398543

01:09:16.110 --> 01:09:17.950
There are multiple novel targets

NOTE Confidence: 0.97398543

01:09:17.950 --> 01:09:19.570
and strategies under investigation,

NOTE Confidence: 0.96295166

01:09:20.270 --> 01:09:22.210
including KRAS directed therapies,

NOTE Confidence: 0.9621582

01:09:22.510 --> 01:09:24.130
expanded HER2 strategies,

NOTE Confidence: 0.9305245

01:09:24.745 --> 01:09:26.505
claudan eighteen point two, and

NOTE Confidence: 0.9305245

01:09:26.505 --> 01:09:27.485
MDM two.

NOTE Confidence: 0.99595135

01:09:27.864 --> 01:09:28.985
At the same time, we're

NOTE Confidence: 0.99595135

01:09:28.985 --> 01:09:30.745
also seeing increased interest in

NOTE Confidence: 0.99595135

01:09:30.745 --> 01:09:31.805
combination approaches,

NOTE Confidence: 0.97216797

01:09:32.344 --> 01:09:33.965
resistance informed sequencing,

NOTE Confidence: 0.9945313

01:09:34.344 --> 01:09:36.364
and liquid biopsy guided strategies.

NOTE Confidence: 0.995638

01:09:37.550 --> 01:09:39.330
Many of these remain investigational,

NOTE Confidence: 0.99853516

01:09:39.870 --> 01:09:41.230
but the broader direction is

NOTE Confidence: 0.99853516

01:09:41.230 --> 01:09:41.730
clear.

NOTE Confidence: 0.9626953

01:09:42.110 --> 01:09:44.210
We're moving toward increasing individualized

NOTE Confidence: 0.9547526

01:09:44.590 --> 01:09:46.990
therapy supported by molecularly selected

NOTE Confidence: 0.9547526

01:09:46.990 --> 01:09:47.490
trials.

NOTE Confidence: 0.9848633

01:09:48.830 --> 01:09:50.270
So to close, these are

NOTE Confidence: 0.9848633

01:09:50.270 --> 01:09:51.470
the main points I hope

NOTE Confidence: 0.9848633

01:09:51.470 --> 01:09:52.450
you'll take away.

NOTE Confidence: 0.9832715

01:09:53.304 --> 01:09:55.645
So to summarize, first, chemoimmunotherapy

NOTE Confidence: 0.962321

01:09:56.344 --> 01:09:57.545
is now the first line

NOTE Confidence: 0.962321

01:09:57.545 --> 01:09:59.324
standard for most FIT patients

NOTE Confidence: 0.962321

01:09:59.545 --> 01:10:01.724
with metastatic biliary tract cancer.

NOTE Confidence: 0.9988281

01:10:02.744 --> 01:10:05.304
Second, early molecular profiling is

NOTE Confidence: 0.9988281

01:10:05.304 --> 01:10:07.885
essential to identify actionable alterations

NOTE Confidence: 0.9988281

01:10:08.180 --> 01:10:09.720
and to guide later sequencing.

NOTE Confidence: 0.99454755

01:10:10.820 --> 01:10:13.160
Third, targeted therapies have meaningfully

NOTE Confidence: 0.99454755

01:10:13.300 --> 01:10:15.780
expanded options beyond chemotherapy for

NOTE Confidence: 0.99454755

01:10:15.780 --> 01:10:16.680
selected patients.

NOTE Confidence: 0.96313477

01:10:17.460 --> 01:10:18.120
And finally,

NOTE Confidence: 0.98291016

01:10:18.500 --> 01:10:19.400
patient selection,

NOTE Confidence: 0.98795575

01:10:19.939 --> 01:10:21.240
access, and multidisciplinary

NOTE Confidence: 0.99800247

01:10:21.860 --> 01:10:24.095
care remain critical in translating

NOTE Confidence: 0.99800247

01:10:24.155 --> 01:10:25.835
these advances into real world

NOTE Confidence: 0.99800247

01:10:25.835 --> 01:10:26.335
practice.

NOTE Confidence: 0.9993286

01:10:27.515 --> 01:10:29.115
This remains a very challenging

NOTE Confidence: 0.9993286

01:10:29.115 --> 01:10:31.115
disease, but precision oncology is

NOTE Confidence: 0.9993286

01:10:31.115 --> 01:10:32.635
clearly changing how we approach

NOTE Confidence: 0.9993286

01:10:32.635 --> 01:10:33.135
it.

NOTE Confidence: 0.9711914

01:10:33.915 --> 01:10:34.655
Thank you.

NOTE Confidence: 0.991378

01:10:36.590 --> 01:10:37.790
Thank you so much, doctor

NOTE Confidence: 0.991378

01:10:37.790 --> 01:10:38.910
Zhang, for wrapping it up

NOTE Confidence: 0.991378

01:10:38.910 --> 01:10:40.750
and just really making sure

NOTE Confidence: 0.991378

01:10:40.750 --> 01:10:42.110
we really understand that so

NOTE Confidence: 0.991378

01:10:42.110 --> 01:10:43.550
much has evolved in this

NOTE Confidence: 0.991378

01:10:43.550 --> 01:10:45.150
space, especially for options for

NOTE Confidence: 0.991378

01:10:45.150 --> 01:10:46.270
our patients and the need

NOTE Confidence: 0.991378

01:10:46.270 --> 01:10:47.490
for tumor profiling

NOTE Confidence: 0.9985514

01:10:47.985 --> 01:10:50.305
early to offer additional options

NOTE Confidence: 0.9985514

01:10:50.305 --> 01:10:51.905
after progression on first line

NOTE Confidence: 0.9985514

01:10:51.905 --> 01:10:53.525
therapy. Thank you so much.

NOTE Confidence: 0.9775696

01:10:54.305 --> 01:10:55.745
I noticed that we do

NOTE Confidence: 0.9775696

01:10:55.745 --> 01:10:57.425
not have any questions in

NOTE Confidence: 0.9775696

01:10:57.425 --> 01:10:58.945
the chat, and I noticed

NOTE Confidence: 0.9775696

01:10:58.945 --> 01:10:59.985
that we also have gone

NOTE Confidence: 0.9775696

01:10:59.985 --> 01:11:01.205
over an hour, but

NOTE Confidence: 0.9901123

01:11:01.550 --> 01:11:03.729
just for some multidisciplinary

NOTE Confidence: 0.97755694

01:11:04.350 --> 01:11:05.710
discussion, given that it's rare

NOTE Confidence: 0.97755694

01:11:05.710 --> 01:11:06.510
that all of us are

NOTE Confidence: 0.97755694

01:11:06.510 --> 01:11:07.870
here together, I figured I

NOTE Confidence: 0.97755694

01:11:07.870 --> 01:11:08.910
allow us to at least

NOTE Confidence: 0.97755694

01:11:08.910 --> 01:11:10.510
have time for some few

NOTE Confidence: 0.97755694

01:11:10.510 --> 01:11:12.430
moments of discussion to maybe

NOTE Confidence: 0.97755694

01:11:12.430 --> 01:11:14.030
generate some questions. And if

NOTE Confidence: 0.97755694

01:11:14.030 --> 01:11:15.470
not, we can end the

NOTE Confidence: 0.97755694

01:11:15.470 --> 01:11:15.970
night.

NOTE Confidence: 0.94638133

01:11:16.295 --> 01:11:17.735
But I'll start off, and

NOTE Confidence: 0.94638133

01:11:17.735 --> 01:11:19.415
I'll ask doctor Sogel a

NOTE Confidence: 0.94638133

01:11:19.415 --> 01:11:22.075
question for you. You reviewed

NOTE Confidence: 0.98923564

01:11:23.415 --> 01:11:25.675
the actual criteria for considering

NOTE Confidence: 0.98923564

01:11:25.735 --> 01:11:27.735
patients for transplant, and I

NOTE Confidence: 0.98923564

01:11:27.735 --> 01:11:28.854
wanted to know if you

NOTE Confidence: 0.98923564

01:11:28.854 --> 01:11:30.660
could discuss what are some

NOTE Confidence: 0.98923564

01:11:30.660 --> 01:11:31.720
common barriers

NOTE Confidence: 0.9914958

01:11:32.260 --> 01:11:34.120
that may reduce the overall

NOTE Confidence: 0.9914958

01:11:34.180 --> 01:11:36.580
equitable approach for transplant for

NOTE Confidence: 0.9914958

01:11:36.580 --> 01:11:37.320
these patients.

NOTE Confidence: 0.9811198

01:11:38.580 --> 01:11:39.380
Well, I think,

NOTE Confidence: 0.88256836

01:11:41.380 --> 01:11:42.340
one thing that we don't

NOTE Confidence: 0.88256836

01:11:42.340 --> 01:11:43.380
know is,

NOTE Confidence: 0.9187012

01:11:44.145 --> 01:11:45.505
somebody who is a resection

NOTE Confidence: 0.9187012

01:11:45.505 --> 01:11:46.005
candidate

NOTE Confidence: 0.7155762

01:11:46.704 --> 01:11:47.204
and,

NOTE Confidence: 0.9083775

01:11:48.625 --> 01:11:49.985
is a transplant will be

NOTE Confidence: 0.9083775

01:11:49.985 --> 01:11:51.184
a beneficial or not. We

NOTE Confidence: 0.9083775

01:11:51.184 --> 01:11:52.405
don't have any trials.

NOTE Confidence: 0.9914551

01:11:52.864 --> 01:11:53.364
So,

NOTE Confidence: 0.7123814

01:11:54.224 --> 01:11:56.324
like, in like, about cerebrocarcinoma,

NOTE Confidence: 0.8874512

01:11:56.864 --> 01:11:57.604
for example,

NOTE Confidence: 0.97119683

01:11:57.920 --> 01:11:59.520
you know, that's also something

NOTE Confidence: 0.97119683

01:11:59.520 --> 01:12:00.960
similar too. When you have

NOTE Confidence: 0.97119683

01:12:00.960 --> 01:12:02.500
a liver resection, it's it's

NOTE Confidence: 0.9727783

01:12:02.880 --> 01:12:03.619
it's available.

NOTE Confidence: 0.9980469

01:12:04.159 --> 01:12:04.659
We

NOTE Confidence: 0.9255127

01:12:04.960 --> 01:12:06.239
tend to go into liver

NOTE Confidence: 0.9255127

01:12:06.239 --> 01:12:08.320
resection if it's liver is,

NOTE Confidence: 0.81463623

01:12:09.119 --> 01:12:10.580
liver function is remain.

NOTE Confidence: 0.9667969

01:12:12.405 --> 01:12:14.885
And but outcome is, generally

NOTE Confidence: 0.9667969

01:12:14.885 --> 01:12:16.425
speaking, actually, transplantation

NOTE Confidence: 0.86499023

01:12:17.285 --> 01:12:18.745
have as a better survival,

NOTE Confidence: 0.83089197

01:12:20.005 --> 01:12:21.445
than the resection if it's,

NOTE Confidence: 0.83089197

01:12:21.445 --> 01:12:22.725
you know, if it's in

NOTE Confidence: 0.83089197

01:12:22.805 --> 01:12:24.725
so, it's good within the

NOTE Confidence: 0.83089197

01:12:24.725 --> 01:12:25.545
Meran's criteria.

NOTE Confidence: 0.92611533

01:12:26.229 --> 01:12:28.470
However, utility of, you know,

NOTE Confidence: 0.92611533

01:12:28.470 --> 01:12:29.590
liver trans you know, or,

NOTE Confidence: 0.92611533

01:12:29.590 --> 01:12:31.770
you know, scarcity of, organs.

NOTE Confidence: 0.92611533

01:12:31.830 --> 01:12:33.050
And then so, therefore,

NOTE Confidence: 0.87939453

01:12:33.430 --> 01:12:34.570
most of our practice,

NOTE Confidence: 0.984713

01:12:35.670 --> 01:12:36.950
generally, if it's somebody who

NOTE Confidence: 0.984713

01:12:36.950 --> 01:12:38.550
is a resection candidate, we're

NOTE Confidence: 0.984713

01:12:38.550 --> 01:12:39.850
going for resection

NOTE Confidence: 0.91432834

01:12:40.345 --> 01:12:41.865
rather than the transplantation. So

NOTE Confidence: 0.91432834

01:12:41.865 --> 01:12:43.945
that's part certainly, we need

NOTE Confidence: 0.91432834

01:12:43.945 --> 01:12:45.645
to have a more clarity

NOTE Confidence: 0.9876709

01:12:46.104 --> 01:12:46.845
for this.

NOTE Confidence: 0.9980469

01:12:47.385 --> 01:12:47.885
And,

NOTE Confidence: 0.91872925

01:12:48.665 --> 01:12:50.265
what I see more and

NOTE Confidence: 0.91872925

01:12:50.265 --> 01:12:52.104
more patient who's, for the

NOTE Confidence: 0.91872925

01:12:52.104 --> 01:12:52.604
chorangio,

NOTE Confidence: 0.8199599

01:12:53.465 --> 01:12:54.425
was found at is the

NOTE Confidence: 0.8199599

01:12:54.425 --> 01:12:55.710
latest stage of age.

NOTE Confidence: 0.9995117

01:12:56.270 --> 01:12:56.770
So,

NOTE Confidence: 0.8679199

01:12:57.950 --> 01:12:59.310
you know, age is not

NOTE Confidence: 0.8679199

01:12:59.310 --> 01:13:00.989
necessarily be a it's a

NOTE Confidence: 0.8679199

01:13:00.989 --> 01:13:02.689
biological age is more important,

NOTE Confidence: 0.8679199

01:13:02.750 --> 01:13:03.250
but

NOTE Confidence: 0.97280276

01:13:03.950 --> 01:13:05.489
not too many people who

NOTE Confidence: 0.97280276

01:13:05.550 --> 01:13:07.170
can go for liver transplantation,

NOTE Confidence: 0.8972052

01:13:08.235 --> 01:13:09.695
like a later of seventies

NOTE Confidence: 0.8972052

01:13:09.755 --> 01:13:10.574
or eighties.

NOTE Confidence: 0.96083575

01:13:11.034 --> 01:13:12.395
It's very hard to do

NOTE Confidence: 0.96083575

01:13:12.395 --> 01:13:13.295
a liver transplantation.

NOTE Confidence: 0.98205566

01:13:13.675 --> 01:13:15.215
So that's that's another,

NOTE Confidence: 0.9995117

01:13:16.314 --> 01:13:16.814
limitation.

NOTE Confidence: 0.9064331

01:13:17.835 --> 01:13:19.295
Number three would be,

NOTE Confidence: 0.8688965

01:13:21.620 --> 01:13:22.120
particularly,

NOTE Confidence: 0.93226457

01:13:23.780 --> 01:13:25.080
above three centimeter.

NOTE Confidence: 0.9370117

01:13:25.700 --> 01:13:26.660
Even you have,

NOTE Confidence: 0.9593506

01:13:27.220 --> 01:13:27.720
downstaging,

NOTE Confidence: 0.9737685

01:13:28.500 --> 01:13:30.100
be able to give a

NOTE Confidence: 0.9737685

01:13:30.100 --> 01:13:30.600
chemo,

NOTE Confidence: 0.9547526

01:13:32.180 --> 01:13:34.280
may potentially get the exception

NOTE Confidence: 0.9547526

01:13:34.420 --> 01:13:35.885
point. However, it's not the

NOTE Confidence: 0.9547526

01:13:35.885 --> 01:13:37.025
automatic exception.

NOTE Confidence: 0.9805501

01:13:37.485 --> 01:13:38.465
So the only,

NOTE Confidence: 0.96005046

01:13:38.925 --> 01:13:41.085
possibility, a living donor. So

NOTE Confidence: 0.96005046

01:13:41.085 --> 01:13:43.085
not not everyone can have

NOTE Confidence: 0.96005046

01:13:43.085 --> 01:13:44.285
a living donor. So that's,

NOTE Confidence: 0.875

01:13:46.604 --> 01:13:47.104
limitation

NOTE Confidence: 0.99035645

01:13:47.885 --> 01:13:49.025
of at this moment.

NOTE Confidence: 0.9995117

01:13:50.590 --> 01:13:51.410
Thank you.

NOTE Confidence: 0.8446045

01:13:52.110 --> 01:13:54.430
Doctor Strzad Bosco, this is,

NOTE Confidence: 0.963845

01:13:54.910 --> 01:13:56.350
a question for you and

NOTE Confidence: 0.963845

01:13:56.350 --> 01:13:58.430
really thinking about potential audience

NOTE Confidence: 0.963845

01:13:58.430 --> 01:13:58.930
members.

NOTE Confidence: 0.99975586

01:13:59.390 --> 01:14:00.930
What are ways that

NOTE Confidence: 0.96875

01:14:01.310 --> 01:14:01.810
oncologists

NOTE Confidence: 1

01:14:02.564 --> 01:14:03.705
can better partner

NOTE Confidence: 0.9708252

01:14:04.165 --> 01:14:04.985
with hepatologists

NOTE Confidence: 0.99316406

01:14:06.085 --> 01:14:06.905
to ultimately

NOTE Confidence: 0.99640447

01:14:07.285 --> 01:14:08.885
improve the outcomes for our

NOTE Confidence: 0.99640447

01:14:08.885 --> 01:14:10.885
patients diagnosed with biliary tract

NOTE Confidence: 0.99640447

01:14:10.885 --> 01:14:11.385
cancers?

NOTE Confidence: 0.89006346

01:14:15.420 --> 01:14:16.960
Oh, you're muted, doctor Strassbosco.

NOTE Confidence: 0.99938965

01:14:20.380 --> 01:14:21.680
Can you hear me now?

NOTE Confidence: 0.99938965

01:14:21.820 --> 01:14:22.720
Yes. I can.

NOTE Confidence: 0.972585

01:14:23.100 --> 01:14:24.560
Well, I think that that

NOTE Confidence: 0.972585

01:14:24.700 --> 01:14:25.979
it's a it's a it's

NOTE Confidence: 0.972585

01:14:25.979 --> 01:14:26.700
a very,

NOTE Confidence: 0.9450335

01:14:27.180 --> 01:14:29.979
stronger and daily partnership, to

NOTE Confidence: 0.9450335

01:14:29.979 --> 01:14:30.640
be honest.

NOTE Confidence: 0.85498047

01:14:31.225 --> 01:14:31.725
Hepatologists

NOTE Confidence: 0.91259766

01:14:32.505 --> 01:14:33.705
are the one that,

NOTE Confidence: 0.9951172

01:14:34.425 --> 01:14:35.485
probably diagnosing

NOTE Confidence: 0.7470703

01:14:35.945 --> 01:14:36.445
more,

NOTE Confidence: 0.8788656

01:14:38.344 --> 01:14:39.485
intraepartic cholangiocarcinoma,

NOTE Confidence: 0.9921875

01:14:40.745 --> 01:14:41.245
and

NOTE Confidence: 0.6251221

01:14:42.185 --> 01:14:43.165
so we,

NOTE Confidence: 0.8607585

01:14:44.025 --> 01:14:45.245
receive the patient.

NOTE Confidence: 0.8684082

01:14:46.460 --> 01:14:46.960
We,

NOTE Confidence: 0.8972684

01:14:48.060 --> 01:14:49.100
kind of work up the

NOTE Confidence: 0.8972684

01:14:49.100 --> 01:14:51.100
patient reaches the anguities. But

NOTE Confidence: 0.8972684

01:14:51.100 --> 01:14:52.320
then after that,

NOTE Confidence: 0.8593588

01:14:53.340 --> 01:14:55.200
it's, it's, it's really teamwork,

NOTE Confidence: 0.94873047

01:14:55.740 --> 01:14:56.240
between,

NOTE Confidence: 0.8980713

01:14:56.860 --> 01:14:57.360
oncology,

NOTE Confidence: 0.8520508

01:14:59.260 --> 01:14:59.760
surgery.

NOTE Confidence: 0.7994791

01:15:01.305 --> 01:15:02.445
Intervention, radiology.

NOTE Confidence: 0.88842773

01:15:03.705 --> 01:15:04.205
And,

NOTE Confidence: 0.96369916

01:15:04.665 --> 01:15:06.825
you know, these cases are,

NOTE Confidence: 0.96369916

01:15:06.825 --> 01:15:08.985
of course, less, frequent than

NOTE Confidence: 0.96369916

01:15:08.985 --> 01:15:09.485
hepatosarcosinoma,

NOTE Confidence: 0.97065336

01:15:10.104 --> 01:15:10.985
but I think that with

NOTE Confidence: 0.97065336

01:15:10.985 --> 01:15:11.565
the hepatosarcosinoma,

NOTE Confidence: 0.85668945

01:15:12.265 --> 01:15:13.725
we are very well

NOTE Confidence: 0.9604492

01:15:14.265 --> 01:15:15.405
oiled and integrated

NOTE Confidence: 0.9842122

01:15:16.960 --> 01:15:17.460
multidisciplinary

NOTE Confidence: 0.91646904

01:15:20.159 --> 01:15:22.099
tumor board and and and

NOTE Confidence: 0.91646904

01:15:22.159 --> 01:15:22.900
and approach.

NOTE Confidence: 0.9983724

01:15:23.520 --> 01:15:24.820
And thinking about

NOTE Confidence: 0.87280273

01:15:25.400 --> 01:15:25.900
the,

NOTE Confidence: 0.8651123

01:15:27.920 --> 01:15:28.960
transplant for,

NOTE Confidence: 0.7265044

01:15:29.520 --> 01:15:30.739
intraparticle angiocarcinoma,

NOTE Confidence: 0.895874

01:15:32.784 --> 01:15:33.764
it seems to me

NOTE Confidence: 0.90045166

01:15:35.025 --> 01:15:36.465
that there is a there

NOTE Confidence: 0.90045166

01:15:36.465 --> 01:15:37.364
is a clear,

NOTE Confidence: 0.93910843

01:15:37.905 --> 01:15:39.184
clear patient where this may

NOTE Confidence: 0.93910843

01:15:39.184 --> 01:15:40.864
be indicated. Right? So, you

NOTE Confidence: 0.93910843

01:15:40.864 --> 01:15:43.025
know, as we discussed, many

NOTE Confidence: 0.93910843

01:15:43.025 --> 01:15:44.005
patient with

NOTE Confidence: 0.9867079

01:15:45.280 --> 01:15:45.780
cholangiocarcinoma,

NOTE Confidence: 0.9005534

01:15:46.560 --> 01:15:48.739
they have steatotic liver disease.

NOTE Confidence: 0.9005534

01:15:48.960 --> 01:15:51.300
Sometimes they they have, cirrhosis.

NOTE Confidence: 0.92567277

01:15:52.159 --> 01:15:53.920
This patient, particularly if they

NOTE Confidence: 0.92567277

01:15:53.920 --> 01:15:55.540
are diagnosed with small,

NOTE Confidence: 0.9338379

01:15:56.000 --> 01:15:56.479
small,

NOTE Confidence: 0.8330078

01:15:56.960 --> 01:15:58.260
tumor, they are

NOTE Confidence: 0.9831238

01:15:59.155 --> 01:16:00.615
difficult to be resected.

NOTE Confidence: 0.92041016

01:16:01.395 --> 01:16:01.875
And,

NOTE Confidence: 0.87908936

01:16:04.035 --> 01:16:05.575
maybe this patient also,

NOTE Confidence: 0.9463501

01:16:06.275 --> 01:16:07.575
a little more compromised.

NOTE Confidence: 0.375

01:16:07.955 --> 01:16:08.455
So

NOTE Confidence: 0.99316406

01:16:08.835 --> 01:16:09.335
immunotherapy

NOTE Confidence: 0.9485786

01:16:10.515 --> 01:16:11.955
adjuvant is not something that

NOTE Confidence: 0.9485786

01:16:11.955 --> 01:16:13.075
you think about, but they

NOTE Confidence: 0.9485786

01:16:13.075 --> 01:16:15.230
could very easily be treated

NOTE Confidence: 0.9313151

01:16:15.850 --> 01:16:16.830
by local regional

NOTE Confidence: 0.9237793

01:16:18.170 --> 01:16:19.870
treatment and go down immediately,

NOTE Confidence: 0.9845703

01:16:20.250 --> 01:16:21.950
go down the the transplant,

NOTE Confidence: 0.97126466

01:16:22.890 --> 01:16:24.410
way, for example. Right? So

NOTE Confidence: 0.97126466

01:16:24.410 --> 01:16:25.950
we see the patient with,

NOTE Confidence: 0.949428

01:16:27.050 --> 01:16:28.970
downstage the tumor. We we

NOTE Confidence: 0.949428

01:16:28.970 --> 01:16:29.710
we buy

NOTE Confidence: 0.94088745

01:16:30.015 --> 01:16:31.614
time, and that is key.

NOTE Confidence: 0.94088745

01:16:31.614 --> 01:16:32.515
It's very important.

NOTE Confidence: 0.9851074

01:16:33.695 --> 01:16:35.155
And then we try to,

NOTE Confidence: 0.9672241

01:16:35.695 --> 01:16:37.455
to to to transfer the

NOTE Confidence: 0.9672241

01:16:37.455 --> 01:16:38.735
patient. And in in this

NOTE Confidence: 0.9672241

01:16:38.735 --> 01:16:39.554
phase also,

NOTE Confidence: 0.85637414

01:16:39.854 --> 01:16:41.775
medical oncology comes in as

NOTE Confidence: 0.85637414

01:16:41.775 --> 01:16:43.074
we discussed, particularly

NOTE Confidence: 0.8919897

01:16:43.455 --> 01:16:44.975
if this tumor are larger

NOTE Confidence: 0.8919897

01:16:44.975 --> 01:16:47.439
than two centimeter with, with

NOTE Confidence: 0.8919897

01:16:47.439 --> 01:16:48.660
an adjuvant treatment.

NOTE Confidence: 0.96972656

01:16:50.640 --> 01:16:51.140
So

NOTE Confidence: 0.9937744

01:16:52.080 --> 01:16:53.520
it's it's very difficult to

NOTE Confidence: 0.9937744

01:16:53.520 --> 01:16:54.020
say

NOTE Confidence: 0.8803304

01:16:54.800 --> 01:16:56.180
where they are the boundaries,

NOTE Confidence: 0.8803304

01:16:56.400 --> 01:16:56.900
honestly,

NOTE Confidence: 0.9033203

01:16:57.835 --> 01:16:58.895
of these different

NOTE Confidence: 0.42700195

01:16:59.675 --> 01:17:00.175
professionals

NOTE Confidence: 0.93273926

01:17:01.354 --> 01:17:03.454
that are working together,

NOTE Confidence: 0.9993286

01:17:07.034 --> 01:17:08.474
to provide the best treatment

NOTE Confidence: 0.9993286

01:17:08.474 --> 01:17:09.454
for our patients.

NOTE Confidence: 0.97422284

01:17:13.729 --> 01:17:15.010
Thank you so much, doctor

NOTE Confidence: 0.97422284

01:17:15.010 --> 01:17:16.610
Strazzavasco. I think we have

NOTE Confidence: 0.97422284

01:17:16.610 --> 01:17:17.810
one question in the chat,

NOTE Confidence: 0.97422284

01:17:17.810 --> 01:17:18.630
so I appreciate,

NOTE Confidence: 0.97213465

01:17:19.410 --> 01:17:20.850
that one question being put

NOTE Confidence: 0.97213465

01:17:20.850 --> 01:17:21.890
in the chat. And that's

NOTE Confidence: 0.97213465

01:17:21.890 --> 01:17:22.390
specifically

NOTE Confidence: 0.9303816

01:17:22.770 --> 01:17:24.370
about the NEOGOLD study. I

NOTE Confidence: 0.9303816

01:17:24.370 --> 01:17:26.210
think you raise a certainly

NOTE Confidence: 0.9303816

01:17:26.210 --> 01:17:27.695
a good point regarding this

NOTE Confidence: 0.9303816

01:17:27.695 --> 01:17:28.655
recently published,

NOTE Confidence: 0.9316406

01:17:29.054 --> 01:17:29.554
study,

NOTE Confidence: 0.8383789

01:17:29.854 --> 01:17:30.354
which,

NOTE Confidence: 0.99902344

01:17:30.895 --> 01:17:32.655
again, is the first study

NOTE Confidence: 0.99902344

01:17:32.655 --> 01:17:34.354
in this particular space.

NOTE Confidence: 0.94718856

01:17:35.454 --> 01:17:36.974
There's certainly as we get

NOTE Confidence: 0.94718856

01:17:36.974 --> 01:17:38.494
further and out further out

NOTE Confidence: 0.94718856

01:17:38.494 --> 01:17:39.870
as far as thinking about

NOTE Confidence: 0.94718856

01:17:39.870 --> 01:17:41.469
about forty two to forty

NOTE Confidence: 0.94718856

01:17:41.469 --> 01:17:42.850
eight months as far as

NOTE Confidence: 0.94718856

01:17:42.910 --> 01:17:44.429
where those tells are closely

NOTE Confidence: 0.94718856

01:17:44.429 --> 01:17:45.870
meeting, which is ultimately what

NOTE Confidence: 0.94718856

01:17:45.870 --> 01:17:47.010
you're alluding to.

NOTE Confidence: 0.9995117

01:17:47.310 --> 01:17:48.050
I think

NOTE Confidence: 0.997857

01:17:49.150 --> 01:17:50.590
that tells me that we

NOTE Confidence: 0.997857

01:17:50.590 --> 01:17:51.810
just need more information.

NOTE Confidence: 0.96304685

01:17:52.485 --> 01:17:53.604
You know, the study was

NOTE Confidence: 0.96304685

01:17:53.604 --> 01:17:55.285
a Chinese study, which means

NOTE Confidence: 0.96304685

01:17:55.285 --> 01:17:56.165
that I think it would

NOTE Confidence: 0.96304685

01:17:56.165 --> 01:17:57.445
be also helpful to have

NOTE Confidence: 0.96304685

01:17:57.445 --> 01:17:59.625
this study done similarly here

NOTE Confidence: 0.7888997

01:17:59.925 --> 01:18:01.145
in Western countries,

NOTE Confidence: 0.99592286

01:18:01.604 --> 01:18:02.965
but I don't think that

NOTE Confidence: 0.99592286

01:18:02.965 --> 01:18:04.165
it shows us that we

NOTE Confidence: 0.99592286

01:18:04.165 --> 01:18:06.665
should not consider neoadjuvant therapy.

NOTE Confidence: 0.87954104

01:18:06.965 --> 01:18:08.400
I think it just ultimately

NOTE Confidence: 0.87954104

01:18:08.460 --> 01:18:09.580
shows us that more work

NOTE Confidence: 0.87954104

01:18:09.580 --> 01:18:10.699
is done. More work is

NOTE Confidence: 0.87954104

01:18:10.699 --> 01:18:11.660
done. If I can add

NOTE Confidence: 0.7901204

01:18:12.300 --> 01:18:13.580
if I can add a

NOTE Confidence: 0.7901204

01:18:13.580 --> 01:18:15.420
a general consideration about the

NOTE Confidence: 0.7901204

01:18:15.420 --> 01:18:17.280
taste of the government mayor

NOTE Confidence: 0.9364537

01:18:17.900 --> 01:18:19.660
is the fact they are

NOTE Confidence: 0.9364537

01:18:19.660 --> 01:18:20.479
very tricky

NOTE Confidence: 0.984375

01:18:21.275 --> 01:18:22.735
because you should look also

NOTE Confidence: 0.984375

01:18:22.795 --> 01:18:23.455
at the

NOTE Confidence: 0.97281903

01:18:23.995 --> 01:18:24.975
how the cases

NOTE Confidence: 0.94262695

01:18:25.995 --> 01:18:26.495
decrease.

NOTE Confidence: 0.95874023

01:18:27.995 --> 01:18:29.354
Some of the some of

NOTE Confidence: 0.95874023

01:18:29.354 --> 01:18:29.835
the,

NOTE Confidence: 0.9326172

01:18:31.115 --> 01:18:32.235
trial that was shown at

NOTE Confidence: 0.9326172

01:18:32.235 --> 01:18:33.275
the end that the two,

NOTE Confidence: 0.9326172

01:18:33.275 --> 01:18:35.229
three patient on the on

NOTE Confidence: 0.9326172

01:18:35.229 --> 01:18:37.490
the later stages. And so

NOTE Confidence: 0.98476565

01:18:38.030 --> 01:18:39.890
how significant can they be?

NOTE Confidence: 0.947347

01:18:40.590 --> 01:18:41.890
Yeah. I think.

NOTE Confidence: 0.9227295

01:18:42.670 --> 01:18:44.590
So many many trials failed

NOTE Confidence: 0.9227295

01:18:44.590 --> 01:18:46.430
the test of the of

NOTE Confidence: 0.9227295

01:18:46.430 --> 01:18:47.170
the tails,

NOTE Confidence: 1

01:18:47.710 --> 01:18:48.210
but

NOTE Confidence: 0.9628906

01:18:49.255 --> 01:18:51.195
how significant that is is

NOTE Confidence: 0.9628906

01:18:51.255 --> 01:18:52.055
is is a is a

NOTE Confidence: 0.9628906

01:18:52.055 --> 01:18:53.415
question that I always ask

NOTE Confidence: 0.9628906

01:18:53.415 --> 01:18:53.915
myself

NOTE Confidence: 0.93094677

01:18:54.375 --> 01:18:55.575
Yeah. Because the number of

NOTE Confidence: 0.93094677

01:18:55.575 --> 01:18:56.935
patient are certainly not the

NOTE Confidence: 0.93094677

01:18:56.935 --> 01:18:58.135
number that for which the

NOTE Confidence: 0.93094677

01:18:58.135 --> 01:18:59.354
study has been designed.

NOTE Confidence: 0.9808757

01:19:02.310 --> 01:19:03.990
Doctor Zhang, I think I'll

NOTE Confidence: 0.9808757

01:19:03.990 --> 01:19:05.350
end with asking you one

NOTE Confidence: 0.9808757

01:19:05.350 --> 01:19:06.790
question before we wrap up

NOTE Confidence: 0.9808757

01:19:06.790 --> 01:19:07.610
for the evening.

NOTE Confidence: 0.9834015

01:19:08.150 --> 01:19:09.350
But and we can kinda

NOTE Confidence: 0.9834015

01:19:09.350 --> 01:19:10.950
discuss this together as well.

NOTE Confidence: 0.9834015

01:19:10.950 --> 01:19:12.390
But one question I often

NOTE Confidence: 0.9834015

01:19:12.390 --> 01:19:13.590
think about when I'm thinking

NOTE Confidence: 0.9834015

01:19:13.590 --> 01:19:14.870
about our patients that have

NOTE Confidence: 0.9834015

01:19:14.870 --> 01:19:15.930
undergone resection,

NOTE Confidence: 0.9936217

01:19:16.475 --> 01:19:17.595
and now they're coming to

NOTE Confidence: 0.9936217

01:19:17.595 --> 01:19:19.455
us and referred by surgery

NOTE Confidence: 0.9936217

01:19:19.755 --> 01:19:21.435
to discuss the role of

NOTE Confidence: 0.9936217

01:19:21.435 --> 01:19:22.495
adjuvant capecitabine.

NOTE Confidence: 0.99952334

01:19:23.515 --> 01:19:26.015
What limits you from offering

NOTE Confidence: 0.99952334

01:19:26.155 --> 01:19:27.295
adjuvant capecitabine

NOTE Confidence: 0.9293457

01:19:27.755 --> 01:19:29.375
or what says I'm absolutely

NOTE Confidence: 0.9293457

01:19:29.595 --> 01:19:31.215
going to do it versus

NOTE Confidence: 0.9403076

01:19:31.570 --> 01:19:33.890
every patient I recommend adjuvant,

NOTE Confidence: 0.9403076

01:19:33.890 --> 01:19:34.390
Kate?

NOTE Confidence: 0.90933615

01:19:35.410 --> 01:19:36.850
Yeah. Great question. So in

NOTE Confidence: 0.90933615

01:19:36.850 --> 01:19:39.010
general, yes, for patients after

NOTE Confidence: 0.90933615

01:19:39.010 --> 01:19:40.390
upfront chemo resection,

NOTE Confidence: 0.8545583

01:19:40.930 --> 01:19:43.010
adjuvant keeps sit sitavine remains

NOTE Confidence: 0.8545583

01:19:43.010 --> 01:19:44.130
a standard based on the

NOTE Confidence: 0.8545583

01:19:44.130 --> 01:19:44.930
BILCAT trial.

NOTE Confidence: 0.98866105

01:19:45.745 --> 01:19:47.185
Assuming that they have recovered,

NOTE Confidence: 0.98866105

01:19:47.185 --> 01:19:48.545
you know, adequately from the

NOTE Confidence: 0.98866105

01:19:48.545 --> 01:19:50.545
surgery and also enough fitness

NOTE Confidence: 0.98866105

01:19:50.545 --> 01:19:51.364
for the treatment.

NOTE Confidence: 0.99142456

01:19:52.145 --> 01:19:53.585
But in practice, you know,

NOTE Confidence: 0.99142456

01:19:53.585 --> 01:19:55.205
the decision has been visualized

NOTE Confidence: 0.99142456

01:19:55.344 --> 01:19:57.265
based on margin status, nodal

NOTE Confidence: 0.99142456

01:19:57.265 --> 01:19:57.765
status,

NOTE Confidence: 0.96736485

01:19:58.219 --> 01:20:00.460
like, performance status, and patient

NOTE Confidence: 0.96736485

01:20:00.460 --> 01:20:02.219
preference too. I think I

NOTE Confidence: 0.96736485

01:20:02.219 --> 01:20:03.820
really appreciate your point during

NOTE Confidence: 0.96736485

01:20:03.820 --> 01:20:04.860
the talk about, you know,

NOTE Confidence: 0.96736485

01:20:04.860 --> 01:20:06.140
patients having high risk of

NOTE Confidence: 0.96736485

01:20:06.140 --> 01:20:07.900
recurrence, and currently, we don't

NOTE Confidence: 0.96736485

01:20:07.900 --> 01:20:09.580
have many other alternatives. You

NOTE Confidence: 0.96736485

01:20:09.580 --> 01:20:11.020
know? So that's something you

NOTE Confidence: 0.96736485

01:20:11.020 --> 01:20:12.314
present upfront with them and

NOTE Confidence: 0.96736485

01:20:12.314 --> 01:20:13.695
also the modest benefit.

NOTE Confidence: 0.94846106

01:20:14.555 --> 01:20:15.835
But in general, I think

NOTE Confidence: 0.94846106

01:20:15.835 --> 01:20:16.955
in the absence of, you

NOTE Confidence: 0.94846106

01:20:16.955 --> 01:20:19.035
know, definitive, like, the fit

NOTE Confidence: 0.94846106

01:20:19.195 --> 01:20:20.395
like, lack of fitness or

NOTE Confidence: 0.94846106

01:20:20.395 --> 01:20:21.995
preference, I would still offer

NOTE Confidence: 0.94846106

01:20:21.995 --> 01:20:23.135
it to most patients.

NOTE Confidence: 0.98513997

01:20:23.515 --> 01:20:24.475
I agree with you. And

NOTE Confidence: 0.98513997

01:20:24.475 --> 01:20:25.515
I think, you know, this

NOTE Confidence: 0.98513997

01:20:25.515 --> 01:20:26.850
is one of those conversations

NOTE Confidence: 0.99902344

01:20:27.310 --> 01:20:27.810
that

NOTE Confidence: 0.9666533

01:20:28.590 --> 01:20:30.590
share decision making. I, you

NOTE Confidence: 0.9666533

01:20:30.590 --> 01:20:32.189
know, review the data with

NOTE Confidence: 0.9666533

01:20:32.189 --> 01:20:33.890
them and show the limitations

NOTE Confidence: 0.9666533

01:20:34.110 --> 01:20:35.010
as NCCN.

NOTE Confidence: 0.98709714

01:20:35.310 --> 01:20:36.930
In their footnote, they highlight,

NOTE Confidence: 0.98709714

01:20:36.989 --> 01:20:38.590
you know, what happened as

NOTE Confidence: 0.98709714

01:20:38.590 --> 01:20:40.125
far as the intention to

NOTE Confidence: 0.98709714

01:20:40.125 --> 01:20:42.225
treat versus per protocol results.

NOTE Confidence: 0.9793091

01:20:42.765 --> 01:20:44.045
But as you alluded to,

NOTE Confidence: 0.9793091

01:20:44.045 --> 01:20:45.425
doctor Zhang, ultimately,

NOTE Confidence: 0.99434406

01:20:46.285 --> 01:20:47.325
we don't have any other

NOTE Confidence: 0.99434406

01:20:47.325 --> 01:20:47.825
alternatives.

NOTE Confidence: 0.97046775

01:20:48.205 --> 01:20:49.165
You know, it's not like,

NOTE Confidence: 0.97046775

01:20:49.165 --> 01:20:50.205
okay. Well, I can offer

NOTE Confidence: 0.97046775

01:20:50.205 --> 01:20:51.405
this instead. And what we

NOTE Confidence: 0.97046775

01:20:51.405 --> 01:20:52.365
do know, which is what

NOTE Confidence: 0.97046775

01:20:52.365 --> 01:20:54.010
I often share with, my

NOTE Confidence: 0.97046775

01:20:54.010 --> 01:20:55.370
patients, is that there's such

NOTE Confidence: 0.97046775

01:20:55.370 --> 01:20:56.590
a high risk of recurrence.

NOTE Confidence: 0.97046775

01:20:56.890 --> 01:20:57.790
And, ultimately,

NOTE Confidence: 0.9799892

01:20:58.250 --> 01:20:59.550
when we think about capecitabine

NOTE Confidence: 0.9799892

01:20:59.850 --> 01:21:01.710
compared to, let's just say,

NOTE Confidence: 0.9799892

01:21:01.770 --> 01:21:03.470
FOLFOX or some other

NOTE Confidence: 0.8869629

01:21:03.850 --> 01:21:05.790
more multi agent regimen,

NOTE Confidence: 0.99820966

01:21:06.195 --> 01:21:07.255
there's less toxicities

NOTE Confidence: 0.98342896

01:21:07.715 --> 01:21:09.314
associated with it depending on

NOTE Confidence: 0.98342896

01:21:09.314 --> 01:21:10.454
what their comorbidities

NOTE Confidence: 0.971405

01:21:10.755 --> 01:21:12.695
are, DPD testing, etcetera.

NOTE Confidence: 0.99902344

01:21:13.074 --> 01:21:14.275
So I certainly agree with

NOTE Confidence: 0.99902344

01:21:14.275 --> 01:21:14.775
you.

NOTE Confidence: 0.99576825

01:21:16.275 --> 01:21:17.314
If there are no other

NOTE Confidence: 0.99576825

01:21:17.314 --> 01:21:18.675
questions in the chat, which

NOTE Confidence: 0.99576825

01:21:18.675 --> 01:21:19.875
it does not look like

NOTE Confidence: 0.99576825

01:21:19.875 --> 01:21:21.280
it is, I first want

NOTE Confidence: 0.99576825

01:21:21.280 --> 01:21:22.420
to thank my panelists

NOTE Confidence: 0.99783325

01:21:22.800 --> 01:21:24.880
for speaking this evening, for

NOTE Confidence: 0.99783325

01:21:24.880 --> 01:21:26.100
taking time to

NOTE Confidence: 1

01:21:26.560 --> 01:21:27.699
educate our community

NOTE Confidence: 0.9667155

01:21:28.159 --> 01:21:29.760
and coming together. And I

NOTE Confidence: 0.9667155

01:21:29.760 --> 01:21:30.960
also want to thank all

NOTE Confidence: 0.9667155

01:21:30.960 --> 01:21:31.620
of the

NOTE Confidence: 0.9376526

01:21:32.000 --> 01:21:33.760
guests that came tonight or

NOTE Confidence: 0.9376526

01:21:33.760 --> 01:21:34.580
will come later,

NOTE Confidence: 0.9460961

01:21:34.955 --> 01:21:35.835
and for all of those

NOTE Confidence: 0.9460961

01:21:35.835 --> 01:21:37.915
that helped organize this event.

NOTE Confidence: 0.9460961

01:21:37.915 --> 01:21:39.035
Thank you so much for

NOTE Confidence: 0.9460961

01:21:39.035 --> 01:21:40.495
joining. Have a good evening.

NOTE Confidence: 0.9460961

01:21:40.635 --> 01:21:42.715
You, Kylie, Jack Jackie, for

NOTE Confidence: 0.9460961

01:21:42.715 --> 01:21:43.535
making this

NOTE Confidence: 0.99560547

01:21:44.555 --> 01:21:45.535
beautiful panel.

NOTE Confidence: 0.9995117

01:21:46.075 --> 01:21:47.295
Of course. Thanks.

NOTE Confidence: 0.9927368

01:21:47.915 --> 01:21:49.275
Thank you. Bye. Thank you

NOTE Confidence: 0.9927368

01:21:49.275 --> 01:21:50.379
so much. Good