Radiation therapy for primary carcinoma of the extrahepatic biliary system. An analysis of 63 cases

Antitumor effect of the paclitaxel-eluting membrane in a mouse model

Local treatment of primary bile duct cancer, which grows locally at the primary lesion and seldom metastasizes to distant sites, is challenging. The present study evaluated the antitumor effect, systemic toxicity, biodistribution and survival benefit of the paclitaxel-eluting polyurethane membrane in a tumor model. Membranes containing various amounts of paclitaxel (0, 100, 300, 600 and 1,200 µg/disc) were inserted beneath the tumor mass in mouse models. Tumor size and body weight of the tumor models were monitored for 26 days after insertion of the membrane. The terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling assay was performed in the tumor tissues. High-performance liquid chromatography was performed for evaluation of paclitaxel concentration in peripheral tissues. Tumor volumes on day 26 of membrane treatment were decreased in a dose-dependent manner. No significant difference in body weight was observed in the groups. A greater number of apoptotic cells were counted per high power field in tumor tissues following an increase of paclitaxel concentration. In the 1,200 µg-group, concentrations of paclitaxel were significantly higher in tumors compared with those of other tissues and serum. The paclitaxel-eluting membrane demonstrated a significant and dose-dependent antitumor activity, and did not exert systemic toxicity in the tumor model.

Diagnosis and Management of Intrahepatic and Extrahepatic Cholangiocarcinoma

Cholangiocarcinomas (CC) are rare tumors which usually present late and are often difficult to diagnose and treat. CCs are categorized as intrahepatic, hilar, or extrahepatic. Epidemiologic studies suggest that the incidence of intrahepatic CCs may be increasing worldwide. In this chapter, we review the risk factors, clinical presentation, and management of cholangiocarcinoma.

Comparison of external beam radiation and brachytherapy to external beam radiation alone for unresectable extrahepatic cholangiocarcinoma

BACKGROUND

Extrahepatic cholangiocarcinoma (EHC) is a rare malignancy with a relatively poor prognosis. There are no randomized, prospective data to help define the optimal method of radiation delivery for unresectable EHC. The purpose of this study was to evaluate the benefit of adding brachytherapy to external beam radiation therapy (EBRT) for unresectable EHC.

METHODS

A retrospective review of 1,326 patients with unresectable EHC using the Surveillance, Epidemiology, and End Results (SEER) database was completed. Kaplan-Meier methods were used to analyze the primary endpoint, overall survival. Univariate and multivariate analysis was performed to identify and control for potential confounding variables, including age at diagnosis, sex, stage, grade, histology, race, year of diagnosis, and reason for no surgery.

RESULTS

Of the 1,326 patients with unresectable EHC, 1,188 (92.9%) received EBRT only, while 91 (7.1%) received both EBRT and brachytherapy. Patients receiving combined modality radiation therapy were more likely to be treated prior to the year 2000. Median overall survival for patients receiving EBRT and EBRT plus brachytherapy was 9 and 11 months, respectively (P=0.04). Cause specific survival was 12 months for those receiving EBRT only, and 15 months for those who received EBRT + brachytherapy (P=0.10). Survival analysis performed on patients with locoregional disease only revealed a trend towards prolonged overall survival with those receiving EBRT + brachytherapy (P=0.08). Multivariate analysis revealed grade and stage of disease were correlated with both overall survival and cause specific survival (P≤0.05).

CONCLUSIONS

Among patients with unresectable EHC, the addition of brachytherapy to EBRT is associated with a prolonged median overall survival. However, the use of brachytherapy boost decreased in the last decade of the study.

Positioning high-dose radiation in multidisciplinary management of unresectable cholangiocarcinomas: review of current evidence

Cholangiocarcinoma is a rare malignancy of the bile ducts. The current standard of care for unresectable nonmetastatic disease is doublet systemic chemotherapy, which provides a median survival of 11.7 months. Although chemoradiation is a therapeutic option that provides almost equivalent or superior survival, the lack of level I evidence presents a major hurdle in routinely recommending it within multidisciplinary clinics. This mini review presents the current evidence on the use of chemoradiation for unresectable nonmetastatic cholangiocarcinoma and rationale for positioning it within multidisciplinary management of unresectable cholangiocarcinomas.

Impact of intraluminal brachytherapy on survival outcome for radiation therapy for unresectable biliary tract cancer: a propensity-score matched-pair analysis

PURPOSE

To determine whether adding intraluminal brachytherapy (ILBT) to definitive radiation therapy (RT) for unresectable biliary tract cancer has a positive impact on survival outcome.

METHODS AND MATERIALS

The original cohort comprised 209 patients, including 153 who underwent external beam RT (EBRT) alone and 56 who received both ILBT and EBRT. By matching propensity scores, 56 pairs (112 patients) consisting of 1 patient with and 1 patient without ILBT were selected. They were well balanced in terms of sex, age, performance status, clinical stage, jaundice, and addition of chemotherapy. The impact of ILBT on overall survival (OS), disease-specific survival (DSS), and local control (LC) was investigated.

RESULTS

The 2-year OS rates were 31% for the ILBT+ group and 40% for theILBT- group (P=.862). The 2-year DSS rates were 42% for the ILBT+ group and 41% for the ILBT- group (P=.288). The 2-year LC rates were 65% for the ILBT+ group and 35% for the ILBT- group (P=.094). Three of the 4 sensitivity analyses showed a significantly better LC for the ILBT+ group (P=.010, .025, .049), and another showed a marginally better LC (P=.068), and none of the sensitivity analyses showed any statistically significant differences in OS or DSS.

CONCLUSIONS

In the treatment for unresectable biliary tract cancer, the addition of ILBT to RT has no impact on OS or DSS but is associated with better LC. Therefore, the role of ILBT should be addressed by other measures than survival benefit, for example, by less toxicity, prolonged biliary tract patency decreasing the need for further palliative interventions, or patient quality of life.

Nonsurgical therapy of biliary tract cancer

PURPOSE OF REVIEW

The management of biliary tract cancers (BTCs) has been challenging partly because of the lack of robust data to define a treatment standard. This in turn has been because of the difficulty in conducting large clinical studies in an uncommon cancer, as well as managing elderly and unwell patients.

RECENT FINDINGS

Recent data and improvements in multidisciplinary patient management have established a standard of care and delivered insights into the natural history of this uncommon cancer. This is critical at a time when the incidence of this malignancy is increasing. This article describes the improving multidisciplinary management as well as seminal randomized data describing standard management. Current clinical trials that are likely to further impact on future management are described.

SUMMARY

These large datasets provide insights into the natural history of BTCs hitherto not forthcoming from the many smaller studies which formed the historical evidence base. This increasing standardization of care will improve outcome for patients with BTCs and provide a platform for further research.

Adjuvant radiotherapy for gallbladder cancer: A dosimetric comparison of conformal radiotherapy and intensity-modulated radiotherapy

AIM: To assess the efficacy and toxicity of conformal radiotherapy (CRT) and compare with intensity-modulated radiotherapy (IMRT) in the treatment of gallbladder cancer.

METHODS: Between November 2003 and January 2010, 20 patients with gallbladder cancer were treated with CRT with or without chemotherapy after surgical resection. Preliminary survival data were collected and examined using both Kaplan-Meier and actuarial analysis. Demographic and treatment parameters were collected. All patients were planned to receive 46-56 Gy in 1.8 or 2.0 Gy per fraction. CRT planning was compared with IMRT.

RESULTS: The most common reported acute toxicities requiring medication (Radiation Therapy Oncology Group, Radiation Therapy Oncology Group Grade 2) were nausea (10/20 patients) and diarrhea (3/20). There were no treatment-related deaths. Compared with CRT planning, IMRT significantly reduced the volume of right kidney receiving > 20 Gy and the volume of liver receiving > 30 Gy. IMRT has a negligible impact on the volume of left kidney receiving > 20 Gy. The 95% of prescribed dose for a planning tumor volume using either 3D CRT or IMRT planning were 84.0% ± 6.7%, 82.9% ± 6.1%, respectively (P > 0.05).

CONCLUSION: IMRT achieves similar excellent target coverage as compared with CRT planning, while reducing the mean liver dose and volume above threshold dose. IMRT offers better sparing of the right kidney compared with CRT planning, with a significantly lower mean dose and volume above threshold dose.

Survival outcomes in resected extrahepatic cholangiocarcinoma: effect of adjuvant radiotherapy in a surveillance, epidemiology, and end results analysis

PURPOSE

The benefit of adjuvant radiotherapy (RT) after surgical resection for extrahepatic cholangiocarcinoma has not been clearly established. We analyzed survival outcomes of patients with resected extrahepatic cholangiocarcinoma and examined the effect of adjuvant RT.

METHODS AND MATERIALS

Data were obtained from the Surveillance, Epidemiology, and End Results (SEER) program between 1973 and 2003. The primary endpoint was the overall survival time. Cox regression analysis was used to perform univariate and multivariate analyses of the following clinical variables: age, year of diagnosis, histologic grade, localized (Stage T1-T2) vs. regional (Stage T3 or greater and/or node positive) stage, gender, race, and the use of adjuvant RT after surgical resection.

RESULTS

The records for 2,332 patients were obtained. Patients with previous malignancy, distant disease, incomplete or conflicting records, atypical histologic features, and those treated with preoperative/intraoperative RT were excluded. Of the remaining 1,491 patients eligible for analysis, 473 (32%) had undergone adjuvant RT. After a median follow-up of 27 months (among surviving patients), the median overall survival time for the entire cohort was 20 months. Patients with localized and regional disease had a median survival time of 33 and 18 months, respectively (p<.001). The addition of adjuvant RT was not associated with an improvement in overall or cause-specific survival for patients with local or regional disease.

CONCLUSION

Patients with localized disease had significantly better overall survival than those with regional disease. Adjuvant RT was not associated with an improvement in long-term overall survival in patients with resected extrahepatic bile duct cancer. Key data, including margin status and the use of combined chemotherapy, was not available through the SEER database.

Radiotherapy is associated with improved survival in adjuvant and palliative treatment of extrahepatic cholangiocarcinomas

PURPOSE

Extrahepatic cholangiocarcinomas (EHC) are rare tumors of the biliary tree because of their low incidence, large randomized studies examining radiotherapy (RT) for EHC have not been performed. The purpose of this study was to examine the role of adjuvant and palliative RT in the treatment of EHC in a large patient population.

METHODS AND MATERIALS

This was a retrospective analysis of 4,758 patients with EHC collected from the Surveillance, Epidemiology, and End Results database. The primary endpoint was overall survival.

RESULTS

Patients underwent surgery (28.8%), RT (10.0%), surgery and RT (14.7%), or no RT or surgery (46.4%). The median age of the patient population was 73 years (range, 23-104), 52.5% were men, and 80.7% were white. The median overall survival time was 16 months (95% confidence interval [CI] 15-17), 9 months (95% CI 9-11), 9 months (95% CI 9-10), and 4 months (95% CI 3-4) for surgery and RT, surgery, RT, and no RT or surgery, respectively. The overall survival was significantly different between the surgery and surgery and RT groups (p < .0001) and RT and no RT or surgery groups (p < .0001) on the log-rank test. The propensity score-adjusted analyses of surgery and RT vs. surgery (hazard ratio, 0.94; 95% CI, 0.84-1.05) were not significantly different, but that for RT vs. no RT or surgery (hazard ratio, 0.61; 95% CI, 0.54-0.70) was significantly different.

CONCLUSION

These results suggest that palliative RT prolongs survival in patients with EHC. The benefit associated with surgery and RT was significant on univariate analysis but not after controlling for potential confounders using the propensity score. Future studies should evaluate the addition of chemotherapy and biologic agents for the treatment of EHC.

Endoscopic intraluminal brachytherapy and metal stent in malignant hilar biliary obstruction: a pilot study

BACKGROUND/AIMS

Malignant hilar biliary obstruction carries a poor prognosis, as the disease is often unresectable at the time of diagnosis. Various palliative measures as surgical/radiological/ endoscopic drainage with or without radiotherapy/chemotherapy have been tried with dismal outcome. We prospectively studied the effect of unilateral metal stent with intraluminal high dose rate (HDR) brachytherapy in patients with type II malignant hilar biliary obstruction.

METHODS

Eight patients with type II malignant hilar biliary obstruction were treated with contrast-free unilateral metal stenting followed by endoscopic intraluminal brachytherapy (ILBT). A retrospectively analyzed group of 10 patients treated only with contrast-free unilateral metal stenting served as historical controls.

RESULTS

A successful drainage was achieved in all, cholangitis occurred in none and no patient died within 30 days in both groups. The mean (+/-SD) patency of metal stent was 305 (+/-183.96) days and 143.9(+/-115.11) days in patients with and without intraluminal brachytherapy, respectively (P=0.03). Mean (+/-SD) survival of these patients was 310 (+/-192.68) days and 154.9 (+/-122.51) days in patients with and without intraluminal brachytherapy, respectively (P=0.05). Kaplan-Meier analysis showed estimated median survival of 225 (95% CI; 169.5, 280.4) days in brachytherapy and 100 (95%CI; 94.1, 105.8) days in control group (P=0.025). No major complications related to metal stent or ILBT were observed.

CONCLUSIONS

Contrast-free unilateral metal stenting with HDR ILBT in type II malignant hilar biliary obstruction is a safe and effective method of palliation and appears to prolong patient survival as well as patency of stent in these patients, however, a larger, randomized trial is required to validate the same.

The role of adjuvant radiotherapy in microscopic tumor control after extrahepatic bile duct cancer surgery

OBJECTIVES

To evaluate effects of radiotherapy (RT) after surgery for extrahepatic bile duct (EHBD) cancer.

METHODS

There were 60 patients with EHBD cancer treated with postoperative RT. Surgical extents were R0 in 24 patients, R1 in 23, and R2 in 13. The indications for adjuvant RT were positive resection margin, lymph node metastasis, or more than pT2. Radiation was delivered to tumor bed and regional lymphatics, and for R1 or R2 patients, boost RT was planned. Overall survival (OS) and progression-free survival (PFS) was calculated and survival in the R0 and R1 patients with negative lymph nodes was compared. The pattern of treatment failures and prognostic factors were analyzed.

RESULTS

The 2- and 5-year survival rates were 36.6% and 12.3% for OS, and 31.2% and 16.2% for PFS. In comparison of R0 with R1 patients who had negative lymph node, 2-year OS and PFS were 53.0% and 55.0% in R0, and 40.7% and 36.7% in R1 (P = ns). The first site of failure was loco-regional in 29 patients. The lymph node metastasis was a significant prognostic factor in OS (P = 0.04) and PFS (P = 0.02).

CONCLUSIONS

Lymph node metastasis was a poor prognostic factor and adjuvant RT may be useful in patients with microscopic residual tumor. However, because there were high loco-regional recurrences, additional study is needed to determine more effective RT such as increased RT dose or use of radiosensitizers.

Hepatic resection in the treatment of hilar cholangiocarcinoma

HC is an uncommon--although readily recognizable-clinical entity. Although current hepatobiliary imaging has improved, accurate staging of HC preoperatively is difficult. In patients who have potentially resectable HC, careful preoperative preparation with biliary drainage, portal vein embolization, or both is indicated because major hepatic resection has become an essential component of surgical treatment, and these interventions may reduce perioperative risks. Currently, lobar or extended lobar hepatic and bile duct resection, regional lymphadenectomy, and Roux-en-Y hepaticojejunostomy are the treatments of choice for HC. Whether major vascular resection coupled with these procedures or hepatic transplantation in selected patients will improve overall survival is unknown. Finally, current outcomes dictate investigation of effective adjuvant therapy.

New advances in the management of biliary tract cancer

Biliary tract cancers are uncommon malignancies arising from biliary epithelium intrahepatically (peripheral cholangiocarcinoma), in the extrahepatic bile duct, the gall bladder and the ampulla of Vater. Treatment has been challenging because of late presentation, complex surgery, complex biliary obstruction with jaundice and a paucity of high quality data on which to establish standard care. With improvements in imaging, biliary stenting, surgical management and the establishment of a national investigational programme we hope to define the modern management of biliary tract cancers and enable a platform for further research.

External-beam radiotherapy for localized extrahepatic cholangiocarcinoma

PURPOSE

The role of radiation therapy (RT) in extrahepatic cholangiocarcinoma (EHCC) is not clear and only limited reports exist on the use of this modality. We have reviewed our institutional experience to determine the pattern of failure in patients after potentially curative resection and the expected outcomes after adjuvant RT and in unresectable patients.

METHODS AND MATERIALS

After institutional review board approval, 81 patients diagnosed with EHCC (gallbladder 28, distal bile duct 24, hilar 29) between June 1986 and December 2004 were identified and their records reviewed. Twenty-eight patients (35%) underwent potentially curative resection with R0/R1 margins. Fifty-two patients (64%) were unresectable or underwent resection with macroscopic residual disease (R2). All patients received three-dimensional planned megavoltage RT. The dose for each patient was converted to the equivalent total dose in a 2 Gy/fraction, using the linear-quadratic formalism and alpha/beta ratio of 10. The median dose delivered was 58.4 Gy (range, 23-88.2 Gy). 54% received concomitant chemotherapy.

RESULTS

With a median follow-up time of 1.2 years (range, 0.1-9.8 years) 75 patients (93%) have died. Median overall survival (OS) and progression-free survival (PFS) were 14.7 (95% CI, 13.1-16.3) and 11 (95% CI, 7.6-13.2) months, respectively. There was no difference among the three disease sites in OS (p = 0.70) or PFS (p = 0.80). Complete resection (R0) was the only predictive factor significantly associated with increase in both OS and PFS (p = 0.002), and there was no difference in outcomes between R1 and R2 resections. The first site of failure was predominantly locoregional (68.8% of all failures).

CONCLUSION

Local failure is a major problem in EHCC, suggesting the need for more intense radiation schedules and better radiosensitizing strategies. Because R1 resection appears to convey no benefit, it appears that surgery should be contemplated only when an R0 resection is likely. Borderline-resectable patients might be better served by neoadjuvant therapy.

Magnitude of combination therapy of radical resection and external beam radiotherapy for patients with carcinomas of the extrahepatic bile duct and gallbladder

The present study sought to identify the therapeutic efficacy of adjuvant external beam radiotherapy (EBRT) for carcinomas of the extrahepatic bile duct (EHBD) and gallbladder. Twenty-one patients with pathologically verified EHBD carcinoma and 18 patients with gallbladder carcinoma were analyzed retrospectively by Cox regression analysis for predictors of survival. The overall 5-year survival rates after resection were 33% for EHBD carcinoma and 56% for gallbladder carcinoma. The overall 5-year survival rate for EHBD carcinoma was 60% in 8 patients without microscopic residual disease (R0), 15% in 9 patients with microscopic residual tumor (R1), and 0% in 4 patients with macroscopic residual tumor (R2). The overall 5-year survival rate of gallbladder carcinoma patients was also decreased with R status equal to 73%, 40%, and 0% for R0, R1 and R2, respectively. Adjuvant radiotherapy significantly improved the 5-year survival rate in 7 patients with R1 disease of EHBD carcinoma (P = .035), compared with survival in 2 patients who underwent resection alone. However, no significant difference was noted in the 5-year survival rate between the resection plus EBRT group and the resection alone group for gallbladder carcinoma. Multivariate analysis revealed that histopathologic grade (G) was an independent predictor of survival for EHBD carcinoma and that direct invasion of liver parenchyma was a predictor of survival for gallbladder carcinoma. This study suggests that curative resection provides the best survival for patients with EHBD and gallbladder carcinoma, and that radiotherapy may play a beneficial role in controlling local-regional residual EHBD carcinoma tumors. However, new strategies for adjuvant therapy are needed to improve survival in patients with gallbladder carcinoma.

Vascular endothelial growth factor (VEGF) expression in operable gallbladder carcinomas

AIM

To investigate the angiogenic and prognostic role of vascular endothelial growth factor (VEGF) in operable gallbladder carcinomas.

METHODS

Sixty patients with early gallbladder carcinomas, treated with surgery alone, were investigated immunohistochemically for the expression of VEGF, thymidine phosphorylase (TP) and new blood vessel formation. The results were correlated with clinico-pathological features and prognosis.

RESULTS

An increased VEGF secretion in gallbladder carcinomas was significantly associated with increased angiogenesis but not with patients survival, although high angiogenesis did relate with poor prognosis. TP was also associated with angiogenesis, but only the combined VEGF/TP expression was associated with unfavourable survival. Histological grade was another independent factor of prognosis.

CONCLUSION

Both VEGF and TP expression are associated with high rate of angiogenesis, a factor directly associated with prognosis. The combined expression of these angiogenic factors confer a particularly poor post-operative outcome, speculature.

Cholangiocarcinoma: the impact of tumor location and treatment strategy on outcome

The purpose of this study was to evaluate how the outcome of patients with extrahepatic cholangiocarcinoma (EHBC) may have been influenced by tumor location and treatment selection. The primary endpoint of this study is overall survival (OS). Between January 1983 and December 1997, 221 patients with biliary tumors were evaluated at Thomas Jefferson University Hospital. Of these, 118 fit the inclusion criteria for this study. The extent of disease was assessed by computed tomography, percutaneous transhepatic cholangiography or endoscopic retrograde cholangiopancreatography, magnetic resonance imaging, and ultrasonography. All patients had histologic confirmation of malignancy. Roux-en Y, hepaticojejunostomy, or choledochojejunostomy followed surgical resection of the primary tumor. Palliative measure (PS) included biliary catheter placement without brachytherapy or external beam irradiation (RT). RT was delivered via high-energy photons. Intraluminal brachytherapy was performed via percutaneous biliary catheterization with iridium-192 ribbon sources. Chemotherapy consisted of either intravenous 5-fluorouracil alone or in combination with doxorubicin, mitomycin C, or paclitaxel. PS consisted of metal bile duct stent placement. Median follow-up time for the entire group was 102 months and 43 months for patients who were still alive at the conclusion of the study period. Patients with proximal tumors underwent resection (n = 5), surgery and RT (n = 23), RT only (n = 31), chemotherapy only (n = 6), or PS (n = 12). Patients with distal tumors were treated with surgical resection (n = 17) or a combination of surgery and RT (n = 13), RT only (n = 6), or PS (n = 4). Median survival time (MST) for all 118 patients was 22 months. The MST for patients with distal tumors was 47 months versus 17 months for those with proximal tumors. The MST has not been reached for patients with distal EHBC treated with surgical resection and postoperative RT, whereas the median survival for those treated with surgery alone is 62.5 months. However, 4 of 17 of these patients had in situ carcinoma. Six patients had distal tumors treated with RT only with a MST of 6 months. Patients with proximal tumors treated with surgery and RT had a superior OS at 5 years compared to patients treated with RT alone (24 vs. 13 months; p = 0.007). There was an improved OS in patients with proximal tumors treated with surgical resection and RT compared to surgery alone (p = 0.023). There is no discernable influence of chemotherapy on outcome in patients with proximal EHBC. The MST for patients treated with PS was 3.5 months. Surgery and postoperative RT appear to be better than either surgery or RT alone in patients with proximal EHBC. In patients with distal EHBC, the addition of resection and RT appears to offer an advantage, which is increasingly apparent with longer follow-up time. The prognosis remains dismal for patients treated with palliative intent.

Diagnosis, Staging, and Treatment of Cholangiocarcinoma

Attention has to be focused on earlier detection of cholangiocarcinoma, especially in high-risk patients such as those with primary sclerosing cholangitis (PSC). Enhanced techniques for diagnosing this disease include imaging studies such as positron emission tomography (PET) scanning, and cytologic analysis including digital image analysis (DIA) and fluorescent in situ hybridization (FISH). Magnetic resonance imaging and endoscopic ultrasonography have also improved and simplified preoperative staging. Despite recent advances in the endoscopic management of cholangiocarcinoma, this neoplastic disease is still fatal in the majority of patients. Surgical resection or liver transplantation offers the only possibility for curing this disease in its early stages. However, most patients present with advanced disease that is not amenable to such therapy. For those patients presenting with unresectable carcinoma above the cystic duct without intrahepatic or extrahepatic metastases, orthotopic liver transplantation combined with preoperative irradiation and chemotherapy is available and demonstrates improved survival on the basis of a recent study conducted at the Mayo Clinic. In the future, chemopreventive strategies aimed at blocking the links between inflammation (eg, nitric oxide synthase and cylcooxygenase 2 inhibitors) and carcinogenesis may help prevent this often fatal disease in high-risk patients (eg, patients with PSC).

Hepatic resection in the treatment of perihilar cholangiocarcinoma

Proximal bile duct cancer poses a difficult surgical problem in hepatobiliary surgery because of its location, patterns of spread, and required extent of resection for complete excision. This article focuses on the anatomic and pathologic issues that are associated with proximal bile duct cancer and assesses the roles of partial hepatectomy and bile duct resection in the surgical management of this cancer. It is hoped that this article provides clinical evidence that supports hepatic resection as an essential and efficacious component of the surgical management of perihilar cholangiocarcinoma in selected patients.

Palliative and postoperative radiotherapy in biliary tract cancer

Local failure is the primary limitation for cure in patients with BTC. whether or not they have been resected. The use of radiotherapy with or without chemotherapy in the postoperative setting is controversial, but some studies have reported improvement in 5-year survival. In patients with unresectable BTC, EBRT offers effective palliation of symptomatic disease and has resulted in improved median and long-term survival in a small number of patients in most studies. Novel approaches, including neoadjuvant chemoradiotherapy combined with OLT, and escalated conformal irradiation, seem to be promising and warrant further investigation.

Thymidine phosphorylase expression in gallbladder adenocarcinomas

The expression of thymidine phosphorylase (TP), a potent chemotactic factor for endothelial cells, was studied in 60 adenocarcinomas of the gallbladder, by use of immunohistochemical techniques. Results on patterns of TP expression were correlated with angiogenesis (anti-CD31), histopathological variables, and patient survival. TP was frequently expressed in tumor cells, stromal cells, tumor-associated macrophages, and lymphocytes of gallbladder adenocarcinomas. The expression was mixed nuclear/cytoplasmic. However, only nuclear TP (TPnuc) expression by tumor cells was correlated with increased angiogenic activity. High angiogenesis, assessed as microvessel density (MVD), was the most significant prognostic factor. The subgroup of patients with TPnuc and medium/high MVD had the worst prognosis as evaluated by the survival curves. Furthermore, CD31+ lymphocytes, frequently seen in carcinomas with high-fibroblastic TP reactivity, were connected with an improved survival. It is concluded that angiogenesis, as verified by multivariate analysis, is the most important prognostic factor in gallbladder carcinomas. In these tumors, high histologic grade and low CD31+ lymphocytic infiltration are also independent predictors of poor prognosis. TP is associated with an aggressive phenotype apparently because of its anglogenic activity. Therapeutic strategies targeting TP may be of value in patients overexpressing this enzyme.

[Conformal therapy of locally advanced cholangiocarcinoma of the main bile ducts]

PURPOSE

Retrospective study of 23 patients treated with conformal radiotherapy for a locally advanced bile duct carcinoma.

PATIENTS AND METHODS

Eight cases were irradiated after a radical resection (R0), because they were N+; seven after microscopically incomplete resection (R1); seven were not resected (R2). A dose of 45 of 50 Gy was delivered, followed by a boost up to 60 Gy in R1 and R2 groups. Concomitant chemotherapy was given in 15 cases.

RESULTS

Late toxicity included a stenosis of the duodenum, and one of the biliary anastomosis. Two patients died from cholangitis, the mechanism of which remains unclear. Five patients are in complete remission, six had a local relapse, four developed a peritoneal carcinosis, and six distant metastases. Actuarial survival rate is 75%, 28% and 7% at 1, 3 and 5 years, respectively (median: 16.5 months). Seven patients are still alive with a 4 to 70 months follow-up. Survival is similar in the 3 small subgroups. The poor local control among R0N+ cases might be related to the absence of a boost to the "tumor bed". In R1 patients, relapses were mainly distant metastases, whereas local and peritoneal recurrences predominated in R2.

CONCLUSION

Conformal radiochemotherapy delivering 60 Gy represents a valuable palliative approach in locally advanced biliary carcinoma.

High-dose-rate remote afterloading intracavitary brachytherapy for the treatment of extrahepatic biliary duct carcinoma

PURPOSE

The purpose of this study was to determine whether a dose response exists for extrahepatic bile duct carcinoma (EBDC) when treated with increasingly higher radiation doses delivered via a combination of external beam radiation (EBRT) and high dose rate intracavitary brachytherapy (HDRIB). To establish the best tolerated dose of HDRIB.

METHODS AND MATERIALS

Eighteen patients with pathologically proven, locoregional but unresectable or incompletely resected EBDC were studied from 1991-1998 in this phase I/II trial. All patients received EBRT, delivered via megavoltage photons at standard fractionation schedules, for a total dose of 45 Gy. The HDRIB was delivered using the nucleotron HDR remote afterloading unit with a 10 Ci Ir192 source. Each treatment of HDRIB delivered 7 Gy at 1 cm depth. The first group of eight patients received one treatment of HDRIB (Group 1, total dose = 52 Gy). The second group of six patients received two weekly treatments (Group 2, total dose = 59 Gy). The last group of four patients received three weekly treatments of HDRIB (Group 3, total dose = 66 Gy). HDRIB was delivered once weekly concomitant with the EBRT. Acute adverse reactions were evaluated after for each group of patients before escalating to the next higher dose level of HDRIB.

RESULTS

The median follow up time for all 18 patients was 15 months. The median survival for all 18 patients was 12.2 months (range 2 to 79.6 months). Overall two-year survival was 27.8%. Three patients (16.7%) had survival of more than 5 years. Dose response is suggested by the median survival of the three groups (9, 12.2, and 20.3 months for Group 1, 2, and 3, respectively), although this did not reach statistical significance. Complete or partial response (>50% reduction in tumor size) was seen in 25% of patients receiving total of 52 Gy compared to 80% of patients (5 patients in Group 2 and 3 patients in Group 3) receiving greater than 59 Gy (P = 0.05). No patients developed Grade 4 complications. One patient in Group 2 developed Grade 3 toxicity after second treatment of HDRIB.

CONCLUSION

High dose rate brachytherapy of 21 Gy in three divided weekly treatments, plus 45 Gy of external beam radiation is well tolerated. A dose response is shown with significant increase of PR and CR rate for dose >59 Gy. This modality of treatment appears to be safe and effective for inoperable extrahepatic biliary duct carcinoma.

A study of carboplatin-coated tube for the unresectable cholangiocarcinoma

Most cases of cholangiocarcinoma have reached an unresectable stage by the time they are discovered despite significant progress of diagnostic modalities. Many of these patients with obstructive jaundice are often treated by biliary drainage using stents to relieve the jaundice. However, the stent patency period is as short as 3 to 9 months because of tumor ingrowth or overgrowth, and mean survival is at most 12 months. Therefore, both continuous relief of obstructive jaundice and local control of the tumor are required in the treatment for advanced cholangiocarcinoma. In this investigation, we developed a new percutaneous transhepatic biliary drainage tube coated with carboplatin (carboplatin-coated tube; CCT). CCT continuously released a fixed amount of carboplatin for 4 weeks and showed an antitumor effect on human cholangiocarcinoma cell line HuCC-T1 in vitro. When CCT was embedded in subcutaneous tumor inoculated in nude mice, a significant reduction of tumor size with no apparent damage to normal adjacent tissue was observed. On the basis of these studies, 5 patients with inoperable cholangiocarcinoma were treated with CCT for 4 weeks. Overall efficacy rate of 5 patients with cholangiocarcinoma was 60% (partial response in 3 and no change in 2). No apparent side effect was observed in these patients. Thus, CCT may provide a new treatment modality for this disease. Randomized controlled trials comparing CCT therapy with palliative stenting are required to confirm these results.

Radiotherapy and multimodality management of cholangiocarcinoma

PURPOSE

To evaluate the results of radiotherapy in cholangiocarcinoma patients managed with various combinations of chemotherapy and surgical resection with selective liver transplantation.

METHODS AND MATERIALS

From January 1990 to December 1995, 61 patients with histologically confirmed biliary duct adenocarcinoma were seen in the Radiation Oncology Department of the University of Pittsburgh. Median follow-up was 22 months (1 to 91 months). The extent of surgery was complete resection in 23 patients (including 17 with orthotopic liver transplant), partial resection in 4, and biopsy in 34. All patients had radiotherapy; median dose was 49.5 Gy. Thirty patients received chemotherapy: 5-fluorouracil (5-FU)-leucovorin with interferon alpha (IFNalpha) in 27, and taxol in 3.

RESULTS

The median survival was 20 months (95% CI 15-25 months). The 5-year actuarial survival was 23.8 +/- 6.8%. The only significant variable in multivariate analysis was achieving a complete resection with negative margins through conventional surgery or liver transplantation (p = 0.001, hazard rate ratio [HRR] = 0.25, 95% CI 0.12-0.54). Patients with complete resections had a 5-year actuarial survival of 53.5 +/- 10.9%.

CONCLUSION

Combined modality therapy that includes complete surgical resection with or without transplantation can be curative in the majority of patients with biliary duct carcinoma. Further study is needed to better define the roles of chemotherapy and radiotherapy in cholangiocarcinoma.

The role of chemotherapy and radiation in the management of biliary cancer: a review of the literature

Carcinoma of the biliary tract is a rare tumour. To date, there is no therapeutic measure with curative potential apart from surgical intervention. Thus, patients with advanced, i.e. unresectable or metastatic disease, face a dismal prognosis. They present a difficult problem to clinicians as to whether to choose a strictly supportive approach or to expose patients to the side-effects of a potentially ineffective treatment. The objective of this article is to review briefly the clinical trials available in the current literature utilising non-surgical oncological treatment (radiotherapy and chemotherapy) either in patients with advanced, i.e. locally inoperable or metastatic cancer of the biliary tract or as an adjunct to surgery. From 65 studies identified, there seems to be no standard therapy for advanced biliary cancer. Despite anecdotal reports of symptomatic palliation and survival advantages, most studies involved only a small number of patients and were performed in a phase II approach. In addition, the benefit of adjuvant treatment remains largely unproven. No clear trend in favour of radiation therapy could be seen when the studies included a control group. In addition, the only randomised chemotherapeutic series seemed to suggest a benefit of treatment in advanced disease, but due to the small number of patients included, definitive evidence from large, randomised series concerning the benefit of non-surgical oncological intervention as compared with supportive care is still lacking. Patients with advanced biliary tract cancer should be offered the opportunity to participate in clinical trials.

External radiation therapy and transcatheter iridium in the treatment of extrahepatic bile duct carcinoma

PURPOSE/OBJECTIVE

Review survival, prognostic factors, and patterns of failure in patients with extrahepatic bile duct (EHBD) carcinoma treated with external beam irradiation (EBRT) and transcatheter iridium.

METHODS AND MATERIALS

The charts of 24 patients with EHBD cancer treated with EBRT and transcatheter boost were reviewed. All patients had transhepatic biliary tubes or endoprostheses placed. Two patients underwent hemihepatectomy with hepaticojejunostomy formation but had residual disease. Two patients had biopsy proven adenopathy. Five patients had Grade 1 adenocarcinoma, nine Grade 2, six Grade 3, and one Grade 4 disease. Median EBRT dose was 50.4 Gy delivered in 1.8 Gy/day fractions. Median transcatheter boost at 1 cm radius was 20 Gy. Nine patients received concomitant 5-Fluorouracil (5-FU) during EBRT.

RESULTS

Median survival was 12.8 months (range 7.5 months to 9 years). Overall 2- and 5-year survival rates were 18.8 and 14.1%, respectively (three disease-free survivors > or =5 years). One patient is still alive without relapse 10 years from diagnosis and 5 years after liver transplantation for liver failure (no cancer in specimen, underlying sclerosing cholangitis). Two additional long-term survivors had no evidence of relapse 6.9 and 8.2 years after diagnosis. Histologic grade, lymph node status, cystic, hepatic, common hepatic or common bile duct involvement, surgical resection, radiation therapy dose, and chemotherapy did not significantly effect survival due to the number of patients analyzed. There was a trend towards improved survival with the addition of 5-FU chemotherapy (5-year survival in two of nine patients, or 22%). Eight of 24 patients (33%) demonstrated radiographic evidence of local recurrence. Distant metastases developed in 6 of 24 (25%) patients. The most common complications were tube related cholangitis (50%) and gastric/duodenal ulceration or bleeding (42%).

CONCLUSION

External beam irradiation combined with a transcatheter boost can result in long-term survival of patients with EHBD cancer. Both distant metastases and local recurrence develop in 25-30% of patients despite irradiation. Survival may be improved by using chemotherapy in combination with EBRT to impact disease relapse (local and distant). Because there may be a dose response with irradiation, survival may also be improved by increasing the dose of radiation delivered by transcatheter boost. A Phase II trial is being developed using a combination of 45-50 Gy EBRT with concomitant 5-FU delivered by protracted venous infusion followed by a 25-30 Gy transcatheter boost.

[Palliative therapy of carcinomas of the biliary system]

CARCINOMA OF THE GALLBLADDER: Only patients suffering from advanced disease have symptoms, that is pain, jaundice, weight loss. Mean 5-year survival rate tends to be lower than 5%. Tumors can be resected with negative margins in 15 to 25% of the patients. Obstructive jaundice can be managed with endoscopic biliary stent in 84% of the patients. After radiotherapy tumor regression is observed in 80% of the patients. Their mean survival time is 10 months.

CHOLANGIOCARCINOMAS

More than 90% of the patients present with jaundice. At the time of presentation, 50% of the patients already have metastases to lymph nodes. Mean total survival time of all patients is 12 months. Surgical resection can successfully be performed in 30 to 40% of the patients suffering from proximal cholangiocarcinomas. Distal unresectable tumors are best palliated with an endoscopically placed stent in 97.5% of the patients. Patients having undergone radiotherapy will have a mean survival time of 9 to 12 months. There is a 12% response rate after chemotherapy with single agents and one of 23% after combined regimens. Intraarterial application of chemotherapy results in 44% response rate.

CONCLUSION

Carcinomas of the biliary tract are often diagnosed at advanced inoperable stages. Patients quality of life can be ameliorated by palliative treatment, i.e. biliary stents, radio-, chemotherapy. Mean survival time does normally not exceed 1 year.

Perihilar cholangiocarcinoma. Postoperative radiotherapy does not improve survival

OBJECTIVE

The aims of this analysis were to determine prospectively the effects of surgical resection and radiation therapy on the length and quality of survival as well as late toxicity in patients with perihilar cholangiocarcinoma.

BACKGROUND

Retrospective analyses have suggested that adjuvant radiation therapy improves survival in patients with perihilar cholangiocarcinoma. However, in these reports, patients receiving radiotherapy tended to have smaller, often resectable tumors, and were relatively fit. In comparison, patients who have not received radiotherapy often had unresectable tumors, metastatic disease, or poor performance status.

METHODS

From 1988 through 1993, surgically staged patients with perihilar cholangiocarcinoma and 1) no evidence of metastatic disease, 2) Karnofsky score > 60, 3) no prior malignancy or radiotherapy, and 4) a patent main portal vein were analyzed. Fifty patients were stratified by resection (n = 31) versus operative palliation (n = 19) and by radiation (n = 23) versus no radiotherapy (n = 27).

RESULTS

Patients undergoing resection had smaller tumors (1.9 +/- 2.8 vs. 2.4 +/- 2.1 cm, p < 0.01) that were less likely to invade the hepatic artery (3% vs. 42%, p < 0.05) or portal vein (6% vs. 53%, p < 0.05). Multiple parameters that might have affected outcome were similar between patients who did and did not receive radiation therapy. Resection improved the length (24.2 +/- 2.5 vs. 11.3 +/- 1.0 months, p < 0.05) and quality of survival. Radiation had no effect on the length (18.4 +/- 2.9 vs. 20.1 +/- 2.4 months) or quality of survival or on late toxicity.

CONCLUSIONS

This analysis suggests that in patients with localized perihilar cholangiocarcinoma, resection prolongs survival whereas radiation has no effect on either survival or late toxicity. Thus, new agents or strategies to deliver adjuvant therapy are needed to improve survival in these patients.

Combined external beam radiotherapy and intraluminal high dose rate brachytherapy on bile duct carcinomas

PURPOSE

The aim of this study was to investigate the effectiveness and complications of combined external beam and intraluminal high dose rate irradiation and various adjuvant biliary drainage techniques on patients with bile duct carcinomas.

METHODS AND MATERIALS

Eighteen patients with carcinomas of the hepatic duct bifurcation and 12 patients with carcinomas of the choledochus duct or the common hepatic duct were treated with combined external beam radiotherapy and intraluminal high-dose rate brachytherapy. Nine patients received radiotherapy after palliative tumor resection and 21 patients were primarily irradiated. Twenty-five patients completed the full course of radiotherapy. On these patients, the reference doses for the external beam varied from 30 to 45 Gy and for brachytherapy from 20 to 45 Gy. Biliary drainage after radiotherapy was achieved either with percutaneous catheters, endoprosthesis, or stents.

RESULTS

The median survival for the entire group was 10 months. The actuarial survival was 34% after 1 year, 18% after 2 and 3 years, and 8% after 5 years. The subgroup with palliative tumor resection exhibit a significantly better survival (median: 12.1 months vs. 7.9 months). Three patients are still living without evidence of disease since 35 to 69 months. Major complications like bacterial cholangitis could be lowered from 37% to 28% through exchange of percutaneous transhepatic catheters to endoprosthesis or stents. The longest lasting drainages were achieved through stents. The frequency of radiogenic ulcera were lowered from 23% to presently 7.6% after the total dose of the high dose rate afterloading boost was reduced to 20 Gy.

CONCLUSIONS

The present standard treatment schedule 40 Gy for the external beam and 20 Gy (fourfold 5 Gy) for the afterloading boost seems to be appropriate and well tolerated. After radiotherapy, a permanent supply of drainage should be made with a stent.

Invasive growth patterns of hepatic hilar ductal carcinoma. A histologic analysis of 18 surgical cases

BACKGROUND

Postoperative recurrence of hepatic hilar ductal carcinoma usually occurs in a localized region around the surgical margin, such as the bile duct. This study was aimed at assessing the invasive patterns of the hepatic hilar ductal carcinoma by histologically examining surgical specimens obtained by extended liver resection, especially the involvement of intrahepatic duct.

METHODS

Eighteen resected specimens of hepatic hilar ductal carcinoma were histologically investigated. Multiple sections vertical to the extrahepatic and intrahepatic bile duct were made at a 5-mm interval. The extension of carcinoma was evaluated on each of three layers (mucosal, extramucosal-intramural, and extramural), and routes of the invasion were examined.

RESULTS

Extramucosal extent toward the hepatic side was observed in 14 patients (77.8%) and that toward the duodenal side in 8 patients (44.4%) (P < 0.05). The distance of extramucosal tumor extent was also significantly longer (P < 0.05) in the hepatic side than in the duodenal side. Histologic tumor margin was usually identified in the extramural layer. Two patients had discontinuous extramucosal invasion. The lymphatic invasions were observed most frequently, followed by perineural invasion, and venous invasion was rare. In the extramucosal invasion of the liver, the left dominant carcinomas had extended toward the left, whereas those right dominant had extended toward the right (P < 0.05). Well differentiated differentiated tubular adenocarcinomas extended to the liver more extensively than moderately and poorly differentiated ones, but not significantly.

CONCLUSIONS

The authors examined the extramucosal invasion of hepatic hilar ductal carcinoma. This invasion extended more frequently and further to the hepatic side than to the duodenal side, usually by the route of the extramural layer.

The impact of radiation dose in combined external beam and intraluminal Ir-192 brachytherapy for bile duct cancer

PURPOSE

To examine the impact of radiation dose on both survival and morbidity in combined modality treatment of bile duct cancer.

METHODS AND MATERIALS

Forty-eight patients with cancer of the extrahepatic bile ducts were treated at Thomas Jefferson University Hospital from 1984-1990. Twenty-four patients received radiation as part of a combined modality approach using external beam radiation, brachytherapy implant and chemotherapy. Twenty-four patients received no radiation in the course of their treatment. Radiation was delivered via high energy photons at standard fractionation, 5 days/week, for an average of 46 Gy. The implant used Ir-192 ribbon sources (average activity was 29 mCi, active length was 6 cm) for a mean dose of 25 Gy at 1 cm. Chemotherapy consisted of 5-FU alone or combined with adriamycin or mitomycin-C.

RESULTS

Two-year survival for all 48 patients was 18% (median 9 months). Patients treated with radiation had a 2-year survival of 30% (median 12 months) vs. the no-radiation group, 17% (5.5 months, median), p = 0.01. Those treated to > 55 Gy experienced an extended 2-year survival of 48% (24 months, median), vs. those receiving < 55 Gy, 0% (6 months, median), p = 0.0003. This benefit was also seen when patients were stratified by T-stage. A dose response is further suggested by a lengthening of the median survival with increasing radiation dose (4.5 months, 9 months, 18 months and 25 months for < 45 Gy, 45-55, 55-65, 66-70 Gy, respectively). Neither surgical resection nor chemotherapy produced statistically significant benefits as independent variables. Complications due to radiation occurred in only one patient.

CONCLUSION

A dose response is shown with more than double the 2-year and median survival for doses > 55 Gy. A brachytherapy dose of 25 Gy, plus 44-46 Gy external beam is well tolerated. High dose combined brachytherapy and external beam radiation (60-75 Gy) appears to be the most effective modality for extrahepatic bile duct cancer.