Analysis of failure following curative irradiation of gallbladder and extrahepatic bile duct carcinoma

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.

Liver Transplant for Cholangiocarcinoma

Liver transplant (LT) for perihilar cholangiocarcinoma (CCA) offers an opportunity for survival among patients with early-stage but anatomically unresectable disease. The 5-year survival rate after LT is 65% to 70%, higher among patients with primary sclerosing cholangitis, who are often diagnosed earlier, and lower among patients with de novo CCA. The results of LT for hilar CCA, along with recent limited data suggesting favorable survival among patients with very early intrahepatic CCA (ICC), have reignited interest in the subject. This article discusses LT following neoadjuvant therapy for CCA and the early data on LT alone for ICC.

Brachytherapy in the treatment of bile duct cancer - a tough challenge

The majority of patients with bile duct cancer are diagnosed with clinically advanced disease. Most of these patients have a short life expectancy and are treated with palliative aim. Most patients present with locally advanced or metastatic disease, which is not amenable to surgical resection, resulting in poor survival. Adjuvant or definitive radiotherapy, with or without chemotherapy, is therefore used in many centers worldwide for better local control, and with the expectation that it will have a favorable effect on survival. However, the lack of appropriate prospective trials, as well as the small size of the published series and their retrospective nature, has produced insufficient evidence for the best treatment for these patients. Intraluminal brachytherapy is an important component in the multimodality approach to bile duct cancers. The objective of this treatment is to deliver a high local dose of radiation to the tumor while sparing surrounding healthy tissues. The treatment can be safely adapted for right and left hepatic duct, and for common bile duct lesions. Brachytherapy plays a limited but specific role in definitive treatment with curative intent in selected cases of early disease, as well as in the postoperative treatment of small residual disease. Depending on the location of the lesion, in some cases, brachytherapy is a treatment of choice. Clinical indications, different techniques, results, and complications are discussed in this work.

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.

Image-guided intensity-modulated radiotherapy (IG-IMRT) for biliary adenocarcinomas: Initial clinical results

PURPOSE

Biliary tract lesions are comparatively rare neoplasms, with ambiguous indications for radiotherapy. The specific aim of this study was to report the clinical results of a single-institution biliary tract series treated with modern radiotherapeutic techniques, and detail results using both conventional and image-guided intensity-modulated radiation therapy (IG-IMRT).

METHODS AND MATERIALS

From 2001 to 2005, 24 patients with primary adenocarcinoma of the biliary tract (gallbladder and extrahepatic bile ducts) were treated by IG-IMRT. To compare outcomes, data from a sequential series of 24 patients treated between 1995 and 2005 with conventional radiotherapy (CRT) techniques were collected as a comparator set. Demographic and treatment parameters were collected. Endpoints analyzed included treatment-related acute toxicity and survival.

RESULTS

Median estimated survival for all patients completing treatment was 13.9 months. A statistically significant higher mean dose was given to patients receiving IG-IMRT compared to CRT, 59 vs. 48Gy. IG-IMRT and CRT cohorts had a median survival of 17.6 and 9.0 months, respectively. Surgical resection was associated with improved survival. Two patients (4%) experienced an RTOG acute toxicity score>2. The most commonly reported GI toxicities (RTOG Grade 2) were nausea or diarrhea requiring oral medication, experienced by 46% of patients.

CONCLUSION

This series presents the first clinical outcomes of biliary tract cancers treated with IG-IMRT. In comparison to a cohort of patients treated by conventional radiation techniques, IG-IMRT was feasible for biliary tract tumors, warranting further investigation in prospective clinical trials.

Adjuvant radiation therapy is associated with improved survival for gallbladder carcinoma with regional metastatic disease

BACKGROUND

Gallbladder carcinoma is a rare malignancy and is associated with dismal outcomes. The aim of this study was to better define the role of adjuvant radiation therapy in the management of gallbladder carcinoma.

METHODS

The Surveillance, Epidemiological, and End Results (SEER) survey from the National Cancer Institute was queried from 1992 to 2002. Retrospective analysis was done. The end-point of the study was overall survival.

RESULTS

There were a total of 3,187 cases of gallbladder carcinoma in the registry from 1992 to 2002. Of the surgical group, 35% were stage I, 36% were stage II, 6% were stage III, and 21% were stage IV. Adjuvant radiation was used in 17% of the cases. The median survival for those patients receiving adjuvant radiation therapy was 14 months compared to an 8 months median survival for those treated without adjuvant radiation therapy (P < or = 0.001). The survival benefit associated with radiation use was only presenting those patients with regional spread (P = 0.0001) and tumors infiltrating the liver (P = 0.011).

CONCLUSION

The use of adjuvant radiation therapy is associated with improved survival in patients with locally advanced gallbladder cancer or gallbladder cancer with regional disease.

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.

Hepatectomy for Peripheral Cholangiocarcinoma in Elderly Patients

BACKGROUND

Peripheral cholangiocarcinoma (CCC) is less common than hepatocellular carcinoma. Little is known about CCC patients older than 70 years who have undergone hepatectomy.

METHODS

Between 1977 and 2004, the clinical features of 33 elderly CCC patients (>70 years old) undergoing hepatectomy were reviewed, and 185 CCC patients younger than 70 years (younger CCC) were used for comparison.

RESULTS

A total of 218 CCC patients undergoing hepatectomy were investigated with ages ranging from 28 to 93 years (median, 59.0 years). The elderly and younger CCC groups had a similar sex ratio and a similar positive rate of carcinoembryonic antigen (CEA) and CA19-9. A similar rate of hepatolithiasis, mucobilia, papillary pattern, stage distribution, curative hepatectomy, surgical morbidity, and mortality for CCC were also observed between the two groups. During a follow-up duration ranging from 1.1 to 145.0 months (median, 11.7 months), elderly CCC and younger CCC patients had similar prognoses after hepatectomy (P = .827). Elderly CCC patients with a low CEA level, an intraductal papillary growth pattern, curative hepatectomy, and postoperative chemotherapy tended to have favorable survival. However, elderly CCC patients with a low CEA level independently showed favorable survival.

CONCLUSIONS

Hepatectomy is feasible for selected elderly CCC patients. Elderly CCC patients undergoing hepatectomy had clinicopathologic features and prognoses similar to those of patients younger than 70 years undergoing hepatectomy. Elderly CCC patients with a low CEA level, intraductal papillary growth pattern, curative hepatectomy, and postoperative chemotherapy tended to have favorable survival. However, elderly CCC patients with low CEA level independently showed favorable survival.

Clinicopathological factors predicting long-term overall survival after hepatectomy for peripheral cholangiocarcinoma

Peripheral cholangiocarcinoma (PCC) is clinically challenging because patients typically do not present until the disease is relatively advanced. Three-year to 5-year survival rates even with resection thus remain dismal. This study aimed to determine the clinicopathological factors for predicting overall survival longer than 5 years in PCC patients treated with hepatectomy. From 1977 to 1997, the clinicopatholgical features of 11 PCC patients who underwent hepatectomy with long-term overall survival (group A) were reviewed. Comparison was made with the clinical features and factors influencing the outcome of 70 PCC patients who survived less than 5 years after hepatectomy (group B). Of 81 PCC patients undergoing hepatectomy, 11 (13.6%) were 5-year survivors. The 81 PCC patients comprised 32 men and 49 women, with a mean age of 56.0 years (range: 34-83 years). Univariate analysis showed that female gender, absence of physical findings, a higher percentage of presence of mucobilia, early staged tumor, intraductal papillary tumor growth, and curative hepatic resection were more frequent in group A patients than group B patients. However, multivariate logistic regression analysis showed that absence of physical findings, presence of mucobilia, early staged tumor, and curative hepatic resection were the four independent factors differentiating group A from B patients. The 1-, 3-, 5-, and 10-year survival rates of the group A patients were 100%, 100%, 100%, and 40%, whereas those of the group B patients were 46.0%, 9.5%, 0%, and 0%, respectively. Absence of physical findings, presence of mucobilia, early staged tumor, and curative hepatectomy could independently predict PCC patients with long-term overall survival after hepatectomy.

Prognostic analysis of surgical treatment of peripheral cholangiocarcinoma: Two decades of experience at Chang Gung Memorial Hospital

AIM: To analyze the prognostic factors influencing the overall survival of peripheral cholangiocarcinoma (PCC) patients undergoing surgical treatment during 25 years at a single institution.

METHODS: This study retrospectively reviewed prospectively collecting data about 373 patients with histologically proven PCC who underwent surgical treatment between 1977 and 2001.

RESULTS: Three hundred and seventy-three PCC patients (159 men and 214 women) underwent surgical treatment from 1977 to 2001. Among them, 187 PCC patients underwent hepatectomy and 135 had curative resection (curative resectability rate: 36.2%). The follow-up duration ranged from 1.05 to 167.6 mo (mean/median = 14.1/7.2 mo). Overall cumulative survival rates at 1, 3, and 5 years were 32.5%, 9.2%, and 4.1%, respectively. Univariate log-rank analysis identified the following as adverse influences on overall survival: presence of symptoms, absence of mucobilia, elevated CEA and CA 19-9 levels, non-papillary tumor type, receiving non-hepatectomy, advanced tumor staging, lack of post-operative chemotherapy, and radiotherapy. Meanwhile, multivariate Cox’s proportional hazard analysis demonstrated that absence of mucobilia, non-papillary tumor type, advanced tumor staging, non-hepatectomy, and lack of post-operative chemotherapy were the five independent prognostic factors that adversely affected overall survival.

CONCLUSION: Favorable overall survival of PCC patients undergoing surgical treatment depends on early tumor stage, presence of mucobilia, papillary tumor type, hepatic resection, and post-operative chemotherapy.

Influence of age on surgical treatment of peripheral cholangiocarcinoma

BACKGROUND

Peripheral cholangiocarcinoma (PCC) constitutes the second most common primary liver cancer. Information is lacking on patients with PCC <40 years old undergoing surgical treatment. The aim of this study was to evaluate the influence of age on surgical treatment of patients with PCC based on reviewing the clinicopathologic features and survival rate of 23 patients with PCC <40 years old who received surgical treatment.

METHODS

The clinical features of 23 younger patients with PCC (<40 years old) who underwent surgical treatment between 1977 and 2000 were reviewed. Clinical features of 284 patients with PCC >40 years old were used for comparison.

RESULTS

Three hundred seven patients with PCC with an age range between 28 and 93 years (mean 57.2, median 56.0) were investigated. The fiftieth decade was the peak PCC age in the series. Clinical presentations and physical findings were similar between younger and older PCC groups. Similar positive serum carcinoembryonic antigen and carbohydrate antigen 19-9 rates (42.9% and 66.7% vs 41.2% and 74.4%, respectively) and a similar rate of hepatolithiasis associated with PCC were also observed between the 2 groups (43.5% vs 48.9%). Younger patients with PCC tended to show less mucobilia, less papillary-type PCC, and a more advanced stage of tumor compared with older patients with PCC. However, postoperative adjuvant chemotherapy and radiotherapy were used more frequently in the older patients with PCC. Operative morbidity and mortality were similar between the 2 groups (surgical mortality rate 7.8%). Follow-up ranged from 1.0 to 167.6 months (mean 13.0, median 5.7). The 1- and 2-year actuarial survival rates were 6.3% and 0% in the younger PCC group and 31.3% and 15.0% in the older PCC group, respectively. Prognosis was dismal for the younger patients with PCC (P = 0.0008), but they may benefit from hepatic resection.

CONCLUSIONS

Younger patients with PCC had a significantly worse survival rate than older patients with PCC. Hepatectomy is rational and may benefit younger patients with PCC.

Intraoperative radiation therapy in the multimodality approach to hepatobiliary tract cancer

IOERT is a reasonable option to consider in patients who have biliary tract cancers above AJCC or Bismuth stage I disease. Inherent resistance of biliary tract cancer cells to ionizing radiation would indicate that IOERT alone would not eradicate most of the tumor clonagen. EBRT (either preoperatively or postoperatively) should be used in combination with IOERT at experienced institutions that have access to both modalities. The single IOERT dose ranges are 10 to 20 Gy [55,67], whereas the EBRT dose ranges from 45 to 50 Gy in 25 to 28 fractions [67]. The most common energy level used is 8 MeV or less. In addition, IOERT port sizes of less than 6 cm in diameter, and often 4 cm or less, are recommended. Finally, intraoperative reconstruction of severely damaged blood vessels may decrease the clinical manifestation of radiation-induced injury to vessels [68].

Intraluminal low-dose-rate 192Ir brachytherapy combined with external beam radiotherapy and biliary stenting for unresectable extrahepatic bile duct carcinoma

PURPOSE

To evaluate the results of combined-modality therapy, including external beam radiotherapy, intraluminal (192)Ir, and biliary stenting for extrahepatic bile duct carcinoma.

MATERIALS AND METHODS

Between 1988 and 1998, 93 patients with unresectable extrahepatic bile duct carcinoma underwent definitive radiotherapy. The dose of external beam radiotherapy was 50 Gy in 25 fractions. Low-dose-rate (192)Ir was delivered at a dose of 27-50 Gy (mean 39.2) at 0.5 cm from the source. An expandable metallic endoprosthesis was used to establish an internal bile passage.

RESULTS

The median survival was 12 months, with a 1-, 3-, and 5-year actuarial survival rate of 50%, 10%, and 4%, respectively. Tumor length, hepatic invasion, and distant metastasis significantly affected survival. Ninety-six percent of patients could successfully remove external drainage catheters. The actuarial biliary patency rate for these patients at 1, 3, and 5 years was 52%, 29%, and 18%, respectively. Tumor length, tumor diameter and T stage were significantly associated with the patency rate. Mild-to-severe gastroduodenal complications were observed in 32 patients and were significantly associated with the active length of (192)Ir and linear source activity. Eight patients had treatment-related biliary fistula.

CONCLUSIONS

Our combined-modality therapy provided reasonable local control and improved the quality of life of patients with extrahepatic bile duct carcinoma. Because none of the treatment characteristics had any impact on survival or biliary patency, lower dose levels and/or a localized target volume are recommended to minimize morbidity.

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.

[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.

Adjuvant external beam radiation therapy with concurrent chemotherapy in the management of gallbladder carcinoma

PURPOSE

This study was performed to evaluate the outcome of patients with gallbladder cancer who received postoperative concurrent chemotherapy and radiation therapy.

METHODS AND MATERIALS

Curative resection followed by adjuvant combined modality therapy with external beam radiation therapy (EBRT) and chemotherapy was attempted in 21 consecutive gallbladder carcinoma (GBC) patients at the Mayo Clinic from 1985 through 1997. All patients received concurrent 5-fluorouracil during EBRT. EBRT fields encompassed the tumor bed and regional lymph nodes (median dose of 54 Gy in 1.8-2.0-Gy fractions). One patient received 15 Gy intraoperatively after EBRT. A retrospective analysis was performed for the end points of local control, distant failure, and overall survival.

RESULTS

After maximal resection, 12 patients had no residual disease on pathologic evaluation, 5 had microscopic residual disease, and 4 had gross residual disease. One patient had Stage I disease, and 20 had Stage III-IV disease. With median follow-up of 5 years (range: 2.6-11.5 years), 5-year survival for the entire cohort was 33%. The 5-year survival rate of patients with Stage I-III disease was 65% vs. 0% for those with Stage IV disease (p < 0.02). For patients with no residual disease, 5-year survival was 64% vs. 0% for those with residual disease (p = 0.002). The median survival was 0.6, 1.4, and 5.1 years for patients with gross residual, microscopic residual, and no residual disease, respectively (p = 0.02). The 5-year local control rate for the entire cohort was 73%. Two-year local control rates were 0%, 80%, and 88% for patients with gross residual, microscopic residual, or no residual disease, respectively (p < 0.01). Five-year local control rates were 100% for the 6 patients who received total EBRT doses >54 Gy (microscopic residual, 3 patients; gross residual, 1 patient; negative but narrow margins, 2 patients) vs. 65% for the 15 who received a lower dose (3, gross residual; 2, microresidual; 10, negative margins).

CONCLUSION

Patients with completely resected (negative margins) GBC followed by adjuvant EBRT plus 5-fluorouracil chemotherapy had a relatively favorable prognosis, with a 5-year survival rate of 64%. These results seem to be superior to historical surgical controls from the Mayo Clinic and other institutions, which report 5-year survival rates of approximately 33% with complete resection alone. Both tumor stage and extent of resection seemed to influence survival and local control. More aggressive measures using current cancer therapies and integration of new cancer treatment modalities will be required to favorably impact on the poor prognosis of patients with Stage IV or subtotally resected GBC. Additional investigation leading to earlier diagnosis is warranted, because most patients with GBC present with advanced disease.

Nonsurgical management of gallbladder cancer: cytotoxic treatment and radiotherapy

Carcinoma of the gallbladder is a rare tumor entity. Apart from surgical intervention, there is no therapeutic measure with curative potential. Therefore, patients with advanced--i.e., unresectable or metastatic-disease present a difficult problem to clinicians, whether to choose a strictly symptomatic treatment or expose the patient to the side effects of potentially ineffective treatment. Despite anecdotal reports about symptomatic palliation and survival advantages, only unrandomized Phase II studies too small to draw meaningful conclusions have been published thus far. Since there is no standard therapy for advanced gallbladder cancer, patients should be offered the opportunity to participate in controlled clinical trials.

Brachytherapy in the elderly

A rapidly and constantly increasing aged population in the western countries poses a wide range of specific problems to oncologists. A different way to face medical issues should be sought for older patients with cancer, looking at the characteristics that are peculiar to the elderly from different points of view. Brachytherapy is an effective form of radiotherapy which, for its specific characteristics, may be a valid alternative to more complex modalities of treatment, thus allowing a better sparing of normal tissues and structures yet achieving a similar tumor control rate. This paper reviews the literature on the subject of cancer treatment in the elderly, focusing on radiotherapy and brachytherapy, to evaluate the current attitude toward this problem in the medical community and to see if it is possible to identify a patient population that will benefit from this technique.

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.

The role of brachytherapy for palliation

The goal of palliative radiation is to alleviate symptoms in a short amount of time and maintain an optimal functional and quality-of-life level while minimizing toxicity and patient inconvenience. Despite advances in multimodality antineoplastic therapies, failure to control the tumor at its primary site frustratingly remains the predominant source of morbidity and mortality in many patients with cancer. Escalation of doses of radiation using external beam irradiation has been shown to improve local tumor control, but limits are imposed by the tolerance of normal surrounding structures. The highly conformal nature of brachytherapy enables the radiation oncologist to accomplish safe escalation of radiation doses to the tumor while minimizing doses to normal surrounding structures. Thus, by enhancing the potential for local control, brachytherapy used alone or as a supplement to external beam radiation therapy retains a significant and important role in achieving the goals of palliation. Proper patient selection, excellent technique, and adherence to implant rules will minimize the risk of complications. The advantages realized with the use of brachytherapy include good patient tolerance, short treatment time, and high rates of sustained palliation. This article reviews various aspects of palliative brachytherapy, including patient selection criteria, implant techniques, treatment planning, dose and fractionation schedules, results, and complications of treatment. Tumors of the head and neck, trachea and bronchi, esophagus, biliary tract, and brain, all in which local failure represents the predominant cause of morbidity and mortality, are highlighted.

Peripheral cholangiocarcinoma (cholangiocellular carcinoma): clinical features, diagnosis and treatment

Peripheral cholangiocarcinoma is a relatively rare cancer. However, it is known to have an unfavourable prognosis compared with that of hepatocellular carcinoma. Little is known about its aetiology, clinical or pathological features. Recently, with the development of imaging modalities, early staged cholangiocarcinoma has been diagnosed with relative ease. Surgery is the optimal therapy. Total hepatectomy does not provide survival benefit. Conventional surgery remains the only effective treatment, even for patients with advanced-stage tumours. Factors influencing survival after hepatectomy were tumour-free margin, lymphnodes metastasis and histopathology of tumour. Palliative intrahepatic tubing or percutaneous transhepatic biliary drainage and brachytherapy can alleviate jaundice and cholangitis, thereby prolonging survival in some cases.

Aggressive surgical treatment of intrahepatic cholangiocarcinoma: predictors of outcomes

BACKGROUND

Intrahepatic cholangiocarcinoma (ICC) is the second most common primary liver cancer and constitutes 10% of primary liver malignancies. Surgery is the optimal therapy; the majority of the patients will require extensive resections that are associated with significant morbidity.

METHODS

We retrospectively studied the records of 26 patients who underwent exploratory laparotomy for intrahepatic cholangiocarcinoma between June 1991 and December 1997 at the Mount Sinai Hospital. Patients with perihilar (Klatskin) tumors were excluded. All patients were considered resectable based on CT or MRI findings. Patients with positive margins or nodal invasion received adjuvant chemotherapy and radiation.

RESULTS

Sixteen patients underwent 18 resections; in 10 patients the tumors were unresectable at laparotomy and only biopsy was performed. The mean age (62 versus 53 years) was significantly higher, and the mean total bilirubin level (0.71 versus 6.17 mg/dL) was significantly lower in the resected group (p=0.031 and 0.017, respectively). No patient with a total bilirubin over 1.2 mg/dL was found to be resectable. Median actuarial survivals were 42.9+/-8.9 months for resectable and 6.7+/-3.6 months for unresectable patients (p=0.005). Positive margins were associated with significantly shorter disease-free survival. But resected patients with positive margins survived significantly longer than those who were unresectable. Tumor size, presence of satellite nodules, and degree of tumor necrosis on histologic examination were significant predictors of outcomes. Survival among patients receiving adjuvant therapy was not significantly altered.

CONCLUSIONS

We conclude that an aggressive surgical approach is warranted in patients with ICC because resection offers the only hope for longterm survival. Our findings emphasize the importance of achieving tumor-free margins. Noncurative resection offers a survival advantage over no resection. Histologic examination of resected specimens can help select patients with poor prognoses.

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.

Intraluminal brachytherapy in the treatment of bile duct carcinomas

Patients with carcinoma of the biliary tract have a poor prognosis because the disease is often unresectable at diagnosis. Intraluminal brachytherapy has been reported as an effective treatment for localized cholangiocarcinoma of the biliary tract. The purpose of our study was to analyse the survival of patients treated with brachytherapy and make some recommendations regarding its use. Fifteen patients underwent brachytherapy via a trans-hepatic approach at the Royal Prince Alfred Hospital from 1983 to 1993. Eleven patients had low-dose rate brachytherapy and four patients had high-dose rate treatment. There were nine males and six females. The median age was 64 years. Other treatment included bypass procedures in two patients, endoscopic stents in 14 patients and external beam irradiation in one patient. The median survival was 12.5 months and 47% of the patients survived 1 year. The only complication reported was cholangitis which was seen in one patient. There did not seem to be any difference in survival or complications between low- and high-dose rate brachytherapy. We conclude that the addition of intraluminal brachytherapy after biliary drainage prolongs survival and is a safe and effective treatment, but patients still have a high rate of local failure, and further studies will be needed to address this problem.

External beam and intraluminal radiotherapy for locally advanced bile duct cancer: role and tolerability

BACKGROUND AND PURPOSE

Cholangiocarcinoma is rare but carries a poor prognosis. Radiotherapy has been used either as an adjuvant treatment following surgical resection of tumour or for palliation. The purpose of this study was to assess the feasibility and morbidity of accelerated external beam radiotherapy with or without intraluminal radiotherapy in the treatment of locally advanced bile duct cancer.

MATERIALS AND METHODS

Thirty eight patients were treated. Surgical procedures performed prior to radiotherapy were extended hepatectomy (3), hepaticojejunostomy with tumour resection (6), palliative biliary-enteric bypass (6), biopsy (4), Whipple's procedure (1), gastrojejunostomy (1) and cholecystectomy (1). Twenty patients received external beam radiotherapy (ERT). Six patients received one Phase of ERT and 12 received two Phases, separated by a 2-week gap. Dose per Phase was 22.5 Gy in 10 twice daily fractions. After 1989, dose per Phase was increased to 27.5 Gy. One patient received Phase I ERT (30.0 Gy) using conventional fractionation and one patient received an uninterrupted, conventionally fractionate course of treatment (50.0 Gy). Fourteen patients received both ERT and intraluminal radiotherapy (IRT) using iridium-192 (192Ir) wire passed through a percutaneous, transhepatic catheter (median dose, ERT 23.8 Gy + IRT 40.0 Gy). In addition, four patients received IRT alone (median dose 45.0 Gy at 1 cm radius). Patients were followed for at least 42 months.

RESULTS

Median overall survival was 15 months. Overall survival for the whole group at 1,2 and 3 years was 59.6%, 32.5% and 16.2%. Thirty four patients died of disease. Radiotherapy caused acute toxicity in seven patients. According to RTOG/EORTC criteria toxicity was Grade 1 in four cases, Grade 2 in two cases and Grade 3 in one case. Two patients developed gastrointestinal bleeding as a late complication of radiotherapy.

CONCLUSIONS

Accelerated external beam radiotherapy with or without intraluminal radiotherapy is feasible and associated with acceptable toxicity when used in the management of advance cholangiocarcinoma.

Intraluminal brachytherapy in bile duct carcinomas

BACKGROUND

Cholangiocarcinoma of the biliary tract is a rare tumour which has been treated with surgery, radiotherapy, chemotherapy, bypass procedures and stenting. Surgery remains the only curative treatment for these tumours, but a large proportion are unresectable. Intraluminal brachytherapy has been reported as an effective treatment for localized cholangiocarcinoma of the biliary tract. The purpose of our study was to analyse the survival of patients with biliary tract carcinoma treated with iridium-192 brachytherapy.

METHODS

A retrospective review of patients treated at Peter MacCallum was undertaken. From 1989 to 1994, 16 patients underwent brachytherapy via transhepatic approach for cholangiocarcinoma. There were 12 male and four female patients. The median age was 65 (range 40-83). All patients had cholangiocarcinoma. Prior treatment included complete resection in three, partial resection in one, bypass procedures in eight, endoscopic stents in five and external biliary drainage in 15 of the 16 patients. One patient had received external beam irradiation.

RESULTS

The median survival was 23 months and 61% survived 1 year. The most common acute complication was cholangitis seen in four patients and the most common late complications were duodenal ulcer seen in two patients and cholangitis seen in two patients.

CONCLUSIONS

We conclude that iridium-192 brachytherapy is a safe effective treatment for biliary tract carcinoma but a comparison between surgery and stenting would be of value. However, the cost of brachytherapy is not cheap and its value in this regard should be carefully analysed.

Intraluminal brachytherapy in the treatment of pancreas and bile duct carcinoma

PURPOSE

A new method of palliation of malignant obstructive jaundice is presented.

METHODS AND MATERIALS

Twelve patients with carcinoma of the extrahepatic bile ducts (EHBD-five patients) or pancreatic head (PH-seven patients) received radiation therapy between 1988 and 1991. Percutaneous transhepatic biliary drainage was performed in four EHBD patients and an endoprosthesis was placed during endoscopic retrograde cholangiopancreatography (ERCP) in the other eight patients. All 12 received intraluminal brachytherapy (ILBT): 20-50 Gy calculated at 1 cm from the Iridium-192 (192Ir) wire. In four PH patients the source was placed in the duct of Wirsung; in the other eight patients ILBT was performed via the common bile duct. Five of the seven PH patients and one of the five EHBD patients received External Beam Radiation Therapy (EBRT): 26-50 Gy, alone or with concomitant 5-Fluorouracil (5-FU).

RESULTS

Cholangitis occurred in six patients. Three PH patients treated with EBRT+ILBT developed gastrointestinal toxicities. With a minimum follow-up of 18 months, median survival times were 14 months (EHBD) and 11.5 months (PH); one of the seven PH patients is alive (29 months) and two of the EHBD patients are alive (18 and 43 months). All patients had satisfactory control of jaundice.

CONCLUSIONS

The results in the EHBD patients suggest that the addition of ILBT after biliary drainage prolongs survival. Further experience is necessary to determine whether ILBT in the common bile duct and/or in the duct of Wirsung may be, in PH patients, an alternative boost technique to Interstitial Brachy-therapy (IBT) or Intraoperative Electron Beam Radiation Therapy (IOEBRT).

Primary carcinoma of the gall-bladder: potential for external radiation therapy

Nineteen patients (14 women, 5 men) received external radiation therapy (ERT) between 1980 and 1988 for gall-bladder carcinoma. Eleven patients had complete resection (cholecystectomy in eight cases), six incomplete gross resection and two only percutaneous transhepatic biliary drainage (PTBD). The modalities of ERT were variable and doses ranged from 30 Gy/10 fractions to 50 Gy/25 fractions. Among 11 patients with complete resection (9/11 with T1 or T2 stages), overall survival was 55% at 48 months and 36% at 60 months, median survival was 48 months and at the time of this report 3/11 patients were alive with no evidence of disease, 54, 65, 76 months after surgery, and eight dead of cancer 8-114 months. Local control was achieved in 66 patients with T1 or T2 stages. All eight patients who had palliative surgery or PTBD died of cancer after 4-20 months with median survival of 6 months. Three complications were noted: one gastric ulcer in the course of ERT (surgical treatment), one duodenal ulcer which occurred 6 months after completion of ERT (medical treatment) and one regressive radiation hepatitis. From this experience it appears that ERT in gall-bladder carcinoma is well tolerated, can obtain local control and prolonged survival after complete resection and good palliation in non-resectable tumors.

Carcinoma of the extrahepatic bile ducts. The University of California at San Francisco experience

OBJECTIVE

The authors investigated the combined experience of a single institution in treating bile duct carcinoma during the modern era.

SUMMARY BACKGROUND DATA

Bile duct carcinomas are notoriously difficult to cure, with locoregional recurrence the rule, even after radical resection. Adjuvant efforts have included various radiation modalities, with limited success. Recently, charged-particle radiotherapy has also been used in these patients.

METHODS

The authors performed a retrospective chart analysis of 129 patients with bile duct adenocarcinomas treated between 1977 and 1987 through the University of California at San Francisco, including 22 patients treated at Lawrence Berkeley Laboratory with the charged particles helium and neon. The minimum follow-up was 5 years. Survival, outcome, and complication results were analyzed.

RESULTS

Sixty-two patients were treated with surgery alone (S), 45 patients received conventional adjuvant x-ray radiotherapy (S + X), and 22 were treated with charged particles (S + CP). The median survival times were 6.5, 11, and 14 months, respectively, for the entire group, and 16, 16, and 23 months in patients treated with curative intent. There was a survival difference in patients undergoing total resection compared with debulking (p = 0.05) and minor resections (p = 0.0001). Patients with microscopic residual disease had increased median survival times when they were treated with adjuvant irradiation, most markedly after CP (p = 0.0005) but also with conventional X (p = 0.0109). Patients with gross residual disease had a less marked but still statistically significant extended survival (p = 0.05 for S + X and p = 0.0423 for S + CP) after irradiatio

CONCLUSIONS

The mainstay of bile duct carcinoma management was maximal surgical resection in these patients. Postoperative radiotherapy gave patients with positive microscopic margins a significant survival advantage and may be of value in selected patients with gross disease.

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.

Adjuvant radiotherapy and chemotherapy for biliary and pancreatic cancer

Due to the limited efficacy of surgery in pancreatico-biliary cancer, perioperative treatment modalities are of high clinical interest. Adjuvant chemoradiation with protracted infusion 5-FU for these tumors is an attractive direction for continued clinical research and may increase local control. Improved local control may influence survival as has been demonstrated by the results of adjuvant chemoradiation for operable rectal cancer. Newer combinations of chemotherapy and external beam radiotherapy (ExBRT) will need to be tested. The results of combined modality therapy indicate that increased normal tissue reactions occur and caution must be exercised during treatment especially in the areas of nutrition and fluid balance. New treatment strategies with electron beam IORT are also investigating higher doses of radiotherapy than those achieved with ExBRT alone in order to achieve better permanent tumor eradication. Data from our institution have demonstrated the safety of aggressive preoperative chemoradiation, surgical resection and IORT. Prophylactic hepatic and whole abdominal chemoradiation for occult liver disease needs further testing in clinical trials, since the liver is the single most frequent site of failure outside the primary site.

Definitive postoperative irradiation of bile duct carcinoma with charged particles and/or photons

PURPOSE

To determine the rates of survival and local control in patients with bile duct adenocarcinomas treated with post-operative photons and/or charged particles.

METHODS AND MATERIALS

A retrospective study was performed analyzing all patients with bile duct adenocarcinomas who received radiotherapy through the University of California San Francisco and at Lawrence Berkeley Laboratory between 1977 and 1987, a total of 62 patients. University of California San Francisco patients received photon therapy (median dose 5400 cGy), and Lawrence Berkeley Laboratory patients were treated with the charged particles helium and/or neon (median dose 6000 cGyE). Forty-eight patients were treated post-operatively with curative intent, 30 with photons and 18 with particles. Thirty-six patients in the study had gross residual disease; none had microscopically negative margins.

RESULTS

The overall two-year actuarial survival was 28%: 44% for particle-treated patients and 18% for patients treated with photons (p = .048). Median actuarial survival was 23 months in particle patients and 12 months in photon patients. Local control was also improved, though less significantly, in patients treated with particles (median disease-free survival 20 months vs. 4.5 months, p = .054). A univariate and multivariate analysis was performed and revealed that only extent of residual disease predicted local failure and overall survival; no other prognostic factors were identified.

CONCLUSION

Compared to conventional photon radiotherapy, treatment with post-operative charged particle irradiation at Lawrence Berkeley Laboratory appeared to offer a survival advantage in this non-randomized series. Additional investigation into protection of surrounding normal tissue with better dose localization through the use of charged particles is planned.

Intraoperative radiotherapy for unresectable cholangiocarcinoma--the Mayo Clinic experience

Thirteen patients with unresectable cholangiocarcinomas were treated with external beam radiation therapy (ERT) and intraoperative radiation therapy (IORT) in combination with biliary stenting. Local treatment failure occurred in 50% of the patients treated with curative intent and an additional two patients developed distant recurrent disease. Patient morbidity was primarily related to biliary sepsis and gastrointestinal complications. There was minimal morbidity related to the IORT. Although the median survival of 16.5 months seemed to be an improvement over our previous results for ERT alone or ERT with 5-fluorouracil, the survival data are still discouraging. Further improvements in treatment will require better means of biliary bypass and increased tumour response perhaps by the use of radiosensitizers or hyperthermia in conjunction with radiation therapy.

Interstitial microwave-induced hyperthermia and iridium brachytherapy for the treatment of obstructing biliary carcinomas

In a phase I clinical study, 10 patients with obstructive biliary carcinomas were treated with single-antenna interstitial microwave hyperthermia and iridium-192 brachytherapy. For each patient a standard biliary drainage catheter was implanted percutaneously through the obstructed common bile duct. This catheter accommodated a single microwave antenna which operated at 915 MHz, and one or two fibreoptic thermometry probes for temperature measurement. Under fluoroscopic guidance the microwave antenna and temperature probes were positioned in the CT-determined tumour mass. The 60-min heat treatment achieved a central tumour temperature of 45-55 degrees C while keeping temperatures at the proximal and distal margins at 43 degrees C. Immediately following the hyperthermia treatment the microwave antenna and temperature probes were removed, and a single strand of iridium-192 double-strength seeds was inserted to irradiate the tumour length. A dose of 5500-7900 cGy calculated at 0.5 cm radially from the catheter was administered over 5-7 days. Upon removal of the iridium a second hyperthermia treatment was performed. A total of 18 hyperthermia treatments were administered to the 10 patients. In two cases the second hyperthermia treatment after brachytherapy was not possible due to a kink in the catheter, or bile precipitation in the catheter. All patients tolerated the procedure well, and there were no acute complications. To evaluate the volumetric heating potential of this hyperthermia method, specific absorption rate (SAR) values were measured at 182 planar points in muscle phantom. Insulated and non-insulated antenna performance was tested at 915 MHz in a biliary catheter filled with air, saline, or bile to mimic clinical treatments. The insulated antenna exhibited the best performance. Differences between antenna performance in saline and bile were also noted. In summary, this technique may have potential for tumours which obstruct biliary drainage and are accessible to percutaneous decompression using standard diagnostic radiological procedures.

Analysis of failure after curative irradiation of extrahepatic bile duct carcinoma

Thirty-four patients with subtotally resected or unresectable carcinoma of the extrahepatic bile ducts received radiation therapy; a minimum of 45 Gy (external beam) to the tumor and regional lymph nodes +/- 5-fluorouracil (5-FU). Seventeen patients received an external beam boost of 5 to 15 Gy to the tumor, and a specialized boost was used in the remaining 17 patients (iridium-192 transcatheter seeds in 10 and intraoperative radiation therapy [IORT] with electrons in seven). The median time to death in all 34 patients was 12 months (range, 4 to 98-months). The only patients who survived longer than 18 months were those either with gross total or subtotal resection before external irradiation (2 of 6) or who received specialized boosts (192Ir, 3 of 10; IORT, 3 of 7). Local failure was documented in 9 of 17 patients who received external beam irradiation alone +/- 5-FU, 3 of 10 patients who received an 192Ir boost, and 2 of 6 patients who received an IORT boost with curative intent.

Ultrasound directed extrahepatic bile duct intraluminal brachytherapy

Intraluminal brachytherapy with a transcatheter Iridium-192 (Ir-192) wire, as a method to deliver a boost to patients with tumors of the extrahepatic bile ducts, has been well described. A major limitation of current imaging techniques is the inability to accurately define the proximal, distal, and most importantly the lateral extent of the tumor. We have found endoluminal ultrasound, which to this date has been used primarily to measure arterial wall layers, can successfully determine tumor volume in the bile ducts. The small diameter of these ultrasound probes allows easy insertion into a biliary duct drainage tube. Given the uncertainties in the determination of tumor size in the bile ducts, ultrasound is an ideal method by which to obtain the measurements. We present a case of recurrent islet cell carcinoma treated with external beam radiation therapy and an Ir-192 intraluminal brachytherapy boost in which the ultrasound probe was used to determine the tumor volume and response to therapy.

Radiotherapy of cholangiocarcinoma: the roles for primary and adjuvant therapies

A total of 22 patients with cholangiocarcinoma who had been treated with external radiotherapy between 1978 and 1989 were analyzed. Of the 22 patients, 18 had cancer of the hepatic hilus (Klatskin) and 4 had intrahepatic biliary cancer; all but 2 of the subjects had advanced disease. In all, 16 patients underwent primary irradiation for unresectable tumors, 4 were subjected to adjuvant irradiation after gross tumor resection, and 2 received preoperative irradiation followed by gross tumor resection. The mean initial irradiation dose was 52.0 Gy (range, 26-78 Gy). The TDF (time-dose-fractionation) for the entire course of radiotherapy ranged from 49 to 154 (mean, 100). The median survival of all patients was 10 months, and the cumulative 1-year survival value was 37.7%. The external radiotherapy proved to be effective in the treatment of cholangiocarcinoma in terms of palliation and survival.

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

From 1976 to 1988, 63 patients received radiation therapy for primary cancers of the extrahepatic biliary system (eight gallbladder and 55 extrahepatic biliary duct). Twelve patients underwent orthotopic liver transplantation. Chemotherapy was administered to 13 patients. Three patients underwent intraluminal brachytherapy alone (range, 28 to 55 Gy). Sixty patients received megavoltage external-beam radiation therapy (range, 5.4 to 61.6 Gy; median, 45 Gy), of whom nine received additional intraluminal brachytherapy (range, 14 to 45 Gy; median, 30 Gy). The median survival of all patients was 7 months. Sixty patients died, all within 39 months of radiation therapy. One patient is alive 11 months after irradiation without surgical resection, and two are alive 50 months after liver transplantation and irradiation. Symptomatic duodenal ulcers developed after radiation therapy in seven patients but were not significantly related to any clinical variable tested. Extrahepatic biliary duct cancers, the absence of metastases, increasing calendar year of treatment, and liver transplantation with postoperative radiation therapy were factors significantly associated with improved survival.

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

From 1976 to 1988, 63 patients received radiation therapy for primary cancers of the extrahepatic biliary system (eight gallbladder and 55 extrahepatic biliary duct). Twelve patients underwent orthotopic liver transplantation. Chemotherapy was administered to 13 patients. Three patients underwent intraluminal brachytherapy alone (range, 28 to 55 Gy). Sixty patients received megavoltage external-beam radiation therapy (range, 5.4 to 61.6 Gy; median, 45 Gy), of whom nine received additional intraluminal brachytherapy (range, 14 to 45 Gy; median, 30 Gy). The median survival of all patients was 7 months. Sixty patients died, all within 39 months of radiation therapy. One patient is alive 11 months after irradiation without surgical resection, and two are alive 50 months after liver transplantation and irradiation. Symptomatic duodenal ulcers developed after radiation therapy in seven patients but were not significantly related to any clinical variable tested. Extrahepatic biliary duct cancers, the absence of metastases, increasing calendar year of treatment, and liver transplantation with postoperative radiation therapy were factors significantly associated with improved survival.

Radiation therapy in extrahepatic bile duct carcinoma

Fifty-one patients with carcinoma of the extrahepatic bile ducts (EHBD) received radiation therapy between January 1980 and December 1988. The location of the tumors was: proximal third, 20 patients; middle third, 23 patients; distal third, 3; diffuse, 5 patients. Thirty-six patients underwent surgery with complete gross resection in 14 (10/14 with positive margins), incomplete gross resection in 12 and only biopsy in 10. Fifteen patients had only biliary drainage without laparotomy after cytologic diagnosis of malignancy in 11/15. Radiation therapy was done with curative intent after complete or incomplete resection (n = 26) and it was palliative in patients who had no resection or only biliary drainage (n = 25). Twenty-five patients received external radiation-therapy (ERT) alone to the tumor and lymph nodes (mean dose 45 Gy/2 Gy per fraction for cure, 35 Gy/10 fractions for palliation), 8 patients had only iridium-192 (192Ir) implant (50-60 Gy at a 1 cm radius for cure, 30 Gy for palliation), 17 patients had both ERT + 192Ir (ERT 42.5 Gy + 192Ir 10-15 Gy for cure; ERT 20 Gy/5 fractions + 192Ir 20-30 Gy for palliation) and one intra-operative irradiation + ERT. The overall survival for the entire group was 55, 28.5 and 15% at 12, 24, 36 months and median survival 12 months. Median survival was 22 months in patients treated with curative intent and only 10 months after palliative treatment (p 0.03). Among patients who had curative treatment, median survival was 27.5 months after complete gross resection and 13 months after incomplete gross resection (p 0.045).(ABSTRACT TRUNCATED AT 250 WORDS)

Resection combined with intraoperative radiation therapy (IORT) for stage IV (TNM) gallbladder carcinoma

From October 1976 to May, 1990, a total of 86 patients with stage IV (TNM) gallbladder cancer were treated at Tsukuba University Hospital. Twenty-seven of the 86 patients underwent tumor resection; 43 patients received palliative surgery. The remaining 16 were too advanced to have surgery. Of 27 patients who had tumor resection, 9 had resection alone, 17 had intraoperative radiation therapy (IORT) +/- postoperative external radiotherapy (ERT), and 1 had postoperative ERT. The procedures used were: extended right hepatic lobectomy plus hepaticobiliary resection (HBR) (n = 2), hepatic segmentectomy (SIVb, SV) plus HBR (n = 9), hepatic segmentectomy (SIV, V, VI) with HBR (n = 1), hepatic segmentectomy (SIV, V) plus HBR with pancreaticoduodenectomy (PD) (n = 3), PD plus HBR (n = 1), cholecystectomy with wedge resection of the gallbladder fossa plus HBR (n = 3), and cholecystectomy plus HBR (n = 3), and cholecystectomy (n = 4). Regional lymph node dissections were performed in every patient and 17 of 27 patients underwent additional resections of adjacent organs such as the stomach, duodenum, colon, and abdominal wall. A single dose of 20-30 Gy was delivered intraoperatively for 17 patients. A mean total dose of 36.4 Gy (1.8/fraction) was added to IORT for 10 patients. The three-year cumulative survival rate was 10.1% for resection plus IORT but 0% for resection alone. The longest survivor is alive and well at 3 years and 3 patients are alive 16, 13, and 4 months after tumor resection followed by IORT plus ERT.

Combined modality therapy of extrahepatic biliary system cancer

From January 1985 to December 1988, 10 patients with local/regional extrahepatic biliary system cancer (gallbladder: 2, Klatskin: 4, common bile duct: 4) underwent combined modality therapy. Laparotomy and biopsy or subtotal resection were performed in six patients and endoscopic retrograde cholangiopancreatography, percutaneous transhepatic cholangiogram, and biliary drainage in four patients. Patients initially received 5000 cGy to the tumor bed and primary nodal area. Eight received an additional 1500 cGy boost to the tumor bed. Chemotherapy (5-FU/mitomycin-C) was delivered at the beginning of each radiation treatment course. Four patients received an additional 1-4 cycles of maintenance chemotherapy and six received a boost with brachytherapy. The mean survival was 32 months and the median survival was 16 months. Five patients are currently NED at 16, 17, 17, 48, and 52 months. The overall 3-year actuarial survival was 50%. The cumulative incidence of failure as a component of failure was local/regional: 50%, abdominal: 40%, and distant: 10%. Of the five patients who developed failure, all developed a component of local/regional failure. Our data show that this approach is feasible and offers similar results to those reported in the literature. However, further follow-up will be needed to determine if this combined modality approach offers improved local control and survival rates compared with surgery or biliary bypass/drainage alone.

The role of radiotherapy in the treatment of bile duct carcinoma

Forty-two patients with irresectable bile duct carcinoma (n = 31) or with microscopic evidence of tumor rest after aggressive surgery for bile duct carcinoma (n = 11) were given radiotherapy consisting intentionally of external-beam therapy and intraluminal 192Iridium (192Ir) wire application(s) following bile drainage procedures. The treatment was well tolerated; complications were mainly infectious and related to the success of the drainage. A median survival of 10 months was achieved for the group as a whole. Patients treated following microscopically incomplete resection survived longer than patients with an irresectable tumor (15 vs 8 months median survival, p = 0.06). Gross lymph node involvement also proved to be a prognostic factor.