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Atanasova EG, Pentchev CP, Nolsøe CP. Intracavitary Applications for CEUS in PTCD. Diagnostics (Basel) 2024; 14:1400. [PMID: 39001290 PMCID: PMC11241276 DOI: 10.3390/diagnostics14131400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2024] [Revised: 06/22/2024] [Accepted: 06/28/2024] [Indexed: 07/16/2024] Open
Abstract
Intracavitary contrast-enhanced ultrasound is widely accepted as a highly informative, safe, and easily reproducible technique for the diagnosis, treatment, and follow-up of different pathologies of the biliary tree. This review article describes the diverse applications for CEUS in intracavitary biliary scenarios, supported by a literature review of the utilization of the method in indications like biliary obstruction by various etiologies, including postoperative strictures, evaluation of the biliary tree of liver donors, and evaluation of the localization of a drainage catheter. We also provide pictorial examples of the authors' personal experience with the use of intracavitary CEUS in cases of PTCD as a palliative intervention. Intracavitary CEUS brings all the positive features of US together with the virtues of contrast-enhanced imaging, providing comparable accuracy to the standard techniques for diagnosing biliary tree diseases.
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Affiliation(s)
- Evelina G Atanasova
- Faculty of Medicine, Medical University of Sofia, 1431 Sofia, Bulgaria
- Clinic of Gastroenterology, "St. Ivan Rilski" University Hospital, 1431 Sofia, Bulgaria
| | - Christo P Pentchev
- Faculty of Medicine, Medical University of Sofia, 1431 Sofia, Bulgaria
- Clinic of Gastroenterology, "St. Ivan Rilski" University Hospital, 1431 Sofia, Bulgaria
| | - Christian P Nolsøe
- Centre for Surgical Ultrasound, Department of Surgery, Zealand University Hospital, 4600 Køge, Denmark
- Institute for Clinical Medicine, University of Copenhagen, 2200 Copenhagen, Denmark
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2
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Yamazaki H, Shibuya K, Kimoto T, Suzuki M, Murakami M, Terashima K, Okimoto T, Iizumi T, Sakurai H, Wakatsuki M, Suzuki O, Katoh N, Arimura T, Ogino T, Takagi M, Araya M, Waki T, Matsumoto S, Ogino H, Fukumoto T, Ohtsuka M. Proton beam therapy for extrahepatic biliary tract cancer: Analysis with prospective multi-institutional patients' registration database, Proton-Net. Clin Transl Radiat Oncol 2023; 41:100634. [PMID: 37234735 PMCID: PMC10206422 DOI: 10.1016/j.ctro.2023.100634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 04/24/2023] [Accepted: 05/01/2023] [Indexed: 05/28/2023] Open
Abstract
Background and purpose To examine the role of proton beam therapy (PBT) in the treatment of extrahepatic biliary tract cancer (EBC). Methods and materials We analyzed the data accumulated in the Proton-Net database, which prospectively registered all individual patient data treated with PBT in all Japanese proton institutions from May 2016 to June 2019. The primary endpoint was overall survival (OS), and the secondary endpoints were local control (LC), progression-free survival (PFS), and toxicity. Results Ninety-three patients with unresectable and/or recurrent EBC were treated with PBT using a median prescribed dose of 67.5 Gy (RBE) (range, 50-72.6 Gy) in 25 (22-30 fractions). With a median follow-up of 16.3 months, the median survival time was 20.1 months and the 2-year OS was 37.8%. Two-year PFS and LC rates were 20.6% and 66.5%, respectively. Poor liver function (Child-Pugh B, C), a narrower distance between the tumor and digestive tract (2 cm >), and a larger tumor diameter (2 cm <) were identified as poor prognostic factors for OS. PBT-related grade 3 ≤ acute and late adverse events occurred in 5.4% and 4.3% of patients, respectively, including one gastrointestinal late toxicity (duodenal ulcer). Conclusions This is the largest prospectively accumulated series of PBT for EBC, and PBT showed favorable outcomes with acceptable toxicity profiles.
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Affiliation(s)
- Hideya Yamazaki
- Department of Radiology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Kei Shibuya
- Gunma University Heavy Ion Medical Center, Maebashi, Japan
| | - Takuya Kimoto
- Department of Radiology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Motohisa Suzuki
- Department of Radiation Oncology, Southern TOHOKU Proton Therapy Center, Koriyama, Japan
| | - Masao Murakami
- Department of Radiation Oncology, Southern TOHOKU Proton Therapy Center, Koriyama, Japan
| | - Kazuki Terashima
- Department of Radiology, Hyogo Ion Beam Medical Center, Hyogo, Japan
| | - Tomoaki Okimoto
- Department of Radiology, Hyogo Ion Beam Medical Center, Hyogo, Japan
| | - Takashi Iizumi
- Department of Radiation Oncology, Proton Medical Research Center, University of Tsukuba Hospital, Tsukuba, Japan
| | - Hideyuki Sakurai
- Department of Radiation Oncology, Proton Medical Research Center, University of Tsukuba Hospital, Tsukuba, Japan
| | - Masaru Wakatsuki
- QST Hospital, National Institutes for Quantum and Radiological Science and Technology, Chiba, Japan
| | - Osamu Suzuki
- Osaka Heavy Ion Administration Company, Otemae, Chuo-ku, Osaka-city, Osaka, Japan
| | - Norio Katoh
- Department of Radiation Oncology, Hokkaido University Faculty of Medicine, Sapporo, Hokkaido, Japan
| | - Takeshi Arimura
- Medipolis Proton Therapy and Research Center, Ibusuki, Kagoshima, Japan
| | - Takashi Ogino
- Medipolis Proton Therapy and Research Center, Ibusuki, Kagoshima, Japan
| | - Masaru Takagi
- Proton Therapy Center, Sapporo Teishinkai Hospital, Sapporo, Hokkaido, Japan
| | - Masayuki Araya
- Proton Therapy Center, Aizawa Hospital, Matsumoto, Nagano, Japan
| | - Takahiro Waki
- Department of Radiology, Tsuyama Chuo Hospital, Tsuyama, Okayama, Japan
| | - Sae Matsumoto
- Proton Therapy Center, Fukui Prefectural Hospital, Fukui, Fukui, Japan
| | - Hiroyuki Ogino
- Department of Radiation Oncology, Nagoya Proton Therapy Center, Nagoya City University West Medical Center, Nagoya, Japan
| | - Takumi Fukumoto
- Department of Surgery, Division of Hepato-Biliary-Pancreatic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Masayuki Ohtsuka
- Department of General Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
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Yamazaki H, Kimoto T, Suzuki M, Murakami M, Suzuki O, Takagi M, Katoh N, Arimura T, Ogino T, Ogino H. Particle Beam Therapy for Intrahepatic and Extrahepatic Biliary Duct Carcinoma: A Multi-Institutional Retrospective Data Analysis. Cancers (Basel) 2022; 14:cancers14235864. [PMID: 36497346 PMCID: PMC9736951 DOI: 10.3390/cancers14235864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 11/25/2022] [Accepted: 11/25/2022] [Indexed: 11/30/2022] Open
Abstract
To examine the efficacy and toxicity of particle beam therapy (PT) for biliary duct carcinoma (BDC) and compare the outcomes between extrahepatic BDC (eBDC) and intrahepatic BDC (iBDC). We analyzed multi-institutional data from May 2009 to December 2019. The primary endpoint was overall survival (OS), and the secondary endpoints were local control (LC), progression-free survival (PFS) and toxicity. We included 150 patients with unresectable BDC treated with PT using a median prescribed dose of 70.2 GyRBE (range, 44-77 GyRBE) in 25 fractions (range, 10-38 fractions). With a median follow-up of 13.0 months, median survival time (MST) was 21 months, and 2-year OS was 44.8%. For eBDC and iBDC, the MSTs were 20 and 23 months, respectively. Two-year PFS and LC rates were 20.6% and 66.5%, respectively. Vascular invasion, prescribed dose and serum tumor marker level (carcinoembryonic antigen: CEA) were identified as poor prognostic factors for OS. A higher radiation dose EQD2 ≥ 67 Gy showed superior OS, with a hazard ratio of 0.341. The radiation dose of PT is an important predisposing factor for overall survival. The MST for patients with eBDC given a higher radiation dose was 25 months, compared to 15 months for those given the lower dose and 23 months for patients with iBDC (all iBDC given higher doses). iBDC and eBDC duct carcinomas showed equivalent outcomes with PT, especially when treated with a high radiation dose. In detailed analysis, baseline CEA level in iBDC, and radiation dose and GTV in eBDC were statistically significant predicators for OS. Acute and late toxicity grade ≥3 occurred in 2.2% and 2.7% of patients, respectively, including two late grade-5 toxicities. In conclusion, PT showed good efficacy for BDC, both eBDC and iBDC, with a low incidence of severe toxicity.
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Affiliation(s)
- Hideya Yamazaki
- Department of Radiology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto Kawaramachi Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan
- Correspondence:
| | - Takuya Kimoto
- Department of Radiology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto Kawaramachi Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan
| | - Motohisa Suzuki
- Department of Radiation Oncology, Southern TOHOKU Proton Therapy Center, Koriyama 963-8052, Japan
| | - Masao Murakami
- Department of Radiation Oncology, Southern TOHOKU Proton Therapy Center, Koriyama 963-8052, Japan
| | - Osamu Suzuki
- Osaka Heavy Ion Administration Company, Otemae, Chuo-ku, Osaka 540-0008, Japan
| | - Masaru Takagi
- Proton Therapy Center, Sapporo Teishinkai Hospital, Sapporo 065-0033, Japan
| | - Norio Katoh
- Department of Radiation Oncology, Hokkaido University Faculty of Medicine, Sapporo 060-8648, Japan
| | - Takeshi Arimura
- Medipolis Proton Therapy and Research Center, Ibusuki, Kagoshima 891-0304, Japan
| | - Takashi Ogino
- Medipolis Proton Therapy and Research Center, Ibusuki, Kagoshima 891-0304, Japan
| | - Hiroyuki Ogino
- Department of Radiation Oncology, Nagoya Proton Therapy Center, Nagoya City University West Medical Center, Nagoya 462-8508, Japan
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Acher AW, Weber SM, Pawlik TM. Liver transplantation for perihilar cholangiocarcinoma: patient selection and outcomes. Expert Rev Gastroenterol Hepatol 2021; 15:555-566. [PMID: 33577361 DOI: 10.1080/17474124.2021.1890584] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Introduction: Peri-hilar cholangiocarcinoma is an aggressive bile duct cancer. Long-term survival is possible with margin-negative surgery. Historically, unresectable disease was approached with non-curative treatment options. In recent decades, an innovative approach of neoadjuvant chemoradiation and liver transplantation has demonstrated long-term survival for highly selected patients.Areas covered: This is a critical analysis of studies published to date on neoadjuvant chemoradiation and liver transplantation for selected patients with peri-hilar cholangiocarcinoma. A PubMed literature search was conducted for years 1970-2020 with the following search criteria: ['hilar' OR 'peri-hilar' AND 'cholangiocarcinoma'] AND ['treatment' OR 'transplantation' OR 'survival' OR 'outcome']; 'neoadjuvant chemoradiation' AND 'unresectable cholangiocarcinoma'. All peer-reviewed original research studies were selected for review.Expert opinion: Neoadjuvant chemoradiation and liver transplantation for patients with early stage unresectable peri-hilar cholangiocarcinoma can achieve long-term survival in highly selected patients who survive to transplantation without disease progression. There are observed differences in survival for patients with PSC-associated versus de novo cholangiocarcinoma and transplanted versus resected patients; however, these differences are not contextualized by established tumor and patient factors that influence recurrence and survival. Therefore, these results must be interpreted within the limitations of the study designs upon which they are based.
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Affiliation(s)
- Alexandra W Acher
- Department of Surgery, Division of Surgical Oncology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Sharon M Weber
- Department of Surgery, Division of Surgical Oncology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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Jethwa KR, Sannapaneni S, Mullikin TC, Harmsen WS, Petersen MM, Antharam P, Laughlin B, Mahipal A, Halfdanarson TR, Merrell KW, Neben-Wittich M, Sio TT, Haddock MG, Hallemeier CL. Chemoradiotherapy for patients with locally advanced or unresectable extra-hepatic biliary cancer. J Gastrointest Oncol 2021; 11:1408-1420. [PMID: 33457010 DOI: 10.21037/jgo-20-245] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background Although surgical resection is the preferred curative-intent treatment option for patients with non-metastatic, extra-hepatic biliary cancer (EBC), radiotherapy (RT) or chemoradiotherapy (CRT) may be utilized in select cases when surgical resection is not feasible. The purpose of this study is to report the efficacy and adverse events (AEs) associated with CRT for patients with locally advanced and unresectable EBC. Methods This was a retrospective cohort study of patients with EBC, including extra-hepatic cholangiocarcinoma or gallbladder cancer, deemed inoperable who received RT between 1998 and 2018. The median RT dose was 50.4 Gy in 28 fractions and 94% received concurrent 5-fluorouracil. The Kaplan-Meier method was used to estimate overall survival (OS) and progression-free survival (PFS) from the start of RT. The cumulative incidence of local progression (LP), locoregional progression (LRP), and distant metastasis (DM) were reported with death as a competing risk. Cox proportional hazards regression models were used to assess for correlation between patient and treatment characteristics and outcomes. Results Forty-eight patients were included for analysis. The median OS was 12.0 months [95% confidence interval (CI): 2.3-73.2 months]. The 2-, 3-, and 5-year OS were 33% (95% CI: 22-50%), 20% (95% CI: 11-36%), and 7% (95% CI: 2-20%), respectively. The 2-year PFS, LP, LRP, and DM were 21% (95% CI: 12-36%), 27% (95% CI: 17-44%), 31% (95% CI: 20-48%), and 33% (95% CI: 22-50%), respectively. On univariate analysis, biologically effective dose (BED) >59.5 Gy10 was associated with improved OS [hazard ratio (HR): 0.40, 95% CI: 0.18-0.92, P=0.03] and PFS (HR: 0.37, 95% CI: 0.16-0.84, P=0.02) and primary tumor size (per 1 cm increase) was associated with worsened PFS (HR: 1.29, 95% CI: 1.02-1.63, P=0.04). BED >59.5 Gy10 remained associated with PFS on multivariate analysis (HR: 0.34, 95% CI: 0.15-0.78, P=0.01). Treatment-related grade 3+ acute and late gastrointestinal AEs occurred in 13% and 17% of patients, respectively. Conclusions RT is associated with 3- and 5-year survival in a subset of patients with unresectable EBC. Further exploration of the role of RT as part of a multi-modality curative treatment strategy is warranted.
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Affiliation(s)
- Krishan R Jethwa
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT, USA.,Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - Shilpa Sannapaneni
- Department of Internal Medicine, Texas Health Presbyterian Hospital, Dallas, TX, USA
| | - Trey C Mullikin
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - William S Harmsen
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Molly M Petersen
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | | | - Brady Laughlin
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
| | - Amit Mahipal
- Department of Medical Oncology, Mayo Clinic, Rochester, MN, USA
| | | | | | | | - Terence T Sio
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
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Gkika E, Hawkins MA, Grosu AL, Brunner TB. The Evolving Role of Radiation Therapy in the Treatment of Biliary Tract Cancer. Front Oncol 2021; 10:604387. [PMID: 33381458 PMCID: PMC7768034 DOI: 10.3389/fonc.2020.604387] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 11/04/2020] [Indexed: 12/13/2022] Open
Abstract
Biliary tract cancers (BTC) are a disease entity comprising diverse epithelial tumors, which are categorized according to their anatomical location as intrahepatic (iCCA), perihilar (pCCA), distal (dCCA) cholangiocarcinomas, and gallbladder carcinomas (GBC), with distinct epidemiology, biology, and prognosis. Complete surgical resection is the mainstay in operable BTC as it is the only potentially curative treatment option. Nevertheless, even after curative (R0) resection, the 5-year survival rate ranges between 20 and 40% and the disease free survival rates (DFS) is approximately 48–65% after one year and 23–35% after three years without adjuvant treatment. Improvements in adjuvant chemotherapy have improved the DFS, but the role of adjuvant radiotherapy is unclear. On the other hand, more than 50% of the patients present with unresectable disease at the time of diagnosis, which limits the prognosis to a few months without treatment. Herein, we review the role of radiotherapy in the treatment of cholangiocarcinoma in the curative and palliative setting.
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Affiliation(s)
- Eleni Gkika
- Department of Radiation Oncology, University Medical Centre Freiburg, Freiburg, Germany
| | - Maria A Hawkins
- Medical Physics and Biomedical Engineering, University College London, London, United Kingdom
| | - Anca-Ligia Grosu
- Department of Radiation Oncology, University Medical Centre Freiburg, Freiburg, Germany
| | - Thomas B Brunner
- Department of Radiation Oncology, University of Magdeburg, Magdeburg, Germany
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Nagino M, Hirano S, Yoshitomi H, Aoki T, Uesaka K, Unno M, Ebata T, Konishi M, Sano K, Shimada K, Shimizu H, Higuchi R, Wakai T, Isayama H, Okusaka T, Tsuyuguchi T, Hirooka Y, Furuse J, Maguchi H, Suzuki K, Yamazaki H, Kijima H, Yanagisawa A, Yoshida M, Yokoyama Y, Mizuno T, Endo I. Clinical practice guidelines for the management of biliary tract cancers 2019: The 3rd English edition. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2020; 28:26-54. [PMID: 33259690 DOI: 10.1002/jhbp.870] [Citation(s) in RCA: 100] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 11/18/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND The Japanese Society of Hepato-Biliary-Pancreatic Surgery launched the clinical practice guidelines for the management of biliary tract cancers (cholangiocarcinoma, gallbladder cancer, and ampullary cancer) in 2007, then published the 2nd version in 2014. METHODS In this 3rd version, clinical questions (CQs) were proposed on six topics. The recommendation, grade for recommendation, and statement for each CQ were discussed and finalized by an evidence-based approach. Recommendations were graded as Grade 1 (strong) or Grade 2 (weak) according to the concepts of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. RESULTS The 31 CQs covered the six topics: (a) prophylactic treatment, (b) diagnosis, (c) biliary drainage, (d) surgical treatment, (e) chemotherapy, and (f) radiation therapy. In the 31 CQs, 14 recommendations were rated strong and 14 recommendations weak. The remaining three CQs had no recommendation. Each CQ includes a statement of how the recommendations were graded. CONCLUSIONS This latest guideline provides recommendations for important clinical aspects based on evidence. Future collaboration with the cancer registry will be key for assessing the guidelines and establishing new evidence.
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Affiliation(s)
| | - Satoshi Hirano
- Department of Gastroenterological Surgery II, Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - Hideyuki Yoshitomi
- Department of Surgery, Saitama Medical Center, Dokkyo Medical University, Koshigaya, Japan
| | - Taku Aoki
- Second Department of Surgery, Dokkyo Medical University, Mibu, Japan
| | - Katsuhiko Uesaka
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Nagaizumi, Japan
| | - Michiaki Unno
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Tomoki Ebata
- Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masaru Konishi
- Department of Hepatobiliary Pancreatic Surgery, National Cancer Center Hospital East, Kashiwa, Japan
| | - Keiji Sano
- Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Kazuaki Shimada
- Hepatobiliary and Pancreatic Surgery Division, National Cancer Center Hospital, Tokyo, Japan
| | - Hiroaki Shimizu
- Department of Surgery, Teikyo University Chiba Medical Center, Ichihara, Japan
| | - Ryota Higuchi
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan
| | - Toshifumi Wakai
- Division of Digestive and General Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Takuji Okusaka
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Toshio Tsuyuguchi
- Department of Gastroenterology, Chiba Prefectural Sawara Hospital, Sawara, Japan
| | - Yoshiki Hirooka
- Department of Gastroenterology and Gastroenterological Oncology, Fujita Health University, Toyoake, Japan
| | - Junji Furuse
- Department of Medical Oncology, Faculty of Medicine, Kyorin University, Mitaka, Japan
| | - Hiroyuki Maguchi
- Education and Research Center, Teine-Keijinkai Hospital, Sapporo, Japan
| | - Kojiro Suzuki
- Department of Radiology, Aichi Medical University, Nagakute, Japan
| | - Hideya Yamazaki
- Department of Radiology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Hiroshi Kijima
- Department of Pathology and Bioscience, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Akio Yanagisawa
- Department of Pathology, Japanese Red Cross Kyoto Diichi Hospital, Kyoto, Japan
| | - Masahiro Yoshida
- Department of Hepato-Biliary-Pancreatic & Gastrointestinal Surgery, International University of Health and Welfare, Ichikawa, Japan
| | - Yukihiro Yokoyama
- Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takashi Mizuno
- Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Itaru Endo
- Department of Gastroenterological Surgery, Graduate School of Medicine, Yokohama City University, Yokohama, Japan
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Azad AI, Rosen CB, Taner T, Heimbach JK, Gores GJ. Selected Patients with Unresectable Perihilar Cholangiocarcinoma (pCCA) Derive Long-Term Benefit from Liver Transplantation. Cancers (Basel) 2020; 12:E3157. [PMID: 33121179 PMCID: PMC7693604 DOI: 10.3390/cancers12113157] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 10/21/2020] [Indexed: 02/07/2023] Open
Abstract
Selected patients with unresectable perihilar cholangiocarcinoma (pCCA) derive long-term benefits from liver transplantation. Between 1993-2019, our group at Mayo Clinic performed 237 transplants for pCCA. With this experience, we note that two distinct patient populations comprise this group of pCCA patients: those with underlying primary sclerosing cholangitis (PSC) and those without identifiable risk factors termed sporadic or de novo pCCA. Long-term survival after transplant is better in PSC patients (74% five-year survival) than in those with de novo pCCA (58% five-year survival). Herein, we review the likely clinical factors contributing to the divergence in outcomes for these two patient populations. We also offer our insights on how further advances may improve patient selection and survival, focusing on the de novo pCCA patient population.
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Affiliation(s)
- Adiba I. Azad
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905, USA;
| | - Charles B. Rosen
- Division of Transplantation Surgery, Mayo Clinic, Rochester, MN 55905, USA; (C.B.R.); (T.T.); (J.K.H.)
| | - Timucin Taner
- Division of Transplantation Surgery, Mayo Clinic, Rochester, MN 55905, USA; (C.B.R.); (T.T.); (J.K.H.)
| | - Julie K. Heimbach
- Division of Transplantation Surgery, Mayo Clinic, Rochester, MN 55905, USA; (C.B.R.); (T.T.); (J.K.H.)
| | - Gregory J. Gores
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905, USA;
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Frosio F, Mocchegiani F, Conte G, Bona ED, Vecchi A, Nicolini D, Vivarelli M. Neoadjuvant therapy in the treatment of hilar cholangiocarcinoma: Review of the literature. World J Gastrointest Surg 2019; 11:279-286. [PMID: 31367275 PMCID: PMC6658363 DOI: 10.4240/wjgs.v11.i6.279] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 05/29/2019] [Accepted: 06/10/2019] [Indexed: 02/06/2023] Open
Abstract
Cholangiocarcinoma (CCA) is a malignant tumor of the biliary system and includes, according to the anatomical classification, intra hepatic CCA (iCCA), hilar CCA (hCCA) and distal CCA (dCCA). Hilar CCA is the most challenging type in terms of diagnosis, treatment and prognosis. Surgery is the only treatment possibly providing long-term survival, but only few patients are considered resectable at the time of diagnosis. In fact, tumor’s extension to segmentary or subsegmentary biliary ducts, along with large lymph node involvement or intrahepatic metastases, precludes the surgical approach. To achieve R0 margins is mandatory for the disease-free survival and overall survival. In case of unresectable locally advanced hCCA, radiochemotherapy (RCT) as neoadjuvant treatment demonstrated to be a therapeutic option before either hepatic resection or liver transplantation. Before liver surgery, RCT is believed to enhance the R0 margins rate. For patients meeting the Mayo Clinic criteria, RCT prior to orthotopic liver transplant (OLT) has proved to produce acceptable 5-years survivals. In this review, we analyze the current role of neoadjuvant RCT before resection as well as before OLT.
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Affiliation(s)
- Fabio Frosio
- Unit of Hepato-pancreato-biliary and Transplant Surgery, Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Ancona 60126, Italy
| | - Federico Mocchegiani
- Unit of Hepato-pancreato-biliary and Transplant Surgery, Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Ancona 60126, Italy
| | - Grazia Conte
- Unit of Hepato-pancreato-biliary and Transplant Surgery, Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Ancona 60126, Italy
| | - Enrico Dalla Bona
- Unit of Hepato-pancreato-biliary and Transplant Surgery, Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Ancona 60126, Italy
| | - Andrea Vecchi
- Unit of Hepato-pancreato-biliary and Transplant Surgery, Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Ancona 60126, Italy
| | - Daniele Nicolini
- Unit of Hepato-pancreato-biliary and Transplant Surgery, Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Ancona 60126, Italy
| | - Marco Vivarelli
- Unit of Hepato-pancreato-biliary and Transplant Surgery, Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Ancona 60126, Italy
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Frakulli R, Buwenge M, Macchia G, Cammelli S, Deodato F, Cilla S, Cellini F, Mattiucci GC, Bisello S, Brandi G, Parisi S, Morganti AG. Stereotactic body radiation therapy in cholangiocarcinoma: a systematic review. Br J Radiol 2019; 92:20180688. [PMID: 30673295 DOI: 10.1259/bjr.20180688] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE Stereotactic body radiation therapy (SBRT) has been used in the treatment of cholangiocarcinoma (CC) but toxicity and clinical results of SBRT in CC are still limited and sparse. Therefore, the aim of this systematic review was to analyze the results of SBRT in the setting of advanced CC. METHODS A systematic literature search was conducted on PubMed, Scopus, and Cochrane library using the PRISMA methodology. Studies including at least 10 patients with diagnosis of advanced CC regardless of tumor site and other treatments were included. The primary outcome was overall survival (OS) and secondary endpoints were local control (LC) and toxicity rates. The ROBINS-I risk of bias tool was used. RESULTS 10 studies (231 patients) fulfilled the selection criteria and were included in this review. All but one study showed moderate to serious risk of bias. Median follow up was 15 months (range: 7.8-64.0 months). Pooled 1 year OS was 58.3% (95% CI: 50.2-66.1%) and pooled 2 year OS was 35.5% (95% CI: 22.1-50.1%). Pooled 1 year LC was 83.4%, (95% CI: 76.5-89.4%). The reported toxicities were acceptable and manageable with only one treatment-related death. CONCLUSION The role of SBRT in CC is not yet supported by robust evidence in literature. However, within this limit, preliminary results seem almost comparable to the ones of standard chemotherapy or chemoradiation. ADVANCES IN KNOWLEDGE SBRT seems effective in terms of LC with acceptable treatment-related toxicities. Therefore, SBRT can be considered a therapeutic option at least in selected patients with CC, possibly combined with adjuvant chemotherapy (CHT).
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Affiliation(s)
- Rezarta Frakulli
- 1 Department of Experimental, Diagnostic and Specialty Medicine - DIMES, University of Bologna, S. Orsola-Malpighi Hospital , Bologna , Italy
| | - Milly Buwenge
- 1 Department of Experimental, Diagnostic and Specialty Medicine - DIMES, University of Bologna, S. Orsola-Malpighi Hospital , Bologna , Italy
| | - Gabriella Macchia
- 2 Radiotherapy Unit, Fondazione "Giovanni Paolo II", Catholic University of Sacred Heart , Campobasso , Italy
| | - Silvia Cammelli
- 1 Department of Experimental, Diagnostic and Specialty Medicine - DIMES, University of Bologna, S. Orsola-Malpighi Hospital , Bologna , Italy
| | - Francesco Deodato
- 2 Radiotherapy Unit, Fondazione "Giovanni Paolo II", Catholic University of Sacred Heart , Campobasso , Italy
| | - Savino Cilla
- 3 Medical Physic Unit, Fondazione "Giovanni Paolo II", Catholic University of Sacred Heart , Campobasso , Italy
| | - Francesco Cellini
- 4 Department of Radiotherapy, Policlinico Universitario "A. Gemelli", Università Cattolica del Sacro Cuore , Rome , Italy
| | - Gian C Mattiucci
- 4 Department of Radiotherapy, Policlinico Universitario "A. Gemelli", Università Cattolica del Sacro Cuore , Rome , Italy
| | - Silvia Bisello
- 1 Department of Experimental, Diagnostic and Specialty Medicine - DIMES, University of Bologna, S. Orsola-Malpighi Hospital , Bologna , Italy
| | - Giovanni Brandi
- 5 Department of Experimental, Diagnostic, and Specialty Medicine, S. Orsola-Malpighi University Hospital, Cancer Research, University of Bologna , Bologna , Italy
| | - Salvatore Parisi
- 6 Unit of Radiotherapy, IRCCS"Casa Sollievo della Sofferenza" San Giovanni Rotondo , Italy
| | - Alessio G Morganti
- 1 Department of Experimental, Diagnostic and Specialty Medicine - DIMES, University of Bologna, S. Orsola-Malpighi Hospital , Bologna , Italy
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Lee J, Yoon WS, Koom WS, Rim CH. Efficacy of stereotactic body radiotherapy for unresectable or recurrent cholangiocarcinoma: a meta-analysis and systematic review. Strahlenther Onkol 2019; 195:93-102. [PMID: 30206644 DOI: 10.1007/s00066-018-1367-2] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Accepted: 08/28/2018] [Indexed: 12/21/2022]
Abstract
PURPOSE Non-surgical treatment including stereotactic body radiation therapy (SBRT) have been used practically as alternative modalities for unresectable or recurrent cholangiocarcinoma (CC). We performed a systematic review and meta-analysis to examine the efficacy of SBRT for such patients. METHODS Embase, PubMed, MEDLINE, and Cochrane library databases were searched systematically until October 2017. Primary endpoint was 1‑year local control (LC) rate; 1‑year overall survival (OS), response rates, and grade ≥3 toxicities were assessed as secondary endpoints. RESULTS Eleven studies (226 patients) were included. The prescribed median SBRT dose was 45 (range 30-55) Gy in 3-5 fractions. The pooled 1‑year LC rate was 81.8% (95% confidence interval [CI] 69.4-89.9%) in the studies using an equivalent dose in 2 Gy per fraction (EQD2) ≥71.3 Gy2 and 74.7% (95% CI 57.1-86.7%) in the studies using an EQD2 <71.3 Gy2. The median OS was 13.6 (range 10-35.5) months. The pooled 1‑year OS rate was 53.8% (95% CI 44.9-62.5%) and the pooled 1‑year LC rate was 78.6% (95% CI 69.0-85.8%). Most common toxicity was duodenal ulcer and gastric ulcer in available studies, with the acute incidence of grade ≥3 of less than 10% and the late incidence of 10-20%. CONCLUSIONS SBRT was a feasible treatment option with respect to achieving a high LC for unresectable or recurrent CC. Gastrointestinal toxicity is acceptable, but remains an obstacle related to dose escalation.
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Affiliation(s)
- Jeongshim Lee
- Department of Radiation Oncology, Yonsei University College of Medicine, Seoul, Korea (Republic of)
- Department of Radiation Oncology, Inha University Hospital, Incheon, Korea (Republic of)
| | - Won Sup Yoon
- Department of Radiation Oncology, Korea University Ansan Hospital, 123 Jeokgeum-ro, Danwon-gu, 15355, Ansan, Gyeonggi-do, Korea (Republic of)
| | - Woong Sub Koom
- Department of Radiation Oncology, Yonsei University College of Medicine, Seoul, Korea (Republic of)
| | - Chai Hong Rim
- Department of Radiation Oncology, Korea University Ansan Hospital, 123 Jeokgeum-ro, Danwon-gu, 15355, Ansan, Gyeonggi-do, Korea (Republic of).
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12
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Boimel PJ, Binder KR, Hong TS, Feng M, Ben-Josef E. Cholangiocarcinoma and Gallbladder Cases: An Expert Panel Case-Based Discussion. Semin Radiat Oncol 2018; 28:351-361. [PMID: 30309645 DOI: 10.1016/j.semradonc.2018.06.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Cholangiocarcinoma and gallbladder malignancies are aggressive gastrointestinal malignancies with management dependent on resectability, comorbidities, and location. A multidisciplinary discussion with medical oncologists, radiation oncologists, and surgeons is necessary to determine the optimal treatment approach for each patient. Surgical resection offers the best chance for a long-term cure. Recent studies, such as the phase II SWOG S0809 and the phase III BILCAP study have highlighted the importance of adjuvant treatment with radiation therapy and chemotherapy, respectively, in resected disease. In patients with unresectable disease chemotherapy and chemoradiation therapy to a high dose can improve overall survival and locoregional control. In this expert panel we have brought together radiation oncologists and a medical oncologist to provide case-based feedback on their institutional practices.
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Affiliation(s)
- Pamela J Boimel
- Radiation Oncology Department, University of Pennsylvania, Philadelphia, PA
| | - Kim Reiss Binder
- Department of Hematology and Oncology, University of Pennsylvania, Philadelphia, PA
| | - Theodore S Hong
- Harvard Radiation Oncology Program, Massachusetts General Hospital, Boston, MA
| | - Mary Feng
- Radiation Oncology Department, University of California, San Francisco, CA
| | - Edgar Ben-Josef
- Radiation Oncology Department, University of Pennsylvania, Philadelphia, PA.
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13
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Chang WW, Hsiao PK, Qin L, Chang CL, Chow JM, Wu SY. Treatment outcomes for unresectable intrahepatic cholangiocarcinoma: Nationwide, population-based, cohort study based on propensity score matching with the Mahalanobis metric. Radiother Oncol 2018; 129:284-292. [PMID: 30279046 DOI: 10.1016/j.radonc.2018.09.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Revised: 09/15/2018] [Accepted: 09/15/2018] [Indexed: 02/06/2023]
Abstract
PURPOSE No prospective randomized trials have been conducted to date to evaluate the efficacy of palliation of pain or jaundice without treatment, definitive concurrent chemoradiotherapy (CCRT), sequential chemotherapy and radiotherapy (CTRT), or chemotherapy (CT) alone for treating unresectable intrahepatic cholangiocarcinoma (ICC). We designed a nationwide, population-based, cohort study to determine the effects of different treatments on patients with unresectable ICC using propensity score matching (PSM) with the Mahalanobis metric. PATIENTS AND METHODS We classified patients with unresectable ICC from the Taiwan Cancer Registry database into the following 4 treatment groups: group 1, definitive CCRT; group 2, sequential CTRT; group 3, no treatment (palliative therapy for relief of pain, pruritus, or jaundice); and group 4, CT alone. Confounding factors among the 4 treatment groups were minimized through propensity score matching (PSM). RESULTS After PSM, the final cohort consisted of 844 patients (211 patients in each of the 4 groups). In both univariable and multivariable Cox regression analyses, adjusted hazard ratios (aHRs; 95% confidence interval [CI]) derived for groups 1 and 2 compared with group 4 were 0.65 (0.59-0.71) and 0.95 (0.83-1.48), respectively. Furthermore, an aHR (95% CI) of 2.25 (1.89-2.67) was derived for significant independent prognostic risk factors for poor overall survival for group 3 compared with group 4. CONCLUSIONS Definitive CCRT is the optimal therapy for patients with unresectable ICC without distant metastasis.
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Affiliation(s)
- Wei-Wen Chang
- Department of General Surgery, Wan Fang Hospital, Taipei Medical University, Taiwan
| | - Ping-Kun Hsiao
- Department of General Surgery, Wan Fang Hospital, Taipei Medical University, Taiwan
| | - Lei Qin
- School of Statistics, University of International Business and Economics, Beijing, China
| | - Chia-Lun Chang
- Department of Hemato-Oncology, Wan Fang Hospital, Taipei Medical University, Taiwan
| | - Jyh-Ming Chow
- Department of Hemato-Oncology, Wan Fang Hospital, Taipei Medical University, Taiwan
| | - Szu-Yuan Wu
- Department of Radiation Oncology, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan; Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; Graduate Institute of Biotechnology, Chinese Culture University, YangMingShan, Taipei 11114, Taiwan.
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14
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Abstract
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.
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Affiliation(s)
- Daniel Zamora-Valdes
- Division of Transplantation Surgery, Mayo Clinic, 200 First Street, Rochester, MN 55905, USA
| | - Julie K Heimbach
- Division of Transplantation Surgery, Mayo Clinic, 200 First Street, Rochester, MN 55905, USA.
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15
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Milella M, Salvetti M, Cerrotta A, Cozzi G, Uslenghi E, Tavola A, Gardani G, Severini A. Interventional Radiology and Radiotherapy for Inoperable Cholangiocarcinoma of the Extrahepatic Bile Ducts. TUMORI JOURNAL 2018; 84:467-71. [PMID: 9824998 DOI: 10.1177/030089169808400406] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Aims and background To evaluate the effectiveness of external radiation therapy (ERT), alone or combined with endoluminal brachytherapy (BRT), following percutaneous transhepatic biliary drainage (PTBD) in the treatment of patients affected by inoperable cholangiocarcinoma. Methods & study design From September 1980 to June 1996, 130 jaundiced patients affected by inoperable cholangiocarcinoma were submitted to PTBD at the Division of Radiology C of the National Cancer Institute of Milan. Nineteen were excluded from the present analysis due to the short survival after PTBD (<30 days). The other 111 patients were divided into three groups according to the following therapy: no further treatment after palliative PTBD in 89 patients (80%, group 1); ERT in 10 patients (9%, group 2); ERT plus BRT in 12 patients (11%, group 3). All the ERT+BRT patients were enrolled after 1990 and were treated with high-energy photon beams followed by en-dobiliary insertion of one or two iridium-192 wires. Results Median overall survival among the 111 assessable patients was 126 days; for groups 1, 2 and 3 it was 108, 345 and 428 days, respectively. The patients submitted to radiotherapy (ERT alone or ERT+BRT) were evaluated by radiologic examinations after the end of radiation. In group 2, a partial remission in 3 cases, a progression of disease in 1 case, and no change in 6 cases were observed. Among the patients of group 3, complete remission in 5 and partial remission in 7 patients were achieved. In all the patients achieving complete remission, the PTBD could be removed. Conclusions The combination of ERT plus BRT improves survival and quality of life of the patients submitted to PTBD for cholangiocarcinoma. Under the technical point of view, radiation treatment is easy to perform, but much caution is required in defining clinical and planning target volumes. Moreover, drainage during the radiation treatment has to be submitted to a very meticulous surveillance.
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Affiliation(s)
- M Milella
- Division of Radiology C, Istituto Nazionale per lo Studio e la Cura dei Tumori, Milan, Italy
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16
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Petera J, Papík Z, Zouhar M, Jansa J, Odrazka K, Dvorak J. The Technique of Intensity-Modulated Radiotherapy in the Treatment of Cholangiocarcinoma. TUMORI JOURNAL 2018; 93:257-63. [PMID: 17679460 DOI: 10.1177/030089160709300305] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Aims and background Conventional radiotherapy in inoperable cholangiocarcinoma is limited by radiotolerance of the surrounding tissues. The aim of our dosimetric study was an evaluation of intensity-modulated radiotherapy in the treatment of inoperable bile duct carcinoma. Methods Four patients with inoperable cholangiocarcinoma treated by self-expandable stent placed to the biliary tree and radiotherapy were studied. The rotational technique, conformal 3D BOX technique and intensity-modulated radiotherapy plan were compared. Dose volume histograms and the normal tissue complication probability concept were used for comparison. The stent was used for target motion verification. Results The intensity-modulated radiotherapy plans showed favorable dose distribution in planning target volume and remarkable sparing of organs at risk. Conclusions The intensity-modulated radiotherapy technique in bile duct carcinomas deserves further research and clinical evaluation.
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Affiliation(s)
- Jirí Petera
- Department of Oncology and Radiotherapy, Charles University Medical School and Teaching Hospital, Hradec Králové, Czech Republic.
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17
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Abstract
Objectives: The aim of this was to determine survival after starting neoadjuvant therapy for patients who became ineligible for orthotopic liver transplantation (OLT). Methods and Materials: Since January 1993, 215 patients with unresectable cholangiocarcinoma began treatment with planned OLT. Treatment included external-beam radiation therapy (EBRT) with fluorouracil, bile duct brachytherapy, and postradiotherapy fluorouracil or capecitabine before OLT. Adverse findings at the staging operation, death, and other factors precluded OLT in 63 patients (29%), of whom 61 completed neoadjuvant chemoradiation. Results: By October 2012, 56 (89%) of the 63 patients unable to undergo OLT had died. Twenty-two patients (35%) became ineligible for OLT before the staging operation, 38 (60%) at the staging operation, and 3 (5%) after staging. From the date of diagnosis, median overall survival was 12.3 months. Survival was 17% at 18 months and 7% at 24 months. Median survival after fallout was 6.8 months. Median survival after the staging operation was 6 months. Two patients lived for 3.7 and 8.7 years before dying of cancer or liver failure caused by persistent biliary stricture at the site of the original cancer, respectively. Univariate analysis showed that time from diagnosis to fallout correlated with overall survival (P=0.04). Conclusions: In highly selected patients initially suitable for OLT, the mortality rate for cholangiocarcinoma was high in patients who became ineligible for OLT. Their survival, however, was comparable to expected survival for patients with locally advanced or metastatic disease treated with nontransplant therapies. The most common reason for patient fallout was adverse findings at the staging operation.
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18
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Kim BH, Chie EK, Kim K, Jang JY, Kim SW, Oh DY, Bang YJ, Ha SW. Impact of radiation dose in postoperative radiotherapy after R1 resection for extrahepatic bile duct cancer: long term results from a single institution. Oncotarget 2017; 8:78076-78085. [PMID: 29100449 PMCID: PMC5652838 DOI: 10.18632/oncotarget.17368] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2016] [Accepted: 04/10/2017] [Indexed: 12/26/2022] Open
Abstract
Purpose This study was conducted to evaluate the impact of radiation dose after margin involved resection in patients with extrahepatic bile duct cancer. Methods Among the 251 patients who underwent curative resection followed by adjuvant chemoradiotherapy, 86 patients had either invasive carcinoma (n = 63) or carcinoma in situ (n = 23) at the resected margin. Among them, 54 patients received conventional radiation dose (40-50.4 Gy) and 32 patients received escalated radiation dose (54-56 Gy). Results Escalated radiation dose was associated with improved locoregional control (5yr rate, 73.8% vs. 47.1%, p = 0.069), but not disease-free survival (5yr rate, 43.4% vs. 32.6%, p = 0.490) and overall survival (5yr rate, 40.6% vs. 29.6%, p = 0.348). In multivariate analysis for locoregional control, invasive carcinoma at the margin (HR 2.957, p = 0.032) and escalated radiation dose (HR 0.394, p = 0.047) were independent prognostic factors. No additional gastrointestinal toxicity was observed in escalated dose group. Conclusions Delivery of radiation dose ≥ 54 Gy was well tolerated and associated with improved locoregional control, but not with overall survival after margin involved resection. Further validation study is warranted.
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Affiliation(s)
- Byoung Hyuck Kim
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Republic of Korea.,Division of Biological Warfare Preparedness and Response, Armed Forces Medical Research Institute, Daejeon, Republic of Korea
| | - Eui Kyu Chie
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Kyubo Kim
- Department of Radiation Oncology, Ewha Womans University School of Medicine, Seoul, Republic of Korea
| | - Jin-Young Jang
- Department of Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Sun Whe Kim
- Department of Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Do-Youn Oh
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Yung-Jue Bang
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Sung W Ha
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Republic of Korea
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19
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Brachytherapy in the treatment of bile duct cancer - a tough challenge. J Contemp Brachytherapy 2017; 9:187-195. [PMID: 28533809 PMCID: PMC5437079 DOI: 10.5114/jcb.2017.66893] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Accepted: 03/18/2017] [Indexed: 02/07/2023] Open
Abstract
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.
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20
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Engineer R, Mehta S, Kalyani N, Chaudhari S, Dharia T, Shetty N, Chopra S, Goel M, Kulkarni S, Shrivastava SK. High dose chemoradiation for unresectable hilar cholangiocarcinomas using intensity modulated external beam radiotherapy: a single tertiary care centre experience. J Gastrointest Oncol 2017; 8:180-186. [PMID: 28280622 DOI: 10.21037/jgo.2017.01.20] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND We present results of patients diagnosed with unresectable hilar cholangiocarcinomas treated with high dose radiotherapy and concurrent chemotherapy. METHODS From Aug 2005 to Dec 2012, 68 consecutive patients were treated. Fifty patients (group 1) presenting to us with obstructive jaundice were planned for endobiliary brachytherapy (EBBT 14 Gy) followed external beam radiotherapy (EBRT 45 Gy). Twenty-two patients (group 2) who had previously undergone biliary drainage underwent EBRT (57 Gy). All patients received injection Gemcitabine 300 mg/m2/weekly along with EBRT. RESULTS Twenty-nine patients in group 1 and 22 patients in group 2 completed the treatment. Twenty-six (55%) patients achieved complete radiological response, 16 (64%) belonging to group 1 and 8 (44%) of group 2 (P=0.05). The median overall survival (MOS) was 17.5 and 16 months for group 1 and 2 respectively (P=0.07). The 1- and 2-year survival was 63%, and 18% for group I and 61% and 22% for group II respectively. The MOS was 5 months and 1 year survival was 14% for patients receiving EBBT only. MOS was significantly better after complete response (P=0.001). CONCLUSIONS Intensity modulated radiotherapy (IMRT) modulated high dose radiotherapy used either alone or with brachytherapy demonstrates potential to prolonged overall survival in unresectable hilar cholangiocarcinomas.
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Affiliation(s)
- Reena Engineer
- Department of Radiation Oncology, Tata Memorial Hospital, Mumbai, India
| | - Shaesta Mehta
- Department of Medical Gastroenterology, Tata Memorial Hospital, Mumbai, India
| | - Nikhil Kalyani
- Department of Radiation Oncology, Tata Memorial Hospital, Mumbai, India
| | - Suresh Chaudhari
- Department of Medical Physics, Tata Memorial Hospital, Mumbai, India
| | - Tejas Dharia
- Department of Interventional Radiology, , Tata Memorial Hospital, Mumbai, India
| | - Nitin Shetty
- Department of Interventional Radiology, , Tata Memorial Hospital, Mumbai, India
| | - Supriya Chopra
- Department of Radiation Oncology, Tata Memorial Hospital, Mumbai, India
| | - Mahesh Goel
- Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, India
| | - Suyash Kulkarni
- Department of Interventional Radiology, , Tata Memorial Hospital, Mumbai, India
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21
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Pollom EL, Alagappan M, Park LS, Whittemore AS, Koong AC, Chang DT. Does radiotherapy still have a role in unresected biliary tract cancer? Cancer Med 2016; 6:129-141. [PMID: 27891822 PMCID: PMC5269698 DOI: 10.1002/cam4.975] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Revised: 10/29/2016] [Accepted: 10/31/2016] [Indexed: 01/02/2023] Open
Abstract
The benefits of radiotherapy for inoperable biliary tract cancer remain unclear due to the lack of randomized data. We evaluated the impact of radiotherapy on survival in elderly patients using the SEER‐Medicare database. Patients in the SEER‐Medicare database with inoperable biliary tract tumors diagnosed between 1998 and 2011 were included. We used multivariate logistic regression to evaluate factors associated with treatment selection, and multivariate Cox regression and propensity score matching to evaluate treatment selection in relation to subsequent survival. Of the 2343 patients included, 451 (19%) received radiotherapy within 4 months of diagnosis. The use of radiotherapy declined over time, and was influenced by receipt of chemotherapy and patient age, race, marital status, poverty status, and tumor stage and type. Median survival was 9.3 (95% CI 8.7–9.7) months among patients who did not receive radiation and 10.0 (95% CI 9.1–11.3) months among those who received radiation, conditional on having survived 4 months. In patients who received chemotherapy (n = 1053), receipt of radiation was associated with improved survival, with an adjusted hazard ratio of 0.82 (95% 0.70–0.97, P = 0.02). In patients who did not receive chemotherapy (n = 1290), receipt of radiation was not associated with improved survival, with an adjusted hazard ratio of 1.09 (95% 0.91–1.30, P = 0.34). Propensity‐scored matched analyses showed similar results. Despite the survival benefit associated with the addition of radiotherapy to chemotherapy, the use of radiation for unresectable biliary tract cancers has declined over time.
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Affiliation(s)
- Erqi L Pollom
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California
| | - Muthuraman Alagappan
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California
| | - Lesley S Park
- Department of Health Research and Policy, Stanford University School of Medicine, Stanford, California
| | - Alice S Whittemore
- Department of Health Research and Policy, Stanford University School of Medicine, Stanford, California
| | - Albert C Koong
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California
| | - Daniel T Chang
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California
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22
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Boothe D, Hopkins Z, Frandsen J, Lloyd S. Comparison of external beam radiation and brachytherapy to external beam radiation alone for unresectable extrahepatic cholangiocarcinoma. J Gastrointest Oncol 2016; 7:580-7. [PMID: 27563448 DOI: 10.21037/jgo.2016.03.14] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
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.
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Affiliation(s)
- Dustin Boothe
- Department of Radiation Oncology, Huntsman Cancer Hospital, University of Utah, Salt Lake City, UT, USA
| | - Zachary Hopkins
- School of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Jonathan Frandsen
- Department of Radiation Oncology, Huntsman Cancer Hospital, University of Utah, Salt Lake City, UT, USA
| | - Shane Lloyd
- Department of Radiation Oncology, Huntsman Cancer Hospital, University of Utah, Salt Lake City, UT, USA
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23
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Brunner TB, Seufferlein T. Radiation therapy in cholangiocellular carcinomas. Best Pract Res Clin Gastroenterol 2016; 30:593-602. [PMID: 27644907 DOI: 10.1016/j.bpg.2016.08.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Accepted: 08/17/2016] [Indexed: 01/31/2023]
Abstract
Cholangiocarcinoma can arise in all parts of the biliary tract and this has implications for therapy. Surgery is the mainstay of therapy however local relapse is a major problem. Therefore, adjuvant treatment with chemoradiotherapy was tested in trials. The SWOG-S0809 trial regimen of chemoradiotherapy which was tested in extrahepatic cholangiocarcinoma and in gallbladder cancer can currently be regarded as highest level of evidence for this indication. In contrast to adjuvant therapy where only conventionally fractionated radiotherapy plays a role, stereotactic body radiotherapy (SBRT) today has become a powerful alternative to chemoradiotherapy for definitive treatment due to the ability to administer higher doses of radiotherapy to improve local control. Sequential combinations with chemotherapy are also frequently employed. Nevertheless, in general cholangiocarcinoma is an orphan disease and future clinical trials will have to improve the available level of evidence.
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Affiliation(s)
- Thomas B Brunner
- Department of Radiation Oncology, University Medical Center Freiburg, Robert-Koch-Str. 3, Freiburg, Germany; German Cancer Consortium (DKTK), Freiburg, Germany; German Cancer Research Center (DKFZ), Heidelberg, Germany.
| | - Thomas Seufferlein
- Department of Internal Medicine I, Ulm University, Albert-Einstein-Allee 23, D-89081, Ulm, Germany.
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24
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Tanenbaum DG, Hall WA, Mittal P, Nickleach DC, Mikell JL, Colbert LE, Moreno CC, Squires MH, Fisher SB, Yu DS, Kooby DA, Maithel SK, Landry JC. Cholangiocarcinoma size on magnetic resonance imaging versus pathologic specimen: Implications for radiation treatment planning. Pract Radiat Oncol 2016; 6:201-206. [PMID: 26979545 DOI: 10.1016/j.prro.2015.10.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Revised: 09/20/2015] [Accepted: 10/08/2015] [Indexed: 10/22/2022]
Abstract
PURPOSE The accuracy of abdominal magnetic resonance imaging (MRI) in measuring gross tumor volume in patients with resectable cholangiocarcinoma (CC) is unknown. CC is a highly difficult tumor to visualize and treatment with dose-escalated radiation therapy requires clear tumor delineation. We aim to investigate the concordance between imaging and pathologic size in patients with resected CC to determine the usefulness of MRI for image guided treatment modalities. METHODS AND MATERIALS The records of 51 patients with resected CC who underwent preoperative MRI were evaluated. Each preoperative MRI was individually reviewed by a diagnostic radiologist (P.M.), who was blinded to pathologic measurements. A combination of dynamic multiphase contrast-enhanced T1- and T2-weighted images, original imaging reports, and pathologic reports were reviewed for greatest tumor dimensions. A general linear regression model was used to examine the outcome MRI minus pathology using MRI report, T1-weighted measurement, or T2-weighted measurement. A multivariable regression model was fit to assess the association of other factors with pathologic underestimation. RESULTS The median age was 69 years. Eleven tumors were categorized distal/extrahepatic, 17 hilar, and 23 intrahepatic CC. The median tumor size on pathology report was 3.00 cm (range, 0.3-19). The median tumor size from the MRI report was 3 cm (range, 0.80-16.20) and median tumor size on independent radiological review was 3 cm (range, 0.90-17) on the T1-weighted and 3 cm (range, 0.90-17) on the T2-weighted MRI sequences. When compared with pathologic tumor size, the MRI report dimension was found to underestimate tumor size by 4.1 mm (P = .04). On multivariable analysis, pathologic size underestimation was influenced by increasing tumor size (slope, -0.20; P < .001); however, underestimation was not affected by tumor location or MRI sequence. CONCLUSIONS MRI underestimates tumor size, which was more pronounced with larger tumors, but not influenced by tumor location. The potential for gross tumor volume underestimation should be considered when planning highly conformal radiation therapy treatment of CC.
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Affiliation(s)
- Daniel G Tanenbaum
- Department of Radiation Oncology, Atlanta, Georgia; Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - William A Hall
- Department of Radiation Oncology, Atlanta, Georgia; Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Pardeep Mittal
- Department of Radiology, Atlanta, Georgia; Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Dana C Nickleach
- Biostatistics and Bioinformatics Shared Resource at Winship, Atlanta, Georgia; Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - John L Mikell
- Department of Radiation Oncology, Atlanta, Georgia; Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Lauren E Colbert
- Department of Radiation Oncology, Atlanta, Georgia; Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Courtney C Moreno
- Department of Radiology, Atlanta, Georgia; Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Malcolm H Squires
- Department of Surgical Oncology, Atlanta, Georgia; Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Sarah B Fisher
- Department of Surgical Oncology, Atlanta, Georgia; Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - David S Yu
- Department of Radiation Oncology, Atlanta, Georgia; Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - David A Kooby
- Department of Surgical Oncology, Atlanta, Georgia; Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Shishir K Maithel
- Department of Surgical Oncology, Atlanta, Georgia; Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Jerome C Landry
- Department of Radiation Oncology, Atlanta, Georgia; Winship Cancer Institute, Emory University, Atlanta, Georgia.
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25
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Brandi G, Venturi M, Pantaleo MA, Ercolani G. Cholangiocarcinoma: Current opinion on clinical practice diagnostic and therapeutic algorithms: A review of the literature and a long-standing experience of a referral center. Dig Liver Dis 2016; 48:231-41. [PMID: 26769568 DOI: 10.1016/j.dld.2015.11.017] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Revised: 11/05/2015] [Accepted: 11/20/2015] [Indexed: 02/06/2023]
Abstract
In the oncology landscape, cholangiocarcinoma is a challenging disease in terms of both diagnosis and treatment. Besides anamnesis and clinical examination, a definitive diagnosis of cholangiocarcinoma should be supported by imaging techniques (US, CT, MRI) and invasive investigations (ERC or EUS with brushing and FNA or US or CT-guided biopsy) followed by pathological confirmation. Surgery is the main curative option, so resectability of the tumour should be promptly assessed. Moreover, jaundice must be evaluated at the outset because biliary tract decompression with drainage and stent placement may be required. If the patient is resectable, pre-operative assessment of postoperative liver function is mandatory. After a curative resection, an adjuvant therapy may be administered. Otherwise, in cases with macroscopic residual disease after surgery or locally recurrent or unresectable cholangiocarcinoma at the diagnosis, first-line chemotherapy is the preferred strategy, possibly associated with radiotherapy and/or locoregional treatments. As the diagnostic and therapeutic pathway for cholangiocarcinoma can be declined in different modalities, patients should be promptly referred to a multidisciplinary team in a tertiary centre, familiar with this rare but lethal disease. Hence, the aim of the present paper is to focus on diagnostic and therapeutic algorithms based on the common guidelines and also on the clinical practice of multispecialist expert groups.
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Affiliation(s)
- Giovanni Brandi
- Haematological and Oncological Institute, Department of Experimental, Diagnostic and Specialty Medicine, St. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy.
| | - Michela Venturi
- Haematological and Oncological Institute, Department of Experimental, Diagnostic and Specialty Medicine, St. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy.
| | - Maria Abbondanza Pantaleo
- Haematological and Oncological Institute, Department of Experimental, Diagnostic and Specialty Medicine, St. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy.
| | - Giorgio Ercolani
- Department of Medical and Surgical Sciences, St. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy.
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Esnaola NF, Meyer JE, Karachristos A, Maranki JL, Camp ER, Denlinger CS. Evaluation and management of intrahepatic and extrahepatic cholangiocarcinoma. Cancer 2016; 122:1349-69. [PMID: 26799932 DOI: 10.1002/cncr.29692] [Citation(s) in RCA: 181] [Impact Index Per Article: 22.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Revised: 08/18/2015] [Accepted: 08/19/2015] [Indexed: 12/13/2022]
Abstract
Cholangiocarcinomas are rare biliary tract tumors that are often challenging to diagnose and treat. Cholangiocarcinomas are generally categorized as intrahepatic or extrahepatic depending on their anatomic location. The majority of patients with cholangiocarcinoma do not have any of the known or suspected risk factors and present with advanced disease. The optimal evaluation and management of patients with cholangiocarcinoma requires thoughtful integration of clinical information, imaging studies, cytology and/or histology, as well as prompt multidisciplinary evaluation. The current review focuses on recent advances in the diagnosis and treatment of patients with cholangiocarcinoma and, in particular, on the role of endoscopy, surgery, transplantation, radiotherapy, systemic therapy, and liver-directed therapies in the curative or palliative treatment of these individuals. Cancer 2016;122:1349-1369. © 2016 American Cancer Society.
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Affiliation(s)
- Nestor F Esnaola
- Department of Surgery, Fox Chase Cancer Center-Temple Health, Philadelphia, Pennsylvania
| | - Joshua E Meyer
- Department of Radiation Oncology, Fox Chase Cancer Center-Temple Health, Philadelphia, Pennsylvania
| | - Andreas Karachristos
- Department of Surgery, Temple University School of Medicine, Philadelphia, Pennsylvania
| | - Jennifer L Maranki
- Department of Medicine, Temple University School of Medicine, Philadelphia, Pennsylvania
| | - E Ramsay Camp
- Department of Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Crystal S Denlinger
- Department of Hematology/Oncology, Fox Chase Cancer Center-Temple Health, Philadelphia, Pennsylvania
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27
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Gulamhusein AF, Sanchez W. Liver transplantation in the management of perihilar cholangiocarcinoma. Hepat Oncol 2015; 2:409-421. [PMID: 30191020 DOI: 10.2217/hep.15.30] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Cholangiocarcinoma (CCA) is the second most common primary hepatic neoplasm and accounts for 10-20% of hepatobiliary cancer-related deaths. The prognosis of patients with CCA is poor with 5-year survival rates of 10%, partially due to the limited effective treatment options that exist for this disease. In this review, we discuss the evolving role of liver transplantation in the management of patients with perihilar CCA (pCCA). We specifically discuss the Mayo Clinic protocol of neoadjuvant chemoradiation followed by liver transplantation in selected patients with pCCA and describe pretransplant, peritransplant, and post-transplant considerations and challenges with this approach. Finally, we review local, national and international outcomes and discuss future directions in optimizing this treatment strategy for patients who otherwise have few therapeutic options and limited survival.
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Affiliation(s)
- Aliya F Gulamhusein
- Division of Gastroenterology & Hepatology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - William Sanchez
- Division of Gastroenterology & Hepatology, Mayo Clinic College of Medicine, Rochester, MN, USA
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Mahadevan A, Dagoglu N, Mancias J, Raven K, Khwaja K, Tseng JF, Ng K, Enzinger P, Miksad R, Bullock A, Evenson A. Stereotactic Body Radiotherapy (SBRT) for Intrahepatic and Hilar Cholangiocarcinoma. J Cancer 2015; 6:1099-104. [PMID: 26516357 PMCID: PMC4615345 DOI: 10.7150/jca.13032] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Accepted: 02/09/2015] [Indexed: 12/15/2022] Open
Abstract
Background: Unresectable intrahepatic and hilar cholangiocarcinomas carry a dismal prognosis. Systemic chemotherapy and conventional external beam radiation and brachytherapy have been used with limited success. We explored the use of stereotactic body radiotherapy (SBRT) for these patients. Methods: Patients with unresectable intrahepatic or hilar cholangiocarcinoma or those with positive margins were included in this study. Systemic therapy was used at the discretion of the medical oncologist. The CyberknifeTM stereotactic body radiotherapy system used to treat these patients. Patients were treated with three daily fractions. Clinical and radiological follow-up were performed every three months. Results: 34 patients (16 male and 18 female) with 42 lesions were included in this study. There were 32 unresectable tumors and two patients with resected tumors with positive margins. The median SBRT dose was 30Gy in three fractions. The median follow-up was 38 months (range 8-71 months). The actuarial local control rate was 79%. The median overall survival was 17 months and the median progression free survival was ten months. There were four Grade III toxicities (12%), including duodenal ulceration, cholangitis and liver abscess. Conclusions: SBRT is an effective and reasonably safe local therapy option for unresectable intrahepatic or hilar cholangiocarcinoma.
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Affiliation(s)
- Anand Mahadevan
- 1. Department of Radiation Oncology, Harvard Medical School, Boston, Massachusetts, USA
| | - Nergiz Dagoglu
- 1. Department of Radiation Oncology, Harvard Medical School, Boston, Massachusetts, USA
| | - Joseph Mancias
- 1. Department of Radiation Oncology, Harvard Medical School, Boston, Massachusetts, USA
| | - Kristin Raven
- 2. Department of Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - Khalid Khwaja
- 2. Department of Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - Jennifer F Tseng
- 2. Department of Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - Kimmie Ng
- 3. Department of Medical Oncology, Dana Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Peter Enzinger
- 3. Department of Medical Oncology, Dana Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Rebecca Miksad
- 4. Department of Medical Oncology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Andrea Bullock
- 4. Department of Medical Oncology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Amy Evenson
- 2. Department of Surgery, Harvard Medical School, Boston, Massachusetts, USA
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29
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Miyazaki M, Yoshitomi H, Miyakawa S, Uesaka K, Unno M, Endo I, Ota T, Ohtsuka M, Kinoshita H, Shimada K, Shimizu H, Tabata M, Chijiiwa K, Nagino M, Hirano S, Wakai T, Wada K, Isayama H, Iasayama H, Okusaka T, Tsuyuguchi T, Fujita N, Furuse J, Yamao K, Murakami K, Yamazaki H, Kijima H, Nakanuma Y, Yoshida M, Takayashiki T, Takada T. Clinical practice guidelines for the management of biliary tract cancers 2015: the 2nd English edition. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2015; 22:249-73. [PMID: 25787274 DOI: 10.1002/jhbp.233] [Citation(s) in RCA: 157] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND The Japanese Society of Hepato-Biliary-Pancreatic Surgery launched the clinical practice guidelines for the management of biliary tract and ampullary carcinomas in 2008. Novel treatment modalities and handling of clinical issues have been proposed after the publication. New approaches for editing clinical guidelines, such as the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system, also have been introduced for better and clearer grading of recommendations. METHODS Clinical questions (CQs) were proposed in seven topics. Recommendation, grade of recommendation and statement for each CQ were discussed and finalized by evidence-based approach. Recommendation was graded to grade 1 (strong) and 2 (weak) according to the concept of GRADE system. RESULTS The 29 CQs covered seven topics: (1) prophylactic treatment, (2) diagnosis, (3) biliary drainage, (4) surgical treatment, (5) chemotherapy, (6) radiation therapy, and (7) pathology. In 27 CQs, 19 recommendations were rated strong and 11 recommendations weak. Each CQ included the statement of how the recommendation was graded. CONCLUSIONS This guideline provides recommendation for important clinical aspects based on evidence. Future collaboration with cancer registry will be a key for assessment of the guidelines and establishment of new evidence. Free full-text articles and a mobile application of this guideline are available via http://www.jshbps.jp/en/guideline/biliary-tract2.html.
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Affiliation(s)
- Masaru Miyazaki
- Department of General Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
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Kim SW, Lim DH, Park HC, Park W, Park JO, Park YS. Salvage Radiation Therapy for Isolated Local Recurrence of Extrahepatic Cholangiocarcinoma After Radical Surgery: A Retrospective Study. Ann Surg Oncol 2014; 22:1308-14. [DOI: 10.1245/s10434-014-4146-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2014] [Indexed: 12/12/2022]
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31
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Jung DH, Kim MS, Cho CK, Yoo HJ, Jang WI, Seo YS, Paik EK, Kim KB, Han CJ, Kim SB. Outcomes of stereotactic body radiotherapy for unresectable primary or recurrent cholangiocarcinoma. Radiat Oncol J 2014; 32:163-9. [PMID: 25324988 PMCID: PMC4194299 DOI: 10.3857/roj.2014.32.3.163] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Revised: 07/29/2014] [Accepted: 08/13/2014] [Indexed: 12/19/2022] Open
Abstract
Purpose To report the results of stereotactic body radiotherapy (SBRT) for unresectable primary or recurrent cholangiocarcinoma. Materials and Methods From January 2005 through August 2013, 58 patients with unresectable primary (n = 28) or recurrent (n = 30) cholangiocarcinoma treated by SBRT were retrospectively analyzed. The median prescribed dose was 45 Gy in 3 fractions (range, 15 to 60 Gy in 1-5 fractions). Patients were treated by SBRT only (n = 53) or EBRT + SBRT boost (n = 5). The median tumor volume was 40 mL (range, 5 to 1,287 mL). Results The median follow-up duration was 10 months (range, 1 to 97 months). The 1-year, 2-year overall survival rates, and median survival were 45%, 20%, and 10 months, respectively. The median survival for primary group and recurrent group were 5 and 13 months, respectively. Local control rate at 1-year and 2-year were 85% and 72%, respectively. Disease progression-free survival rates at 1-year and 2-year were 26% and 23%, respectively. In univariate analysis, ECOG performance score (0-1 vs. 2-3), treatment volume (<50 vs. ≥50 mL), and pre-SBRT CEA level (<5 vs. ≥5 ng/mL) were significant in overall survival rate. In multivariate analysis, ECOG score (p = 0.037) and tumor volume (p = 0.030) were statistically significant. In the recurrent tumor group, patients with >12 months interval from surgery to recurrence showed statistically significant higher overall survival rate than those with ≤12 months (p = 0.026). Six patients (10%) experienced ≥grade 3 complications. Conclusion SBRT can be considered as an effective local modality for unresectable primary or recurrent cholangiocarcinoma.
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Affiliation(s)
- Da Hoon Jung
- Department of Radiation Oncology, Korea Institute of Radiological & Medical Sciences, Seoul, Korea
| | - Mi-Sook Kim
- Department of Radiation Oncology, Korea Institute of Radiological & Medical Sciences, Seoul, Korea
| | - Chul Koo Cho
- Department of Radiation Oncology, Korea Institute of Radiological & Medical Sciences, Seoul, Korea
| | - Hyung Jun Yoo
- Department of Radiation Oncology, Korea Institute of Radiological & Medical Sciences, Seoul, Korea
| | - Won Il Jang
- Department of Radiation Oncology, Korea Institute of Radiological & Medical Sciences, Seoul, Korea
| | - Young Seok Seo
- Department of Radiation Oncology, Korea Institute of Radiological & Medical Sciences, Seoul, Korea
| | - Eun Kyung Paik
- Department of Radiation Oncology, Korea Institute of Radiological & Medical Sciences, Seoul, Korea
| | - Kum Bae Kim
- Department of Radiation Oncology, Korea Institute of Radiological & Medical Sciences, Seoul, Korea
| | - Chul Ju Han
- Department of Internal Medicine, Korea Institute of Radiological & Medical Sciences, Seoul, Korea
| | - Sang Bum Kim
- Department of Surgical Oncology, Korea Institute of Radiological & Medical Sciences, Seoul, Korea
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32
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The Role of Radiotherapy and Chemoradiation in the Management of Primary Liver Tumours. Clin Oncol (R Coll Radiol) 2014; 26:569-80. [DOI: 10.1016/j.clon.2014.05.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Revised: 02/18/2014] [Accepted: 05/28/2014] [Indexed: 12/11/2022]
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Chopra S, Mathew AS, Engineer R, Shrivastava SK. Positioning high-dose radiation in multidisciplinary management of unresectable cholangiocarcinomas: review of current evidence. Indian J Gastroenterol 2014; 33:401-7. [PMID: 25135161 DOI: 10.1007/s12664-014-0495-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2014] [Accepted: 07/07/2014] [Indexed: 02/04/2023]
Abstract
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.
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Affiliation(s)
- Supriya Chopra
- Department of Radiation Oncology, Advanced Centre for Treatment Research and Education in Cancer, Tata Memorial Centre, Kharghar, Navi Mumbai, 410 210, India,
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Yoshioka Y, Ogawa K, Oikawa H, Onishi H, Kanesaka N, Tamamoto T, Kosugi T, Hatano K, Kobayashi M, Ito Y, Takayama M, Takemoto M, Karasawa K, Nagakura H, Imai M, Kosaka Y, Yamazaki H, Isohashi F, Nemoto K, Nishimura Y. Impact of intraluminal brachytherapy on survival outcome for radiation therapy for unresectable biliary tract cancer: a propensity-score matched-pair analysis. Int J Radiat Oncol Biol Phys 2014; 89:822-9. [PMID: 24969796 DOI: 10.1016/j.ijrobp.2014.04.020] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Revised: 03/17/2014] [Accepted: 04/11/2014] [Indexed: 01/02/2023]
Abstract
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.
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Affiliation(s)
- Yasuo Yoshioka
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Kazuhiko Ogawa
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, Osaka, Japan.
| | - Hirobumi Oikawa
- Department of Radiology, Iwate Medical University, Iwate, Japan
| | - Hiroshi Onishi
- Department of Radiology, University of Yamanashi, Yamanashi, Japan
| | - Naoto Kanesaka
- Department of Radiology, Tokyo Medical University, Tokyo, Japan
| | - Tetsuro Tamamoto
- Department of Radiation Oncology, Nara Medical University of Medicine, Nara, Japan
| | - Takashi Kosugi
- Department of Radiology, Hamamatsu University School of Medicine, Shizuoka, Japan
| | - Kazuo Hatano
- Department of Radiation Oncology, Chiba Cancer Center, Chiba, Japan
| | - Masao Kobayashi
- Department of Radiology, Jikei University School of Medicine, Tokyo, Japan
| | - Yoshinori Ito
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Makoto Takayama
- Department of Radiology, Kyorin University School of Medicine, Tokyo, Japan
| | | | - Katsuyuki Karasawa
- Department of Radiation Oncology, Tokyo Metropolitan Komagome Hospital, Tokyo, Japan
| | - Hisayasu Nagakura
- Department of Radiology, KKR Sapporo Medical Center, Hokkaido, Japan
| | - Michiko Imai
- Department of Radiation Oncology, Iwata City Hospital, Shizuoka, Japan
| | - Yasuhiro Kosaka
- Department of Radiation Oncology, Kobe City Medical Center General Hospital, Hyogo, Japan
| | - Hideya Yamazaki
- Department of Radiology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Fumiaki Isohashi
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Kenji Nemoto
- Department of Radiation Oncology, Yamagata University, Yamagata, Japan
| | - Yasumasa Nishimura
- Department of Radiation Oncology, Kinki University Faculty of Medicine, Osaka, Japan
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35
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Thomas TO, Hasan S, Small W, Herman JM, Lock M, Kim EY, Mayr NA, Teh BS, Lo SS. The tolerance of gastrointestinal organs to stereotactic body radiation therapy: what do we know so far? J Gastrointest Oncol 2014; 5:236-46. [PMID: 24982772 PMCID: PMC4074956 DOI: 10.3978/j.issn.2078-6891.2014.024] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Accepted: 05/08/2014] [Indexed: 12/14/2022] Open
Abstract
As stereotactic body radiation therapy (SBRT) for gastrointestinal (GI) gains popularity, there is a need to optimize doses and fractionation to minimize GI toxicity. GI organs that have classically developed radiation-induced toxicity include the liver & biliary system, small bowel, esophagus, and rectum. While the literature quantifies dose restrictions for these organs under standard fractionation, there is limited data regarding toxicity with the ablative dose schedules used in SBRT. We conducted a review of the literature to identify prospective and retrospective studies that detail GI toxicities when SBRT was employed. Based on the literature, the median SBRT dose for abdominal and thoracic tumors ranged from 24 to 60 Gy, at 5 to 25 Gy per fraction. The respective observed frequencies of grade 3 and 4 toxicities for the liver, biliary system, small bowel, and esophagus were variable among different studies. Typically, patients who suffered grade 3 and 4 toxicities were more likely to have had some form of systemic therapy as well. The effect of dose, fractionation, timing, and volume on GI toxicities has been described in the literature but more data is necessary to develop uniform treatment guidelines for SBRT.
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Shah KN, Clary BM. Endoscopic and Percutaneous Approaches to the Treatment of Biliary Tract and Primary Liver Tumors. Surg Oncol Clin N Am 2014; 23:207-30. [DOI: 10.1016/j.soc.2013.10.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Mattiucci GC, Autorino R, D’Agostino GR, Deodato F, Macchia G, Perri V, Tringali A, Morganti AG, Mutignani M, Valentini V. Chemoradiation and brachytherapy in extrahepatic bile duct carcinoma. Crit Rev Oncol Hematol 2014; 90:58-67. [DOI: 10.1016/j.critrevonc.2013.10.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2013] [Revised: 09/25/2013] [Accepted: 10/28/2013] [Indexed: 12/19/2022] Open
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Yoshioka Y, Ogawa K, Oikawa H, Onishi H, Uchida N, Maebayashi T, Kanesaka N, Tamamoto T, Asakura H, Kosugi T, Hatano K, Yoshimura M, Yamada K, Tokumaru S, Sekiguchi K, Kobayashi M, Soejima T, Isohashi F, Nemoto K, Nishimura Y. Factors influencing survival outcome for radiotherapy for biliary tract cancer: a multicenter retrospective study. Radiother Oncol 2014; 110:546-52. [PMID: 24560766 DOI: 10.1016/j.radonc.2014.01.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2013] [Revised: 01/06/2014] [Accepted: 01/12/2014] [Indexed: 01/02/2023]
Abstract
PURPOSE To seek for the possible factors influencing overall survival (OS) with radiotherapy (RT) for biliary tract cancer. MATERIALS AND METHODS Data were collected retrospectively from RT database of 31 institutions in Japan. All patients underwent at least external beam RT. The factors influencing OS were investigated. RESULTS Data of 498 patients were analyzed. Median OS of the 212 patients who underwent surgery was significantly better than that of the 286 patients without surgery (31 vs. 15 months, p<0.001). The OS for the R0 or R1 resection group was significantly longer than that for the R2 or non-surgery group, as well as for n0 compared to n1 (all p<0.001). Chemoradiotherapy (CRT), both sequential and concurrent, resulted in a better OS than RT alone for the n1 group (31 vs. 13 months, p<0.001), and marginally better for the R0/R1 group (p=0.065; p=0.054 for concurrent CRT). However, no such benefit was observed for the R2/non-surgical patients. Multivariate analysis identified performance status, clinical stage, and surgery as significant factors. CONCLUSION Surgery, especially R0/R1 resection, seemed as the gold standard for treatment of biliary tract cancer including RT, even in the highly heterogeneous population obtained from the multicenter retrospective study. The possibility was shown that CRT yielded better survival benefit especially for n1 patients. We recommend that future prospective trials include an arm of adjuvant CRT at least for n1 and possibly R0/R1 patients.
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Affiliation(s)
- Yasuo Yoshioka
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, Japan
| | - Kazuhiko Ogawa
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, Japan.
| | | | | | - Nobue Uchida
- Department of Radiation Oncology, Shimane University, Japan
| | - Toshiya Maebayashi
- Department of Radiology, Nihon University School of Medicine, Tokyo, Japan
| | - Naoto Kanesaka
- Department of Radiology, Tokyo Medical University, Japan
| | - Tetsuro Tamamoto
- Department of Radiation Oncology, Nara Medical University of Medicine, Japan
| | | | - Takashi Kosugi
- Department of Radiology, Hamamatsu University School of Medicine, Shizuoka, Japan
| | - Kazuo Hatano
- Department of Radiation Oncology, Chiba Cancer Center, Japan
| | - Michio Yoshimura
- Department of Radiation Oncology and Image-applied Therapy, Kyoto University Graduate School of Medicine, Japan
| | - Kazunari Yamada
- Department of Radiation Oncology, Seirei Mikatahara General Hospital, Shizuoka, Japan
| | - Sunao Tokumaru
- Department of Heavy Particle Therapy and Radiation Oncology, Saga University, Japan
| | - Kenji Sekiguchi
- Department of Radiation Oncology, St. Luke's International Hospital, Tokyo, Japan
| | - Masao Kobayashi
- Department of Radiology, Jikei University School of Medicine, Tokyo, Japan
| | | | - Fumiaki Isohashi
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, Japan
| | - Kenji Nemoto
- Department of Radiation Oncology, Yamagata University, Japan
| | - Yasumasa Nishimura
- Department of Radiation Oncology, Kinki University Faculty of Medicine, Osaka, Japan
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Makita C, Nakamura T, Takada A, Takayama K, Suzuki M, Ishikawa Y, Azami Y, Kato T, Tsukiyama I, Kikuchi Y, Hareyama M, Murakami M, Fuwa N, Hata M, Inoue T. Clinical outcomes and toxicity of proton beam therapy for advanced cholangiocarcinoma. Radiat Oncol 2014; 9:26. [PMID: 24422711 PMCID: PMC3904195 DOI: 10.1186/1748-717x-9-26] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2013] [Accepted: 01/09/2014] [Indexed: 12/25/2022] Open
Abstract
Background We examined the efficacy and toxicity of proton beam therapy (PBT) for treating advanced cholangiocarcinoma. Methods The clinical data and outcomes of 28 cholangiocarcinoma patients treated with PBT between January 2009 and August 2011 were retrospectively examined. The Kaplan–Meier method was used to estimate overall survival (OS), progression-free survival (PFS), and local control (LC) rates, and the log-rank test to analyze the effects of different clinical and treatment variables on survival. Acute and late toxicities were assessed using the National Cancer Institute Common Terminology Criteria for Adverse Events version 4.0. Results The median age of the 17 male and 11 female patients was 71 years (range, 41 to 84 years; intrahepatic/peripheral cholangiocarcinoma, n = 6; hilar cholangiocarcinoma/Klatskin tumor, n = 6; distal extrahepatic cholangiocarcinoma, n = 3; gallbladder cancer, n = 3; local or lymph node recurrence, n = 10; size, 20–175 mm; median 52 mm). The median radiation dose was 68.2 Gy (relative biological effectiveness [RBE]) (range, 50.6 to 80 Gy (RBE)), with delivery of fractions of 2.0 to 3.2 Gy (RBE) daily. The median follow-up duration was 12 months (range, 3 to 29 months). Fifteen patients underwent chemotherapy and 8 patients, palliative biliary stent placement prior to PBT. OS, PFS, and LC rates at 1 year were 49.0%, 29.5%, and 67.7%, respectively. LC was achieved in 6 patients, and was better in patients administered a biologically equivalent dose of 10 (BED10) > 70 Gy compared to those administered < 70 Gy (83.1% vs. 22.2%, respectively, at 1 year). The variables of tumor size and performance status were associated with survival. Late gastrointestinal toxicities grade 2 or greater were observed in 7 patients <12 months after PBT. Cholangitis was observed in 11 patients and 3 patients required stent replacement. Conclusions Relatively high LC rates after PBT for advanced cholangiocarcinoma can be achieved by delivery of a BED10 > 70 Gy. Gastrointestinal toxicities, especially those of the duodenum, are dose-limiting toxicities associated with PBT, and early metastatic progression remains a treatment obstacle.
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Affiliation(s)
- Chiyoko Makita
- Department of Radiation Oncology, Southern Tohoku Proton Therapy Center, 7-172, Yatsuyamada, 963-8052 Koriyama, Fukushima, Japan.
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Moureau-Zabotto L, Turrini O, Resbeut M, Raoul JL, Giovannini M, Poizat F, Piana G, Delpero JR, Bertucci F. Impact of radiotherapy in the management of locally advanced extrahepatic cholangiocarcinoma. BMC Cancer 2013; 13:568. [PMID: 24299517 PMCID: PMC4219485 DOI: 10.1186/1471-2407-13-568] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2013] [Accepted: 11/05/2013] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Optimal therapy for patients with unresectable locally advanced extrahepatic cholangiocarcinoma (ULAC) remains controversial. We analysed the role of radiotherapy in the management of such tumors. METHODS We retrospectively reviewed the charts of patients treated in our institution with conformal-3D external-beam-radiotherapy (EBRT) with or without concurrent chemotherapy. RESULTS Thirty patients were included: 24 with a primary tumor (group 1) and 6 with a local relapse (group 2). Toxicity was low. Among 25 patients assessable for EBRT response, we observed 9 complete responses, 4 partial responses, 10 stabilisations, and 2 progressions. The median follow-up was 12 months. Twenty out of 30 patients (66%) experienced a relapse, which was metastatic in 75% of cases in the whole series, 87% in group 1, 60% in group 2 (p = 0.25). Twenty-eight patients (93%) died of relapse or disease complications. Median overall survivals in the whole group and in group 1 or 2 were respectively 12, 11 and 21 months (p = 0.11). The 1-year and 3-year progression-free survivals were respectively 38% and 16% in the whole series; 31% and 11% in group 1, 67% and 33% in group 2 (p = 0.35). CONCLUSION EBRT seems efficient to treat ULAC, with acceptable toxicity. For primary disease, the high rate of metastatic relapse suggests to limit EBRT to non-progressive patients after induction chemotherapy.
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Affiliation(s)
- Laurence Moureau-Zabotto
- Department of Radiation Therapy, Institut Paoli-Calmettes, 232 Boulevard de Sainte Marguerite, 13009 Marseille, France.
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Ramírez-Merino N, Aix SP, Cortés-Funes H. Chemotherapy for cholangiocarcinoma: An update. World J Gastrointest Oncol 2013; 5:171-176. [PMID: 23919111 PMCID: PMC3731530 DOI: 10.4251/wjgo.v5.i7.171] [Citation(s) in RCA: 111] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2012] [Accepted: 04/16/2013] [Indexed: 02/05/2023] Open
Abstract
Cholangiocarcinomas (bile duct cancers) are a heterogeneous group of malignancies arising from the epithelial cells of the intrahepatic, perihilar and extrahepatic bile ducts. Patients diagnosed with cholangiocarcinoma must be evaluated by a multidisciplinary team and be treated with individualized management. First of all, it is very important to define the potential resectability of the tumor because surgery is the main therapeutic option for these patients. Overall, cholangiocarcinomas have a very poor prognosis. The 5-year survival rate is 5%-10%. In cases with a potentially curative surgery, 5-year survival rates of 25%-30% are reported. Therefore, it is necessary to increase the cure rate from surgery, exploring the survival benefit of any adjuvant strategy. It is difficult to clarify the role of adjuvant treatment in localized and locally advanced cholangiocarcinomas. There are limited data and the role of adjuvant chemotherapy/chemoradiation in patients with resected biliary tract cancer is poorly defined. The most relevant studies in the adjuvant setting are one from Japan, the well known ESPAC-3 and BILCAP from the United Kingdom and a meta-analysis. We show the results of these trials. According to medical oncology guidelines, postoperative adjuvant therapy is widely recommended for all patients with intrahepatic or extrahepatic cholangiocarcinoma who have microscopically positive resection margins, as well as for those with a complete resection but node-positive disease. Clinical trials are ongoing. The locally advanced cholangiocarcinoma setting includes a heterogeneous mix of patients: (1) patients who have had surgery but with macroscopic residual disease; (2) patients with locally recurrent disease after potentially curative treatment; and (3) patients with locally unresectable disease at presentation. In these patients, surgery is not an option and chemoradiation therapy can prolong overall survival and provide control of symptoms due to local tumor effects. Nowadays, no neoadjuvant therapy can be considered a standard approach for the treatment of patients with cholangiocarcinoma. There are promising results and randomized trials are needed in patients with a metastatic cholangiocarcinoma. In systemic therapy, no single drug or combination has consistently increased median survival beyond the expected 8-12 mo. It is always recommended that patients enrol in clinical trials. Clinical trials have shown that the more standard chemotherapy for a first line regimen of gemcitabine plus cisplatin (or oxaliplatin as a potentially better tolerated agent) is superior to gemcitabine alone. Leucovorin-modulated 5-fluorouracil, capecitabine monotherapy or single agent gemcitabine are reasonable options for patients with a borderline performance status. After progression in patients with an adequate performance status, active regimens that could be considered include gemcitabine plus capecitabine, or erlotinib plus bevacizumab, for second line treatment.
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Isohashi F, Ogawa K, Oikawa H, Onishi H, Uchida N, Maebayashi T, Kanesaka N, Tamamoto T, Asakura H, Kosugi T, Uno T, Ito Y, Karasawa K, Takayama M, Manabe Y, Yamazaki H, Takemoto M, Yoshioka Y, Nemoto K, Nishimura Y. Patterns of radiotherapy practice for biliary tract cancer in Japan: results of the Japanese radiation oncology study group (JROSG) survey. Radiat Oncol 2013; 8:76. [PMID: 23547715 PMCID: PMC3622593 DOI: 10.1186/1748-717x-8-76] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2012] [Accepted: 03/23/2013] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND The patterns of radiotherapy (RT) practice for biliary tract cancer (BTC) in Japan are not clearly established. METHODS A questionnaire-based national survey of RT used for BTC treatment between 2000 and 2011 was conducted by the Japanese Radiation Oncology Study Group. Detailed information was collected for 555 patients from 31 radiation oncology institutions. RESULTS The median age of the patients was 69 years old (range, 33-90) and 81% had a good performance status (0-1). Regarding RT treatment, 78% of the patients were treated with external beam RT (EBRT) alone, 17% received intraluminal brachytherapy, and 5% were treated with intraoperative RT. There was no significant difference in the choice of treatment modality among the BTC subsites. Many patients with EBRT were treated with a total dose of 50 or 50.4 Gy (~40%) and only 13% received a total dose ≥60 Gy, even though most institutions (90%) were using CT-based treatment planning. The treatment field consisted of the primary tumor (bed) only in 75% of the patients. Chemotherapy was used for 260 patients (47%) and was most often administered during RT (64%, 167/260), followed by after RT (63%, 163/260). Gemcitabine was the most frequently used drug for chemotherapy. CONCLUSIONS This study established the general patterns of RT practice for BTC in Japan. Further surveys and comparisons with results from other countries are needed for development and optimization of RT for patients with BTC in Japan.
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Affiliation(s)
- Fumiaki Isohashi
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, 2-2 (D-10) Yamadaoka, Suita, Osaka, 565-0871, Japan.
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Turaga KK, Tsai S, Wiebe LA, Evans DB, Gamblin TC. Novel multimodality treatment sequencing for extrahepatic (mid and distal) cholangiocarcinoma. Ann Surg Oncol 2012; 20:1230-9. [PMID: 23064778 DOI: 10.1245/s10434-012-2648-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2012] [Indexed: 12/15/2022]
Abstract
Neoadjuvant chemoradiation has demonstrated significant advantages in the management of pancreatic adenocarcinoma. A similar tumor in a nearby anatomical location is extrahepatic cholangiocarcinoma, which has proven to be largely unresponsive to current forms of therapy. Neoadjuvant therapy for hilar cholangiocarcinoma has been combined with surgical resection and/or liver transplantation with a 25-33 % complete pathological response rate. We propose a wider application of neoadjuvant chemoradiation for patients with distal cholangiocarcinoma and present our rationale for this form of treatment sequencing.
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Affiliation(s)
- Kiran K Turaga
- Department of Surgery, Dvision of Surgical Oncology, Medical College of Wisconsin, Milwaukee, WI, USA.
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Darwish Murad S, Kim WR, Harnois DM, Douglas DD, Burton J, Kulik LM, Botha JF, Mezrich JD, Chapman WC, Schwartz JJ, Hong JC, Emond JC, Jeon H, Rosen CB, Gores GJ, Heimbach JK. Efficacy of neoadjuvant chemoradiation, followed by liver transplantation, for perihilar cholangiocarcinoma at 12 US centers. Gastroenterology 2012; 143:88-98.e3; quiz e14. [PMID: 22504095 PMCID: PMC3846443 DOI: 10.1053/j.gastro.2012.04.008] [Citation(s) in RCA: 361] [Impact Index Per Article: 30.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2011] [Revised: 03/28/2012] [Accepted: 04/12/2012] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS Excellent single-center outcomes of neoadjuvant chemoradiation and liver transplantation for unresectable perihilar cholangiocarcinoma caused the United Network of Organ Sharing to offer a standardized model of end-stage liver disease (MELD) exception for this disease. We analyzed data from multiple centers to determine the effectiveness of this treatment and the appropriateness of the MELD exception. METHODS We collected and analyzed data from 12 large-volume transplant centers in the United States. These centers met the inclusion criteria of treating 3 or more patients with perihilar cholangiocarcinoma using neoadjuvant therapy, followed by liver transplantation, from 1993 to 2010 (n = 287 total patients). Center-specific protocols and medical charts were reviewed on-site. RESULTS The patients completed external radiation (99%), brachytherapy (75%), radiosensitizing therapy (98%), and/or maintenance chemotherapy (65%). Seventy-one patients dropped out before liver transplantation (rate, 11.5% in 3 months). Intent-to-treat survival rates were 68% and 53%, 2 and 5 years after therapy, respectively; post-transplant, recurrence-free survival rates were 78% and 65%, respectively. Patients outside the United Network of Organ Sharing criteria (those with tumor mass >3 cm, transperitoneal tumor biopsy, or metastatic disease) or with a prior malignancy had significantly shorter survival times (P < .001). There were no differences in outcomes among patients based on differences in surgical staging or brachytherapy. Although most patients came from 1 center (n = 193), the other 11 centers had similar survival times after therapy. CONCLUSIONS Patients with perihilar cholangiocarcinoma who were treated with neoadjuvant therapy followed up by liver transplantation at 12 US centers had a 65% rate of recurrence-free survival after 5 years, showing this therapy to be highly effective. An 11.5% drop-out rate after 3.5 months of therapy indicates the appropriateness of the MELD exception. Rigorous selection is important for the continued success of this treatment.
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Affiliation(s)
| | - W. Ray Kim
- William J. von Liebig Transplant Center, Mayo Clinic, Rochester, MN
| | - Denise M. Harnois
- Division of Gastroenterology and Hepatology, Mayo Clinic Florida, Jacksonville, FL
| | - David D. Douglas
- Division of Gastroenterology and Hepatology, Mayo Clinic Arizona, Phoenix, AZ
| | - James Burton
- Division of Gastroenterology and Hepatology, University of Colorado, Denver, CO
| | - Laura M. Kulik
- Department of Hepatology, Northwestern University, Chicago, IL
| | - Jean F. Botha
- Division of Transplantation, University of Nebraska Medical Center, Omaha, NE
| | - Joshua D. Mezrich
- Division of Transplantation, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | | | - Jason J. Schwartz
- Department of Surgery, Columbia University Medical Center, New York, NY
| | - Johnny C. Hong
- Division of Transplant, University of Illinois at Chicago, Chicago, IL
| | | | | | - Charles B. Rosen
- William J. von Liebig Transplant Center, Mayo Clinic, Rochester, MN
| | - Gregory J. Gores
- William J. von Liebig Transplant Center, Mayo Clinic, Rochester, MN
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Outcomes from combined chemoradiotherapy in unresectable and locally advanced resected cholangiocarcinoma. J Gastrointest Cancer 2012; 43:50-5. [PMID: 21049308 DOI: 10.1007/s12029-010-9213-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE Whilst surgery is the only potentially curative treatment for cholangiocarcinoma, many patients are either unfit for major surgery or have unresectable disease. Patients who undergo attempted curative resective surgery often have involved resection margins. The role of radiotherapy in these settings has not been clarified and is often not considered because of fears of late complications, especially liver and gastrointestinal toxicity. We present our experience of treating cholangiocarcinoma, either unresectable or locally advanced, with conformal radiotherapy and concurrent chemotherapy, examining survival, toxicity, patterns of failure and details of radiotherapy and chemotherapy administered. METHODS Between 1995 and 2005, 20 patients, median age 60.5 years (range 45-78 years) with cholangiocarcinoma received radical conformal radiotherapy (median dose 46 Gy in 1.8-2.0 Gy fractions) with concurrent cisplatin/5-FU and sequential gemcitabine chemotherapy. RESULTS Overall median survival was 20.4 months, 2 year survival, 43% and relapse-free survival, 9.6 months. 19/20 patients (95%) have died. One patient remains alive with liver and bone metastases. First site of failure was local and within radiotherapy field in 9/20 (45%) patients. No patient required interruption of radiotherapy for radiation toxicity, and none experienced subsequent late liver toxicity. CONCLUSIONS The survival of this group of historically poor prognosis patients is encouraging. Durable local control was achieved in a majority of patients having chemoradiotherapy and toxicity was not severe. Although most patients still succumbed to disease, treatment delayed onset of progression. Conformal radiotherapy should be considered as an integral component in new investigative approaches to treatment in this rare cancer.
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Barney BM, Olivier KR, Miller RC, Haddock MG. Clinical outcomes and toxicity using stereotactic body radiotherapy (SBRT) for advanced cholangiocarcinoma. Radiat Oncol 2012; 7:67. [PMID: 22553982 PMCID: PMC3464963 DOI: 10.1186/1748-717x-7-67] [Citation(s) in RCA: 77] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2012] [Accepted: 04/26/2012] [Indexed: 12/11/2022] Open
Abstract
Background To report single-institutional clinical outcomes and toxicity with SBRT for cholangiocarcinoma. Methods From March 2009 to July 2011, 10 patients with 12 unresectable primary (n = 6) or recurrent (n = 6) cholangiocarcinoma lesions underwent abdominal SBRT. Sites treated included liver (n = 10), abdominal lymph nodes (n = 1), and adrenal gland (n = 1). SBRT was delivered in three (n = 2) or five (n = 10) consecutive daily fractions over one week. The median prescription dose was 55 Gy (range, 45–60). Treatment response was graded by RECIST v.1.1, and toxicities were scored by CTCAE v.4.0. Data was analyzed using the Kaplan-Meier method to determine rates of local control (LC), freedom from distant progression (FFDM) and overall survival (OS). Results The median follow-up was 14 months (range, 2–26 months). LC, defined as freedom from progression within the SBRT field, was 100%, but four patients treated to intrahepatic sites experienced progression elsewhere in the liver. Estimates for FFDM at 6 and 12 months were 73% and 31%, respectively. Sites of disease relapse included liver (n = 3), liver and lymph nodes (n = 1), liver and lungs (n = 1), lymph nodes (n = 1), and mesentery (n = 1). OS estimates for the cohort at 6 and 12 months were 83% and 73%, respectively. The most common Grade ≥2 early toxicities were Grade 2 nausea and vomiting (n = 5) and gastrointestinal pain (n = 2). Late ≥2 toxicities included Grade 2 gastrointestinal pain (n = 3), Grade 3 biliary stenosis (n = 1), and Grade 5 liver failure (n = 1). Conclusions SBRT shows promise as an effective local therapy for properly-selected patients with cholangiocarcinoma. Further follow-up is needed to better quantify the risk of late complications associated with SBRT.
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Affiliation(s)
- Brandon M Barney
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA.
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Panjala C, Nguyen JH, Al-Hajjaj AN, Rosser BA, Nakhleh RE, Bridges MD, Ko SJ, Buskirk SJ, Kim GP, Harnois DM. Impact of neoadjuvant chemoradiation on the tumor burden before liver transplantation for unresectable cholangiocarcinoma. Liver Transpl 2012; 18:594-601. [PMID: 22140024 DOI: 10.1002/lt.22462] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
The very early experience with liver transplantation (LT) for cholangiocarcinoma (CC) was dismal because of the poor survival outcomes and the high recurrence rates. However, LT for CC in conjunction with neoadjuvant chemoradiation recently has shown encouraging results, although the data are extremely limited. At our institution between 2001 and 2008, 22 CC patients underwent protocol orthotopic LT at a median age of 45 years (range = 24-63 years). At a median follow-up of 601.5 days (range = 111-1388 days), the median survival time of the cohort was 3.3 years. The 1-, 2-, and 3-year Kaplan-Meier survival probabilities were 90%, 70%, and 63%, respectively, whereas the historical 5-year survival rates were 0% to 18% for intrahepatic CC and 23% to 26% for extrahepatic CC when patients underwent transplantation without neoadjuvant therapy. These encouraging survival rates for patients with this type of tumor, which is difficult to diagnose and treat, are no less significant when they are compared to the national 1- and 3-year survival rates (86% and 68%, respectively) of patients undergoing deceased donor LT for malignant neoplasms of the liver (as reported by the United Network for Organ Sharing). In our series, disease recurrence was significantly associated with a larger residual tumor [6.3 versus 2.0 cm (mean values), P = 0.008] and with a shorter waiting time for LT after the chemoradiation protocol [18 versus 56 days (mean values), P = 0.04]. Our LT protocol for CC was found to be promising for patients with truly extrahepatic CC and for patients within stages I to IIB of the American Joint Committee on Cancer Staging system (100% survival at a median follow-up of 2.2 years), but the results were notably poor for patients with stage III extrahepatic CC (median survival = 1.2 years). These observations highlight the need for accurate preoperative staging of CC for ideal LT recipient selection and the importance of a low tumor burden and a longer wait after neoadjuvant therapy. More effective chemoradiation regimens for reducing the tumor burden and the appropriate timing of LT after neoadjuvant chemoradiation require further research.
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Affiliation(s)
- Chakri Panjala
- Divisions of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA
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Alvaro D, Cannizzaro R, Labianca R, Valvo F, Farinati F. Cholangiocarcinoma: A position paper by the Italian Society of Gastroenterology (SIGE), the Italian Association of Hospital Gastroenterology (AIGO), the Italian Association of Medical Oncology (AIOM) and the Italian Association of Oncological Radiotherapy (AIRO). Dig Liver Dis 2010; 42:831-8. [PMID: 20702152 DOI: 10.1016/j.dld.2010.06.005] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2010] [Accepted: 06/11/2010] [Indexed: 12/11/2022]
Abstract
The incidence of Cholangiocellular carcinoma (CCA) is increasing, due to a sharp increase of the intra-hepatic form. Evidence-ascertained risk factors for CCA are primary sclerosing cholangitis, Opistorchis viverrini infection, Caroli disease, congenital choledocal cist, Vater ampulla adenoma, bile duct adenoma and intra-hepatic lithiasis. Obesity, diabetes, smoking, abnormal biliary-pancreatic junction, bilio-enteric surgery, and viral cirrhosis are emerging risk factors, but their role still needs to be validated. Patients with primary sclerosing cholangitis should undergo surveillance, even though a survival benefit has not been clearly demonstrated. CCA is most often diagnosed in an advanced stage, when therapeutic options are limited to palliation. Diagnosis of the tumor is often difficult and multiple imaging techniques should be used, particularly for staging. Surgery is the standard of care for resectable CCA, whilst liver transplantation should be considered only in experimental settings. Metal stenting is the standard of care in inoperable patients with an expected survival >4 months. Gemcitabine or platinum analogues are recommended in advanced CCA whilst there are no validated neo-adjuvant treatments or second-line chemotherapies. Even though promising results have been obtained in CCA with radiotherapy, further randomized controlled trials are needed.
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Affiliation(s)
- Domenico Alvaro
- (for SIGE) Department of Clinical Medicine, Division of Gastroenterology, Polo Pontino, Sapienza University of Rome, Rome, Italy
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Radiotherapy and chemotherapy as therapeutic strategies in extrahepatic biliary duct carcinoma. Strahlenther Onkol 2010; 186:672-80. [PMID: 21136029 DOI: 10.1007/s00066-010-2161-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2010] [Accepted: 09/16/2010] [Indexed: 12/11/2022]
Abstract
PURPOSE this report aims to provide an overview on radiotherapy and chemotherapy in extrahepatic biliary duct carcinoma (BDC). PATIENTS AND METHODS a PubMed research identified clinical trials in BDC through April 1, 2010 including randomised controlled trials, SEER analyses and retrospective trials. Additionally, publications on the technical progress of radiotherapy in or close to the liver were analysed. RESULTS most patients with cholangiocarcinoma present with unresectable disease (80-90%), and more than half of the resected patients relapse within 1 year. Adjuvant and palliative treatment options need to be chosen carefully since 50% of the patients are older than 70 years at diagnosis. Adjuvant radiotherapy or chemotherapy after complete resection (R0) has not convincingly shown a prolongation of survival but radiotherapy did after R1 resection. However, data suggest that liver transplantation could offer long-term survival in selected patients when combined with neoadjuvant chemoradiotherapy in patients with marginally resectable disease. For patients with unresectable biliary tract carcinoma (BTC), palliative stenting was previously the treatment of choice. But recent SEER analyses show that radiotherapy prolongs survival, relieves symptoms and contributes to biliary decompression and should be regarded as the new standard. Novel technical advances in radiotherapy may allow for dose-escalation and could significantly improve outcome for patients with cholangiocarcinoma. CONCLUSION both the literature and recent technical progress corroborate the role of radiotherapy in BDC offering chances for novel clinical trials. Progress is less pronounced in chemotherapy.
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Vern-Gross TZ, Shivnani AT, Chen K, Lee CM, Tward JD, MacDonald OK, Crane CH, Talamonti MS, Munoz LL, Small W. Survival outcomes in resected extrahepatic cholangiocarcinoma: effect of adjuvant radiotherapy in a surveillance, epidemiology, and end results analysis. Int J Radiat Oncol Biol Phys 2010; 81:189-98. [PMID: 20971573 DOI: 10.1016/j.ijrobp.2010.05.001] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2009] [Revised: 05/04/2010] [Accepted: 05/04/2010] [Indexed: 12/15/2022]
Abstract
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.
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Affiliation(s)
- Tamara Z Vern-Gross
- Department of Radiation Oncology, Wake Forest University Baptist Medical Center, Winston-Salem, NC, USA
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