Intraoperative radiotherapy for unresectable cholangiocarcinoma--the Mayo Clinic experience

Intraoperative Radiation Therapy for Gastrointestinal Malignancies

Despite improvements in definitive therapy, many patients with gastrointestinal malignancies experience local recurrences or have unresectable disease making subsequent management often challenging and morbid. Although higher doses of radiation may offer improved local control, the ability for dose escalation of external beam radiation therapy is often limited by adjacent radiosensitive structures. Intraoperative radiation therapy allows for additional radiotherapy to be delivered directly to the tumor or areas at highest risk for local recurrence while minimizing toxicity to adjacent structures, offering potentially improved outcomes for patients with unresectable disease or those with a high risk of local recurrence.

Recurrent cholangiocarcinoma with long-term survival by multimodal treatment: A case report

Long-term outcomes after surgical resection of bile duct cancer remain unsatisfactory, and survival, particularly after tumor recurrence, is poor. Gemcitabine and cisplatin combination (GC) therapy is the standard first-line treatment; however, second-line approaches are yet to be established. Radiotherapy may prolong the survival of patients with advanced biliary tract cancer, and particle radiotherapy delivers a more concentrated dose than conventional radiotherapy to deeper tumors. The present report describes the long-term survival of a 65-year-old man with distal bile duct cancer of pathological stage IIA (T2N0M0; depth of invasion, 5.5 mm) following multimodal treatment. Following subtotal stomach-preserving pancreatoduodenectomy, multiple hepatic recurrences were identified 9 months later, and GC therapy was initiated. The tumors were no longer evident 18 months later, and GC therapy was discontinued at the patient's request. A computed tomography (CT) scan performed 30 months after surgery identified a new solitary hepatic recurrence and duke pancreatic monoclonal antigen type-2 (DUPAN-2) levels were increased. Further GC therapy was declined. Carbon ion radiotherapy (CIRT) at a dose of 60 Gy [relative biological effectiveness (RBE)-weighted absorbed dose] was then delivered in four fractions over 4 days [15 Gy (RBE)/day]. Tumor size decreased on CT, and fluorodeoxyglucose-positron emission tomography/CT revealed a decline in the standardized uptake value of the tumor after 2 months, with decreased DUPAN-2 levels. Following regrowth of the hepatic recurrence, CIRT was repeated at a dose of 66 Gy (RBE) in four fractions over 4 days [16.5 Gy (RBE)/day] and stable disease was maintained for 19 months. After 19 months, CT revealed tumor regrowth and another new metastatic lesion was identified in the left kidney. The patient received systematic chemotherapy again and died of the disease 81 months after the initial surgery. In conclusion, CIRT is a potential treatment option to control solitary recurrence of biliary tract cancer.

Clinical analysis of cholangiocarcinoma patients receiving adjuvant radiotherapy

Cholangiocarcinoma (CCA) or bile duct cancer is a rare cancer type in developed countries, while its prevalence is increased in southeast Asia, affecting ~33.4 men and ~12.3 women per 100,000 individuals. CCA is one of the most lethal types of cancer. Neo-adjuvant and adjuvant therapies have been shown to have limited efficacy in improving the overall prognosis of patients. Radiotherapy has been reported to prolong the survival times of patients with certain characteristics. The present study retrospectively evaluated the medical records and follow-up data from 27 CCA patients who received radiotherapy at Chulabhorn Hospital (Bangkok, Thailand) between 2008 and 2014. A total of 14 patients underwent surgery followed by adjuvant chemoradiotherapy. Of the 27 CCA patients, 14 had intrahepatic CCA, 2 had extrahepatic CCA and 11 had hilar CCA. The 2-year survival rate was 40.7%. Tumor resectability, clinical symptoms and the Eastern Cooperative Oncology Group performance status score were found to be indicative of patient prognosis. In addition, the planning target volume and biologically effective radiotherapy dose were of prognostic value; however, initial treatment response was ambiguous in predicting survival time. The findings of the present study suggested that the currently used radiotherapy protocols for CCA may require modification to improve their efficacy.

Palliative and postoperative radiotherapy in biliary tract cancer

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

The expression of antiapoptotic proteins Bcl-2, Bcl-X(L), and Mcl-1 in benign, dysplastic, and malignant biliary epithelium

AIM

Cholangiocarcinoma can be cured by surgery, but only in a minority of cases. The activation of apoptosis is a major mode of action of chemotherapy and radiotherapy, which have limited benefit in the treatment of cholangiocarcinoma. The antiapoptotic members of the Bcl-2 protein family (Bcl-2, Bcl-X(L), and Mcl-1) are important inhibitors of apoptosis, but have not been investigated extensively in cholangiocarcinoma.

METHODS

The expression of Bcl-2, Bcl-X(L), and Mcl-1 was investigated in normal biliary epithelium (17), biliary dysplasia (three), and invasive cholangiocarcinoma (51), in addition to three human cholangiocarcinoma cell lines, by immunohistochemistry and immunofluorescence.

RESULTS

The expression of Bcl-2 was not detected in normal or malignant biliary tissue. In contrast, granular cytoplasmic Bcl-X(L) and Mcl-1 staining was found in 60-100% of cells in all normal, dysplastic, and malignant specimens, including the human cell lines examined in this study.

CONCLUSION

These findings indicate that Mcl-1 and Bcl-X(L), but not Bcl-2, are involved in the survival of normal and neoplastic cells in the biliary tree. By prolonging survival through blocking apoptosis, these proteins might be reducing the efficacy of cytotoxic anticancer treatments in cholangiocarcinoma.

Role of radiotherapy, in particular intraluminal brachytherapy, in the treatment of proximal bile duct carcinoma

PURPOSE

To perform an analysis of the results obtained with radiotherapy in patients with either resectable or unresectable cholangiocarcinoma of the proximal bile ducts. Emphasis will be paid to analyse the role of radiotherapy, particularly brachytherapy.

PATIENTS AND METHODS

Between 1985 and 1997, 109 patients received radiotherapy. In 71 patients (group I) tumor resection was combined with postoperative irradiation in 52 patients and pre- plus post-operative irradiation in 19 patients. Among this group, 41 patients had a boost of 10 Gy to the biliodigestive anastomosis using intraluminal brachytherapy. Median total dose was between 50-55 Gy. The other 38 patients (group II) had an unresectable tumor at laparotomy (16 patients) or were considered primary unresectable because locoregional tumor extension (22 patients). Brachytherapy boost through a nasobiliary approach was given to 19 patients (22-25 Gy). The median total dose varied between 60 to 68 Gy. Mean follow-up was 25 +/- 23 months.

RESULTS

In group I, the survival rates at 1, 3, and 5 year were 84%, 37%, and 24%, respectively. Median survival was 24 months. Sixteen patients did live longer than 4 years. Analysis of prognostic factors among resected patients showed the tumor differentiation grade, microscopically involved margins other than the upper (hepatic) and lower (choledocus) resection parameters analysed, only the total dose had influence on margins, and elevated alkaline phosphatase as factors which significantly influence survival. From the different radiotherapy prognosis, patients receiving a total dose above 55 Gy had a shorter survival. It is important to note that patients receiving brachytherapy boost did not have a better survival than patients treated with external beam irradiation alone. Preoperative radiotherapy did not have impact on survival but recurrences in the surgical scars were not observed as compared to 15% recurrences if preoperative radiotherapy was not given. In group II the median survival was 10.4 months. Survival rates at 1 and 2 year were 43% and 10%, respectively. The only significant prognostic factor found was if unresectability was defined primarily or during laparotomy. As it was the case in group I, brachytherapy boost did not have influence on prognosis as compared to external beam irradiation alone. Observed late complications consisted of duodenal stenosis, upper digestive tract bleeding and cholangitis. Probably these complications were not only attributable to radiotherapy, as tumor relapse was also present in the majority of the cases.

CONCLUSIONS

The role of radiotherapy either as adjuvant or as primary treatment remains to be demonstrated in prospective randomised studies. From our results, it seems that high radiation doses could be dangerous and could detriment prognosis. Brachytherapy boost was not superior to treatment with external beam irradiation alone.

[Intraoperative radiotherapy in 1997]

Intra Operative Radiation Therapy (IORT) has been routinely used for the past 20 years. It is a feasible treatment, with a reasonable cost and an acceptable acute and late toxicity. There is so far no strong randomized trial demonstrating that IORT can improve overall survival. Nevertheless, in many institutions it is recognized as an efficient treatment in selected patients. In case of locally recurrent disease an incomplete gross resection is often the only choice; IORT in such a situation has led to very encouraging results. For locally advanced deep seated primary tumors IORT seems to improve local control. In the near future IORT should be used on a larger and stronger basis. The manufacturing of new mobile linac should allow more surgeons to perform IORT and to conduct clinical trials to confirm the present indications in cancers with high local malignancy.

[Palliative therapy of carcinomas of the biliary system]

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

CHOLANGIOCARCINOMAS

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

CONCLUSION

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