Hepatic duct stricture after radical radiation therapy for biliary cancer: recurrence or fibrosis?

Unrecognized digestive toxicities of radiation therapy

The aim of this article is to review unrecognized toxicities resulting from radiation therapy of digestive neoplasms. Due to their precocious occurrence, acute toxicities are well-known by radiation oncologist, and their treatment well-established. Thus, acute toxicities will not be described in this review. We will focus on incidence, diagnosis, and management of late and uncommon toxicities occurring in the digestive tract and digestive organs. Prevention, by respecting healthy tissues constraints, is the main tool to reduce incidence of those rare complications. Nonetheless, once installed, late toxicities remain a major burden in terms of quality of life and can even be life threatening. Hence, information and education about their diagnosis and management is important.

Radiation-induced cholangitis with hepatocellular carcinoma

There are no reports of hepatocellular carcinoma complicating postradiotherapy cholangitis. We report the case of a 45-year-old patient who had undergone upper abdominal radiotherapy for Hodgkin's disease, 21 years before, which was complicated years later by cholangitis with stricture of the common bile duct. Biliodigestive anastomosic surgery was scheduled due to recurrent angiocholitis, and hepatocellular carcinoma was discovered. The patient died from carcinoma some months later.

Radical pancreatoduodenectomy for misdiagnosed pancreatic mass

Occasionally pancreatoduodenectomy is performed for clinically suspected pancreatic malignancy only for the surgeon to find that a benign aetiology accounts for the pancreatic mass. The aim of this study was twofold: to determine the incidence of pancreatoduodenectomy performed for a misdiagnosis of pancreatoduodenal malignancy and to identify potentially avoidable errors in preoperative and intraoperative judgement. Between 1956 and 1990, radical pancreatoduodenectomy was performed in 603 patients at the Mayo Clinic; 29 (5 per cent) underwent pancreatoduodenectomy for a diagnosis made before and during surgery of primary pancreatic or periampullary malignancy that was later proven histopathologically to be either unsuspected subacute or chronic pancreatitis (22 patients), benign fibrous common bile duct stricture (two), and penetrating duodenal ulcer, metastatic melanoma, ampullary adenoma, intrahepatic drug-induced cholestasis and pseudocyst (one each). No patient had a preoperative diagnosis of chronic pancreatitis. Weight loss, pain and/or jaundice were present in 27 of the 29 patients. Objective imaging tests, such as computed tomography, ultrasonography and/or endoscopic retrograde cholangiopancreatography, were performed in 25 patients. Potential errors in judgement may be avoided by a more aggressive attempt at biopsy in selected patients; in others, resection for presumed malignancy may be unavoidable.

Analysis of failure after curative irradiation of extrahepatic bile duct carcinoma

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

Intraoperative radiation therapy for carcinoma of the gallbladder

The recognition of a high incidence of local failure following surgical management of adenocarcinoma of the gallbladder has led to the use of adjuvant radiation therapy. In order to deliver higher doses to the gallbladder bed, intraoperative radiation therapy (IORT) has been used both with and without external beam radiation. The experience to date is reviewed. Ten patients have been treated, all of whom had either gross residual or unresected disease. The median survival for the group was approximately 1 year. There were no long-term survivors. The IORT did not contribute to the overall morbidity. Because of the limited number of patients and the advanced nature of the disease, the role of IORT in the management of gallbladder carcinoma has yet to be determined. The utility of this modality will most likely reside in the treatment of minimal residual disease at the time of cholecystectomy rather than in the palliative treatment of unresectable tumors.