Endoscopic palliation of cholangiocarcinoma

Peroral cholangioscopy: Update on the state-of-the-art

Peroral cholangioscopy (POC) is an endoscopic procedure that allows direct intraductal visualization of the biliary tract. POC has emerged as a vital tool for indeterminate biliary stricture evaluation and treatment of difficult biliary stones. Over several generations of devices, POC has fulfilled additional clinical needs where other diagnostic or therapeutic modalities have been inadequate. With adverse event rates comparable to standard endoscopic retrograde cholangioscopy and unique technical attributes, the role of POC is likely to continue expand. In this frontiers article, we highlight the existing and growing clinical applications of POC as well as areas of ongoing research.

Radiofrequency ablation in the management of primary hepatic and biliary tumors

In the United States, 80%-90% of primary hepatic tumors are hepatocellular carcinomas and 10%-15% are cholangiocarcinomas (CCA), both with high mortality rate, particularly CCA, which portends a worse prognosis. Traditional management with surgery has good outcomes in appropriately selected patients; however, novel ablative treatment options have emerged, such as radiofrequency ablation (RFA), which can improve the prognosis of both hepatic and biliary tumors. RFA is aimed to generate an area of necrosis within the targeted tissue by applying thermal therapy via an electrode, with a goal to completely eradicate the tumor while preserving surrounding healthy tissue. Role of RFA in management of hepatic and biliary tumors forms the focus of our current mini-review article.

Ablative therapies for hepatic and biliary tumors: endohepatology coming of age

Ablative therapies refer to minimally invasive procedures performed to destroy abnormal tissue that may arise with many conditions, and can be achieved clinically using chemical, thermal, and other techniques. In this review article, we explore the different ablative therapies used in the management of hepatic and biliary malignancies, namely hepatocellular carcinoma (HCC) and cholangiocarcinoma (CCA), with a particular focus on radiofrequency ablation (RFA) and photodynamic therapy (PDT) techniques.

Biliary endoscopy in the management of primary sclerosing cholangitis and its complications

Primary sclerosing cholangitis (PSC) is a chronic, idiopathic, cholestatic liver disease characterized by inflammation and fibrosis of the intrahepatic and/or extrahepatic bile ducts. It can affect individuals of all age groups and gender, has no established pharmacotherapy, and is associated with a variety of neoplastic (e.g. cholangiocarcinoma) and non-neoplastic (e.g. dominant strictures) hepatobiliary complications. Given these considerations, endoscopy plays a major role in the care of patients with PSC. In this review, we discuss and provide updates regarding endoscopic considerations in the management of hepatobiliary manifestations and complications of PSC. Where evidence is limited, we suggest pragmatic approaches based on currently available data and expert opinion.

A novel photodynamic therapy-based drug delivery system layered on a stent for treating cholangiocarcinoma

This study aimed to investigate the drug delivery efficacy and bio-effectiveness of a novel photodynamic therapy (PDT)-matrix drug delivery system for cholangiocarcinoma (CCA). Metallic stents were coated with polyurethane (PU) as the first layer. A 2-hydroxyethyl methacrylate (2-HEMA)/ethylene glycol dimethacrylate (EGDMA)/benzoyl peroxide (BPO) layer and a poly(ethylene-co-vinyl acetate) (PEVA)/poly(n-butyl methacrylate) (PBMA)/polyvinylpyrrolidone K30 (K30) layer containing various concentrations of Photofrin were then incorporated onto the stent as the second and third layers. After incubating the layered membranes with cultured CCA cell line, the release of Photofrin, cell viability, the intracellular uptake of Photofrin, reactive oxygen species (ROS) generation, and apoptosis were determined. Using a single-layer diffusion model, the maximum release of Photofrin from the 5 to 10% K30 formulas was 80 and 100%, respectively, after 24 h. When using the multiple-layer diffusion model, the released Photofrin showed an initial burst of the loading dose from the PEVA/PBMA/K30 layer. In the immobilized model, less than 5% of the Photofrin from the 2-HEMA/EGDMA/BPO layer was released over the 24-h period. Cell viability decreased linearly with increasing Photofrin concentrations, and ROS generation and apoptosis were shown to increase significantly with increasing Photofrin concentrations, until the concentration of Photofrin reached a saturation point of 1.5 μg/ml. This new, multiple-layered, PDT-based stent with dual-release mechanisms is a promising treatment for CCA and cancer-related ductal stenosis.

Impact of Radiofrequency Ablation on Malignant Biliary Strictures: Results of a Collaborative Registry

BACKGROUND

Radiofrequency ablation of malignant biliary strictures has been offered for the last 3 years, but only limited data have been published.

AIM

To assess the safety, efficacy, and survival outcomes of patients receiving endoscopic radiofrequency ablation.

METHODS

Between April 2010 and December 2013, 69 patients with unresectable neoplastic lesions and malignant biliary obstruction underwent 98 radiofrequency ablation sessions with stenting.

RESULTS

A total of 69 patients (22 male, aged 66.1 ± 13.3) were included in the registry. The etiology of malignant biliary stricture included unresectable cholangiocarcinoma (n = 45), pancreatic cancer (n = 19), gallbladder cancer (n = 2), gastric cancer (n = 1), and liver metastasis from colon cancer (n = 3). Seventy-eight percentage of patients had prior chemotherapy. All strictures were stented post-radiofrequency ablation with either plastic stents or metal stents. The mean stricture length treated was 14.3 mm. There was a statistically significant improvement in stricture diameter post-ablation (p < 0.0001). The likelihood of stricture improvement was significantly greater in pancreatic cancer-associated strictures [RR 1.8 (95 % 1.03-5.38)]. Seven patients (10 %) had adverse events, not linked directly to radiofrequency ablation. Median survival was 11.46 months (6.2-25 months).

CONCLUSION

Radiofrequency ablation is effective and safe in malignant biliary obstruction and seems to be associated with improved survival.

Impact of Radiofrequency Ablation on Malignant Biliary Strictures: Results of a Collaborative Registry

BACKGROUND

Radiofrequency ablation of malignant biliary strictures has been offered for the last 3 years, but only limited data have been published.

AIM

To assess the safety, efficacy, and survival outcomes of patients receiving endoscopic radiofrequency ablation.

METHODS

Between April 2010 and December 2013, 69 patients with unresectable neoplastic lesions and malignant biliary obstruction underwent 98 radiofrequency ablation sessions with stenting.

RESULTS

A total of 69 patients (22 male, aged 66.1 ± 13.3) were included in the registry. The etiology of malignant biliary stricture included unresectable cholangiocarcinoma (n = 45), pancreatic cancer (n = 19), gallbladder cancer (n = 2), gastric cancer (n = 1), and liver metastasis from colon cancer (n = 3). Seventy-eight percentage of patients had prior chemotherapy. All strictures were stented post-radiofrequency ablation with either plastic stents or metal stents. The mean stricture length treated was 14.3 mm. There was a statistically significant improvement in stricture diameter post-ablation (p < 0.0001). The likelihood of stricture improvement was significantly greater in pancreatic cancer-associated strictures [RR 1.8 (95 % 1.03-5.38)]. Seven patients (10 %) had adverse events, not linked directly to radiofrequency ablation. Median survival was 11.46 months (6.2-25 months).

CONCLUSION

Radiofrequency ablation is effective and safe in malignant biliary obstruction and seems to be associated with improved survival.

Endoscopic ablation therapy for biliopancreatic malignancies

Biliopancreatic malignancies such as cholangiocarcinoma (CCA) has notoriously been diagnosed late. As such most therapy have been palliative in nature. Cholangioscopy allows for an earlier diagnosis to be made. Brachytherapy with the insertion of catheter with iridium-132 seeds, percutaneously or through endoscopic retrograde cholangiopancreatography (ERCP) was the earliest ablative techniques used. It has been shown to have a beneficial effect only in prolonging survival. Photodynamic therapy (PDT) has also been used for several years. stenting with PDT versus stenting alone for unresectable CCA showed a marked survival benefit with the addition of PDT. However the most exciting endoscopic ablative modality appears to be intraductal radiofrequency ablation using the Habib catheter and device. Several case series have shown the effectiveness of this technique in ablating tumors. This technique is evolving and coupled with early diagnosis of CCA through cholangioscopy will allow for a curative therapy. The crux to the effective treatment of early cancerous lesions in the bile or pancreatic duct is the early diagnosis of such lesions. Effective endoscopic ablative therapy is now available with the advent of radiofrequency ablation probes that can be passed through the duodenoscope via ERCP.

Biliary stenting for cholangiocarcinoma: An update

Cholangiocarcinoma (bile duct cancer) is the most common malignant tumor of the biliary tree. This devastating malignancy presents late, and is notoriously difficult to diagnose, thus resulting a high mortality. The majority of cholangiocarcinoma patients present with an unresectable disease, and survive less than 12 mo following diagnosis. Biliary stent placement is an effective palliative therapy for malignant biliary obstruction, which can significantly improve the quality of life, and extend the survival time of patients. Different biliary stent placement methods would closely affect the prognosis of patients. The purpose of this article is to review the treatment efficacy, insertion paths and types of biliary stents. This paper also covers emerging biliary stents including drug stents, and biliary stent combination local therapy.

Palliation: treating patients with inoperable biliary tract and primary liver tumors

This article summarizes the current literature in treatment of unresectable biliary tract and primary liver tumors. Locoregional therapies including radiofrequency ablation, percutaneous ethanol injection, cryoablation, microwave ablation, transarterial chemoembolization, hepatic artery infusion, radioembolization ((90)Y), and bland embolization are discussed and clinical trials compared. Palliative strategies including surgical, percutaneous, and endoscopic techniques to decompress the biliary system and improve symptoms are also summarized. Systemic chemotherapy and sorafenib used in conjunction with locoregional therapies or as sole therapeutic options are discussed.

Efficacy of percutaneous transhepatic biliary drainage in treatment of high malignant biliary obstruction

AIM: To investigate the therapeutic effect of percutaneous transhepatic biliary drainage and biliary stent placement in patients with malignant hilar biliary obstruction to provide a basis for clinical selection of appropriate treatments.

METHODS: Clinical data for 76 patients with malignant hilar biliary obstructive jaundice treated at the Fourth Hospital of Hebei Medical University were analyzed retrospectively. Forty-two patients were men and 34 were women. Their age ranged from 42 to 76 years, with a mean value of 64.2 years. The majority of patients (42/69) had hilar bile duct carcinoma or postoperative recurrence. Other primary diseases included gallbladder carcinoma (n = 13), liver cancer (n = 6), hepatic metastasis of pancreatic, gastric and cardiac cancer (n = 14). Based on the Bismuth-Corlette classification, we divided the cases into five types: I (n = 16), II (n = 23), IIIa (n = 19), IIIb (n = 3) and IV (n = 15). All patients had complete clinical data, stable diseases and no absolute contraindications on intervention. Renal and liver function was examined in all patients to estimate the decreasing range of total bilirubin, which can be an index of short-term curative effect. The differences in total bilirubin change and survival between the unilateral and bilateral drainage groups were also compared.

RESULTS: Total bilirubin decreased significantly after treatment (338.52 mmol/L ± 93.21 mmol/L vs 128.13 mmol/L ± 52.17 mmol/L, P < 0.05). The decrease in total bilirubin showed no significant difference between the unilateral drainage group and the bilateral drainage group (99.19 mmol/L ± 53.81 mmol/L vs 104.62 mmol/L ± 63.12 mmol/L, P > 0.05). There was also no significant difference in survival rate between the unilateral drainage group and bilateral drainage group.

CONCLUSION: For high obstructive jaundice, multi-channel drainage is preferred. For patients with Bismuth III-IV disease, biliary drainage can also achieve satisfactory therapeutic effect. Biliary drainage and stent placement are safe and effective methods for relieving biliary obstruction, reducing bilirubin and lengthening the survival time.

Ursodeoxycholic acid-conjugated chitosan for photodynamic treatment of HuCC-T1 human cholangiocarcinoma cells

Chitosan was hydrophobically modified with ursodeoxycholic acid (UDCA) to fabricate nano-photosensitizer for photodynamic therapy (PDT) of HuCC-T1 cholangiocarcinoma cells. Synthesis of UDCA-conjugated chitosan (ChitoUDCA) was confirmed using (1)H NMR spectra. Chlorin E6 (Ce6) was used as a photosensitizer and incorporated into ChitoUDCA nanoparticles through formation of ion complexes. Morphology of Ce6-incorporated ChitoUDCA nanoparticles was observed using TEM and their shapes were spherical with sizes around 200-400 nm. The PDT potential of Ce6-incorporated ChitoUDCA nanoparticles were studied with HuCC-T1 human cholangiocarcinoma cells. The results showed that ChitoUDCA nanoparticles enhances of Ce6 uptake into tumor cells, phototoxicity, and ROS generation compared to Ce6 itself. Furthermore, Ce6-incorporated ChitoUDCA nanoparticles showed quenching in aqueous solution and sensing at tumor cells. We suggest that Ce6-incorporated ChitoUDCA nanoparticles are promising candidates for PDT of cholangiocarcinoma cells.

Modern diagnostic approaches to cholangiocarcinoma

BACKGROUND

Cholangiocarcinoma is a very aggressive tumor with poor survival. Therefore, early diagnosis and surgical resection are of paramount importance. Its diagnosis is difficult because access to the tumor is not easy. Biopsy is possible only for intrahepatic cholangiocarcinoma, which accounts for 10% of cases. Routine brush cytology from endoscopic retrograde cholangiopancreatography (ERCP) has a high specificity of 100% but unfortunately a low sensitivity of 30%. In this review we briefly describe new diagnostic techniques applicable to ERCP brush cytology specimens and targeting the genetic background of the disease, in particular fluorescence in situ hybridization (FISH) and digital image analysis (DIA).

DATA SOURCES

The PubMed database up to 2011 was used for the retrieval of relevant articles. The search terms FISH, fluorescence in situ hybridization, DIA, digital image analysis and cholangiocarcinoma were used. Both original and review articles were used.

RESULTS

FISH identifies cells with chromosomal abnormalities, mainly numerical aberrations, using a mixture of fluorescence-labeled probes. FISH offers a higher sensitivity than routine cytology, retaining a high level of specificity. The DIA criterion for malignancy is demonstration of aneuploidy. This technique increases the sensitivity to 40%, but the specificity remains low. Preliminary data from application to other tumors suggest that combination of FISH and DIA may be of further benefit.

CONCLUSIONS

The new techniques offer a significantly enhanced diagnostic efficacy in the evaluation of ERCP brush specimens. Apart from contributing to a more timely diagnosis, their wider application to cholangiocarcinoma may also facilitate the genetic study of the disease and add to our understanding of oncogenesis at the molecular level, with the prospect of identifying targets for novel therapeutic interventions.

5-aminolevulinic acid-incorporated poly(vinyl alcohol) nanofiber-coated metal stent for application in photodynamic therapy

Background

The study investigated the use of combined photodynamic therapy (PDT) and stent placement for the treatment of cholangiocarcinoma (CC). For this purpose, 5-aminolevulinic acid (ALA) was incorporated into poly(vinyl alcohol) (PVA) nanofiber, and coated onto metal stents. Their efficacy was assessed in PDT towards HuCC-T1 CC cells.

Methods

Fabrication of ALA-PVA nanofiber, and simultaneous coating onto metal stents, was performed through electrospinning. The dark-toxicity, generation of protoporphyrin IX (PpIX), and PDT effect of ALA and ALA-PVA nanofiber were studied in vitro, using HuCC-T1 CC cells.

Results

The ALA-PVA nanofibers were coated onto metal stents less than 1000 nm in diameter. ALA-only displayed marginal cytotoxicity; ALA-PVA nanofiber showed less cytotoxicity. PpIX generation was not sigficantly different between ALA and ALA-PVA nanofiber treatments. PVA itself did not generate PpIX in tumor cells. ALA and ALA-PVA nanofiber displayed a similar PDT effect on tumor cells. Cell viability was decreased, dose-dependently, until ALA concentration reached 100 μg/mL. Necrosis and apoptosis of tumor cells occurred similarly for ALA and ALA- PVA nanofiber treatments.

Conclusion

The ALA-PVA nanofiber-coated stent is a promising candidate for therapeutic use with cholangiocarcinoma.

Endoscopic stent placement in the palliation of malignant biliary obstruction

Biliary drainage with biliary stent placement is the treatment of choice for palliation in patients with malignant biliary obstruction caused by unresectable neoplasms. In such patients, the endoscopic approach can be initially used with percutaneous radiological intervention. In patients with unresectable malignant distal bile duct obstructions, endoscopic biliary drainage with biliary stent placement has now become the main and least invasive palliative modality, which has been proven to be more effective in >80% of cases with lower morbidity than surgery, and perhaps may provide a survival benefit. In patients with unresectable malignant hilar obstruction, the endoscopic approach for biliary drainage with biliary stent placement has also been considered as the treatment of choice. There is still a lack of clear consensus on the use of covered versus uncovered metal stents in malignant distal bile duct obstructions and plastic versus metal stents and unilateral versus bilateral drainage in malignant hilar obstructions.

Expandable metal stents for malignant hilar biliary obstruction

Most patients with malignant hilar stenoses are candidates for palliation. For this purpose, biliary drainage plays a major role in improving liver function and managing or avoiding cholangitis. Endoscopic interventions are less invasive than the percutaneous approach and should be considered as the first-line drainage procedures in most cases. Transhepatic interventions should be reserved for endoscopic failures or performed as a complementary approach in a combined procedure. After successful endoscopic access to biliary obstruction, implantation of self-expandable metal stents offers advantages over plastic endoprostheses in terms of stent patency and number of reinterventions.

Advances in photodynamic therapy for the treatment of hilar biliary tract cancer

The prognosis of patients with nonresectable hilar biliary tract cancer (hBTC) is poor. Responsiveness to chemotherapy or radiochemotherapy is moderate at best, and patients are at a high risk of dying early from complications of local tumor infiltration (e.g., cholestasis, septic cholangitis, empyema or liver failure) rather than systemic disease. Therefore, palliative local therapy for the prevention of tumor complications plays a central role and still yields the longest survival times. Photodynamic therapy (PDT) is a local-ablative, tumor tissue-specific treatment currently representing the standard of care for nonresectable hBTC. Throughout the literature, PDT plus biliary drainage achieves median survival times in the range of 9-21 months (average 14-16 months), compared with approximately 6 months for drainage only. This article summarizes the recent advances in preclinical and clinical experience of PDT for hBTC, including experimental in vitro and in vivo studies, clinical studies and an overview of the ongoing clinical trials.

Y-shaped endoscopic bilateral metal stent placement for malignant hilar biliary obstruction: prospective long-term study

OBJECTIVE

Although still controversial, bilateral stenting may be the best option for palliative drainage of malignant hilar biliary obstruction. The aim of our study was to evaluate the technical and clinical efficacies of endoscopic bilateral metal stenting using a biliary Y-stent for the management of malignant hilar obstruction.

MATERIAL AND METHODS

This prospective, uncontrolled study included 30 consecutive patients with unresectable malignant hilar strictures in whom we intended to perform endoscopic bilateral stent-in-stent deployment using a biliary Y-stent. After deployment of the Y-stent across the hilar stricture, a conventional biliary metal stent was inserted in a Y-configuration in which it traversed the wider-mesh central portion of the Y-stent to enter the opposite hepatic lobe.

RESULTS

Bilateral metal stenting using a Y-stent was successful in 26 of 30 patients (86.7%), and successful drainage was achieved in all 26 patients (100%). Early complications occurred in 3 patients (cholangitis, 1; cholecystitis, 2) without procedure-related mortality. As late complications during the follow-up period (median, 176 days; range, 70-473 days), stent occlusion occurred in 10 of 26 patients (38.5%). Four patients were managed with the insertion of a plastic stent through the occluded metal stent, and the remaining patients were treated with percutaneous biliary drainage. The median survival and stent patency were 176 days and 140 days, respectively.

CONCLUSIONS

Y-shaped endoscopic bilateral stenting using a Y-stent appears to be a feasible and effective method with high technical success and low stent-related complications for palliation of unresectable malignant hilar biliary obstruction.

Unilateral versus bilateral drainage using self-expandable metallic stent for unresectable hilar biliary obstruction

BACKGROUND

There is no consensus on the choice of either unilateral or bilateral drainage in stent placement for patients with unresectable hilar biliary obstruction. The aim of the present study was to clarify which drainage method is superior.

METHODS

We retrospectively reviewed 82 patients with hilar biliary obstruction who underwent metallic stenting. These patients were divided into a unilateral drainage group (Uni group) and a bilateral drainage group (Bi group).

RESULTS

There was no significant difference between the groups in median survival time, median stent patency period, and median complication-free survival time. The most frequent complication was stent obstruction, followed by cholangitis. Liver abscess was found at a higher frequency in the Bi group (17.6%) than in the Uni group (1.5%) (P=0.0266). There was no significant difference between the groups in the occurrence of two or more complications (P=0.247), life-threatening severe complications (P=0.0577), and stent obstruction by sludge (P=0.0912).

CONCLUSION

When compared with bilateral biliary drainage, unilateral biliary drainage is associated with a lower incidence of liver abscess as well as a comparable outcome of stent patency time and complication-free survival. We therefore propose that hilar biliary obstruction can be treated first by unilateral drainage with a metallic stent and by bilateral drainage only in patients who develop cholangitis in the contralateral biliary tree.

R0 but not R1/R2 resection is associated with better survival than palliative photodynamic therapy in biliary tract cancer

BACKGROUND

There is a need for better management strategies to improve the survival and quality of life in patients with biliary tract cancer (BTC).

AIM

To assess prognostic factors for survival in a large, non-selective cohort of patients with BTC.

METHOD

We compared outcomes in 321 patients with a final diagnosis of BTC (cholangiocarcinoma n = 237, gallbladder cancer n = 84) seen in a tertiary referral cancer centre between 1998 and 2007. Survival according to disease stage and treatment category was compared using log-rank testing. Cox's regression analysis was used to determine independent prognostic factors.

RESULTS

Eighty-nine (28%) patients underwent a surgical intervention with curative intent, of whom 38% had R0 resections. Among the 321 patients, 34% were given chemo- and/or radiotherapy, 14% were palliated with photodynamic therapy (PDT) and 37% with biliary drainage procedures alone. The overall median survival was 9 months (3-year survival, 14%). R0-resective surgery conferred the most favourable outcome (3-year survival, 57%). Although patients palliated with PDT had more advanced clinical T-stages, their survival was similar to those treated with attempted curative surgery but who had positive resection margins. On multivariable analysis, treatment modality, serum carbohydrate-associated antigen 19-9, distant metastases and vascular involvement were independent prognostic indicators of survival.

CONCLUSION

In this large UK series of BTC, palliative PDT resulted in survival similar to those with curatively intended R1/R2 resections. Surgery conferred a survival advantage only in patients with R0 resection margins, emphasising the need for accurate pre-operative staging.

Current management of hilar cholangiocarcinoma

Hilar cholangiocarcinoma is a rare tumor with poor prognosis. Surgical resection provides the only possibility for cure. Due to the central anatomic localization within the liver hilum, established guidelines of oncologic surgery are difficult to apply. Advances in hepatobiliary imaging and surgical strategies to treat this disease have resulted in improved postoperative outcomes. However, selection of extended hepatectomy or vascular resection or not as well as the efficacy of chemiotherapy remain great challenges to hepatobiliary surgeons. Here, we will review the recent advances in the management of hilar cholangiocarcinoma.

Percutaneous treatment of malignant jaundice due to extrahepatic cholangiocarcinoma: covered Viabil stent versus uncovered Wallstents

To compare clinical effectiveness of Viabil-covered stents versus uncovered metallic Wallstents, for palliation of malignant jaundice due to extrahepatic cholangiocarcinoma, 60 patients were enrolled in a prospective and randomized study. In half of the patients a bare Wallstent was used, and in the other half a Viabil biliary stent. Patients were followed up until death. Primary patency, survival, complication rates, and mean cost were calculated in both groups. Stent dysfunction occurred in 9 (30%) patients in the bare stent group after a mean period of 133.1 days and in 4 (13.3%) patients in the covered stent group after a mean of 179.5 days. The incidence of stent dysfunction was significantly lower in the covered stent group (P = 0.046). Tumor ingrowth occurred exclusively in the bare stent group (P = 0.007). Median survival was 180.5 days for the Wallstent and 243.5 days for the Viabil group (P = 0.039). Complications and mean cost were similar in the two groups. Viabil stent-grafts proved to be significantly superior to Wallstents for the palliation of malignant jaundice due to extrahepatic cholangiocarcinoma, with comparable cost and complication rates. Appropriate patient selection should be performed prior to stent placement.

Photodynamic therapy for non-resectable perihilar cholangiocarcinoma

Photodynamic therapy (PDT) has emerged as a useful tool for palliative treatment of the otherwise difficult to treat perihilar cholangiocarcinoma (CC). PDT is a minimally invasive and effective technique for local tumour ablation with rare and predictable side effects. A modest number of studies and randomised trials using porfimer (Photofrin) could demonstrate an improvement in quality of life and survival time. A novel approach to a priori non-resectable perihilar CC was proven in a pilot study using neoadjuvant porfimer-PDT for down-sizing of the tumour followed by R0 resection. These days, active phase II and phase III trials investigate if the tumouricidal activity can be increased using temoporfin (Foscan) as an alternative photosensitiser with higher penetration capability and whether porfimer-based PDT plus stenting is superior to biliary stenting alone in terms of overall survival, respectively. The local tumour ablation and correction of obstructive cholestasis with PDT will allow for novel multimodal strategies to treat cholangiocarcinoma.