Pilot study to assess patient outcomes following endoscopic application of photodynamic therapy for advanced cholangiocarcinoma

A Snapshot of Photoresponsive Liposomes in Cancer Chemotherapy and Immunotherapy: Opportunities and Challenges

To provide precise medical regimens, photonics technologies have been involved in the field of nanomedicine. Phototriggered liposomes have been cast as promising nanosystems that achieve controlled release of payloads in several pathological conditions such as cancer, autoimmune, and infectious diseases. In contrast to the conventional liposomes, this photoresponsive element greatly improves therapeutic efficacy and reduces the adverse effects of gene/drug therapy during treatment. Recently, cancer immunotherpay has been one of the hot topics in the field of oncology due to the great success and therapeutic benefits that were well-recognized by the patients. However, several side effects have been encountered due to the unmonitored augmentation of the immune system. This Review highlights the most recent advancements in the development of photoresponsive liposome nanosystems in the field of oncology, with a specific emphasis on challenges and opportunities in the field of cancer immunotherapy.

Photodynamic Therapy (PDT), Radiofrequency Ablation (RFA) With Biliary Stents in Palliative Treatment of Unresectable Extrahepatic Cholangiocarcinoma: A Systematic Review and Meta-analysis

BACKGROUND AND AIM

Extrahepatic unresectable cholangiocarcinoma carries a dismal prognosis. In addition to biliary drainage by stent placement; photodynamic therapy (PDT) and radiofrequency ablation (RFA) have been tried to prolong survival. In this meta-analysis, we appraise the current known data on the use of PDT, RFA in the palliative treatment of extrahepatic unresectable cholangiocarcinoma.

METHODS

We searched multiple databases from inception through July 2020 to identify studies that reported on PDT and RFA. Pooled rates of survival, stent patency, 30-, 90-day mortality, and adverse events were calculated. Study heterogeneity was assessed using I2% and 95% prediction interval.

RESULTS

A total of 55 studies (2146 patients) were included. A total of 1149 patients underwent treatment with PDT (33 studies), 545 with RFA (22 studies), and 452 patients with stent-only strategy. The pooled survival rate with PDT, RFA, and stent-only groups was 11.9 [95% confidence interval (CI): 10.7-13.1] months, 8.1 (95% CI: 6.4-9.9) months, and 6.7 (95% CI: 4.9-8.4) months, respectively. The pooled time of stent patency with PDT, RFA, and stent-only groups was 6.1 (95% CI: 4.2-8) months, 5.5 (95% CI: 4.2-6.7) months, and 4.7 (95% CI: 2.6-6.7) months, respectively. The pooled rate of 30-day mortality with PDT was 3.3% (95% CI: 1.6%-6.7%), with RFA was 7% (95% CI: 4.1%-11.7%) and with stent-only was 4.9% (95% CI: 1.7%-13.1%). The pooled rate of 90-day mortality with PDT was 10.4% (95% CI: 5.4%-19.2%) and with RFA was 16.3% (95% CI: 8.7%-28.6%).

CONCLUSION

PDT seemed to demonstrate better overall survival and 30-day mortality rates than RFA and/or stent-only palliation.

Lipid-based nanoparticles for photosensitive drug delivery systems

Background

Numerous drug delivery strategies have been studied, but many hurdles exist in drug delivery rates to the target site. Recently, researchers have attempted to remotely control the in vivo behavior of drugs with light to overcome the shortcomings of conventional drug delivery systems. Photodynamic and photothermal systems are representative strategies wherein a photosensitive material is activated in response to a specific wavelength of light.

Area covered

Photosensitive materials generally exhibit poor solubility and low biocompatibility. Additionally, their low photostability negatively affects delivery performance. A formulation of lipid-based nanoparticles containing photosensitive substances can help achieve photosensitive drug delivery with improved biocompatibility. The lipid bilayer structure, which can be assembled and disassembled by modulating the surrounding conditions (temperature, pH, etc.), can also be crucial for controlled release of drugs.

Expert opinion

To the best of our knowledge, translation research on photoresponsive nanoparticles is scarce. However, as various drugs based on lipid nanoparticles have been clinically approved, the development potential of the lipid-based photoresponsive nanoparticles seems high. Thus, the identification of valid indications and development of optimum medical devices will increase the interest in photoresponsive material-based nanoparticles.

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.

Clinical outcomes and prognostic factors of stereotactic body radiation therapy for intrahepatic cholangiocarcinoma

Stereotactic body radiation therapy (SBRT) has been an emerging non-invasive treatment modality for patients with intrahepatic cholangiocarcinoma (ICC) when surgical treatment cannot be applied. The CyberKnife^® is a SBRT system that allows for real-time tracking of the tumor. The purpose of this study was to evaluate the clinical outcomes and prognostic factors for ICC patients receiving this treatment. Twenty-eight patients with ICC were enrolled in the present study. The median prescription dose was 45 Gy (range, 36-54 Gy), fractionated 3 to 5 times with a 70% to 92% isodose line. Local control, overall survival, progression-free survival and toxicity were studied. The median follow-up time was 16 months (3-42 months). Based on modified Response Evaluation and Criteria in Solid Tumors (mRECIST), response rate and disease control rate of SBRT in ICC were 46.4% (13/28) and 89.3% (25/28), respectively. Median overall survival was 15 months (95% CI, 7.22-22.78). 1- and 2-years survival rates were 57.1% and 32.1%, and 1- and 2- years Progression-free Survival rates were 50.0 % and 21.4 %. Multivariate analysis revealed that number of lesions (solitary vs. multiple nodules), CA19-9 levels (≤37 U/mL vs. 37-600/>600) and TNM stage (AJCC stage) were independent prognostic factors for ICC patients treated with SBRT. Toxicity was mostly transient and tolerable. No greater than grade 3 toxicity was observed. These results suggested that CyberKnife SBRT might be a good alternative treatment for unresectable ICC.

Photodynamic therapy with polyhematoporphyrin for malignant biliary obstruction: A nationwide retrospective study of 150 consecutive applications

BACKGROUND

Photodynamic therapy (PDT) is a palliative treatment for malignant biliary obstruction.

OBJECTIVE

The objective of this article is to assess the feasibility and safety of this technique.

METHODS

In this nationwide, retrospective study of prospectively collected clinical data, all patients treated with PDT using polyhematoporphyrin in Austria from March 2004 to May 2013 were included. Feasibility, adverse events, stent patency and mortality rates were investigated.

RESULTS

Eighty-eight patients (54 male, 34 female, median age 69 years) underwent 150 PDT procedures at seven Austrian referral centers for biliary endoscopy. The predominant underlying disease was Klatskin tumor (79/88). All PDT procedures were feasible without technical issues. Cholangitis was the most frequent adverse event (21/88). Stent patency was 246 days (95% CI 203-289) median and was significantly longer for metal than for plastic stents (269 vs. 62 days, p < 0.01). The median survival was 12.4 months (95% CI 9.7-14.9 m) calculated from first PDT and 15.6 months (95% CI 12.3-18.7 m) calculated from initial diagnosis. In patients suffering from biliary tract cancer, Cox regression revealed the number of PDT treatment sessions as the only independent predictor of survival at a multivariate analysis (p = 0.048).

CONCLUSION

PDT using polyhematoporphyrin was feasible and safe in this nationwide analysis. Survival data suggest a benefit of PDT in this unselected real-life patient population. Prospective trials comparing PDT to other palliative treatments will help to define its role in the management of malignant biliary obstruction. The study is registered at ClinicalTrials.gov number: NCT02504957.

Photodynamic Therapy in Patients with Advanced Hilar Cholangiocarcinoma: Percutaneous Cholangioscopic Versus Peroral Transpapillary Approach

OBJECTIVE

This study aimed to compare the clinical outcomes of patients with advanced hilar cholangiocarcinoma (CC) who underwent photodynamic therapy (PDT) with either percutaneous transhepatic cholangioscopy (PTCS) or endoscopic retrograde cholangiopancreatography (ERCP).

BACKGROUND DATA

PDT has been proposed as a promising therapy for treatment of unresectable hilar CC that is resistant to conventional standard treatment. However, few studies have compared the delivery methods of PDT in unresectable hilar CC patients.

METHODS

Thirty-seven adult patients with advanced hilar CC were included in this study. Twenty-four patients treated with PTCS-directed PDT and 13 patients treated with ERCP-directed PDT were analyzed retrospectively.

RESULTS

The PTCS- and ERCP-directed PDT groups were comparable with respect to age, gender, health status, pretreatment bilirubin levels, Bismuth type, and hilar CC stage. The length of hospital stay differed significantly (p < 0.001) between the two groups, with a median hospital stay of 37 days (range, 13-77 days) in the ERCP-directed PDT group versus 63 days (range, 23-125 days) in the PTCS-directed group. PTCS-directed PDT patients demonstrated an overall survival similar to that of ERCP-directed PDT patients, with a median survival of 11.6 versus 9.5 months, respectively (p = 0.96). Only lower pre-PDT bilirubin levels (p = 0.002) were a significant predictor of improved survival in all patients who underwent PDT, as determined by multivariate analysis. Median metal stent patency was similar between the groups [PTCS-directed PDT group (n = 8), 6.2 months; ERCP-directed PDT group (n = 7), 7.2 months; p = 0.642]. Survival after PTCS- or ERCP-directed PDT was not statistically different in patients with advanced hilar CC.

CONCLUSIONS

Lower pre-PDT bilirubin levels were associated with longer survival in all patients.

Advances in endoscopic retrograde cholangiopancreatography for the treatment of cholangiocarcinoma

Cholangiocarcinoma (CCA) is a malignancy of the bile ducts that carries high morbidity and mortality. Patients with CCA typically present with obstructive jaundice, and associated complications of CCA include cholangitis and biliary sepsis. Endoscopic retrograde cholangiopancreatography (ERCP) is a valuable treatment modality for patients with CCA, as it enables internal drainage of blocked bile ducts and hepatic segments by using plastic or metal stents. While there remains debate as to if bilateral (or multi-segmental) hepatic drainage is required and/or superior to unilateral drainage, the underlying tenant of draining any persistently opacified bile ducts is paramount to good ERCP practice and good clinical outcomes. Endoscopic therapy for malignant biliary strictures from CCA has advanced to include ablative therapies via ERCP-directed photodynamic therapy (PDT) or radiofrequency ablation (RFA). While ERCP techniques cannot cure CCA, advancements in the field of ERCP have enabled us to improve upon the quality of life of patients with inoperable and incurable disease. ERCP-directed PDT has been used in lieu of brachytherapy to provide neoadjuvant local tumor control in patients with CCA who are awaiting liver transplantation. Lastly, mounting evidence suggests that palliative ERCP-directed PDT, and probably ERCP-directed RFA as well, offer a survival advantage to patients with this difficult-to-treat malignancy.

Role of photodynamic therapy and intraductal radiofrequency ablation in cholangiocarcinoma

Cholangiocarcinoma comprises 3% of all gastrointestinal malignancies. Prognosis is poor as the disease is locally advanced at the time of its presentation. Biliary endoprosthesis are widely used for biliary decompression, however, they only provides temporary relief. Photodynamic therapy and Radiofrequency ablation are two innovative approaches performed endoscopically to locally destruct the malignant tissue. This chapter focuses on their application and appropriate use along with their benefits and complications.

Current status of photodynamic therapy in digestive tract carcinoma in Japan

Photodynamic therapy (PDT) is an effective local treatment modality as a cancer-specific laser ablation in malignancy of some organs including digestive tracts or bile duct. In Japan, PDT has been applied at the early period after the first clinical induction in 1980’s. Although the useful efficacy was clarified, PDT has not been fully applied because of the phototoxicity of the porfimer sodium. The next generated talaporfin-sodium was used for PDT, in which phototoxicity was reduced and, however, the clinical efficacy for digestive tract malignancy has not yet been clarified. By proceeding the experimental and clinical trials, it is necessary to clarify the evidence of efficacy as a local powerful treatment with the conventional surgery, brachiotherapy and chemotherapy in the future step.

How to access photodynamic therapy for bile duct carcinoma

BACKGROUND

Photodynamic therapy (PDT) is a promising treatment option for local control of remnant cancer after surgical resection or biliary stenosis by the unresectable tumor in patients with bile duct carcinomas (BDC). To achieve effective tumor necrosis, an appropriate approach to laser irradiation is necessary.

METHODS

The efficacy of endoscopy-guided PDT using porfimer (n=12) or talaporfin sodium (n=13) was investigated by evaluating the transhepatic biliary routes and endoscopic retrograde biliary (ERB) routes in 25 patients with BDC.

RESULTS

Diseases included perihilar intrahepatic cholangiocarcinoma (ICC) in four patients, extrahepatic BDCs in 19 and ampular carcinoma (AC) in two patients. Adjuvant PDT after surgical resection was performed in 18 patients, and PDT for tumor biliary stenosis was performed in seven. In patients undergoing surgical resections, the mean period between the operation and PDT was 87±42 days. In patients who underwent prior surgical resections, the transhepatic route was used in five (28%), the jejunal loop was used in 11 (61%), the T-tube route was used in one, and the endoscopic retrograde cholangiography (ERC) route via papilla Vater was used in one. In unresectable BDC, the ERC route was used in four patients (57%), and the transhepatic biliary route was used in three (43%). Endoscopic-guided PDT could not be performed in one patient because of a technical failure. Except for the complication of photosensitivity, endoscopy-related complications were not observed in any patients. Patients undergoing PDT with porfimer sodium had a significantly longer admission period compared to patients undergoing PDT with talaporfin sodium (36 vs. 5 days, respectively) (P<0.01).

CONCLUSIONS

PDT was safely and definitively performed using the endoscopy-guided approach via the transhepatic or ERC route. By considering the disadvantages of both routes, PDT must be adequately achieved for local control of BDC.

Endoscopic treatment options for cholangiocarcinoma

Cholangiocarcinomas are often locally advanced or have metastasized, and at the time of diagnosis individuals often have a poor prognosis. Endoscopic treatment options traditionally include biliary decompression via stenting to allow for systemic chemotherapy and radiotherapy, with self-expanding metal biliary stents being preferred. Recent developments in locoregional therapy delivered endoscopically, such as photodynamic therapy and radiofrequency abalation, have shown promising results in improving patient survival.

Endoscopic treatment options for cholangiocarcinomas

Cholangiocellular carcinoma (CCC) is a very aggressive tumor, which remains highly resistant to current chemoradiation therapies. Death is usually caused by the tumor burden. However, biliary obstruction, which leads to cholangitis and liver failure, is also a cause of death. Therefore, relief of biliary obstruction is one of the key palliative treatment options for patients with hilar or distal CCC. Radiologic or endoscopic insertions of stents (plastic or self-expanding metal) are definite biliary drainage options. Whereas stents alone can help achieve relief of bile duct obstruction, endoscopic ablative interventions with photodynamic therapy or radiofrequency ablation are also useful in destroying intraluminal tumor. Destroying the tumor leads to an increase in the luminal diameter of the obstructed bile duct, allowing for placement of more or larger diameter stents, and thus improving bile flow. Besides decreasing morbidity associated with obstruction, ablative therapies such as photodynamic therapy have also been associated with improved survival in a sub-group of patients with CCC and should therefore be incorporated into the treatment algorithm of any center treating patients with CCC.

Randomised phase II trial of photodynamic therapy plus oral fluoropyrimidine, S-1, versus photodynamic therapy alone for unresectable hilar cholangiocarcinoma

BACKGROUND

Hilar cholangiocarcinoma is an uncommon cancer and its overall incidence is increasing. Photodynamic therapy (PDT) has been proposed as palliative management for unresectable hilar cholangiocarcinoma (UHC). To date, little is known about the role of the addition of systemic chemotherapy to PDT for UHC. We performed a prospective, randomised, phase II trial to compare PDT plus S-1 and PDT alone for UHC.

METHODS

Patients with UHC were randomly assigned (in a 1:1 ratio) to PDT plus S-1 or PDT alone. The primary end-point was overall survival. The secondary end-points were progression-free survival, complications, re-intervention rate and quality of life. This trial is registered with clinicalTrials.gov, number NCT00869635.

FINDINGS

Between February 2009 and May 2012, we randomly assigned 21 patients to receive PDT plus S-1 and 22 to receive PDT alone. The UHC patients treated with PDT plus S-1 showed higher 1-year survival rate compared with the patients treated with PDT alone (76.2% versus 32%, P=0.003) and prolonged overall survival (median 17 months, 95% confidence interval [CI]: 12.6-21.4, versus 8 months, 95% CI: 6-10, P=0.005, hazard ratio [HR], 0.36; 95% CI: 0.17-0.75). Regarding the secondary end-points, PDT plus S-1 was associated with prolonged progression-free survival compared with PDT alone (median 10 months [95% CI: 4.1-16] versus 2 months [95% CI: 0.4-3.5], P=0.009 (HR for progression 0.39, 95% CI: 0.19-0.83). There were no differences in the number of PDT sessions, the frequency of cholangitis, overall adverse events or the quality of life in either group.

INTERPRETATIONS

PDT plus S-1 was well tolerated and was associated with a significant improvement of overall survival and progression-free survival compared with PDT alone in patients with UHC. These findings warrant further clinical investigation of PDT plus S-1 in patients with UHC.

A review of the clinical diagnosis and therapy of cholangiocarcinoma

Cholangiocarcinoma (CCA) is the second most common primary hepatic malignancy worldwide. The incidence of intrahepatic CCA is increasing, whereas that of extrahepatic CCA is decreasing. This review looks at the new advances that have been made in the management of CCA, based on a PubMed and Science Citation Index search of results from randomized controlled trials, reviews, and cohort, prospective and retrospective studies. Aggressive interventional approaches and new histopathological techniques have been developed to make a histological diagnosis in patients with high risk factors or suspected CCA. Resectability of the tumour can now be assessed using multiple radiological imaging studies; the main prognostic factor after surgery is a histologically negative resection margin. Biliary drainage and/or portal vein embolization may be performed before extended radical resection, or liver transplantation may be undertaken in combination with neoadjuvant chemotherapy or chemoradiotherapy. Though many advances have been made in the management of CCA, the standard modality of treatment has not yet been established. This review focuses on the clinical options for different stages of CCA.

Photodynamic therapy in unresectable cholangiocarcinoma: not for the uncommitted

Background/Aims

Photodynamic therapy (PDT) in unresectable cholangiocarcinoma has been associated with improved survival. We report a single tertiary care center experience over the past 6 years.

Methods

Fifty-five patients with unresectable cholangiocarcinoma received PDT between 2004 and 2010. Plastic stents were placed after PDT to prevent cholangitis.

Results

Twenty-seven patients (49%) showed Bismuth type IV, 22 (41%) showed Bismuth type III, and six (10%) showed Bismuth type I and II. Twenty patients (37%) received chemotherapy and radiation therapy, five (9%) received chemotherapy only; and one (2%) received radiation therapy only. Mean number of PDT sessions was 1.9±1.5 sessions (range, 1 to 9). Mean survival duration was 293±266 days (median, 190; range, 25 to 1,332). PDT related complications included three (5%) facial burn, three (5%) photosensitivity, and two (3%) rash. Kaplan-Meier analysis comparing the survival means of patients who received PDT and chemotherapy/radiation therapy (median survival 257 days; 95% confidence interval [CI], 166 to 528) versus who received PDT only (median survival 183 days; 95% CI, 129 to 224) showed no significant difference (log-rank p=0.20).

Conclusions

PDT has a measurable impact on survival in unresectable cholangiocarcinoma but requires aggressive stenting posttherapy.

Endoscopic retrograde cholangiopancreatography for distal malignant biliary stricture

Endoscopic biliary stent placement is widely accepted as palliation for malignant biliary obstruction or as a treatment of benign biliary stricture. Although various biliary stent designs have become available since self-expandable metallic stents were introduced, no single ideal stent has been developed. An ideal stent should be patent until death, or surgery, in patients with resectable malignant biliary obstruction. Fewer complications, maneuverability, cost-effectiveness, and removability are also important factors. Alternatively, should we develop a novel method for biliary drainage other than biliary stenting via endoscopic retrograde cholangiopancreatography? This article reviews the current status of biliary stenting for malignant biliary obstructions.

Metal stents for hilar lesions

Strictures at the hilum are caused by varied conditions and don't usually become symptomatic until obstructing the bile ducts, thus posing diagnostic and therapeutic challenges to physicians. ERCP is the method of choice for tissue diagnosis and decompression. MRCP or MRI with dedicated liver protocol provides a unique ability to visualize anatomy and promote procedure planning. In patients with unresectable tumor, endoscopic biliary stenting is a palliative approach. Percutaneous or EUS-guided approach is reserved for endoscopic failure. Various new modalities such as radiotherapy, chemotherapy and Photodynamic therapy have emerged but their superiority needs to be confirmed with Randomized Control studies.

Photodynamic therapy for unresectable cholangiocarcinoma: a comparative effectiveness systematic review and meta-analyses

BACKGROUND

Photodynamic therapy (PDT) with placement of a biliary stent may improve bile duct patency in patients with cholangiocarcinoma (CCA). We aimed to determine the effectiveness of biliary stenting with PDT compared to biliary stenting alone in the palliative treatment of CCA.

MATERIALS AND METHODS

Several databases were searched from inception to December 2011 for prospective studies comparing biliary stenting with PDT vs. biliary stenting only for CCA. Outcomes of interest included patient survival, quality of life (using Karnofsky score), and serum bilirubin levels. The relative risk (RR) for dichotomous outcomes and the weighted mean difference (WMD) for continuous outcomes were estimated using DerSimonian and Laird random-effects model. Inconsistency was quantified using I(2) statistics. The extent of publication bias was ascertained by visual inspection of funnel plots and Egger's test.

RESULTS

There were six studies that met inclusion criteria. A total of 170 participants received PDT and 157 had biliary stenting only. Compared with biliary stenting, PDT was associated with a statistically significant increase in the length of survival (WMD 265 days; 95% CI: 154-376; p = 0.01; I(2) = 65%), improvement in Karnofsky scores (WMD 7.74; 95% CI: 3.73-11.76; p = 0.01; I(2)= 14%), and a trend for decline in serum bilirubin (WMD -2.92 mg/dL; 95% CI: -7.54 to 1.71; p=0.22; I(2) = 94%). The pooled event rate for biliary sepsis was 15% and was similar between PDT and control groups.

CONCLUSION

Palliative treatment of CCA with PDT is associated with increased survival benefit, improved biliary drainage, and quality of life. However, the quality of this evidence is low.

Photodynamic therapy for unresectable cholangiocarcinoma

Cholangiocarcinoma (CC) is a rare primary malignancy of the biliary tract with a dismal prognosis. Curative resection can only be applied to a small proportion of early diagnosed patients. Palliative biliary drainage by either percutaneous or endoscopic insertion of endoprostheses improves quality-of-life by reducing pruritis, cholangitis, and pain, but has been reported to improve survival time only slightly. Photodynamic therapy (PDT) is a relatively new local, minimally invasive palliative strategy for unresectable CC. PDT uses a photosensitive molecule that accumulates in proliferating tissue such as tumors. Activation of the photosensitizer by use of light of a specific wavelength generates reactive oxygen species leading to selective tumor-cell death. After initial feasibility studies and promising prospective phase II studies, results from two prospective randomized controlled trials comparing PDT after endoprostheses insertion with endoprostheses alone for patients with unresectable CC have been published. One study resulted in dramatically prolonged median survival in the PDT group (493 days) compared with the non-PDT group (98 days) (P < 0.0001), and significantly improved performance status (PS) in the PDT group. A second study with high baseline patients' PS confirmed the benefit of PDT for survival (630 days in the PDT group compared with 210 days for endoprostheses alone, P < 0.01). The procedures were generally well tolerated. PDT has also been reported to have a favorable outcome as adjuvant and neoadjuvant therapy for CC. Although accumulated data and local expertise are limited, PDT can be regarded as a standard palliative therapy for unresectable CC.

Feasibility and safety of long-term photodynamic therapy (PDT) in the palliative treatment of patients with hilar cholangiocarcinoma

Background and Aim

PDT is an important palliative option for patients with unresectable extrahepatic cholangiocarcinoma (CC). However, the results published to date reported on studies with no more than 6 (mostly up to 4) PDT procedures. Furthermore, the clinical experience of PDT in combination with chemotherapy is limited. The purpose of this retrospective analysis was to evaluate the feasibility and safety of multiple (4 to 14) settings of PDT, combined with biliary drainage, and (in some cases) with chemotherapy.

Methods

Ten patients with unresectable extrahepatic CC were treated with biliary stenting and at least 4 PDT procedures in our department between 10/2005 and 08/2010.

Results

Ten patients (male/female = 5/5), mean age 68.8 years (range, 54 - 81 years) who received at least 4 PDT procedures were analyzed. All patients underwent endoscopic biliary drainage. Nine patients received metallic stents and one patient a plastic stent. In 4 patients (40%) bilateral metal stenting (JoStent SelfX^®) was performed. The mean number of PDT sessions was 7.9 ± 3.9 (range: 4 - 14). Eight patients had elevated bilirubin levels with a mean bilirubin at admission of 9.9 ± 11.3 mg/dL, which had decreased to an average minimum of 1.2 ± 0.9 mg/dL after 3 months. No severe toxicity was noted. Two patients received concomitant chemotherapy (GEMCIS as 1^st line, GEMOX plus cetuximab as 2^nd line). The median overall survival has not been reached, whereas the estimated survival of all patients was 47.6 months, 95% CI 25.9 - 48.1.

Conclusion

Long-term PDT in patients with extrahepatic CC is feasible and effective and is accompanied - at least in this cohort- by a survival time of more than 2 years.

Combination of conservative and interventional therapy strategies for intra- and extrahepatic cholangiocellular carcinoma: a retrospective survival analysis

Background. Due to the predominantly advanced stage at the time of diagnosis treatment of cholangiocarcinoma is difficult. Apart from surgical resection, interventional treatment strategies are increasingly used in advanced stage tumours. The aim of the study was a retrospective comparison of the effect of the various forms of treatment on morbidity and mortality. Method. A total of 195 patients, received either chemotherapy or a combination of photodynamic therapy (PDT) or transarterial chemoembolization (TACE) and chemotherapy. Results. The median survival rate for all patients was 15.6 months, 50.8% were still alive 1 year after diagnosis. Patients, who had previously undergone surgery, survived 17.1 months longer than those without surgical treatment (P < .01). Chemotherapy prolonged the survival by 9.2 months (P = .47). Palliative patients under combination of chemotherapy and PDT survived on average 1.8 months longer (P = .28), with chemotherapy and TACE 9.8 months longer (P = .04) compared to chemotherapy alone. Conclusions. It appears that surgical treatment and chemotherapy combined with PDT or TACE may prolong survival.

Photodynamic therapy for unresectable cholangiocarcinoma: contribution of single operator cholangioscopy for targeted treatment

Photodynamic therapy (PDT) for unresectable cholangiocarcinoma is associated with improvement in cholestasis and survival. Single operator cholangioscopy (SOC) has been used for targeted laser illumination. We analyzed our growing experience of SOC with direct PDT. This is a retrospective analysis of a consecutive series of patients prospectively entered into a registry. Forty-five patients (24 male, aged 67.3 ± 10.6 years) were treated with PDT for cholangiocarcinoma during a five-year period. Thirty-two patients were treated with ERCP and PDT alone, and 13 were treated with ERCP and PDT using SOC. The two groups were then compared to observe any statistically significant difference in regards to age, gender, serum bilirubin, MELD score, adverse effects, or survival. An overall median of 1 PDT session per patient (range: 1-9) was performed. Twenty-six total sessions of PDT using SOC were performed in 13 patients with a median of 2.0 sessions per patient (range: 1-6). Median global survival was 168 days (range: 26-1353). Median survival for the PDT-only group was 200 days, and median survival for the PDT-with-SOC group was 386 days (p = 0.45). There was a statistically significant difference (p < 0.0001) between the two groups in regards to fluoroscopy time, with the PDT-only group having a median time of 21.1 min and the PDT-with-SOC group having a median time of 11.1 min. PDT related complications included 7 cases of mild phototoxicity and one case of moderate phototoxicity requiring hospitalization. SOC permits targeted therapy during PDT and can be successfully performed without adverse events while simultaneously reducing exposure to radiation.

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.

Photodynamic therapy: Palliation and endoscopic technique in cholangiocarcinoma

Cholangiocarcinoma is the primary malignancy arising from the biliary epithelium. The disease is marked by jaundice, cholestasis, and cholangitis. Over 50 percent of patients present with advanced stage disease, precluding curative surgical resection as an option of treatment. Prognosis is poor, and survival has been limited even after biliary decompression. Palliative management has become the standard of care for unresectable disease and has evolved to include an endoscopic approach. Photodynamic therapy (PDT) consists of administration of a photosensitizer followed by local irradiation with laser therapy. Several studies conducted in Europe and the United States have shown a marked improvement in the symptoms of cholestasis, survival, and quality of life. This article summarizes the published experience regarding PDT for cholangiocarcinoma and the steps required to administer this therapy safely.

Peroral direct cholangioscopic-guided biopsy and photodynamic therapy using an ultraslim upper endoscope for recurrent hepatocellular carcinoma with intraductal tiny nodular tumor growth

Bile-duct invasion is rare in patients with hepatocellular carcinoma (HCC). We report a case that received peroral direct cholangioscopy (PDCS)-guided endoscopic biopsy and photodynamic treatment (PDT) for recurrent HCC with intraductal tiny nodular tumor growth. A 64-year-old woman presented with recurrent right upper-quadrant pain. Six months previously she had been diagnosed with HCC with bile-duct invasion in the right anterior segment and had received right anterior segmentectomy. On pathological examination, the margin of resection was clear, but macroscopic bile-duct invasion was noted. On admission, magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography (ERCP) revealed a 0.5-cm-sized polypoid mass at the hilar portion. ERCP-guided biopsy failed, and an ampullary stricture was noted. PDCS-guided endoscopic biopsy was thus performed, and histopathology of the retrieved specimen revealed HCC. The patient submitted to PDT. There was no procedure-related complication. After 1 month of PDT the polypoid lesion and scar change at the hilar lesion had disappeared.

Photodynamic therapy for cholangiocarcinoma

Cholangiocarcinoma is the primary malignancy arising from the biliary epithelium, and it presents as jaundice, cholestasis, and cholangitis. Over 50 percent of patients present with advanced-stage disease, and the prognosis is poor with the survival measured in months even after biliary decompression. Palliative management has become the standard of care for unresectable disease, and this involves an endoscopic approach. Photodynamic therapy (PDT) involves the administration of a photosensitizer followed by local irradiation with laser therapy. The use of PDT for palliation of bile-duct tumors has produced promising results. Several studies conducted in Europe and the United States have shown that PDT produces a marked improvement in the symptoms of cholestasis, survival, and quality of life. This chapter summarizes the principle of PDT, the technique employed, and the published experience regarding PDT for cholangiocarcinoma.

Uptake and phototoxicity of meso-tetrahydroxyphenyl chlorine are highly variable in human biliary tract cancer cell lines and correlate with markers of differentiation and proliferation

Photodynamic therapy (PDT) using Photofrin and, recently, Foscan has gained broad acceptance for palliative treatment of non-resectable cholangiocarcinoma (CC). No information, however, is available whether the phenotype of CC tumour cells has an effect on the efficiency of the treatment. Using a well-characterised set of n = 9 biliary tract cancer cell lines this study investigated the uptake, phototoxicity, and release of meso-tetrahydroxyphenyl chlorine (mTHPC, Foscan) after incubation with 200 or 400 ng ml(-1) mTHPC. For uptake of mTHPC we found great variations between the individual cell lines (up to a factor 2), resulting in even more pronounced differences in phototoxicity. Based on statistical classification by hierarchical cluster analysis, two groups of cell lines can be distinguished which are characterised by either high or low susceptibility towards mTHPC-based photodynamic treatment. Correlation analysis with previously established immunochemical parameters showed that cells with a low cytokeratin-19 (ductal differentiation), high vimentin (mesenchymal marker), and high proliferative phenotype preferentially show higher uptake of mTHPC and subsequent phototoxicity. These results demonstrate high variability of biliary tract cancer cells when subjected to mTHPC-based photodynamic treatment and identify possible markers that could be used in the clinical setting in order to predict the efficiency of PDT and adjust the dose for complete tumour elimination.

Endoscopic retrograde cholangiopancreatography in the diagnosis and management of cholangiocarcinoma

Cholangiocarcinomas (CCAs) are rare malignancies that arise from the biliary epithelium. Intrahepatic CCAs usually present as mass lesions that are asymptomatic or cause nonspecific systemic symptoms such as fatigue, fever, and weight loss. Hilar and extrahepatic tumors most commonly present with jaundice, though cholangitis also can be seen. Tumor markers such as carbohydrate antigen 19-9 and carcinoembryonic antigen have been used to diagnose CCA, but these are nonspecific and may be elevated in infection, inflammation, or any obstruction. Endoscopic retrograde cholangiopancreatography (ERCP) has been used for the diagnosis and management of CCA for many years. This article summarizes the data regarding the application of ERCP in the diagnosis and management of CCA.

Biliary drainage, photodynamic therapy and chemotherapy for unresectable cholangiocarcinoma with jaundice

BACKGROUND AND AIM

The combination of photodynamic therapy and biliary stenting seems to be beneficial in the palliative treatment of unresectable cholangiocarcinoma. We aimed to assess the accuracy of photodynamic therapy in a single centre.

METHODS

Fourteen selected patients, with jaundice related to unresectable cholangiocarcinoma, underwent photodynamic therapy and biliary stenting (with or without chemotherapy). Photofrin was injected intravenously (2 mg/kg) 2 days before intraluminal photoactivation. In case of malignant progression, photodynamic therapy was repeated. The outcome parameters were overall survival and quality of life.

RESULTS

There were eight men and six women (median age: 67 [42-81]). Unresectability was related to a low Karnofski index (n = 2), peritoneal carcinomatosis (n = 4), vascular involvement (n = 3), invasion of the hepatoduodenal ligament (n = 2) and an under-sized liver remnant (n = 3). Biliary stenting was efficient (> or = 50% total bilirubin) in 78.5% of cases. Eight patients developed cholangitis. The mean number of photodynamic therapy procedures was two (1-4). Six (43%) patients needed > or = 2 procedures. No severe toxicity was noted. Photodynamic therapy improved the Karnofski index in 64% of cases. Six (42.8%) patients received concomitant chemotherapy (gemcitabine). The median survival time was 13.8 [0.7-29.2] months. The 3-, 6- and 12-month survival rates were 85%, 77% and 77%, respectively.

CONCLUSION

These results confirm the beneficial effect of biliary drainage, photodynamic therapy and chemotherapy for unresectable cholangiocarcinoma in selected patients with jaundice.

Inflammation and carcinogenesis of the biliary tract: update on endoscopic treatment

Both diagnosis and treatment of cholangiocarcinoma are suboptimal. From the former standpoint, fluorescence in situ hybridization, direct cholangioscopy, endocystoscopy, and optical coherence tomography are just a few of the myriad technologies being studied or employed to improve diagnostic yield. From the latter standpoint, most series suggest that fewer than 1 third of patients are resectable for cure, although liver transplantation has increasingly been used in a subset of cholangiocarcinoma patients with extrahepatic disease. Palliation has included chemotherapy which is of dubious value in most series. Instead, a majority of therapies have addressed mechanisms to improve biliary drainage to delay and preclude hepatic failure and minimize the risk of cholangitis. Although the latter has been accomplished with surgery and attempted with external beam irradiation and brachytherapy, percutaneous and/or endoscopic drainage are the most commonly employed methods in widespread use. There are prospective, randomized studies that suggest that bilateral stenting is associated with improved outcomes in bifurcation lesions if plastic stents are placed, that percutaneous transhepatic biliary drainage is more successful than endoscopic stenting in Klatskin tumors, that self-expandable biliary stents have prolonged patency compared with plastic prostheses, and that, if approached with computed tomography and magnetic resonance imaging guidance to preclude contamination of the contralateral undrained system, outcomes are comparable in patients treated with unilateral as opposed to bilateral self-expandable metal stents. There is a single prospective, randomized study suggesting that patients treated with endoscopic or percutaneous stenting in conjunction with photodynamic therapy have prolonged survival compared with stent placement alone.

Photodynamic therapy for cholangiocarcinoma: overview and new developments

PURPOSE OF REVIEW

Photodynamic therapy (PDT) with hematoporphyrins has emerged as promising treatment for nonresectable cholangiocarcinoma in several prospective observational studies and two randomized studies. This review describes the mechanism of action of PDT, gives an overview of clinical experience in cholangiocarcinoma and summarizes the results published in 2007 and 2008.

RECENT FINDINGS

The mechanism of action of PDT has been further elucidated. PDT induces an apoptotic, antiangiogenic as well as an immunomodulatory response. Interleukin-6, a bile duct epithelium growth factor correlating with tumor burden, decreases after PDT. The efficacy of PDT was confirmed in a comparative study in the United States. Patients with no visible mass on imaging studies, high serum albumin levels and treatment immediately after diagnosis seem to benefit most from PDT. Although it is recommended to perform PDT in bile ducts without stents in place, illumination through metal stents is possible if the light dose is adjusted. Meso-tetrahydroxyphenyl chlorine is a new potent photosensitizer for PDT of cholangiocarcinoma.

SUMMARY

In advanced nonresectable cholangiocarcinoma, PDT is the only evidence-based treatment that improves survival when compared with stenting. Therefore, PDT should be offered to those who are unsuitable for surgery.

Palliation of malignant obstructive jaundice

Peri-ampullary and hepatic malignancies will frequently present with obstructive jaundice. For unresectable tumors, effective and lasting decompression of the biliary tree is essential to improve quality of life and survival. An overview of present treatment modalities for palliation of obstructive jaundice is provided, including a systematic review of the English literature regarding the optimum choice of palliation.

Systematic review: photodynamic therapy for unresectable cholangiocarcinoma

BACKGROUND

Palliative therapies for unresectable cholangiocarcinoma such as stent, radiotherapy and chemotherapy have generally been disappointing. Therefore, it is necessary to find a new approach to fighting the disease. Several published clinical trials have reported the therapeutic effect of photodynamic therapy (PDT) for unresectable cholangiocarcinoma.

OBJECTIVE

To assess the safety and efficacy of photodynamic therapy for patients with unresectable cholangiocarcinoma.

METHODS

Relevant studies were retrieved from the Medline, Current Contents, Embase, and Cochrane Library databases. Inclusion of papers was determined by using a predetermined protocol; independent assessments and the final consensus decision were performed by two independent reviewers. Acceptable study designs included randomized controlled trials (RCTs), controlled clinical trials (CCTs), case studies, and case reports. Twenty studies met the inclusion criteria, and were tabulated and critically appraised in terms of characteristics, methods, outcomes, and complications.

RESULTS

Twenty studies were included. The quality of the available evidence was low to moderate with the majority of studies being uncontrolled before and after design and thus limited by the retrospective nature of much of the available data. After PDT, it is reported that bilirubin serum levels declined, quality of life improved and survival time increased in most of the patients. At the same time, there were few complications.

CONCLUSIONS

Based on currently available evidence, PDT was safe and effective for patients with inoperable cholangiocarcinoma.

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.

Photodynamic therapy of cholangiocarcinoma

Photodynamic therapy (PDT) is a local photochemical tumor treatment that consists of a photosensitizing agent in combination with laser irradiation of a distinct wavelength. In some case reports and small non-randomized pilot studies, PDT has proved feasible in patients with hilar bile duct cancer. Those studies showed an astonishing long survival time of the treated patients. In the yet published two randomized controlled studies, PDT showed a significant extension of survival compared to sole bile duct stenting. A possible explanation for this improved survival is a suspected anti-tumor immunological effect induced by PDT. PDT reaches the same level of survival time as incomplete resection. The main complication is a high risk of severe bacterial cholangitis and liver abscesses requiring peri-interventional antibiotics. Skin phototoxicity, which at the beginning of PDT was the most dreaded potential complication, seems to play an ancillary role using mild light protection. As the available photosensitizers, mainly hematoporphyrin derivative (HPD), are not very effective in terms of depth of tumor necrosis, newer photosensitizers with light absorption in the near infrared spectrum and therefore deeper penetration depth are currently under investigation.

Unresectable cholangiocarcinoma: comparison of survival in biliary stenting alone versus stenting with photodynamic therapy

BACKGROUND & AIMS

Photodynamic therapy (PDT) for unresectable cholangiocarcinoma is associated with improvement in cholestasis, quality of life, and potentially survival. We compared survival in patients with unresectable cholangiocarcinoma undergoing endoscopic retrograde cholangiopancreatography (ERCP) with PDT and stent placement with a group undergoing ERCP with stent placement alone.

METHODS

Forty-eight patients were palliated for unresectable cholangiocarcinoma during a 5-year period. Nineteen were treated with PDT and stents; 29 patients treated with biliary stents alone served as a control group. Multivariate analysis was performed by using Model for End-Stage Liver Disease score, age, treatment by chemotherapy or radiation, and number of ERCP procedures and PDT sessions to detect predictors of survival.

RESULTS

Kaplan-Meier analysis demonstrated improved survival in the PDT group compared with the stent only group (16.2 vs 7.4 months, P<.004). Mortality in the PDT group at 3, 6, and 12 months was 0%, 16%, and 56%, respectively. The corresponding mortality in the stent group was 28%, 52%, and 82%, respectively. The difference between the 2 groups was significant at 3 months and 6 months but not at 12 months. Only the number of ERCP procedures and number of PDT sessions were significant on multivariate analysis. Adverse events specific to PDT included 3 patients with skin phototoxicity requiring topical therapy only.

CONCLUSIONS

ERCP with PDT seems to increase survival in patients with unresectable cholangiocarcinoma when compared with ERCP alone. It remains to be proved whether this effect is attributable to PDT or the number of ERCP sessions. A prospective randomized multicenter study is required to confirm these data.

Cholangiocarcinoma

Cholangiocarcinoma is a primary hepatic malignancy originating from bile duct epithelium. It is the second most common primary hepatic neoplasia, and its incidence has increased within the last 3 decades. Although several risk factors have been identified, especially chronic biliary tract inflammation, most patients with cholangiocarcinoma have no identifiable risk factors. Recent developments in radiologic and molecular diagnostic methods have helped in the diagnosis of this disease. The only curative therapy is surgical resection or liver transplantation. For patients with advanced stage disease, survival remains limited. With growing understanding of the molecular and cellular etiology of this disease, new targeted therapies are being developed.

Factors associated with increased survival after photodynamic therapy for cholangiocarcinoma

BACKGROUND & AIMS

Recent studies have shown a survival advantage using photodynamic therapy (PDT) in patients with unresectable cholangiocarcinoma. Factors associated with increased survival after PDT are unknown.

METHODS

Twenty-five patients with cholangiocarcinoma who were treated with PDT at the Mayo Clinic Rochester from 1991 to 2004 were studied. Porfimer sodium (2 mg/kg) was administered intravenously to patients with Bismuth type I (3 patients), type III a/b (13 patients), and type IV (9 patients) tumors. Forty-eight hours later, PDT was administered using a 1.5- to 2.5-cm diffusing fiber that was advanced across the tumor by either retrograde (20 patients) or percutaneous (5 patients) cholangiography. Laser light was applied for a total energy of 180 J/cm2 in 1-3 applications. Patients received PDT treatments every 3 months. Plastic biliary stents (10-11.5 F) were inserted to decompress the biliary system after PDT. Survival analysis was performed using Kaplan-Meier curves and Cox proportional hazards models.

RESULTS

Patients were 64 (standard error of the mean, +/-2.6) years of age; 20 (80%) were men. The median overall survival period was 344 days. The median survival period after PDT was 214 days. The 1-year survival rate was 30%. On multivariate analysis, the presence of a visible mass on imaging studies (hazard ratio, 3.55; 95% confidence interval, 1.21-10.38), and increasing time between diagnosis and PDT (hazard ratio, 1.13; 95% confidence interval, 1.02-1.25) predicted a poorer survival rate after PDT. A higher serum albumin level (hazard ratio, 0.16; 95% confidence interval, 0.04-0.59) predicted a lower mortality rate after PDT.

CONCLUSIONS

Patients with unresectable cholangiocarcinoma without a visible mass may benefit from earlier treatment with PDT.

Advances in the endoscopic management of patients with pancreatic and biliary malignancies

Major advances in endoscopic techniques to diagnose and manage pancreatic biliary diseases have fundamentally changed the approach to these difficult clinical challenges. The diagnosis of benign and malignant pancreatic-biliary diseases is much more readily obtained through a combination of cross-sectional imaging and endoscopic procedures. Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) are the most important endoscopic tools for imaging and accessing the pancreatic biliary system. The review summarizes the major imaging methods for providing a diagnosis of bile duct malignancy, including ERCP, transhepatic cholangiography (THC), and magnetic resonance cholangiopancreatography (MRCP). High quality image examples of cholangiocarcinoma are provided. EUS has provided a new imaging modality for the detection of pancreatic and biliary malignancy. EUS is particularly sensitive for the detection of early pancreatic malignancy. Furthermore, EUS excels at the guidance of fine needle aspiration of pancreatic lesions. Diagnostic tissue acquisition for cholangiocarcinoma remains an important challenge. The endoscopic therapy for pancreatic-biliary malignancy involves the use of stenting which relieves the biliary obstruction commonly seen in these patients.