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

First-In-Human Computer-Optimized Endobronchial Ultrasound-Guided Interstitial Photodynamic Therapy for Patients With Extrabronchial or Endobronchial Obstructing Malignancies

Objective

Patients with inoperable extrabronchial or endobronchial tumors who are not candidates for curative radiotherapy have dire prognoses with no effective long-term treatment options. To reveal that our computer-optimized interstitial photodynamic therapy (I-PDT) is safe and potentially effective in the treatment of patients with inoperable extra or endobronchial malignancies inducing central airway obstructions.

Methods

High-spatial resolution computer simulations were used to personalize the light dose rate and dose for each tumor. Endobronchial ultrasound with a transbronchial needle was used to place the optical fibers within the tumor according to an individualized plan. The primary and secondary end points were safety and overall survival, respectively. An exploratory end point evaluated changes in immune markers.

Results

Eight patients received I-PDT with planning, and five of these received additional external beam PDT. Two additional patients received external beam PDT. The treatment was declared safe. Three of 10 patients are alive at 26.3, 12, and 8.3 months, respectively, after I-PDT. The treatments were able to deliver a prescribed light dose rate and dose to 87% to 100% and 18% to 92% of the tumor volumes, respectively. A marked increase in the proportion of monocytic myeloid-derived suppressor cells expressing programmed death-ligand 1 was measured in four of seven patients.

Conclusions

Image-guided light dosimetry for I-PDT with linear endobronchial ultrasound transbronchial needle is safe and potentially beneficial in increasing overall survival of patients. I-PDT has a positive effect on the immune response including an increase in the proportion of programmed death-ligand 1-expressing monocytic myeloid-derived suppressor cells.

Comparing palliative treatment options for cholangiocarcinoma: photodynamic therapy vs. radiofrequency ablation

Referral to an endoscopist is often done once curative resection is no longer an option for cholangiocarcinoma management. In such cases, palliation has become the main objective of the treatment. Photodynamic therapy and radiofrequency ablation can be performed to achieve palliation, with both procedures associated with improved stent patency and survival. Despite the greatly increased cost and association with photosensitivity, photodynamic therapy allows transmission to the entire biliary tree. In contrast, radiofrequency ablation is cheaper and faster to apply, but requires intraductal contact. This paper reviews both modalities and compares their efficacy and safety for bile duct cancer palliation.

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.

A systematic review of intraluminal high dose rate brachytherapy in the management of malignant biliary tract obstruction and cholangiocarcinoma

PURPOSE

To conduct a systematic review evaluating the impact of high dose rate (HDR) intraluminal brachytherapy (ILBT) in the management of malignant biliary obstruction and cholangiocarcinoma with specific focus on stent patency, clinical outcomes and toxicities.

METHODS AND MATERIALS

A review of published articles was conducted using Medline, Embase and Cochrane databases using the search terms "bile duct carcinoma" or "cholangiocarcinoma" or "bile duct neoplasms" in combination with "brachytherapy" or "high dose rate brachytherapy" or "HDR brachytherapy". Studies published in English and reporting outcomes of ≥10 patients were included in the review. Only the most recent experience was included if same patients were included in sequential publications.

RESULTS

Seventeen studies were identified that met the inclusion criteria. Significant heterogeneity was observed in treatment regimens, which included use of surgery, external beam radiation (EBRT), and/or intra-arterial and intravenous chemotherapy in conjunction with ILBT. Nevertheless, among the included studies, use of ILBT appeared to result in longer duration of stent patency: 10 months with ILBT compared to 4-6 months without ILBT. A trend was observed towards prolonged local control and improved complete and partial response rates in patients treated with ILBT with or without EBRT. Weighted mean overall survival of patients treated with ILBT alone was 11.8 months compared to 10.5 months for those that received EBRT +/- chemotherapy in addition to ILBT. The included studies reported low complication rates and toxicity related to ILBT.

CONCLUSION

Brachytherapy can be an effective and safe tool in the management of malignant biliary tract obstruction in combination with stenting. Both retrospective and prospective studies have suggested improved outcomes when HDR ILBT is combined with percutaneous stenting.

Extrahepatic cholangiocarcinoma: Current status of endoscopic approach and additional therapies

The prognosis of patients with advanced or unresectable extrahepatic cholangiocarcinoma is poor. More than 50% of patients with jaundice are inoperable at the time of first diagnosis. Endoscopic treatment in patients with obstructive jaundice ensures bile duct drainage in preoperative or palliative settings. Relief of symptoms (pain, pruritus, jaundice) and improvement in quality of life are the aims of palliative therapy. Stent implantation by endoscopic retrograde cholangiopancreatography is generally preferred for long-term palliation. There is a vast variety of plastic and metal stents, covered or uncovered. The stent choice depends on the expected length of survival, quality of life, costs and physician expertise. This review will provide the framework for the endoscopic minimally invasive therapy in extrahepatic cholangiocarcinoma. Moreover, additional therapies, such as brachytherapy, photodynamic therapy, radiofrequency ablation, chemotherapy, molecular-targeted therapy and/or immunotherapy by the endoscopic approach, are the nonsurgical methods associated with survival improvement rate and/or local symptom palliation.

Nonsurgical Approaches to Treat Biliary Tract and Liver Tumors

Endoscopic and percutaneous therapies have been shown to prolong life and reduce morbidity for patients with unresectable advanced stages of primary hepatobiliary malignancies. This article reviews pertinent studies published within the last 5 years that involve locoregional techniques to manage hepatocellular carcinoma, perihilar and distal cholangiocarcinoma. A major emphasis is placed on photodynamic therapy, radiofrequency ablation, irreversible electroporation, and microwave ablation. Technical advances, combinational therapies, and postintervention outcomes are discussed. Despite widespread application, high-quality evidence does not show superiority of any particular locoregional technique for treating advanced hepatobiliary cancers.

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.

WITHDRAWN: A comparative effectiveness meta-analysis of photodynamic therapy and stent drainage for unresectable cholangiocarcinoma

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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.

Photodynamic Therapy Plus Chemotherapy Compared with Photodynamic Therapy Alone in Hilar Nonresectable Cholangiocarcinoma

Background/Aims

Standard treatments are not available for hilar nonresectable cholangiocarcinoma (NCC). It is unknown whether combination therapy of photodynamic therapy (PDT) plus systemic chemotherapy is superior to PDT alone.

Methods

We retrospectively reviewed 68 patients with hilar NCC treated with either PDT plus chemotherapy (PTD-C) or PDT monotherapy (PDT-M). The primary endpoint was the mean overall survival rate. Secondary endpoints included the 1-year survival rate, risk of cholangitic complications, and outcomes, which were evaluated according to the chemotherapy protocol.

Results

More than 90% of the study population had advanced hilar NCC Bismuth type III or IV. In the PDT-M group (n=35), the mean survival time was 374 days compared with 520 days in the PDT-C group (n=33, p=0.021). The 1-year survival rate was significantly higher in the PDT-C group compared with the PDT-M group (88% vs 58%, p=0.001) with a significant reduction of mortality (hazard ratio, 0.20; 95% confidence interval, 0.07 to 0.58; p=0.003). Gemcitabine monotherapy resulted in a shorter survival time compared with the gemcitabine combination therapy (mean, 395 days vs 566 days; p=0.09). Cholangitic complications were observed at a similar frequency in the PDT-C and PDT-M groups.

Conclusions

Combining repeated PDT with a gemcitabine-based combination therapy might offer a significant survival benefit in patients with hilar NCC.

Radiological interventions in malignant biliary obstruction

Malignant biliary obstruction is commonly caused by gall bladder carcinoma, cholangiocarcinoma and metastatic nodes. Percutaneous interventions play an important role in managing these patients. Biliary drainage, which forms the major bulk of radiological interventions, can be palliative in inoperable patients or pre-operative to improve liver function prior to surgery. Other interventions include cholecystostomy and radiofrequency ablation. We present here the indications, contraindications, technique and complications of the radiological interventions performed in patients with malignant biliary obstruction.

Efficacy and safety of photodynamic therapy for unresectable cholangiocarcinoma: A meta-analysis

BACKGROUND

Photodynamic therapy with the placement of a biliary stent may improve the prognosis in patients with unresectable cholangiocarcinoma. The aim of this research is to determine the hazard ratio of photodynamic therapy with stent compared to biliary stenting alone or other therapies for the treatment of cholangiocarcinoma.

METHODS

Several databases were searched from inception to December 31 2013 for trials comparing photodynamic therapy+stent vs. stent-only or other treatments for cholangiocarcinoma. The outcomes of interest included patient survival, the changes of serum bilirubin levels, the quality of life (Karnofsky performance status), and adverse events. The hazard ratios (HR) were extracted from the survival curves using Tierney's Method. LnHR and its variance were pooled using an inverse variance-weighted average. Inconsistency was quantified using I(2) statistics.

RESULTS

In all, 8 trials comparing PDT+stent with other therapeutic methods were selected. We made a meta-analysis based on the 7 trials, which compared the result of PDT+stent and the stent-only group. HR summarizes the survival for the two groups. Overall survival was significantly better in patients who received photodynamic therapy than those who did not [HR=0.49, 95% confidence interval (CI), 0.33∼0.73, P=0.0005]. Among the 8 trials (642 subjects), 5 assessed the changes of serum bilirubin levels, and/or Karnofsky performance status, as other indications for improvement. In all, the incidence for phototoxic reaction is 11.11%. The incidence for other events in photodynamic therapy and the stent-only group was 13.64% and 12.79%, respectively.

CONCLUSION

The palliative treatment of cholangiocarcinoma, with photodynamic therapy, is associated with an increased survival benefit, an improved biliary drainage, and a better quality of life. However, the quality of this evidence is low.

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.

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.

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.

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.

Prognostic significance of snail expression in hilar cholangiocarcinoma

Many patients with hilar cholangiocarcinoma (HC) have a poor prognosis. Snail, a transcription factor and E-cadherin repressor, is a novel prognostic factor in many cancers. The aim of this study was to evaluate the relationship between snail and E-cadherin protein expression and the prognostic significance of snail expression in HC. We examined the protein expression of snail and E-cadherin in HC tissues from 47 patients (22 males and 25 females, mean age 61.2 years) using immunohistochemistry and RT-PCR. Proliferation rate was also evaluated in the same cases by the MIB1 index. High, low and negative snail protein expression was recorded in 18 (38%), 17 (36%), and 12 (26%) cases, respectively, and 40.4% (19/47) cases showed reduced E-cadherin protein expression in HC samples. No significant correlation was found between snail and E-cadherin protein expression levels (P = 0.056). No significant correlation was found between snail protein expression levels and gender, age, tumor grade, vascular or perineural invasion, nodal metastasis and invasion, or proliferative index. Cancer samples with positive snail protein expression were associated with poor survival compared with the negative expresser groups. Kaplan-Meier curves comparing different snail protein expression levels to survival showed highly significant separation (P < 0.0001, log-rank test). With multivariate analysis, only snail protein expression among all parameters was found to influence survival (P = 0.0003). We suggest that snail expression levels can predict poor survival regardless of pathological features and tumor proliferation. Immunohistochemical detection of snail protein expression levels in routine sections may provide the first biological prognostic marker.

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.

Clinical feasibility of direct peroral cholangioscopy-guided photodynamic therapy for inoperable cholangiocarcinoma performed by using an ultra-slim upper endoscope (with videos)

BACKGROUND

Photodynamic therapy (PDT) has emerged as a promising palliative treatment for inoperable cholangiocarcinoma. Cholangioscopy-guided PDT can be useful for identification of tumor margins, determination of the appropriate location for placement of the diffuser, and evaluation of the patient's response to therapy.

OBJECTIVE

To evaluate the feasibility of PDT under direct peroral cholangioscopy (POC) by using an ultra-slim upper endoscope in patients with inoperable cholangiocarcinoma.

DESIGN

Prospective, observational, pilot study.

SETTING

Single tertiary-care referral center.

PATIENTS

This study involved 9 patients with inoperable extrahepatic cholangiocarcinoma.

INTERVENTION

Photofrin II was administered intravenously 48 hours before PDT. Additional PDT was performed up to 48 hours after the initial application of therapy. A successful direct POC-guided PDT was defined as advancement of the endoscope into the distal margin of the tumor and maintenance of endoscope position until PDT was completed.

MAIN OUTCOME MEASUREMENTS

The clinical feasibility, usefulness, and complications of direct POC for PDT.

RESULTS

Seventeen sessions of direct POC for PDT were performed in 9 patients. PDT was performed successfully in 15 of 17 sessions (88.2%) and 7 of 9 patients (77.8%). Biliary drainage under direct POC, if necessary after PDT, was possible in 100% of patients (7/7). Follow-up direct POC confirmed significant tumor ablation after PDT in 5 patients. One patient reported mild skin redness; no major procedure-related complications were observed.

LIMITATIONS

Small sample size, pilot study.

CONCLUSION

Direct POC-guided PDT by using an ultra-slim upper endoscope seems to be both feasible and safe in select patients with inoperable extrahepatic cholangiocarcinoma.

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.

Cisplatin plus gemcitabine versus gemcitabine for biliary tract cancer

Evaluation of: Valle J, Wasan H, Palmer DH et al. Cisplatin plus gemcitabine versus gemcitabine for biliary tract cancer. N. Engl. J. Med. 362, 1273-1281 (2010). Biliary tract cancer is a rare disease and it is associated with a poor clinical outcome and survival. A standard therapy has not been established yet. The evaluated article reports on the first Phase III randomized controlled multicenter trial (ABC-02 trial) on palliative chemotherapy for biliary tract cancer. A total of 410 patients with locally advanced or metastatic cholangiocarcinoma, gallbladder cancer or ampullary cancer were included to receive either cisplatin followed by gemcitabine or gemcitabine alone for up to 24 weeks. The primary end point was overall survival and the secondary end point was progression-free survival. The median overall survival was 11.7 months in the cisplatin plus gemcitabine group and 8.1 months in the gemcitabine only group. The median progression-free survival was 8.0 months in the cisplatin plus gemcitabine group and 5.0 months in the gemcitabine-only group (p < 0.001). Adverse events were comparable in the two groups. Cisplatin plus gemcitabine, compared with gemcitabine alone, was associated with a significant survival advantage without an increase in substantial toxicity.