The role of photodynamic therapy for hilar cholangiocarcinoma

Long-term efficacy of percutaneous transhepatic cholangioscopy-guided photodynamic therapy for postoperative recurrent extrahepatic cholangiocarcinoma

BACKGROUND

Cholangiocarcinoma recurs frequently following excision surgery and is usually inoperable, while radiotherapy, chemotherapy, and immunotherapy are of limited benefit. As palliative care, percutaneous transhepatic cholangial drainage (PTCD) can relieve biliary obstruction, prevent jaundice, and maintain quality of life (QOL), but does not improve overall survival. In contrast, photodynamic therapy (PDT) has been demonstrated to prolong the survival of inoperable cancer patients.

OBJECTIVE

This study evaluated the clinical efficacy of percutaneous transhepatic cholangioscopy (PTCS)-guided PDT following PTCD versus PTCD alone for recurrent inoperable cholangiocarcinoma.

METHODS

The case files of 39 patients with postoperative recurrence were retrospectively analyzed, including 18 receiving PTCS-guided PDT (PTCS-PDT group) and 21 receiving PTCD only as a control (PTCD group). Survival time was compared by Kaplan-Meier analysis and log-rank test, and QOL by the Functional Assessment of Cancer Therapy-Hepatobiliary (FACT-HEP) questionnaire. Clinicodemographic factors, including serum bilirubin and adverse reaction rates, were compared by Student's t-test or Fisher's exact test. The maximum follow-up period was 71 months.

RESULTS

Median survival time was significantly longer in the PTCS-PDT group than the PTCD group (23 months vs. 10 months, P = 0.00001). At 6 and 12 months post-treatment, total FACT-HEP score was lower in the PTCS-PDT group (P < 0.05), indicating improved QOL. There was no significant difference in total adverse events incidence between groups (19 [51.4%] vs. 15 [71.4%]; P = 0.131).

CONCLUSION

PTCS-guided PDT can prolong survival and improve the QOL of patients with postoperative cholangiocarcinoma recurrence without increasing complications.

SIGNIFICANT AND/OR NEW FINDINGS

Compared to PTCD alone, PTCS-guided PDT significantly prolonged the survival time of patients with postoperative recurrent extrahepatic cholangiocarcinoma. Photodynamic therapy also improved patient quality of life by facilitating timely removal of the PTCD drainage tube. PTCS-guided PDT did not increase surgery-related complications except for skin phototoxicity, which can be easy avoided and treated.

Endoscopic management of benign and malignant hilar stricture

Management of hilar strictures pose a significant challenge for endoscopists. Several strategies have been demonstrated in the last decade beyond decompression, however, there remains controversy and minimal consensus in the literature. This review seeks to summarize the current literature and discuss emerging therapies, such as photodynamic therapy and radiofrequency ablation.

Role of ERCP in Malignant Hilar Biliary Obstruction

Malignant hilar biliary obstruction (MHO), an aggressive perihilar biliary obstruction caused by cholangiocarcinoma, gallbladder cancer, or other metastatic malignancies, has a poor prognosis. Surgical resection is the only curative treatment method for biliary malignancies. However, most of the patients with MHO cannot undergo surgeries on presentation because of an advanced inoperable state or a poor performance state due to old age or comorbid diseases. Therefore, palliative biliary drainage is mandatory to improve symptomatic jaundice and quality of life. Among drainage methods, endoscopic biliary drainage is the current standard for the palliation of unresectable advanced MHO. The development of stents and various accessories and advances in endoscopic techniques including endoscopic ultrasonography have facilitated primary endoscopic intervention in difficult high-grade hilar strictures. However, some issues are still under debate, such as palliation methods, appropriate stents, the number of stents, deployment methods, and additional local ablation therapies. Therefore, this review presents currently optimal endoscopic palliation methods for advanced MHO based on the reported literature.

The miR-34a/WNT7B modulates the sensitivity of cholangiocarcinoma cells to p53-mediated photodynamic therapy toxicity

Photodynamic therapy (PDT) provides apparent survival benefits for unresectable cholangiocarcinoma patients. the insufficient sensitivity of cancer cell to PDT treatment limits the clinical application. In this study, according to the GEO datasets, WNT7B expression was decreased by PDT treatment in cholangiocarcinoma samples. In cholangiocarcinoma cells, PDT treatment inhibited Wnt signaling, suppressed cell viability, and enhanced cell apoptosis. Within cholangiocarcinoma cells, PDT treatment induced p53 and miR-34a-5p expression. Under PDT treatment, p53 knockdown downregulated miR-34a-5p expression, whereas the inhibition effect of p53 knockdown on miR-34a-5p could be partially attenuated by agomir-34a-5p. p53 knockdown enhanced cell viability and suppressed cell apoptosis, whereas miR-34a-5p overexpression exerted opposite effects; miR-34a-5p overexpression partially attenuated p53 knockdown effects on PDT-treated cholangiocarcinoma cells. miR-34a-5p directly targeted WNT7B and inhibited WNT7B expression. Under PDT treatment, WNT7B knockdown inhibited the Wnt signaling and cell viability, and promoted cell apoptosis, while miR-34a-5p suppression showed the opposite trends; WNT7B knockdown partially attenuated miR-34a-5p inhibition effects on PDT-treated cholangiocarcinoma cells. In conclusion, PDT treatment induces p53-induced miR-34a transactivation to inhibit cholangiocarcinoma cell proliferation; the miR-34a-5p/WNT7B axis and Wnt signaling are involved.

Novel biliopancreatic duct endoscope combining optical coherence tomography with intraductal US for exploring the bile duct: a diagnostic study in a porcine model

BACKGROUND AND AIMS

Existing biliopancreatic duct endoscopy is deficient in the examination of early biliary and pancreatic tumors. This study aimed to evaluate the usefulness and feasibility of a novel ultrafine, separable, biliopancreatic duct endoscopy device with dual modalities of intraductal US (IDUS) and optical coherence tomography (OCT) for the in vivo assessment of the biliopancreatic duct system during ERCP.

METHODS

Five Bama miniature pigs were selected to probe their common bile duct and branches by using this novel equipment during ERCP. The feasibility of the procedure was evaluated by clear, clinically interpretable images obtained by using spiral scanning with the pull-back method. The clinical usefulness of the novel product was evaluated by postoperative choledochoscopy and assessment of the animal's general condition.

RESULTS

One hundred forty-one pairs of images from 5 Bama miniature pigs were acquired. Visualization of the bile duct using both OCT and IDUS was characterized by a differentiated 3-layer architecture, whereas IDUS had poor clarity when compared with OCT. Postoperative choledochoscopy showed no local lesion in the bile duct wall, and the general condition of animals was normal.

CONCLUSIONS

This prospective evaluation indicated the feasibility and potential clinical value of the novel, ultrafine, separable biliopancreatic duct endoscopy device. The fusion of the 2 imaging modalities can shed light on the early diagnosis of biliary and pancreatic tumors. Further studies will be carried out to establish diagnosis criteria with the dual-modality imaging using an animal pathologic model and a human clinical study.

[A Recent Update on Endoscopic Drainage of Advanced Malignant Hilar Obstruction]

Malignant hilar obstruction (MHO) is considered an aggressive perihilar obstruction caused by cholangiocarcinoma, gallbladder cancer, or metastatic malignancies and has a poor prognosis. Although surgical resection is the only curative treatment method, the majority of patients with MHO do not undergo surgery due to an advanced inoperable state at presentation. Currently, effective biliary drainage provides the necessary palliation for symptomatic improvement. Among the drainage methods, percutaneous access may be preferred, especially for advanced MHO because of the technical difficulty involved with other techniques. Recently, primary endoscopic palliation using plastic or metal stents has been shown to have higher technical feasibility and clinical success without increasing adverse events even in patients with high-degree MHO. The development of various accessories, endoscopic ultrasonography, and advances in techniques have facilitated primary endoscopic intervention. However, some aspects continue to be debated such as the palliation methods, appropriate stents, the number of stents, the deployment methods, and additional local ablation therapies. Therefore, this review discusses the current optimal endoscopic treatment methods for advanced MHO based on reported literature.

Laser ablation in biliary tree: analysis of the intraductal and superficial thermal effects during the treatment

The treatment of choice for the unresectable cholangiocarcinoma is based on biliary decompression procedures. Despite stent placement is the standard of care, it is related to well-known complications. Hence, alternative techniques were proposed. Ideally, they should guarantee an adequate intraductal disobstruction, without injuring the surrounding tissues.This pre-clinical study aims to investigate the thermal effects of the laser ablation (LA) in the biliary tree, in terms of intraductal and surrounding tissue temperature achieved with different laser settings. The common bile ducts (in their upper and lower portions) of two pigs were ablated for 6 minutes with a diode laser at 3 W and 5 W. A custom-made laser applicator was used to obtain a circumferential ablation within the ducts. The intraductal temperature (T_id) was monitored by means of a fiber Bragg grating (FBG) sensor, while an infrared thermal camera monitored the T distribution in the surrounding tissues (T_sup). A maximum T difference of 65 °C and 57 °C was evidenced between the two power settings for the T_id measured in the upper and lower ducts, respectively. The mean difference between T_id and the averaged T_sup values was evaluated. At 5 W, a difference of 37±3 °C and 44±10 °C were obtained for the upper and lower ducts, respectively. At 3 W, a T difference of 2±1 °C was obtained for the upper biliary duct, while a difference of 8±1 °C was documented for the lower duct. Based on the results obtained in this preliminary study, the possibility to equip the laser probe with temperature sensor can improve the control and the safety of the procedure; this solution will guarantee the monitoring of the treatment while preserving the lumen and the surrounding structures.

Laser ablation of the biliary tree: in vivo proof of concept as potential treatment of unresectable cholangiocarcinoma

OBJECTIVES

The palliative treatment of cholangiocarcinoma is based on stent placement with well-known procedure-related complications. Consequently, alternative energy-based techniques were put forward with controversial long-term results. This study aims to evaluate the safety and effectiveness of biliary tree laser ablation (LA) in terms of: (i) absence of perforation, (ii) temperature increase, (iii) induced thermal damage in in vivo models.

MATERIALS AND METHODS

The common bile duct and cystic ducts of two pigs were ablated with a diode laser (circumferential irradiation pattern) for 6 and 3 min at 7 W. Laser settings were chosen from previous ex vivo experiments. Local temperature was monitored through a fibre Bragg grating (FBG) sensor embedded into the laser delivery probe. Histopathological analysis of the ablated specimen was performed through in situ endomicroscopy, haematoxylin and eosin (H&E) and nicotinamide adenine dinucleotide (NADH) stains.

RESULTS

Temperature reached a plateau of 53 °C with consequent thermal damage on the application area, regardless of laser settings and application sites. No perforation was detected macroscopically or microscopically. At the H&E stain, wall integrity was always preserved. The NADH stain allowed to evaluate damage extension. It turned out that the ablation spreading width depended on application time and duct diameter. In situ endomicroscopy revealed a clear distinction between ablated and non-ablated areas.

CONCLUSIONS

The temperature distribution obtained through LA proved to induce a safe and effective intraductal coagulative necrosis of biliary ducts. These results represent the basis for further experiments on tumour-bearing models for the treatment of obstructive cholangiocarcinoma.

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.

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.

Biliary Tumor Ablation with Photodynamic Therapy and Radiofrequency Ablation

Within the past two decades, major progress has been made in biliary endoscopy both with stenting and with ablative therapy. A primary goal in patients with malignant biliary lesions who are not candidates for surgery is to provide localized and efficient necrosis of the lesions. This article summarizes the current literature on biliary tumor ablation with photodynamic therapy and radiofrequency ablation. Prognosis, treatment technique, potential complications, treatment efficacy, and controversies are discussed.

Validation of the diagnostic accuracy of probe-based confocal laser endomicroscopy for the characterization of indeterminate biliary strictures: results of a prospective multicenter international study

BACKGROUND

Characterization of indeterminate biliary strictures remains problematic. Tissue sampling is the criterion standard for confirming malignancy but has low sensitivity. Probe-based confocal laser endomicroscopy (pCLE) showed excellent sensitivity in a registry; however, it has not been validated in a prospective study.

OBJECTIVE

To prospectively validate pCLE in real time during ERCP for indeterminate biliary strictures.

DESIGN

Prospective, international, multicenter study.

SETTING

Six academic centers.

PATIENTS

A total of 136 patients with indeterminate biliary strictures.

INTERVENTIONS

Investigators provided a presumptive diagnosis based on the patient history, ERCP impression, and pCLE during the procedure before and after tissue sampling results were available. A presumptive diagnosis also was made separately by a blinded investigator during ERCP and after tissue sampling to estimate care without pCLE. Follow-up was at least 6 months.

MAIN OUTCOME MEASUREMENTS

Accuracy, sensitivity, and specificity during ERCP alone, ERCP with pCLE, and ERCP with pCLE and tissue sampling.

RESULTS

A total of 112 patients were evaluated (71 with malignant lesions). Tissue sampling alone was 56% sensitive, 100% specific, and 72% (95% confidence interval [CI], 63%-80%) accurate. pCLE with ERCP was 89% sensitive, 71% specific, and 82% (95% CI, 74%-89%) accurate. After tissue sampling returned, strictures could be characterized with 88% (95% CI, 81%-94%) accuracy.

LIMITATIONS

No randomization of care maps. pCLE not blinded.

CONCLUSION

pCLE provided a more accurate and sensitive diagnosis of cholangiocarcinoma compared with tissue sampling alone. Incorporation of pCLE into the diagnostic armamentarium of patients with indeterminate biliary strictures may allow for a more accurate assessment, potentially reducing delays in diagnosis and costly repeat testing. (

CLINICAL TRIAL REGISTRATION NUMBER

NCT01392274.).

Photodynamic Therapy using Talaporfin Sodium for the Recurrence of Cholangiocarcinoma after Surgical Resection

We herein report the case of a 72-year-old man who underwent photodynamic therapy (PDT) with talaporfin sodium for recurrent cholangiocarcinoma after surgical resection. Endoscopic retrograde cholangiography (ERC) showed severe stenosis with an irregular surface measuring approximately 1 cm in length from the anastomotic site, and a recurrent nodular lesion was observed at the anastomotic site of the right anterior intrahepatic bile duct on gastrointestinal endoscopy. ERC after PDT revealed a dramatic improvement in the bile duct stenosis, and the nodular lesion had disappeared. No adverse events from the PDT were detected. PDT using talaporfin sodium may be a safe alternative treatment for cholangiocarcinoma.

Long-term outcome of photodynamic therapy with systemic chemotherapy compared to photodynamic therapy alone in patients with advanced hilar cholangiocarcinoma

Background/Aims

Patients with cholangiocarcinoma usually present at an advanced stage, and more than 50% of cases are not resectable at the time of diagnosis. Recently, photodynamic therapy (PDT) has been proposed as a palliative and neoadjuvant modality. We evaluated whether combination of PDT and chemotherapy is more effective than PDT alone.

Methods

In total, 161 patients with cholangiocarcinoma diagnosed between February 1999 and September 2009 were evaluated. Sixteen patients were treated with PDT and chemotherapy (group A), and 58 were treated with PDT (group B).

Results

The median survival was 538 days (95% confidence interval [CI], 475.3 to 600.7) in group A and 334 days (95% CI, 252.5 to 415.5) in group B (p=0.05). Lymph node metastasis status, serum bilirubin of pretreatment, tumor node metastasis stage, treatment method (PDT with chemotherapy vs PDT alone), time to PDT and the number of PDT sessions were prognostic factors with statistical significance in the univariate analysis. A multivariate analysis showed that PDT with chemotherapy and more than two sessions of PDT were significant independent predictors of longer survival in advanced cholangiocarcinoma (hazard ratio [HR], 2.23; 95% CI, 1.18 to 4.20; p=0.013 vs HR, 1.79; 95% CI, 1.044 to 3.083; p=0.034).

Conclusions

PDT with chemotherapy results in longer survival than PDT alone.

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.

Photodynamic therapy prolongs metal stent patency in patients with unresectable hilar cholangiocarcinoma

AIM: To evaluate the effect of photodynamic therapy (PDT) on metal stent patency in patients with unresectable hilar cholangiocarcinoma (CC).

METHODS: This was a retrospective analysis of patients with hilar CC referred to our institution from December, 1999 to January, 2011. Out of 232 patients, thirty-three patients with unresectable hilar CC were treated. Eighteen patients in the PDT group were treated with uncovered metal stents after one session of PDT. Fifteen patients in the control group were treated with metal stents alone. Porfimer sodium (2 mg/kg) was administered intravenously to PDT patients. Forty-eight hours later, PDT was administered using a diffusing fiber that was advanced across the tumor by either endoscopic retrograde cholangiopancreatography or percutaneous cholangiography. After performance of PDT, uncovered metal stents were inserted to ensure adequate decompression and bile drainage. Patient survival rates and cumulative stent patency were calculated using Kaplan-Meier analysis with the log-rank test.

RESULTS: The PDT and control patients were comparable with respect to age, gender, health status, pre-treatment bilirubin, and hilar CC stage. When compared to control, the PDT group was associated with significantly prolonged stent patency (median 244 ± 66 and 177 ± 45 d, respectively, P = 0.002) and longer patient survival (median 356 ± 213 and 230 ± 73 d, respectively, P = 0.006). Early complication rates were similar between the groups (PDT group 17%, control group 13%) and all patients were treated conservatively. Stent malfunctions occurred in 14 PDT patients (78%) and 12 control patients (80%). Of these 26 patients, twenty-two were treated endoscopically and four were treated with external drainage.

CONCLUSION: Metal stenting after one session of PDT may be safe with acceptable complication rates. The PDT group was associated with a significantly longer stent patency than the control group in patients with unresectable hilar CC.

Reversal of Jaundice in Two Patients with Inoperable Cholangiocarcinoma Treated with Cisplatin and Gemcitabine Combination

Two patients are presented with severe jaundice, due to inoperable cholangiocarcinoma. The chemotherapeutic approach in patients with severe jaundice is discussed. Many schedules of chemotherapy were developed in this tumor type with normal serum bilirubin. We report here the first successful use of cisplatin and gemcitabine combination chemotherapy in these patients. Tolerability was good and liver function tests gradually improved.