Photodynamic therapy and Klatskin tumour: An overview

Chemoradiation treatment with gemcitabine plus stereotactic body radiotherapy for unresectable, non-metastatic, locally advanced hilar cholangiocarcinoma. Results of a five year experience

BACKGROUND

Hilar cholangiocarcinoma (Klatskin tumor-KT) accounts for about 0.5-1.5% of all gastrointestinal cancers and for 40-60% of all biliary malignancies. Tumor resection is attainable in about 30-50% of patients. When resection is not possible other treatment options have little or no impact on survival. We present the results of hypofractionated Stereotactic Body Radiotherapy (SBRT) on a small series of non resectable locally advanced KT patients.

MATERIALS AND METHODS

Ten patients with histologically proven KT underwent SBRT plus gemcitabine. Radiotherapy (30Gy) was delivered in three fractions. Treatment toxicity was assessed according to the Common Terminology Criteria for Adverse Events (CTCAE v. 3.0). Alive patients with less than 1 year of follow up were excluded from the present study. Local control was assessed according to Response Evaluation Criteria in Solid Tumors (RECIST) criteria.

RESULTS

Two grade 1 and Two grade 2 acute toxicities were observed, moreover one grade 2 late toxicity was recorded. The overall local response ratio was 80% (4 PR+2 SD). SBRT showed a good efficacy in achieving local control. Median time to progression was 30 months. Two-year survival was 80% and four-year survival 30%. Six patients developed metastatic disease. Response to treatment and nodal metastases were the only independent indicators of prolonged survival.

CONCLUSIONS

The chemoradiation given by SBRT plus gemcitabine is a promising treatment for non-metastatic unresectable KT. High local control rates, even compared to historical data from conventional radiotherapy, can be achieved with minimal toxicity.

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.

Management of hilar biliary strictures

Biliary strictures at the liver hilum are caused by a heterogeneous group of benign and malignant conditions. In the absence of a clear-cut benign etiology, i.e. bile duct damage during surgery, hilar biliary strictures remain a diagnostic and therapeutic challenge for which a multidisciplinary approach is often necessary. A definitive diagnosis can be achieved in only 40-60% of the patients, while in all the other cases strictures are treated as though they are malignant until surgical pathology determines otherwise. Surgical resection is the only treatment that prolongs survival in patients with malignant strictures. Because these tumors frequently extend longitudinally via the hepatic ducts into the liver parenchyma, partial hepatic resection has been gradually added to biliary resection to ensure tumor-free surgical margins. For unresectable cases, endoscopic stenting of biliary obstruction is considered the preferred palliation modality to relieve pruritus, cholangitis, pain and jaundice, while the percutaneous approach has been reserved for cases of failure. Other modalities of treatment such as radiotherapy, chemotherapy, and photodynamic therapy currently remain investigational. For benign post surgical hilar strictures, surgical repair can be difficult and requires specific skills and experience. As an alternative, a multi-stent technique with endoscopic placement of an increasing number of stents over time until complete resolution of the stricture has been proposed.

Rupture of hepatocellular carcinoma into the biliary system with resulting bile duct thrombi: report of two cases

We report two cases of hepatocellular carcinoma revealed by jaundice and the presence of free-floating tumoural fragments within the biliary system. Two men (one of 64 and one of 73) presented with isolated jaundice. The results from ultrasound, CT and MRI were suggestive of a cholangiocarcinoma. Surgical intervention demonstrated bile duct thrombi from the primary tumour causing obstructive jaundice.