Stent placement with iodine-125 seeds strand effectively extends the duration of stent patency and survival in patients with unresectable malignant obstructive jaundice

Safety and efficacy of biliary stenting combined with iodine-125 seed strand followed by hepatic artery infusion chemotherapy plus lenvatinib with PD-1 inhibitor for the treatment of extrahepatic cholangiocarcinoma with malignant obstructive jaundice

Objectives

To evaluate the efficacy and safety of biliary stenting implantation with iodine-125 seed strand (SI) followed by hepatic artery infusion chemotherapy (HAIC) plus lenvatinib (Len) with programmed death-1 (PD-1) inhibitor for patients diagnosed with extrahepatic cholangiocarcinoma (ECC) and malignant obstructive jaundice (MOJ).

Methods

In this single-center retrospective study, the data of ECC patients with MOJ from March 2015 to January 2023 was assessed. Using probability score matching (PSM), the selection bias of patients was reduced. Primary study outcomes included overall survival (OS) and progression-free survival (PFS). The OS and PFS were performed using the Kaplan-Meier method and evaluated with the log-rank test.

Results

A total of 104 patients were enrolled finally, including 52 patients treated with interventional therapy (SI+HAIC) plus Len with PD-1 inhibitor (SI+HAIC+Len+P group) and 52 patients treated with interventional therapy (SI+HAIC) plus lenvatinib (SI+HAIC+Len group). 26 pairs of patients were matched after PSM analysis. After PSM analysis, the median OS and PFS in the SI+HAIC+Len+P group were significantly longer compared to those in the SI+HAIC+Len group (OS:16.6 vs. 12.3 months, P = 0.001; PFS:12.6 vs 8.5 months, P = 0.004). The DCR was significantly different between groups (P = 0.039), while ORR not (P = 0.548). The addition of PD-1 inhibitor was generally well tolerated without treatment-associated mortality.

Conclusion

Interventional therapy (SI+HAIC) plus Len with PD-1 inhibitor was effective for ECC patients accompanied by MOJ with a manageable safety profile.

Comparison of intraluminal brachytherapy combined with and without stent placement for treatment of obstructive jaundice induced by tumor thrombus

PURPOSE

To compare the safety and efficacy of intraluminal brachytherapy with iodine-125 (125I) seed strand implantation combined with and without stent placement to treat patients with obstructive jaundice induced by tumor thrombus.

METHODS

Between January 2018 and June 2022, 42 patients with malignant obstructive jaundice (MOJ) induced by tumor thrombus were included. 20 patients received 125I seed strand implantation and stent placement (group A). The remaining 22 patients, implanted 125I seed strands only, served as control (group B). The two groups' overall survival and jaundice-free survival were compared using the Kaplan-Meier method and log-rank test.

RESULTS

During the follow-up period, the mean survival time of group A was 38.0 ± 4.1 months (95%CI, 30.0-46.1 months), while that of group B was 25.1 ± 2.8 (95% CI, 19.5-30.6 months) (p = 0.406). The mean survival rates of 12 months for all patients, group A, and group B was 66.7%, 65%, and 68%, respectively. The mean jaundice-free survival of group A and group B were 34.0 ± 3.6 months (95% CI, 27.9-41.2months) and 22.9 ± 2.7 months (95%CI, 17.5-28.2months) (p = 0.254), respectively. Two PTBD drainage tube infection cases occurred in group A and group B separately.

CONCLUSIONS

125I intraluminal brachytherapy is an effective and safe therapy for treating patients with obstructive jaundice induced by tumor thrombus.

Biliary drainage combined with simultaneous 125I seed strand brachytherapy for the treatment of hilar cholangiocarcinoma

BACKGROUND

To evaluate the clinical efficacy of percutaneous biliary drainage (PBD) combined with ¹²⁵I seed strand brachytherapy (ISSB) for the treatment of hilar cholangiocarcinoma (HCCA).

METHODS

The clinical data of 64 patients with HCCA (median age 62.5, male 29, female 35) treated in our department from April 2017 to April 2021 were retrospectively analyzed. Thirty-four patients in the experimental group (EG) were treated with PBD combined with ISSB, while 30 patients in the control group (CG) were treated with PBD alone. The primary study endpoints were technical success, clinical success and the 2-month local tumor control (LTC) rate. Secondary endpoints were early/late complications, median progression-free survival (mPFS) and overall survival (mOS).

RESULTS

The technical and clinical success in the EG and CG showed no significant differences (100 vs. 100%, 94.1 vs. 93.3%, P > 0.05). Both early and late complications showed no significant differences between the two groups (P > 0.05). The 2-month LTC rates were significantly better in the EG versus the CG (94.1% vs. 26.7%, 157.7 ± 115.3 vs. 478.1 ± 235.3 U/ml), respectively (P < 0.05). The mPFS and mOS were 4.3 (95% CI 3.9-4.7) months and 2.8 (95% CI 2.5-3.1) months and 13.5 (95% CI 10.7-16.3) months and 8.8 (95% CI 7.8-9.8) months, respectively, with significant differences (P < 0.05).

CONCLUSION

PBD combined with ISSB is a safe and effective treatment for HCCA that can inhibit local tumors and prolong PFS and OS.

Percutaneous transhepatic cholangial drainage/percutaneous transhepatic biliary stent implantation for treatment of extrahepatic cholangiocarcinoma with obstructive jaundice

Extrahepatic cholangiocarcinoma is a malignant tumor originating from the extrahepatic bile duct including the hilar region to the lower bile duct of the common bile duct. With the development of interventional techniques and medical materials, percutaneous transhepatic cholangial drainage (PTCD) or percutaneous transhepatic biliary stent implantation (PTBS) has become the main treatment to relieve biliary obstruction. However, the occurrence of postoperative complications seriously affects the prognosis of patients, and the combination of biliary stenting with local treatment has been found to significantly prolong the time to biliary patency. This article reviews the progress of PTCD/PTBS in the treatment of extrahepatic cholangiocarcinoma with obstructive jaundice, evaluates its clinical efficacy, and points out the current problems and posible solutions to provide more reference for subsequent related studies.

An alternative palliative surgical method for advanced malignant obstructive jaundice: Laparoscopic bridge choledochoduodenostomy

Background

This study introduces an alternative palliative surgical procedure called laparoscopic bridge choledochoduodenostomy (LBCDD) for patients with advanced malignant obstructive jaundice (AMOJ).

Methods

Patients with AMOJ who had LBCDD between January 2017 and August 2021 were identified from databases of two institutions in China.

Results

A total of 35 patients (male 12; female 23) with an average age of 64 years were enrolled. The average diameter of the tumor is 4.24 cm. All patients undertook LBCDD within an average operation time of 75 min with a mean blood loss of 32 ml. One patient had controlled bile leakage after the operation and two developed surgical site infection involving the epigastric orifices. All of them were solved by conservative treatment. All patients were discharged smoothly after an average hospital stay of 5.5 days, and no conversion to open surgery was required.

Conclusions

LBCDD is a safe and efficient palliative surgery, which has a good therapeutic effect on patients with AMOJ.

Percutaneous biliary stent combined with brachytherapy using 125I seeds for treatment of unresectable malignant obstructive jaundice: A meta-analysis

BACKGROUND

Malignant obstructive jaundice (MOJ) is a common pathologic manifestation of malignant biliary obstruction. Recently, several clinical trials have explored the clinical effectiveness of intraluminal ¹²⁵I seed-based brachytherapy for MOJ patients, and various outcomes have been reported.

AIM

To assess the efficacy and safety of percutaneous biliary stents with ¹²⁵I seeds compared to conventional metal stents in patients with unresectable MOJ.

METHODS

A systematic search of English-language databases (PubMed, Embase, Cochrane Library, and Web of Science) was performed to identify studies published prior to June 2020 that compared stents with or without ¹²⁵I seeds in the treatment of unresectable MOJ. The outcomes analyzed included primary outcomes (stent patency and overall survival) and secondary outcomes (complications and liver function parameters).

RESULTS

Six randomized controlled trials and four retrospective studies involving 875 patients were eligible for the analysis. Of the 875 included patients, 404 were treated with ¹²⁵I seed stents, while 471 were treated with conventional stents. Unadjusted pooled analysis demonstrated that compared to conventional stents, ¹²⁵I seed stents extended the stent patency time [hazard ratio (HR) = 0.36, 95% confidence interval (CI) = 0.28-0.45, P < 0.0001] and overall survival period (HR = 0.52, 95%CI = 0.42–0.64, P < 0.00001). Subgroup analyses based on the type of ¹²⁵I seed stent and type of study design showed consistent results. However, there were no significant differences in the occurrence of total complications [odds ratio (OR) = 1.12, 95%CI = 0.75-1.67, P = 0.57], hemobilia (OR = 1.02, 95%CI = 0.45-2.3, P = 0.96), pancreatitis (OR = 1.79, 95%CI = 0.42-7.53, P = 0.43), cholangitis (OR = 1.13, 95%CI = 0.60-2.13, P = 0.71), or pain (OR = 0.67, 95%CI = 0.22-2, P = 0.47). In addition, there were no reductions in the levels of serum indices, including total bilirubin [mean difference (MD) = 10.96, 95%CI = -3.56-25.49, P = 0.14], direct bilirubin (MD = 7.37, 95%CI = -9.76-24.5, P = 0.4), alanine aminotransferase (MD = 7.52, 95%CI = -0.71-15.74, P = 0.07), and aspartate aminotransferase (MD = -4.77, 95%CI = -19.98-10.44, P = 0.54), after treatment. Publication bias was detected regarding the outcome overall survival; however, the conclusions were not changed after the adjustment.

CONCLUSION

Placement of stents combined with brachytherapy using ¹²⁵I seeds contributes to a longer stent patency and higher overall survival than placement of conventional stents without extra complications or severe liver damage. Thus, it can be considered an effective and safe treatment for unresectable MOJ.

Stent with radioactive strand insertion for inoperable hilar cholangiocarcinoma: comparison of unilateral and bilateral insertion

PURPOSE

To evaluate the relative clinical efficacy associated with the unilateral and bilateral insertion of a stent with a radioactive strand (RS) for the treatment of inoperable hilar cholangiocarcinoma (HCCA) patients.

METHODS

From January 2017 to June 2020, consecutive patients diagnosed with inoperable HCCA underwent either unilateral or bilateral stent with RS insertion in our hospital. Outcomes compared between these groups included rates of technical success, clinical success, stent-related complications, stent patency and overall survival (OS).

RESULTS

Unilateral and bilateral stent with RS insertion procedures were performed in 36 and 30 patients over the study period, respectively, with 100% technical and clinical success rates in both groups. No instances of procedure-related complications were reported. Cholangitis was observed in 7 (19.4%) and 6 (20%) patients in unilateral and bilateral groups (p= .955), respectively, while these groups exhibited respective cholecystitis in 2 (5.5%) and 1 (3.3%) cases, respectively (p=.662), and stent restenosis in 9 (25%) and 7 (23.3%) cases, respectively (p=.661). The median duration of stent patency in the unilateral and bilateral groups was comparable at 208 and 222 d, respectively (p=.889). All patients died over the course of follow-up, with similar median OS rates in the unilateral and bilateral groups of 250 and 246 d, respectively (p=.483).

CONCLUSIONS

These data indicated that similar inoperable HCCA patient clinical outcomes are achieved following stent with RS insertion regardless of whether it is conducted via a unilateral or bilateral approach.

125I Intracavitary Irradiation Combined with 125I Seeds Implantation for Treatment of Locally Advanced Pancreatic Head Cancer: A Retrospective Analysis of 67 Cases

Background

Pancreatic cancer is an aggressive malignant tumor of the digestive system and the fourth leading cause of tumor-related death. Intracavitary ¹²⁵I seed irradiation has been recently developed as a therapy for locally advanced pancreatic head carcinoma. However, there are still many limitations, and more investigations are needed in order to optimize this new treatment method.

Methods

Sixty-seven patients were included in our study; 41 cases treated by SEMS-CL-¹²⁵I intracavular irradiation (SEMS-CL-¹²⁵I group) and 26 cases treated by SEMS-CL-¹²⁵I intracavular irradiation combined with ¹²⁵I particle implantation in the tumor body (the combined group). Among the 67 patients, 43 were males and 24 were females, with an average age of 69.64±8.84 years. Tumor site size was determined based on the MRI or CT imaging scans, and the number and radius of ¹²⁵I particle placement were calculated according to a specific formula. ¹²⁵I particles were inserted into the tumor with a radius of 1.5 cm and a row spacing of 1 cm. The main postoperative biochemical indexes, imaging analysis, postoperative analgesia degree, median survival time and rate of complications were compared between the two groups.

Results

Jaundice and liver function improved in both groups after treatment for 6 months. The combined group did better. Kaplan–Meier analysis showed that patients in the combined group had a significantly better overall survival than those in the SEMS-CL-¹²⁵I group. Patients in the combined group had less complications than those in the SEMS-CL-¹²⁵I group (23.1% vs 34.1%), and the postoperative pain status of the combined group was improved (26.8% vs 53.8%).

Conclusion

Compared with the SEMS-CL-¹²⁵I intracavular irradiation alone, the combination of ¹²⁵I seed implantation with solid tumor ¹²⁵I seed implantation had a better therapeutic effect in LAPHC patients, with improved biochemical indicators, survival prognosis, pain relief, and fewer complications.

A stent with radioactive seed strand insertion for inoperable malignant biliary obstruction: A meta-analysis

PURPOSE

The purpose of the study was to assess the relative clinical effectiveness of stent insertion with or without radioactive seed strand (RSS) insertion in patients suffering from malignant biliary obstruction (MBO).

METHODS AND MATERIALS

Relevant articles published as of November 2020 in the Embase, PubMed, and Cochrane Library databases were identified and analyzed. Primary study endpoints for this meta-analysis were stent dysfunction, stent patency, and overall survival (OS), whereas secondary endpoints were rates of clinical success and complications. RevMan v5.3 was used to perform all meta-analyses.

RESULTS

In total, there were nine studies incorporating 643 patients (280 and 363 who underwent stent insertion with and without RSS, respectively). No differences were observed between these groups with respect to pooled rates of clinical success (p = 0.25), stent dysfunction (p = 0.47), cholangitis (p = 0.97), cholecystitis (p = 0.95), or pancreatitis (p = 0.66). However, stent patency duration (p < 0.00001) and patients' OS (p < 0.00001) were significantly increased in patients in the stent + RSS group. No heterogeneity was detected for any of these endpoints, nor did funnel plots yield any publication bias. A subgroup analysis of patients with hilar MBO similarly exhibited stent + RSS insertion to be associated with longer stent patency and OS as compared with stent insertion alone.

CONCLUSIONS

These findings showed that relative to stent insertion, stent + RSS insertion is associated with longer OS and stent patency in patients with inoperable MBO.

Stent Insertion With High Intensity-Focused Ultrasound Ablation for Biliary Obstruction Caused by Pancreatic Carcinoma: A Randomized Controlled Trial

PURPOSE

This study was designed to assess the clinical efficacy of stent insertion with high intensity-focused ultrasound ablation (HIFUA) in patients with malignant biliary obstruction (MBO) as a consequence of pancreatic carcinoma (PC).

MATERIALS AND METHODS

This was a single-center, open-label, prospective, randomized controlled trial. Consecutive patients with MBO caused by PC were randomly assigned to undergo stent insertion with or without HIFUA from June 2019 to February 2020. This study was registered at ClinicalTrials.gov (NCT03962478).

RESULTS

In total, 92 patients were enrolled in this study and assigned to the stent-only (n=46) or combined (stent+HIFUA; n=46) treatment groups. Stent insertion was associated with a 100% technical success rate. For patients in the combination treatment group, 26, 18, and 2 patients underwent 2, 3, and 4 cycles of HIFUA, respectively. A positive clinical response to HIFUA treatment was noted in 38 patients (82.6%). Stent dysfunction was detected in 9 and 15 patients in the combination and stent-only groups, respectively (P=0.154), while median stent patency in these 2 groups was 188 and 120 days, respectively (P<0.001). All patients died over the course of the follow-up, with median survival periods of 218 and 140 days in the combination and stent-only treatment groups, respectively (P=0.001). The only detected predictor of prolonged survival was HIFUA treatment (P=0.004), and there were no significant differences in complication rates between these 2 treatment groups.

CONCLUSION

A combination of stent insertion and HIFUA can improve stent patency and overall survival in patients suffering from MBO because of PC relative to stent insertion alone.