Advances in systemic therapy for advanced pancreatobiliary malignancies

Results of Endoscopic Treatment of Recurrent Malignant Biliary Obstruction in Patients with Self-Expanding Metal Stents

BACKGROUND AND AIM

Endoscopic biliary drainage with placement of a self-expanding metal stent (SEMS) is the preferred palliative treatment of malignant biliary obstruction. Recent advances in the treatment have prolonged survival, thus, increasing the chance of recurrent biliary obstruction (RBO) after SEMS placement. The aim of this study was to compare different endoscopic approaches in patients with a SEMS and RBO, regarding clinical success and time to RBO.

METHODS

This retrospective study included all patients with a SEMS placed because of malignant biliary strictures who underwent endoscopic retrograde cholangiopancreatography between January 2011 and December 2018. We evaluated the results of different endoscopic interventions to RBO, including insertion of a new SEMS, stent cleaning, and insertion of a plastic stent (PS).

RESULTS

From January 2011 to December 2018, 70 (22.4%) patients developed RBO requiring endoscopic reintervention (n = 105 sessions). From the 105 ERCPs, technical success, clinical success, and adverse events rates were 91,4%, 71,8%, and 7,8%, respectively. Younger age (OR = 1.11 95%CI: 1.03-1.19) and the finding of a patent SEMS (OR = 0.17 95%CI: 0.04-0.08) were predictors of clinical failure (P = 0.006 and P = 0.024, respectively). The mean patency time (in days) after endoscopic reintervention was greater for SEMSs than for PSs (417.2 [95% CI: 250.0-584.4] vs 175.2 [95% CI: 124.0-226.5], P = 0.002).

CONCLUSIONS

Correct identification and treatment of the causal factor of RBO typically lead to technical and clinical success. Placement of a second SEMS provides longer patency compared to a plastic stent if ingrowth (overgrowth) occurs.

Phase Ib trial of gemcitabine with yttrium-90 in patients with hepatic metastasis of pancreatobiliary origin

Background

Gemcitabine, a chemotherapy for hepatic metastasis with pancreatic cancer (PC) or intrahepatic cholangiocarcinoma (ICC) origin, may radiosensitize the targeted tumor cells for yttrium-90 radioembolization (90Y-RE). This clinical trial was designed to investigate the effects of a combination of 90Y-RE and gemcitabine in hepatic metastasis of PC or ICC origin.

Methods

Fourteen patients who had histopathologic diagnosis of unresectable hepatic metastasis of PC or ICC origin were enrolled into the open-label phase Ib clinical trial. Induction dose of gemcitabine on day 1 was followed by 90Y-RE on day 2 with predetermined doses of gemcitabine to follow till week 12. Maximal tolerated dose (MTD) of gemcitabine in combination with 90Y-RE, associated toxicities and hepatic progression free survival (HPFS) were assessed. The tumor response rate was evaluated using both RECIST and PERCIST criteria.

Results

Eight patients met the study criteria; three with PC and five with ICC. The mean age of the patients was 69.4 years. Seven out of 8 patients tolerated predetermined gemcitabine regime (dose level 1 at 400 mg/m² and dose level 2 at 600 mg/m²). All of the patients developed grade 1 toxicities. Three patients (37.5%) had grade 2 hepatobiliary toxicity and one patient (12.5%) had grade 3 hepatobiliary toxicity, who was hospitalized for a short-term. The median HPFS was 8.7 months for all patients. The objective response rate was 62%.

Conclusions

A combination of 90Y-RE and gemcitabine at 600 mg/m² is a safe and potential treatment option for hepatic metastasis of pancreaticobiliary origin.