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Unresectable Hilar Cholangiocarcinoma: Multimodality Approach with Percutaneous Treatment Associated with Radiotherapy and Chemotherapy R. GOLFIERI1, E. GIAMPALMA1, M. RENZULLI1, A. GALUPPI2, L. VICENZI2, M.C. GALAVERNI1 and A. CAPPELLI1 1Unità
Operativa Radiologia Malpighi and 2Unità Operativa Radioterapia, Azienda Ospedaliero-Universitaria Policlinico S. Orsola-Malpighi, 40138, Bologna, Italy
Abstract. Klatskin-type cholangiocarcinoma is a rare tumor, bearing a very poor prognosis: at diagnosis, most patients can only undergo palliation. Evaluation of outcome, mean survival and quality of life was performed in patients with unresectable hilar cholangiocarcinoma treated with multimodality approach in comparison with surgical palliation, biliary stenting or brachytherapy alone. Twenty-six patients with hilar cholangiocarcinoma were studied: 16 patients were enrolled in the multimodality protocol (bilateral biliary drainage; Iridium192 brachytherapy; plastic endoprosthesis or metallic stent positioning and external radiotherapy plus systemic chemotherapy), 5 patients underwent surgical palliation and 5 percutaneous decompression alone. Nine patients completed the protocol and 7 were treated with brachytherapy followed by biliary stenting alone. The multimodality approach obtained mean survival (10 months) similar to that for surgery and higher than that of the brachytherapy and metallic stenting groups (6 and 2.75 months, respectively). The average hospital stay (15 days) was lower than that of the surgical group (20 days). A multimodality approach is a suitable alternative to palliative surgery of unresectable hilar cholangiocarcinoma. Cholangiocarcinoma (CLCA) is a rare tumor, accounting for 2 to 6% of all cancer patients, originating from the extrahepatic bile ducts, with high local invasiveness but uncommon distant metastases (1-3). The topographic classification has major prognostic value and identifies three types of cholangiocarcinoma: (i) CLCA in the lower third of
Correspondence to: Dr. Rita Golfieri, Department of Radiology, Sant’Orsola-Malpighi Hospital, Via Albertoni 15, 40138 Bologna, Italy. Tel: +390516362307, Fax: +390516362699, e-mail:
[email protected] Key Words: Biliary tract neoplasms, brachytherapy, radiotherapy, iridium radioisotopes, expandable metallic stents.
0258-851X/2006 $2.00+.40
the bile duct; (ii) CLCA in the middle third of the bile duct (common bile duct); and (iii) CLCA in the upper third of the bile duct, located at the hepatic duct confluence. The latter, also called Klatskin tumor, account for more than 50% of cases (4, 5) and are divided into four types by Bismuth (1), according to the location and extent of the tumor and carry a poorer prognosis since surgical resection is possible in only 0 to 47% of cases (5-7). Therefore, at the time of diagnosis, most patients can only undergo palliative treatments. Many therapeutic protocols using radiotherapy (intraluminal brachytherapy and external beam) combined with biliary decompression have been advocated to provide a resolution of jaundice associated with elective treatment of neoplastic stenosis (8-12). The aim of this study was to evaluate outcome and mean survival of the multimodality approach (percutaneous drainage of both right and left biliary systems; Iridium-192 intraluminal brachytherapy; replacement of the drainages with plastic endoprosthesis or metallic stents and external radiotherapy associated with systemic chemotherapy) in comparison with palliative surgical treatment, percutaneous decompression or brachytherapy alone.
Patients and Methods From January 1998 to December 2005, 26 patients with obstructive jaundice due to hepatic hilar cholangiocarcinoma were evaluated. All patients underwent the following diagnostic examinations: abdominal spiral CT to detect hepatic, lymphatic or peritoneal metastases; angiography of the celiac trunk and hepatic artery to detect arterial or portal infiltration; percutaneous transhepatic cholangiogram (PTC) to detect stenosis location, morphology and extent and position internal biliary drainage (PIBD) to obtain jaundice remission. According to the diagnostic findings (vascular infiltration, neoplastic extension to intrahepatic bile ducts and hepatic metastases), 16 patients with >3 cm tumor extension were considered unresectable and were enrolled in our multimodality protocol. Out of the remaining patients, five with a favourable
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in vivo 20: 757-760 (2006) anatomical (3 cm, an independent negative prognostic factor for the outcome of patients with hilar CLCA. An accurate evaluation of the diagnostic findings is mandatory in order to select suitable unresectable patients, thus avoiding an explorative laparotomy, and to enrol these patients in alternative treatment. In conclusion, in the absence of Randomized Controlled Trials comparing different palliative treatments, and based on our results, we believe that combined percutaneous and radiochemotherapy approach represents a valid alternative to surgical palliation of unresectable hilar cholangiocarcinoma, improving patient survival, with lower morbidity, shorter hospital stay and subsequent lower cost/benefit ratio.
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Received June 29, 2006 Revised October 13, 2006 Accepted October 16, 2006
