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. Fortyeight 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, pretreatment 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.     

Surgery for cholangiocarcinoma: the role of liver transplantation

Liver transplantation alone for unresectable hilar cholangiocarcinoma (CCA) is fraught with frequent recurrence and poor long-term survival. The Mayo Clinic developed a novel therapeutic protocol combining neoadjuvant chemoradiation and orthotopic liver transplantation (OLT) in 1993 to treat patients with unresectable hilar CCA or CCA arising in the setting of PSC. Aim. We recently reviewed our experience over the past 14 years with the specific aim to evaluate the long-term outcomes of CCA patients treated according to our study protocol. Methods. We analyzed data from all patients enrolled in the Mayo Clinic liver transplant protocol since 1993. Statistical data analysis of recurrence and survival rates was performed using the Kaplan-Meier method. Results. 148 patients were enrolled in the protocol. Of 90 patients who completed neoadjuvant therapy and subsequent OLT, 71 are alive and 19 have died – only 8 due to recurrent CCA. Nineteen patients are awaiting OLT and 39 were removed from the protocol owing to disease progression or death. Overall, 1-, 3-, and 5-year patient survival was 82%, 63%, and 55%, respectively; 1-, 3-, and 5-year survival after OLT was 90%, 80%, and 71%. Conclusions. Neoadjuvant chemoradiation and OLT achieves significantly lower recurrence and higher long-term survival rates than resection, OLT alone, or medical treatment in hilar CCA. Additional experience at independent transplant centers is necessary to confirm these encouraging results, address the role of neoadjuvant therapy and liver transplantation versus conventional resection, determine appropriate inclusion/exclusion criteria, and define the risk of disease progression while awaiting transplantation.     

CONTRAST‐FREE BALLOON‐ASSISTED UNILATERAL PLASTIC STENTING IN MALIGNANT HILAR BILIARY OBSTRUCTION: A NEW METHOD

Background: Unilateral endoscopic drainage in unresectable type II malignant hilar biliary obstruction is effective. Contrast injection leads to cholangitis. Recently, contrast‐free unilateral metal stenting in malignant hilar biliary obstruction has shown encouraging results, however, it is costly. Methods: We prospectively studied the outcome of unilateral balloon‐assisted plastic stenting in 15 patients with type II malignant hilar biliary obstruction without contrast. Results: A successful endoscopic drainage was achieved in 100% (15/15) patients. Cholangitis occurred in none and no patient died within 30 days. Mean patency of stent was 104.8 ± 18.3 days. Mean (±SD) survival of these patients was 129.5 ± 39.2 days. No major complications were observed. Conclusions: Unilateral endoscopic contrast‐free balloon‐assisted plastic stenting in type II malignant hilar biliary obstruction is a safe and effective method of palliation. However, a larger study is needed to validate the findings.     

SINGLE‐SESSION ENDOSCOPIC BILATERAL Y‐CONFIGURED PLACEMENT OF METAL STENTS FOR HILAR MALIGNANT BILIARY OBSTRUCTION

Background: The aim of this study was to evaluate the efficacy and safety of endoscopic bilateral biliary metal stent placement for hilar malignant obstruction. Patients and Methods: Twenty patients with unresectable malignant hilar biliary obstruction who had undergone endoscopic bilateral Y‐configured biliary drainage with metal stents were enrolled as a study group (YMS group). Thirty‐seven patients who had undergone bilateral drainage with plastic stents were selected as a historical control (PS group). Two newly designed metal stents for bilateral Y‐configured placement were endoscopically deployed in a partial stent‐in‐stent manner in one session. Technical success, early complications, and stent patency were evaluated. Results: The technical success rate in the YMS group was 100%. Mild post‐endoscopic retrograde cholangiopancreatography pancreatitis occurred in one patient in the YMS group and in two in the PS group. The success rate of biliary decompression was 95% in the YMS group and 89% in the PS group (P = 0.65). During a median follow‐up period of 7.3 months, the incidence of stent occlusion in the YMS group was significantly lower than that in the PS group (30% vs 62%, P = 0.028). Mean stent patency in the YMS group was 250 days and that in the PS group was 115 days (P = 0.0061). Risk factors for stent occlusion were bile duct cancer (P = 0.035) and the PS group (P = 0.07) by multivariate analysis. Conclusion: Single‐session endoscopic bilateral biliary placement of newly designed metal stents for hilar malignant obstruction is safe and useful with a high technical success rate and a long patency period.     

Comparison of salvage chemoradiation versus salvage surgery for recurrent esophageal squamous cell carcinoma after definitive radiochemotherapy or radiotherapy alone

A consensus treatment strategy for esophageal squamous cell carcinoma (ESCC) patients who recur after definitive radiochemotherapy/radiotherapy has not been established. This study compared the outcomes in ESCC patients who underwent salvage surgery, salvage chemoradiation (CRT) or best supportive care (BSC) for local recurrence. Ninety‐five patients with clinical stage I to III ESCC who had completely responded to the initial definitive radiochemotherapy or radiotherapy alone and developed local recurrence were enrolled in this study. Fifty‐one of them received salvage esophagectomy, and R0 resection was performed in 41 patients, 36 underwent salvage CRT, and the remaining eight patients received BSC only. The 5‐year overall survival was 4.6% for the 87 patients receiving salvage surgery or CRT, while all patients in the BSC group died within 12.0 months, the difference was statistically significant (P = 0.018). The 1‐, 3‐, 5‐year survival rates in the salvage surgery and salvage CRT groups were 45.1%, 20.0%, 6.9% and 51.7%, 12.2%, 3.1%, respectively, there was no difference of overall survival between the two groups (P = 0.697). Patients also presented with lymph node relapse had inferior survival compared to those with isolated local tumor recurrence after salvage therapy. In the salvage surgery group, infections occurred in eight patients, and three developed anastomotic leakage. In the salvage CRT group, grade 2–4 esophagitis and radiation pneumonitis was observed in 19 and 3 patients, respectively. Seven patients (19.4%) developed esophagotracheal fistula or esophageal perforation. This study of salvage CRT versus salvage surgery for recurrent ESCC after definitive radiochemotherapy or radiotherapy alone did not demonstrate a statistically significant survival difference, but the frequency of complications including esophagotracheal fistula and esophageal perforation following salvage CRT was high.     

Neoadjuvant therapy for downstaging of locally advanced hilar cholangiocarcinoma: a systematic review

Background

Hilar cholangiocarcinoma is a rare but highly lethal type of cancer. A minority of patients present with resectable disease. Surgery remains the only treatment modality offering a chance of long-term survival. Unresectable patients are typically offered palliative treatment. The aim of this systematic review was to summarize the evidence for neoadjuvant therapy followed by surgical resection in patients presenting with hilar cholangiocarcinoma.

Methods

Cochrane databases, Medline, PubMed and EMBASE were systematically searched to identify articles describing neoadjuvant therapy and surgical resection or re-assessment of resectability in patients with hilar cholangiocarcinoma. Included were all articles with original research. Study selection and data extraction were performed separately by two reviewers using a standardized protocol.

Results

From 732 articles 8 full text articles and 2 abstracts met the inclusion criteria. The 2 abstracts and 1 full text article were case reports, 3 articles were retrospective and 4 were prospective studies (2 phase I and 2 phase II studies). Photodynamic therapy, chemotherapy and radiation therapy were used in various indications in populations that included patients with hilar cholangiocarcinoma, some of which were primarily unresectable. Overall quality of articles was limited.

Conclusion

Current evidence suggests that neoadjuvant therapy in patients with unresectable hilar cholangiocarcinoma can be performed safely and in a selected group of patients can lead to subsequent surgical R0 resection. Surgical resection of downstaged patients should be assessed in properly designed phase II studies.     

Salvage radiation therapy and chemoradiation therapy for postoperative locoregional recurrence of esophageal cancer

The purpose of this retrospective study was to assess the efficacy of salvage radiation therapy (RT) or chemoradiation therapy (CRT) for locoregional recurrence (LR) of esophageal cancer after curative surgery. Forty‐two patients who received salvage RT or CRT for LR of esophageal cancer after curative surgery between November 2000 and May 2012 were reviewed. The intended RT regimen was 60 Gy in 30 fractions combined with concurrent platinum‐based chemotherapy. Median follow‐up periods were 17.9 months for all evaluable patients and 28.2 months for patients still alive (19 patients) at analysis time. The 1‐, 2‐, and 3‐year survival rates were 81.2 ± 6.4%, 51.3 ± 8.6%, and 41.1 ± 8.7%, respectively, with a median survival time of 24.3 ± 4.1 months. Out of 41 evaluable patients, 16 patients (39%) were alive beyond 2 years from salvage therapy. However, univariate analyses for overall survival showed no significant prognostic factor. Grade 3 or higher leukocytopenia was observed in 46% of the patients. Salvage RT or CRT for LR after surgery for esophageal cancer was safe and effective. These therapies may offer long‐term survival to some patients. RT or CRT should be considered for LR.     

Experience with miltefosine for persistent or relapsing visceral leishmaniasis in solid organ transplant recipients: A case series from Spain

The incidence of visceral leishmaniasis (VL) after solid organ transplantation (SOT) is increasing. The optimal therapy for post‐transplant VL remains unclear, as relapses after liposomal amphotericin B (L‐AmB) are common. Miltefosine has been shown to be effective for treating VL in immunocompetent patients, although data in the specific population of SOT recipients are lacking. In the setting of an outbreak of leishmaniasis occurring in Southwest Madrid, we reviewed our experience in 6 SOT recipients with persistent or relapsing VL who received a 28‐day course of miltefosine (2.5 mg/kg/day) as salvage therapy. All patients had been treated previously with L‐AmB as first‐line therapy. The incident episode of VL occurred at a median of 14 months after transplantation. Two patients experienced persistent infection and the remaining 4 had a relapse after a median interval of 168 days since the completion of the course of L‐AmB. All the patients had an apparent initial clinical improvement with miltefosine. However, VL relapsed in 3 of them (after a median interval of 46 days), which required retreatment with L‐AmB‐based regimens. Miltefosine therapy was followed by a prolonged secondary prophylaxis with L‐AmB in the only 2 cases with sustained clinical response and ongoing immunosuppression. No adverse effects associated with miltefosine were observed. Albeit limited, our experience suggests that miltefosine monotherapy likely has a limited utility to obtain a long‐lasting clinical response in complicated (persistent or relapsing) forms of post‐transplant VL, although its role in association with L‐AmB‐based secondary prophylaxis may merit further investigation.     

One-step percutaneous transhepatic insertion of a balloon-expanding metallic stent for obstructive jaundice

Background and Aim: The aim of this study was to evaluate the efficacy and safety of one‐step percutaneous transhepatic insertion of the Express LD stent, a balloon‐expanding stainless steel stent used for the management of distal artery stenosis in the treatment of obstructive jaundice caused by various inoperable malignancies. Methods: Seventy‐one consecutive patients with unresectable malignant biliary obstruction who underwent Express LD stent placement between 2007 and 2010 at our institute were reviewed. Results: Mean stent patency was 165 ± 144 days and mean patient survival was 180 ± 156 days, while the cumulative stent patency rate and patient survival rate at 6 and 12 months were 79% and 65%, and 38% and 16%, respectively. Stents were successfully placed in all cases without any stent migration or misplacement. Stent failure occurred in 14 patients (20%), and 16 complications were observed, including 12 cholangitis (17%), two cholecysitis (3%), and two pancreatitis (3%). Y‐configuration stenting for hilar bile duct obstruction was the only independent prognostic factor for stent failure. Conclusions: One‐step percutaneous transhepatic insertion of the Express LD stent is effective and safe for the management of obstructive jaundice caused by inoperable malignancies.     

PLASTIC STENT PLACEMENT FOR UNRESECTABLE MALIGNANT BILIARY STRICTURE

Background: Endoscopic stent placement is an efficacious treatment for patients with malignant biliary stricture. We investigated the indications for plastic stent placement in patients with unresectable malignant biliary stricture. Patients and methods: Eighty‐three patients with unresectable malignant biliary stricture who had undergone endoscopic placement of either a plastic stent or a covered metal stent in our department between February 1997 and September 2002 were reviewed retrospectively. Results: Metal stents had significantly longer patency (273 ± 99 days) than plastic stents (155 ± 52 days) (P = 0.0292). The two groups showed similar patency curves up to 150 days. Conclusions: The indication for plastic stent placement as palliative therapy for unresectable malignant biliary stricture is drainage for patients with an expected survival of less than 5 months.     

多学科协作诊治模式下治疗不可切除结直肠癌67例

目的:总结多学科协作诊治模式下治疗不可切除结直肠癌的经验.方法:本研究纳入67例符合条件的患者,其中男38例,女29例,平均年龄为55.62岁,右半结肠癌15例,左半结肠癌9例,直肠癌43例.67例患者均经综合治疗小组评估为不可切除,且组织学证实为结直肠癌.患者的治疗由结直肠专科医师与多学科组成的综合治疗小组完成.结果:67例患者中,无完全缓解(CR)病例,部分缓解(PR)43例,稳定(ND)16例,进展(PD)8例;近期症状缓解率100%;生存期10-38mo,平均24mo;9例患者实施了根治性手术,外科干预比例为13.4%(9/67);总并发症发生率为52.2%(35/67).结论:采用综合治疗方式,包括全身化疗、介入化疗、局部放疗、分子靶向治疗、中医中药治疗、手术治疗以及针对病灶的局部治疗,可提高不可切除结直肠癌患者的生存质量,延长存活时间.     

Complete eradication of hepatic metastasis from colorectal cancer by Yttrium-90 SIRT

Yttrium-90 (Y-90) radioembolization,also known as selective internal radiation therapy (SIRT),is a regional hepatic therapy used in the treatment of unresectable colorectal cancer (CRC) liver metastases. In SIRT,Y-90 impregnated microspheres are injected into the VASCULAR SUPPLY of hepatic tumor,leading to selective irradiation and necrosis of tumor TISSUE. While several studies demonstrate improved local control and survival with SIRT,the specific indications for this therapy have yet to be defined. Typically,SIRT is given in combination with chemotherapy as multimodal treatment for unresectable hepatic CRC. However,it HAS ALSO FOUND INCREASING USE as a salvage therapy in chemo-refractory patients. Herein,the authors describe their experience with SIRT as "stand alone" therapy in a surgically-prohibitive,chemotherapy naive patient with hepatic CRC metastasis. The results suggest that Y-90 SIRT may have potential applications beyond its usual role as a palliative or salvage therapy for unresectable hepatic CRC.     

Second autologous transplant as salvage therapy in multiple myeloma

High‐dose chemotherapy followed by autologous haematopoetic stem cell transplantation (ASCT) is a standard frontline therapy for multiple myeloma (MM). Unfortunately, there are no randomized clinical studies examining the role of a second ASCT in patients who relapse after the initial autotransplant. Analysing all available retrospective studies, it seems that salvage ASCT can safely be performed in most patients with an overall treatment‐related mortality rate <5%. Approximately 65% of patients will achieve an objective response and progression‐free and overall survival will be around 12 months and 32 months, respectively. Retrospective data suggest that patients with a progression‐free survival of ≥18 months after initial ASCT are most likely to benefit from a salvage autotransplant. However, patients with a <12‐month duration of response after initial ASCT should not be considered for a second autograft in the relapsed setting because this group will probably only experience ASCT‐related toxicity without any clinical benefit. Quality of response after initial ASCT and number of therapies preceding salvage ASCT may also have a predictive value. Importantly, these findings need to be verified by randomized clinical trials in order to firmly integrate salvage ASCT into a global therapeutic concept for myeloma patients including optimized induction, consolidation, and maintenance approaches.     

UNILATERAL VERSUS BILATERAL DRAINAGE USING SELF‐EXPANDABLE METALLIC STENT FOR UNRESECTABLE HILAR BILIARY OBSTRUCTION

Background: There is no consensus on the choice of either unilateral or bilateral drainage in stent placement for patients with unresectable hilar biliary obstruction. The aim of the present study was to clarify which drainage method is superior. Methods: We retrospectively reviewed 82 patients with hilar biliary obstruction who underwent metallic stenting. These patients were divided into a unilateral drainage group (Uni group) and a bilateral drainage group (Bi group). Results: There was no significant difference between the groups in median survival time, median stent patency period, and median complication‐free survival time. The most frequent complication was stent obstruction, followed by cholangitis. Liver abscess was found at a higher frequency in the Bi group (17.6%) than in the Uni group (1.5%) (P = 0.0266). There was no significant difference between the groups in the occurrence of two or more complications (P = 0.247), life‐threatening severe complications (P = 0.0577), and stent obstruction by sludge (P = 0.0912). Conclusion: When compared with bilateral biliary drainage, unilateral biliary drainage is associated with a lower incidence of liver abscess as well as a comparable outcome of stent patency time and complication‐free survival. We therefore propose that hilar biliary obstruction can be treated first by unilateral drainage with a metallic stent and by bilateral drainage only in patients who develop cholangitis in the contralateral biliary tree.     

Endoscopic intraluminal brachytherapy and metal stent in malignant hilar biliary obstruction: a pilot study.

BACKGROUND/AIMS: Malignant hilar biliary obstruction carries a poor prognosis, as the disease is often unresectable at the time of diagnosis. Various palliative measures as surgical/radiological/ endoscopic drainage with or without radiotherapy/chemotherapy have been tried with dismal outcome. We prospectively studied the effect of unilateral metal stent with intraluminal high dose rate (HDR) brachytherapy in patients with type II malignant hilar biliary obstruction. METHODS: Eight patients with type II malignant hilar biliary obstruction were treated with contrast-free unilateral metal stenting followed by endoscopic intraluminal brachytherapy (ILBT). A retrospectively analyzed group of 10 patients treated only with contrast-free unilateral metal stenting served as historical controls. RESULTS: A successful drainage was achieved in all, cholangitis occurred in none and no patient died within 30 days in both groups. The mean (+/-SD) patency of metal stent was 305 (+/-183.96) days and 143.9(+/-115.11) days in patients with and without intraluminal brachytherapy, respectively (P=0.03). Mean (+/-SD) survival of these patients was 310 (+/-192.68) days and 154.9 (+/-122.51) days in patients with and without intraluminal brachytherapy, respectively (P=0.05). Kaplan-Meier analysis showed estimated median survival of 225 (95% CI; 169.5, 280.4) days in brachytherapy and 100 (95%CI; 94.1, 105.8) days in control group (P=0.025). No major complications related to metal stent or ILBT were observed. CONCLUSIONS: Contrast-free unilateral metal stenting with HDR ILBT in type II malignant hilar biliary obstruction is a safe and effective method of palliation and appears to prolong patient survival as well as patency of stent in these patients, however, a larger, randomized trial is required to validate the same.     

Metallic stents are more efficacious than plastic stents in unresectable malignant hilar biliary strictures: a randomized controlled trial

Background

Endoscopic biliary stenting is a well-established palliative treatment for unresectable malignant biliary strictures, for which plastic tube stents (PSs) and self-expandable metallic stents (SEMSs) are most commonly used. The efficacy of these stents has been extensively described in distal biliary strictures, but not in hilar biliary strictures. The present study aimed to compare the efficacy of PSs and SEMSs for unresectable malignant hilar biliary strictures.

Methods

From June 2004 to November 2008, 60 patients were enrolled and prospectively randomized into the PS or SEMS group.

Results

The 6-month patency rate was significantly higher in the SEMS group than in the PS group (81 vs. 20%; p = 0.0012). Kaplan–Meier analysis showed significantly longer patency in the SEMS group than in the PS group (p = 0.0002); the 50% patency period was 359 days in the SEMS group and 112 days in the PS group. There was no significant difference in the overall survival period between the PS and SEMS groups (p = 0.2834). The mean number of reinterventions for stent failures was significantly lower in the SEMS group (0.63 times/patient) than in the PS group (1.80 times/patient) (p = 0.0008). The overall total cost for the treatment was significantly lower in the SEMS group than in the PS group (p = 0.0222).

Conclusions

SEMSs were associated with a longer patency than PSs in patients with unresectable hilar biliary stricture. SEMSs were also more advantageous in reducing the number of reintervention sessions and the overall treatment cost.     

Importance of the angiosome concept for endovascular therapy in patients with critical limb ischemia

Objective: We investigated the role of the angiosome concept in endovascular therapy (EVT) for limb salvage. Background: The angiosome concept is clinically useful in bypass surgery for critical limbs ischemia (CLI). However, comparison with direct and indirect flow to the site of ulceration based on angiosome concept regarding freedom from amputation has not been systematically studied for the patient with CLI undergoing EVT. Methods: We analyzed 203 limbs in 177 consecutive patients (male = 127, age = 70 ± 11 years) with ischemic ulceration that was Rutherford 5 or 6 (5 in 145 limbs and 6 in 58 limbs; pretreatment ankle‐brachial index = 0.74 ± 0.27), who underwent EVT alone without bypass surgery. We classified these patients into direct and indirect groups depending on whether feeding artery flow to the site of ulceration was successfully acquired or not acquired based on the angiosome concept. Freedom from amputation was compared between the direct and the indirect groups by Kaplan‐Meier analysis. Results: The overall limb salvage rate was 82% (167/203). Skin perfusion pressure was significantly higher in the direct group (67 ± 25 mm Hg) than in the indirect group (41 ± 20 mm Hg, P = 0.002). The limb salvage rate was also significantly (P = 0.03) higher in the direct group (86%) than in the indirect group (69%) for up to 4 years after the procedure. The number of vessels with run‐off flow did not influence the limb salvage rate in either the direct group (P = 0.84) or the indirect group (P = 0.90). Conclusion: Acquiring direct flow based on the angiosome concept is important for limb salvage by EVT in patients with CLI.© 2010 Wiley‐Liss, Inc.     

以多西他赛为主二联与三联疗法对老年低分化胃癌的疗效对比分析

目的对比以多西他赛为主二联和三联疗法对老年低分化胃癌的临床效果。方法将60例老年低分化胃癌患者随机分成三联化疗组和二联化疗组,每组30例。二联化疗组给予多西他赛联合奥沙利铂方案化疗,三联化疗组给予多西他赛联合奥沙利铂、替吉奥方案化疗。对两组近期疗效、KPS评分、肿瘤进展时间(TTP)、生存时间(OS)及不良反应进行比较。结果二联化疗组客观缓解率、临床获益率为36.7%、63.3%,三联化疗组客观缓解率、临床获益率为33.3%、70.0%,差异无统计学意义(P0.05);治疗后,二联化疗组KPS评分为(71.5±6.6)分,显著性低于三联化疗组的(79.5±7.9)分,差异有统计学意义(P0.05);二联化疗组TTP为8.5个月,三联化疗组TTP为8.7个月,差异无统计学意义(P0.05);二联化疗组OS为13.4个月,三联化疗组OS为15.1个月,差异无统计学意义(P0.05);二联化疗组不良反应(白细胞降低、贫血、乏力)率显著低于三联化疗组,差异有统计学意义(P0.05)。结论相比于多西他赛为主三联疗法,多西他赛为主二联疗法对对老年低分化胃癌效果同样显著,且不良反应较少,适合老年人使用。     

Management of unresectable hilar bile duct cancer--preoperative diagnosis,treatment selection,and clinical outcome

BACKGROUND/AIMS: Hilar bile duct cancer progresses slowly but easily invades the nearby portal vein or hepatic artery. Thus, in some cases, curative resection is impossible, so we need to determine the best non-surgical treatments for this tumor. METHODOLOGY: We classified 98 patients with hilar bile duct cancer into 3 categories: a non-surgical group (34 cases), an exploratory laparotomy group (9 cases), and a surgical resection group (55 cases). Survival rates were examined in the light of clinical factors. RESULTS: In the non-surgical group, extensive vessel invasion was the most common reason for unresectability (13 cases), with broad biliary extension the second most common (11 cases). In the exploratory laparotomy group the most common reason for unresectability was severe vessel invasion (6 cases). Cumulative 1- and 2-year survival rates for patients with unresectable tumors without distant metastasis were 26.9% and 7.2%, respectively. One- and 2-year survival rates for patients with unresectable tumors and with total bilirubin of less than 2 mg/dL on discharge were 36.8% and 9.8%, respectively. The 1-year survival rate with placement of an expandable metallic stent was as high as 55.6%; without the stent it was 7.1% (P = 0.005). Radiation therapy gave a better prognosis than did no radiation (P = 0.01). CONCLUSIONS: Portal and arterial invasion were the principal reasons for unresectability. Use of an expandable metallic stent or radiation therapy, and a total bilirubin level of less than 2 mg/dL on discharge, were factors that enhanced survival in unresectable cases, but distant metastasis, dissemination, and poor general condition or liver function were negative factors for survival.     

Long-term survival after intraluminal brachytherapy for inoperable hilar cholangiocarcinoma： A case report

Surgical resection with a tumor-free margin is the only curative treatment for hilar cholangiocarcinoma (Klatskin tumor). However, over half of the patients present late with unresectable tumors. Radiotherapy using external beam irradiation or intraluminal brachytherapy (ILBT) has been used to treat unresectable hilar cholangiocarcinoma with satisfactory outcome. We reported a patient with unresectable hilar cholangiocarcinoma surviving more than 6 years after combined external beam irradiation and ILBT.