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21 - Extrahepatic biliary cancer: Stenting, brachytherapy, and photodynamic therapy

from Section V - Organ-specific cancers – extrahepatic biliary cancer

Published online by Cambridge University Press:  05 September 2016

By
Vlastimil Valek  and
Tomas Andrasina
Edited by
Jean-Francois H. Geschwind  and
Michael C. Soulen
Vlastimil Valek
Affiliation:
Masaryk University
Tomas Andrasina
Affiliation:
Masaryk University, Brno
Jean-Francois H. Geschwind
Affiliation:
Yale University School of Medicine, Connecticut
Michael C. Soulen
Affiliation:
Department of Radiology, University of Pennsylvania Hospital, Philadelphia
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Summary

Obstruction or stenosis of the extrahepatic bile duct may be caused by primary tumor, tumors arising from surrounding organs (gallbladder, pancreas), or compression from lymph nodes. Bile duct obstruction is a frequent cause of morbidity and mortality among oncological patients. Failing liver functions due to obstruction in the bile ducts could preclude early surgical intervention, the application of chemotherapy agents which metabolize directly in the liver, and, in later stages, therapeutic intervention of any kind due to bleeding complications.

Extrahepatic obstructions may be differentiated as hilar or distal according to their locations anatomically. Tumors growing from the epithelium of the biliary tract are most common in the hilar region (65% of cases), and the complexity of the perihilar liver region causes curative surgical resection to be very complicated. Only a small percentage of such tumors are detected at an early stage. Tumors located in the hilar region often infiltrate or encase the branches of the common hepatic artery and portal vein, and cholangiocarcinomas expand longitudinally into the intra- and extrahepatic bile ducts, submucosally and perineurially. As a result, the actual radicality of the surgery may be debatable. Success in surgical resection is very low, and the 5-year survival rate is unsatisfactory even after curative resection due to a high percentage of local recurrence. The difficulty of resection rises in accordance with the level in the Bismuth–Corlette classification system. For type I, sometimes only localized resection of the common bile duct with biliodigestive anastomosis is possible. For types II–IV, liver resection is usually necessary. Extended left or right hemihepatectomy often requires presurgical embolization of the portal vein. Radical procedures include extensive lymphadenectomy, which is made difficult by the structure of the hepatoduodenal ligament with respect to the adjoining branches from the portal vein and the adhesion of afflicted lymph nodes on the biliary tract, portal vein, hepatic artery, or head of the pancreas.

Even though surgical techniques are continually improving, resectability of hilar cholangiocarcinomas is in the range of 15–20%, the 5-year survival rate is in the range of 10–30%, and local recurrence occurs in 75% of cases.

Type
Chapter
Information
Interventional Oncology
Principles and Practice of Image-Guided Cancer Therapy
 , pp. 193 - 202
Publisher: Cambridge University Press
Print publication year: 2016

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References

1. Serrablo, A, Tejedor, L. Outcome of surgical resection in Klatskin tumors. World J Gastrointest Oncol 2013; 5 (7): 147–158.Google Scholar
2. Scheithauer, W. Review of gemcitabine in biliary tract carcinoma. Semin Oncol 2002; 29 (6 Suppl 20): 40–45.Google Scholar
3. Yang, R, Wang, B, Chen, YJ, Li, HB, Hu, JB, Zou, SQ. Efficacy of gemcitabine plus platinum agents for biliary tract cancers: a meta-analysis. Anticancer Drugs 2013; 24 (8): 871–877.Google Scholar
4. Zhu, AX, Meyerhardt, JA, Blaszkowsky, LS, Kambadakone, AR, Muzikansky, A, Zheng, H, et al. Efficacy and safety of gemcitabine, oxaliplatin, and bevacizumab in advanced biliary-tract cancers and correlation of changes in 18-fluorodeoxyglucose PET with clinical outcome: a phase 2 study. Lancet Oncol 2010; 11 (1): 48–54.Google Scholar
5. Andrasina, T, Valek, V, Panek, J, Kala, Z, Kiss, I, Tucek, S, et al. Multimodal oncological therapy comprising stents, brachytherapy, and regional chemotherapy for cholangiocarcinoma. Gut Liver 2010; 4 Suppl 1: S82–S88.Google Scholar
6. Soehendra, N. H. Joachim Burhenne Lecture. Common areas of interest between interventional biliary radiology and endoscopy. AJR Am J Roentgenol 1995; 164 (3): 547–551.Google Scholar
7. Deviere, J, Baize, M, Toeuf, J de, Cremer, M. Long-term follow-up of patients with hilar malignant stricture treated by endoscopic internal biliary drainage. Gastrointest Endosc 1988; 34 (2): 95–101.Google Scholar
8. Palma, GD de, Galloro, G, Siciliano, S, Iovino, P, Catanzano, C. Unilateral versus bilateral endoscopic hepatic duct drainage in patients with malignant hilar biliary obstruction: results of a prospective, randomized, and controlled study. Gastrointest Endosc 2001; 53 (6): 547–553.Google Scholar
9. Dowsett, JF, Vaira, D, Hatfield, AR, Cairns, SR, Polydorou, A, Frost, R, et al. Endoscopic biliary therapy using the combined percutaneous and endoscopic technique. Gastroenterology 1989; 96 (4): 1180–1186.Google Scholar
10. Raju, RP, Jaganmohan, SR, Ross, WA, Davila, ML, Javle, M, Raju, GS, et al. Optimum palliation of inoperable hilar cholangiocarcinoma: comparative assessment of the efficacy of plastic and self-expanding metal stents. Dig Dis Sci 2011; 56 (5): 1557–1564.Google Scholar
11. Lammer, J, Hausegger, KA, Fluckiger, F, Winkelbauer, FW, Wildling, R, Klein, GE, et al. Common bile duct obstruction due to malignancy: treatment with plastic versus metal stents. Radiology 1996; 201 (1): 167–172.Google Scholar
12. Paik, WH, Park, YS, Hwang, JH, Lee, SH, Yoon, CJ, Kang, SG, et al. Palliative treatment with self-expandable metallic stents in patients with advanced type III or IV hilar cholangiocarcinoma: a percutaneous versus endoscopic approach. Gastrointest Endosc 2009; 69 (1): 55–62.Google Scholar
13. Lee, DH, Yu, JS, Hwang, JC, Kim, KH. Percutaneous placement of self-expandable metallic biliary stents in malignant extrahepatic strictures: indications of transpapillary and suprapapillary methods. Korean J Radiol 2000; 1 (2): 65–72.Google Scholar
14. Thornton, RH, Frank, BS, Covey, AM, Maybody, M, Solomon, SB, Getrajdman, GI, et al. Catheter-free survival after primary percutaneous stenting of malignant bile duct obstruction. AJR Am J Roentgenol 2011; 197 (3): W514–W518.Google Scholar
15. Inal, M, Aksungur, E, Akgul, E, Oguz, M, Seydaoglu, G. Percutaneous placement of metallic stents in malignant biliary obstruction: one-stage or two-stage procedure? Pre-dilate or not? Cardiovasc Intervent Radiol 2003; 26 (1): 40–45.Google Scholar
16. Huibregtse, K, Cheng, J, Coene, PP, Fockens, P, Tytgat, GN. Endoscopic placement of expandable metal stents for biliary strictures – a preliminary report on experience with 33 patients. Endoscopy 1989; 21 (6): 280–282.Google Scholar
17. Lawson, AJ, Beningfield, SJ, Krige, JE, Rischbieter, P, Burmeister, S. Percutaneous transhepatic self-expanding metal stents for palliation of malignant biliary obstruction. S Afr J Surg 2012; 50 (3): 54, 6, 8 passim.Google Scholar
18. Lammer, J, Klein, GE, Kleinert, R, Hausegger, K, Einspieler, R. Obstructive jaundice: use of expandable metal endoprosthesis for biliary drainage. Work in progress. Radiology 1990; 177 (3): 789–792.Google Scholar
19. Lameris, JS, Stoker, J, Nijs, HG, Zonderland, HM, Terpstra, OT, Blankenstein, M Van, et al. Malignant biliary obstruction: percutaneous use of self-expandable stents. Radiology 1991; 179 (3): 703–707.Google Scholar
20. Brountzos, EN, Ptochis, N, Panagiotou, I, Malagari, K, Tzavara, C, Kelekis, D. A survival analysis of patients with malignant biliary strictures treated by percutaneous metallic stenting. Cardiovasc Intervent Radiol 2007; 30 (1): 66–73.Google Scholar
21. Karnabatidis, D, Spiliopoulos, S, Katsakiori, P, Romanos, O, Katsanos, K, Siablis, D. Percutaneous trans-hepatic bilateral biliary stenting in Bismuth IV malignant obstruction. World J Hepatol 2013; 5 (3): 114–119.Google Scholar
22. Schima, W, Prokesch, R, Osterreicher, C, Thurnher, S, Fugger, R, Schofl, R, et al. Biliary Wallstent endoprosthesis in malignant hilar obstruction: long-term results with regard to the type of obstruction. Clin Radiol 1997; 52 (3): 213–219.Google Scholar
23. Lee, MJ, Dawson, SL, Mueller, PR, Hahn, PF, Saini, S, Lu, DS, et al. Failed metallic biliary stents: causes and management of delayed complications. Clin Radiol 1994; 49 (12): 857–862.Google Scholar
24. Rossi, P, Bezzi, M, Rossi, M, Adam, A, Chetty, N, Roddie, ME, et al. Metallic stents in malignant biliary obstruction: results of a multicenter European study of 240 patients. J Vasc Interv Radiol 1994; 5 (2): 279–285.Google Scholar
25. Becker, CD, Glattli, A, Maibach, R, Baer, HU. Percutaneous palliation of malignant obstructive jaundice with the Wallstent endoprosthesis: follow-up and reintervention in patients with hilar and non-hilar obstruction. J Vasc Interv Radiol 1993; 4 (5): 597–604.Google Scholar
26. Krokidis, M, Fanelli, F, Orgera, G, Bezzi, M, Passariello, R, Hatzidakis, A. Percutaneous treatment of malignant jaundice due to extrahepatic cholangiocarcinoma: covered Viabil stent versus uncovered Wallstents. Cardiovasc Intervent Radiol 2010; 33 (1): 97–106.Google Scholar
27. Krokidis, M, Fanelli, F, Orgera, G, Tsetis, D, Mouzas, I, Bezzi, M, et al. Percutaneous palliation of pancreatic head cancer: randomized comparison of ePTFE/FEP-covered versus uncovered nitinol biliary stents. Cardiovasc Intervent Radiol 2011; 34 (2): 352–361.Google Scholar
28. Ito, K, Ogawa, T, Horaguchi, J, Koshita, S, Fujita, N. Reintervention for occluded biliary metal stent for patients with malignant distal biliary stricture. Dig Endosc 2013; 25 Suppl 2: 126–131.Google Scholar
29. Ortner, MA. Photodynamic therapy in cholangiocarcinomas. Best Pract Res Clin Gastroenterol 2004; 18 (1): 147–154.Google Scholar
30. Talreja, JP, Degaetani, M, Ellen, K, Schmitt, T, Gaidhane, M, Kahaleh, M. Photodynamic therapy in unresectable cholangiocarcinoma: not for the uncommitted. Clin Endosc 2013; 46 (4): 390–394.Google Scholar
31. Cosgrove, ND, Al-Osaimi, AM, Sanoff, HK, Morris, MM, Read, PW, Cox, DG, et al. Photodynamic therapy provides local control of cholangiocarcinoma in patients awaiting liver transplantation. Am J Transplant 2014; 14 (2): 466–471.Google Scholar
32. Zoepf, T, Jakobs, R, Arnold, JC, Apel, D, Riemann, JF. Palliation of nonresectable bile duct cancer: improved survival after photodynamic therapy. Am J Gastroenterol 2005; 100 (11): 2426–2430.Google Scholar
33. Ortner, ME, Caca, K, Berr, F, Liebetruth, J, Mansmann, U, Huster, D, et al. Successful photodynamic therapy for nonresectable cholangiocarcinoma: a randomized prospective study. Gastroenterology 2003; 125 (5): 1355–1363.Google Scholar
34. Leggett, CL, Gorospe, EC, Murad, MH, Montori, VM, Baron, TH, Wang, KK. Photodynamic therapy for unresectable cholangiocarcinoma: a comparative effectiveness systematic review and meta-analyses. Photodiagnosis Photodyn Ther 2012; 9 (3): 189–195.Google Scholar
35. Cheon, YK, Lee, TY, Lee, SM, Yoon, JY, Shim, CS. Longterm outcome of photodynamic therapy compared with biliary stenting alone in patients with advanced hilar cholangiocarcinoma. HPB (Oxford) 2012; 14 (3): 185–193.Google Scholar
36. Matull, WR, Dhar, DK, Ayaru, L, Sandanayake, NS, Chapman, MH, Dias, A, et al. R0 but not R1/R2 resection is associated with better survival than palliative photodynamic therapy in biliary tract cancer. Liver Int 2011; 31 (1): 99–107.Google Scholar
37. Witzigmann, H, Berr, F, Ringel, U, Caca, K, Uhlmann, D, Schoppmeyer, K, et al. Surgical and palliative management and outcome in 184 patients with hilar cholangiocarcinoma: palliative photodynamic therapy plus stenting is comparable to r1/r2 resection. Ann Surg 2006; 244 (2): 230–239.Google Scholar
38. Kahaleh, M, Mishra, R, Shami, VM, Northup, PG, Berg, CL, Bashlor, P, et al. Unresectable cholangiocarcinoma: comparison of survival in biliary stenting alone versus stenting with photodynamic therapy. Clin Gastroenterol Hepatol 2008; 6 (3): 290–297.Google Scholar
39. Lee, TY, Cheon, YK, Shim, CS. Current status of photodynamic therapy for bile duct cancer. Clin Endosc 2013; 46 (1): 38–44.Google Scholar
40. Milano, MT, Chmura, SJ, Garofalo, MC, Rash, C, Roeske, JC, Connell, PP, et al. Intensity-modulated radiotherapy in treatment of pancreatic and bile duct malignancies: toxicity and clinical outcome. Int J Radiat Oncol Biol Phys 2004; 59 (2): 445–453.Google Scholar
41. Fletcher, MS, Brinkley, D, Dawson, JL, Nunnerley, H, Wheeler, PG, Williams, R. Treatment of high bile duct carcinoma by internal radiotherapy with iridium-192 wire. Lancet 1981; 2 (8239): 172–174.Google Scholar
42. Mayo-Smith, WW, Dawson, SL, Mauceri, T, Mueller, PR. Attenuation effects of biliary endoprostheses on therapeutic radiation. Radiology 1996; 199 (2): 571–572.Google Scholar
43. Alden, ME, Mohiuddin, M. The impact of radiation dose in combined external beam and intraluminal Ir-192 brachytherapy for bile duct cancer. Int J Radiat Oncol Biol Phys 1994; 28 (4): 945–951.Google Scholar
44. Takamura, A, Saito, H, Kamada, T, Hiramatsu, K, Takeuchi, S, Hasegawa, M, et al. Intraluminal low-dose-rate 192Ir brachytherapy combined with external beam radiotherapy and biliary stenting for unresectable extrahepatic bile duct carcinoma. Int J Radiat Oncol Biol Phys 2003; 57 (5): 1357–1365.Google Scholar
45. Shin, HS, Seong, J, Kim, WC, Lee, HS, Moon, SR, Lee, IJ, et al. Combination of external beam irradiation and high-dose-rate intraluminal brachytherapy for inoperable carcinoma of the extrahepatic bile ducts. Int J Radiat Oncol Biol Phys 2003; 57 (1): 105–112.Google Scholar
46. Chan, SY, Poon, RT, Ng, KK, Liu, CL, Chan, RT, Fan, ST. Long-term survival after intraluminal brachytherapy for inoperable hilar cholangiocarcinoma: a case report. World J Gastroenterol 2005; 11 (20): 3161–3164.Google Scholar
47. Shinohara, ET, Guo, M, Mitra, N, Metz, JM. Brachytherapy in the treatment of cholangiocarcinoma. Int J Radiat Oncol Biol Phys 2010; 78 (3): 722–728.Google Scholar
48. Valek, V, Kysela, P, Kala, Z, Kiss, I, Tomasek, J, Petera, J. Brachytherapy and percutaneous stenting in the treatment of cholangiocarcinoma: a prospective randomised study. Eur J Radiol 2007; 62 (2): 175–179.Google Scholar
49. Chen, Y, Wang, XL, Yan, ZP, Cheng, JM, Wang, JH, Gong, GQ, et al. HDR-192Ir intraluminal brachytherapy in treatment of malignant obstructive jaundice. World J Gastroenterol 2004; 10 (23): 3506–3510.Google Scholar
50. Park, S, Park, JY, Bang, S, Park, SW, Chung, JB, Song, SY. Radiotherapy prolongs biliary metal stent patency in malignant pancreatobiliary obstructions. Gut Liver 2013; 7 (4): 480–485.Google Scholar
51. Dolak, W, Schreiber, F, Schwaighofer, H, Gschwantler, M, Plieschnegger, W, Ziachehabi, A, et al. Endoscopic radiofrequency ablation for malignant biliary obstruction: a nationwide retrospective study of 84 consecutive applications. Surg Endosc 2014; 28 (3): 854–860.Google Scholar

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