HDR intraluminal Brachytherapy for cholangiocarcinoma: A pictorial illustration Poster No.:
T. Thachil, L. Chong, E. Y. Liang, E. Sun, G. Marx; Sydney/AU
Cancer, Radiation therapy / Oncology, Brachytherapy, Percutaneous, Interventional non-vascular, Biliary Tract / Gallbladder
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To understand the treatment options available for unresectable cholangiocarcinoma and its prognosis. To understand the indication, safety, and effectiveness of High Dose Rate (HDR) Intraluminal Brachytherapy (ILBT) To appreciate the percutaneous biliary access procedure required prior to ILBT.
Cholangiocarcinoma is a rare, fatal malignancy .The median survival in unresectable cholangiocarcinoma is less than 15 months.[1-3] Mortality is usually by liver failure secondary to biliary obstruction and cholangitis.  The key points in management of unresectable cholangiocarcinoma are long term relief of jaundice and prevention of cholangitis. Biliary decompression and stenting by endoscopic or radiological techniques provide symptomatic and QOL benefits. ILBT prevents local tumour recurrence and prolongs stent patency, therefore delaying the need for external biliary drainage. [2, 4] The optimal dose of ILBT is unknown. Most reported series described the use of low dose rate (LDR) brachytherapy in combination with EBRT with a brachytherapy dose range of 20 to 50Gy. [1, 3-5] Few studies described LDR ILBT alone. HDR ILBT series for cholangiocarcinoma is even scarcer. HDR ILBT has been used as a boost with dose 7-21Gy. Data on the use of HDR brachytherapy as a solo palliative radiotherapy is scant. There is no evidence to support combining EBRT to ILBT or vice versa. Addition of EBRT is associated with increased gastro intestinal toxicity. ILBT is generally well tolerated. Rarely complications like cholangitis, pancreatitis, haemobilia, catheter displacement, duodenal ulceration, wound infection, liver abscess and bile leakage are reported. [1-7] Data is scarce regarding the ILBT effect on QOL.
Imaging Findings OR Procedure Details Imaging findings and procedure details:
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We report a case of recurrent cholangiocarcinoma with resolution of biliary stricture after high dose rate (HDR) ILBT and illustrate the procedure of ILBT. An 80 year old woman with metatstatic cholangiocarcinoma presented with symptomatic and recurrent obstructive jaundice and sepsis, 15 months post pancraeticoduodenectomy with margin positive disease. ERCP demonstrated a filling defect in the proximal common bile duct (CBD) with dilatation of the proximal ducts. Hilar strictures were illustrated on percutaneous transhepatic cholangiogram (Fig1).MRCP revealed an intraluminal CBD growth. Balloon dilatation of the stricture was done (Fig 2).Bilateral percutaneous transhepatic biliary access through the hilar strictures into the duodenum was performed(Fig 3). Through the two interno-external biliary catheters, HDR ILBT was planned and performed using Iridium-192 (Fig 4). A total dose of 18Gy in 2 fractions was given (D=1cm) and was well tolerated. Bilirubin levels normalised over two weeks with significant symptomatic improvement. Cholangiogram prior to permanent metallic stenting at one month post ILBT showed radiological resolution of strictures.(Fig 5).Metallic stenting was delayed to allow more effective ILBT(Fig 6). Distant progressive disease developed 6 months later but bilirubin remained normal. Images for this section:
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Fig. 1: (Fig 1)Percutaneous transhepatic cholangiogram via right intrahepatic duct showed a tight stricture( arrows) involving the common hepatic duct and common bile duct. The left intrahepatic ducts are isolated and not opacified, suggesting that this is a hilar stricture, involving the confluence of the right and left ducts.
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Fig. 2: (Fig 2)Balloon dilatation of stricture.
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Fig. 3: (Fig 3)Cholangiogram showing the hilar stricture (arrows) around the two internoexternal biliary drainage catheters.
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Fig. 4: (Fig 4)ILBT planning wires with radio -opaque markers in the internoexternal biliary drainage catheters.
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Fig. 5: (Fig 5)At one month post ILBT, note flowing of contrast around the internoexternal bilary catheter suggesting the relief of the hilar strictures
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Fig. 6: (Fig 6)Bilateral metallic stenting one month post ILBT.
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The emphasis in palliating unresectable cholangiocarcinoma should be on optimising palliation, with minimal risk and toxicity. HDR ILBT is safe and effective, yet underutilized. It can be easily incorporated as part of the percutaneous biliary drainage /stenting procedure. Stent patency maybe prolonged. It does not require prolonged hospitalization. We propose ILBT be performed following percutaneuos biliary access but before definitive metallic stenting, in order to maximize the effect of ILBT.
Personal Information 1
T.Thachil ; L. Chong
; E.Y .Liang ; E Sun ; G.Marx
Radiation Oncology Institute, Sydney Adventist Hospital, Sydney, Australia.
Sydney Adventist Hospital Clinical School, University of Sydney, Australia.
1.John C. Flickinger, Alan H. Epstein, , Shunzaburo Iwatsuki, , Brian I. Carr, and Thomas E. Starzl, Radiation Therapy for Primary Carcinoma of the Extrahepatic Biliary System: An Analysis of 63 Cases.Cancer.1991 July 15;68(2):289-294. 2.Siu-Yin Chan, Ronnie T Poon, Kelvin K Ng, Chi- Leung Liu, Raymond T. Chan, Sheung-Tat Fan. Long term survival after intraluminal brachytherapy for inoperable hilar cholangiocarcinoma: World J Gastroenterol 2005; 11 (20): 3161-3164. 3.Morganti AG, Trodella L, Valentini V, Motemaggi P, Costamagna G,Smaniotto D,Luzi s,Zicarelli P,Macchia G, Perri V,Mutignani M,Cellini N. Combined modality treatment in unresectable extrahepatic biliary carcinoma. Int J radiat Oncol Biol Phys.2000;46:913-919. 4.Vlatimil Valek,Petr Kysela,Zdenek Kala, igor Kiss, Jiri thomasek, Jiri Petera. Brachytherapy and percutaneous stenting in the treatment of cholangiocarcionoma: A prospective randomized study European Journal of Radiology.62 (2007)175-179.
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5 .Fritz P,Brambs HJ, Schraube P, Freund U, Berns C, Wannenmacher M. Combined external beam radiotherapy and intraluminal brachythreapy on bile duct carcinoma.Int J radiat Oncol Biol Phys. 1994 July 1;(29) 4:855-61 6.M D Levitt,B H Laurence,C Cameron and P F B klemp.Transpappillary Iridium 192 wire in the treatment of malignant bile duct obstruction. Gut, 1988, 29, 149-152. 7. Lu JJ, Bains YS, Abdel-Wahab M,BrandonAH, Wolfson AH,RaubWA, Wilkinson CM, Markoe AM. High -dose- rate remote afterloading intracavitary brachytherapy for the treatment of extrahepatic biliary duct carcinoma. Cancer J 2002;8:74-78. PMID 11895206.
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