Unresectable hilar cholangiocarcinoma completely reduced by external radiation therapy.

A 68-year-old woman was referred to our hospital with liver dysfunction. Abdominal ultrasonography showed an isoechoic mass in the hepatic hilum. Abdominal computed tomography (CT) disclosed a homogenous mass adjacent to the portal bifurcation, and endoscopic retrograde choledocho-pancreatography (ERCP) revealed complete obstruction from the common hepatic duct to the hepatic duct confluence. After insertion of the endoscopic nasobiliary drainage (ENBD) tube, laparotomy was performed, revealing an approximately 5x6-cm elastic hard mass at the hepatic hilum, mainly spreading to the left hepatic duct, and involving surrounding vascular structures such as the portal vein and right and left hepatic arteries. Therefore, she was treated by external radiation therapy (ERT) of 60 Gy in 30 sessions after insertion of endoscopic retrograde biliary drainage (ERBD) tubes to bilateral hepatic ducts to replace the ENBD tube. After the completion of ERT, she was discharged from the hospital in good health. Three months later, she was readmitted for cholangitis and received antibiotic treatment. Surprisingly, abdominal CT disclosed complete remission of the tumor. ERCP revealed patency of the common hepatic duct and hepatic duct confluence. Therefore, the ERBD tubes were removed. Specimens from the hepatic duct confluence, and bilateral hepatic ducts showed no malignancy histologically. She is doing well without recurrence more than 4 years after surgery.

[Transcutaneous radiotherapy combined with low dose intraluminal brachytherapy in the treatment of non-operable neoplastic stenoses of the bile ducts]. / Radioterapia transcutanea associata a brachiterapia endoluminale con basso rateo di dolore nel trattamento delle stenosi neoplastiche inoperabili delle vie biliari.

Percutaneous biliary drainage is an excellent method to relieve the acute symptoms related to neoplastic stenoses of extrahepatic bile ducts. However, survival rates are low and the quality of life of these patients is poor. High dose irradiation--combined with external beams (ERT) and intraluminal brachytherapy (BRT) through percutaneous drainage--allows effective disease control and, therefore, not only higher survival rates but also a much better quality of life when drainage can be removed after bile duct stenosis resolution. March, 1990, through March, 1993, eleven patients (8 with extrahepatic cholangiocarcinomas and 3 with extrinsic tumors) were treated with combined ERT (40-60 Gy, 6-15 MV X-rays) and intraluminal BRT (6-25 Gy, 192Ir wire, LDR). In 8 patients the biliary stenosis was resolved, completely (CR) in 5 and partially (PR) in 3, as shown by posttreatment cholangiography. In 5 patients biliary drainage could be removed for an average 9 months' period; 3 of 11 patients did not respond to treatment at all (NR). Average overall survival was 14 months: 11 months for NR patients and 16.5 months for CR+PR patients. Treatment complications were acceptable: in two patients only treatment had to be discontinued, both during BRT. Two cases of high grade postirradiation stenosis were observed, both resolved with percutaneous cholangioplasthy.

[Radiotherapy of malignant obstructive jaundice]. / Strahlentherapie beim malignen Verschlussikterus.

Brachytherapy using the afterloading technique with iridium 192 and percutaneous irradiation using 16 MV photons are used for the irradiation of malignant obstructive jaundice. Mostly, however, a combination of both methods can be used to advantage. In bile duct tumors and Klatskin tumors, the endoluminal part can be treated using brachytherapy. The extralumenal growth and, if necessary, all affected regional lymph node areas can be treated by a 3D planned, percutaneous, moving field technique. Intraoperative radiotherapy can be used in a few cases as booster irradiation of tumor conglomerates at the porta hepatis. The decision to use irradiation must be made very carefully since solid tumors are usually involved that require a high target dose, the application of which can lead to unacceptable side effects. The radio-oncological spectrum is therefore confined predominantly to palliative therapy.

Interstitial microwave-induced hyperthermia and iridium brachytherapy for the treatment of obstructing biliary carcinomas.

In a phase I clinical study, 10 patients with obstructive biliary carcinomas were treated with single-antenna interstitial microwave hyperthermia and iridium-192 brachytherapy. For each patient a standard biliary drainage catheter was implanted percutaneously through the obstructed common bile duct. This catheter accommodated a single microwave antenna which operated at 915 MHz, and one or two fibreoptic thermometry probes for temperature measurement. Under fluoroscopic guidance the microwave antenna and temperature probes were positioned in the CT-determined tumour mass. The 60-min heat treatment achieved a central tumour temperature of 45-55 degrees C while keeping temperatures at the proximal and distal margins at 43 degrees C. Immediately following the hyperthermia treatment the microwave antenna and temperature probes were removed, and a single strand of iridium-192 double-strength seeds was inserted to irradiate the tumour length. A dose of 5500-7900 cGy calculated at 0.5 cm radially from the catheter was administered over 5-7 days. Upon removal of the iridium a second hyperthermia treatment was performed. A total of 18 hyperthermia treatments were administered to the 10 patients. In two cases the second hyperthermia treatment after brachytherapy was not possible due to a kink in the catheter, or bile precipitation in the catheter. All patients tolerated the procedure well, and there were no acute complications. To evaluate the volumetric heating potential of this hyperthermia method, specific absorption rate (SAR) values were measured at 182 planar points in muscle phantom. Insulated and non-insulated antenna performance was tested at 915 MHz in a biliary catheter filled with air, saline, or bile to mimic clinical treatments. The insulated antenna exhibited the best performance. Differences between antenna performance in saline and bile were also noted. In summary, this technique may have potential for tumours which obstruct biliary drainage and are accessible to percutaneous decompression using standard diagnostic radiological procedures.

[Non-vascular interventional radiology expandable metallic biliary endoprosthesis and afterloading intracavitary irradiation for malignant biliary obstruction].

Biliary endoprostheses (EMBE) using expandable metallic stents or intracavitary irradiation with remote afterloading (RALS) were carried out in eighteen patients with malignant biliary obstruction. There were 11 patients with bile duct cancer, 3 patients with gallbladder cancer, 2 patients with pancreas cancer and 2 patients with metastatic gastric cancer. The favourable results were obtained. Placement of stents was successful in all 17 cases in which the EMBE was conducted, and in all cases but one, the duct was cleared. At the follow-up of 2 to 59 weeks, all stents maintained patency and there were no severe complications, although only one patient had jaundice due to obstruction at the stented duct 4 months after EMBE. In nine cases, intracavitary irradiation with RALS was performed using a newly developed 14 Fr applicator. The bile duct walls at the irradiation site were smooth and expansion of the constricted area was seen. These results indicate that the combined use of EMBE and intracavitary irradiation with RALS could form a new part of treatment of malignant tumors of the bile duct in which radical surgery is not possible.

[Combined intraductal and percutaneous radiotherapy of malignant bile duct obstruction with subsequent prosthetic management]. / Kombinierte intraduktale und perkutane Radiotherapie bei maligner Gallenwegsobstruktion mit anschliessender prothetischer Versorgung.

Radiotherapy of the inoperable malignant bile duct obstruction is performed to prolong the survival time in comparison to the palliative drainage. The preferable method is a combination of intracavitary irradiation via a percutaneous transhepatic drainage (30-40 Gy at a distance of 1 cm) and a moving field technique (30-40 Gy). This combination allows a high local tumor dose and a relatively large treatment volume. After radiotherapy, the PTD is being exchanged by a large-bore biliodigestive prosthesis.

[Endocavitary radiotherapy in an after-loading technic in malignant stenoses of the upper gastrointestinal tract and bile ducts]. / Endokavitäre Strahlentherapie in After-loading-Technik bei malignen Stenosen des oberen Gastrointestinaltraktes und der Gallenwege.

Palliative brachytherapy with 192iridium in high dose rate technique was applied until August 1985 in 44 patients: 40 suffering from an inoperable malignant stenoses of the esophagus or cardia, and 4 from bile duct carcinomas located in the upper part of the duct. The patients with malignant stenoses of the upper gastrointestinal tract underwent laser therapy until an endoscope could be passed beyond this stenoses. Then an after-loading tube was placed endoscopically and the stenoses irradiated endocavitarily (7/Gray/session in 1 cm distance). In the patients with malignant bile duct obstruction a PTCD-catheter served to guide the iridium wire up to the stenotic region.

The diagnosis and treatment of obstructive jaundice secondary to malignant lymphoma: a problem in multidisciplinary management.

Approximately 1.3% of patients with lymphoma develop obstructive jaundice secondary to lymphomatous involvement of the extrahepatic biliary system. This may occur either as an initial or as a late manifestation of disease. Clinically and radiographically the condition may mimic a variety of more common causes of obstructive jaundice. Surgical exploration may be necessary to confirm the diagnosis, but local radiotherapy would appear to be the preferred mode of treatment. Rapid progression to systemic disease occurs in the majority of patients, necessitating multidrug chemotherapy. Control of jaundice by radiotherapy is good, but long-term prognosis is poor. Supervening sepsis and gastrointestinal bleeding caused the majority of deaths, suggesting that adjunctive nutritional support, immunologic enhancement, and stress ulcer prophylaxis may be necessary if survival is to be improved.