Intraluminal pulsed dose rate (PDR) brachytherapy and trans-hepatic technique in treatment of locally advanced bile duct cancer – preliminary assessment

Abstract

Background

Treatment options for bile duct cancer remain limited due to the large number of patients with advanced disease at the time of diagnosis. Radical surgery is possible in less than 10–15% of these cases. Unresectable bile duct cancers are very difficult to treat with external beam therapy alone due to the proximity of adjacent normal organs and the high doses required to effectively irradiate these neoplasms. Indications for brachytherapy include all malignant strictures of the bile duct which can be cannulated. Patients should be fit enough for the procedure and should have been reviewed to confirm that they are not suitable for resection. Combined treatment is possible in patients who are in good condition; it is usual to combine bile duct brachytherapy (BT) with external beam radiation therapy (EBRT).

Aim

To assess the feasibility of intraluminal palliative pulsed dose rate brachytherapy (PDR-BT) in the treatment of locally advanced bile duct cancer.

Materials/Methods

Seventeen patients with advanced inoperable bile duct cancer were treated between May 2002 and December 2005 in Greatpoland Cancer Centre. Patients were disqualified from surgery or radical external beam radiation therapy (EBRT). Thirteen patients were treated exclusively with PDR brachytherapy, 4 patients were qualified for combined treatment: PDR brachytherapy and palliative EBRT. Percutaneous trans-hepatic technique was used to implant a catheter into the bile duct. All patients received 25 pulses of 0.8Gy hourly to the total dose of 20Gy. In 4 cases PDR was repeated after one week. Target Volume encompassed tumour visualized at cholangiography and a one or two cm margin taken proximally and distally. Dose was prescribed at 10mm from the source axis. For palliative EBRT 15MV photons were used.

Results

In all 17 cases trans-hepatic technique allowed insertion of the BT catheter into the bile duct and safe application of PDR-BT. In 13/17 (76.5%) cases improvement in jaundice was noted at the first check-up after 4 weeks. Median overall survival time (OS) was 10 months, longest survival time was 36 months, shortest was 2 months. Acute and late complications were not observed.

Conclusions

1. It was established that the use of pulsed dose rate brachytherapy was feasible and had a low early complication rate. A new percutaneous trans-hepatic technique allowed whole treatment (insertion of catheter, PDR brachytherapy) to be performed in one day. 2. In most cases a satisfactory palliative effect was achieved.