Conformal high dose rate percutaneous transhepatic intraluminal cholangio-irradiation for unresectable cholangiocarcinoma

The treatment of unresectable locally advanced cholangiocarcinoma is still unrewarding, resulting in limited survival of the patients. Intraluminal low dose rate brachytherapy via a percutaneous or an endoscopic approach, with or without external beam radiation therapy (EBRT), yielded only moderate results and was associated with a high rate of complications. Conformal high dose rate (HDR) percutaneous transhepatic intraluminal cholangio-irradiation was evaluated together with external beam irradiation and 5-fluorouracil in patients with unresectable cholangiocarcinoma. Fourteen patients were treated during 1990 to 1993 by percutaneous transhepatic drainage of the bile system followed by EBRT, 180 cGy per fraction, to a midplane total dose of 4500 to 5040 cGy combined with 5-fluorouracil. A conformal HDR was applied on an outpatient schedule. Using a remote afterloading moving-source technique, a single 10-Ci (nominal activity) iridium-192 source was placed within the biliary system. A dose of 500 cGy was delivered within ten minutes. A total dose of 1500 to 2000 cGy was administered by three to four fractions during three to four weeks. A total of 46 HDR brachytherapy sessions were administered. The treatment, consisting of EBRT combined with 5-fluorouracil and a boost given by conformal HDR, was well tolerated by all the patients. Eight patients reported mild to moderate gastrointestinal systems, ie, nausea and diarrhea, due to the EBRT, and were treated symptomatically. None of the patients experienced severe treatment-related complications necessitating admission. The median survival in our series was 19 months. Conformal HDR combined with EBRT and 5-fluorouracil appears to be a well-tolerated, safe, convenient, and effective treatment for unresectable cholangiocarcinoma.