Cholangiocarcinoma
Chemoradiation treatment with gemcitabine plus stereotactic body radiotherapy for unresectable, non-metastatic, locally advanced hilar cholangiocarcinoma. Results of a five year experience

https://doi.org/10.1016/j.radonc.2011.05.016Get rights and content

Abstract

Background

Hilar cholangiocarcinoma (Klatskin tumor–KT) accounts for about 0.5–1.5% of all gastrointestinal cancers and for 40–60% of all biliary malignancies. Tumor resection is attainable in about 30–50% of patients. When resection is not possible other treatment options have little or no impact on survival. We present the results of hypofractionated Stereotactic Body Radiotherapy (SBRT) on a small series of non resectable locally advanced KT patients.

Materials and methods

Ten patients with histologically proven KT underwent SBRT plus gemcitabine. Radiotherapy (30 Gy) was delivered in three fractions. Treatment toxicity was assessed according to the Common Terminology Criteria for Adverse Events (CTCAE v. 3.0). Alive patients with less than 1 year of follow up were excluded from the present study. Local control was assessed according to Response Evaluation Criteria in Solid Tumors (RECIST) criteria.

Results

Two grade 1 and Two grade 2 acute toxicities were observed, moreover one grade 2 late toxicity was recorded. The overall local response ratio was 80% (4 PR + 2 SD). SBRT showed a good efficacy in achieving local control. Median time to progression was 30 months. Two-year survival was 80% and four-year survival 30%. Six patients developed metastatic disease. Response to treatment and nodal metastases were the only independent indicators of prolonged survival.

Conclusions

The chemoradiation given by SBRT plus gemcitabine is a promising treatment for non-metastatic unresectable KT. High local control rates, even compared to historical data from conventional radiotherapy, can be achieved with minimal toxicity.

Section snippets

Patient population

During the period August 2004 to May 2009, 49 patients with Klatskin tumor were referred to our hepatobiliopancreatic surgery group. Ten consecutive patients, seven men and three women (mean age 67.4 ± 8.15 years, range 49–75 years, median 69.5 years), with Unresectable non-metastatic KT were included in this study. Inclusion criteria were: unresectable KT of no more than 6 cm in maximum diameter, normal live function tests, Karnovsky index >70, age >18 and <75 years and given informed consent. Patient’s

Results

All subjects underwent complete staging. Enlarged nodes at the hilum of the liver were identified in six cases. In four cases they were histologically confirmed as metastatic by intraoperative sampling. Median follow-up time was 35.5 months. All patients underwent thin-cut, contrast-enhanced CT before treatment and 7 underwent magnetic resonance imaging with biliary reconstruction. Thin cut CT scan was again performed at 3 and 6 months after treatment and every 6 months thereafter. Tumors were

Discussion

The treatment of non-metastatic unresectable KT remains a clinical challenge that lacks a widely accepted consensus. Many papers reported of this subset of patients with a wide range of proposals varying between extremely aggressive treatments such as orthotopic liver transplantation with or without neoadjuvant radiotherapy [7], [8] to photodynamic therapy [9], [10] or palliative chemotherapy [11], [12], [13], [14], [15], [16] and biliary stenting alone.

Gemcitabine has a well recognized

Conflicts of interest

None.

Funding

None.

References (33)

  • H. Witzigmann 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)
  • National Cancer Institute, Cancer Therapy Evaluation Program. Common Terminology Criteria for Adverse Events, version...
  • P. Therasse et al.

    New guidelines to evaluate the response to treatment in solid tumors. European Organization for Research and Treatment of Cancer, National Cancer Institute of the United States, National Cancer Institute of Canada

    J Natl Cancer Inst

    (2000)
  • D.J. Rea et al.

    Liver transplantation with neoadjuvant chemoradiation is more effective than resection for hilar cholangiocarcinoma

    Ann Surg

    (2005)
  • F.L. Domoulin et al.

    Palliative locoregional therapy for hilar cholangiocarcinoma: photodynamic therapy and brachytherapy

    Zentralbl Chir

    (2007)
  • E.A. Rauws

    Photodynamic therapy and Klatskin tumor: an overview

    Scand J Gastroenterol Suppl

    (2006)
  • Cited by (0)

    View full text