Purpose: Evaluate, in patients with inoperable hilar CLCA, the efficacy of multimodality treatment (brachiotherapy, chemotherapy, external radiotherapy and endoprosthesis positioning) in terms of survival, quality of life and cost/benefit compared to palliative surgical treatment.
Material and methods: 20 patients with inoperable hilar CLCA were evaluated. Ten were considered for combined palliative and radiotherapy treatment according to the following protocol: percutaneous colangiography followed by positioning of right and left internal biliar drainage (10-12 F); intraductal brachiotherapy using Ir-192 needles was performed (7 Gy). A second administration was after 7 days. Total dose was 14 Gy; the biliar drainages were then replaced by endoprosthesis (12-14 F) and left in position for 3 months in order to model the post-attinic fibrosis and to prevent stenosis; external radiotherapy was administered starting 15 days after last brachiotherapy treatment (26 administrations (180 cGy) in 5 weeks, total 46 Gy); chemotherapy (5 FU: 350 mg/mq/die) for 5 days during the first and the fifth week of external radiotherapy; biliar endoprosthesis were removed by endoscopic and, or transhepatic mode after 3 months from end of therapy, verifying. Cholangiography assessed the patency of the biliar duct. Metallic stents were placed if results were not satisfactory; follow-up was by: hepatic lab work-up, tumoral markers, US or TC evaluated disease progression.
Results: In 5 of the 10 patients considered for the combined treatment, 5 patients completed the protocol and 5 were treated only with brachiotherapy because of deterioration of clinical conditions. All patients had initial complete remission of jaundice although it recurred with disease progression that led to death. No acute post-radiotherapy complication was observed. Digestive hemorrhage (chronic post-radiotherapy complication) was the cause of death in one patient.
Discussion and conclusions: Good results were observed in the patients that completed the protocol, mean survival was 7,5 months instead of 1,75 months as in patients that underwent only percutaneous drainage. Better results may be obtained taking in consideration the poor clinical conditions of the patients at the time of diagnosis. The proposed therapeutic protocol requires an average hospitalization of 10-15 days instead of 15-20 days as for palliative biliar-digestive deviation, being less invasive and thus associated to lower morbidity and no mortality.