BILLIARY TRACT CANCER RADIOTHERAPY

BILLIARY TRACT CANCERS
HELPING THROUGH
RADIOTHERAPY
DR KANHU CHARAN PATRO
MD,DNB[RT], FAROI[USA], PDCR [CLINI.RESEARCH]
CEPC[PALL.CARE], CBB[HOSP.MX]
EX-RESIDENT TATA MEMORIAL HOSPITAL
HOD,RADIATION ONCOLOGY
DEPARTMENT OF RADIOTHERAPY
MAHATMAGANDHI CANCER HOSPITAL RESEARCH INSTITUTE
1/17/20181

Anatomically, biliary tree is divided into 3 parts,
upper 3rd-55%, middle 3rd 15% and lower 3rd 10%.Of
these tumours, 10% are diffuse
1/17/20184

Cholangiocarcinoma
 Also called bile duct carcinoma
 10% of primary liver cancers
 High prevalence in southeast and eastern Asia
 10-20% are associated with
 Diagnosis of exclusion (must rule out metastatic
adenocarcinoma)
 Usually age 60+ years; no gender preference
 Laboratory: normal AFP
 Poor prognosis; death usually within 6 months
 50-75% metastasize to regional lymph nodes, lungs,
vertebrae, adrenals, brain, elsewhere at autopsy
1/17/20185

Etiology
 Cholangitis due to autosomal dominant polycystic
disease,
 congenitally dilated hepatic ducts
 (Caroli’s disease),
 Congenital hepatic fibrosis,
 Infection by liver flukes,
 Thorotrast, anabolic steroids,
 Intrahepatic lithiasis (5-10% of these patients),
 Primary sclerosing cholangitis (7-42% of these
patients)
1/17/20186

PATHOPHYSIOLOGY
 Bile duct tumours cause bile duct obstruction -
biliary stasis and alteration of liver function tests
 Prolonged obstruction then leads to-
 Hepatocellular dysfunction, renal dysfunction
 Progressive malnutrition, Pruritus, coagulopathy
 Cholangitis- esp if previous endoscopic,
percutaneous or surgical biliary interventions
have been performed.
1/17/20187

CT- abdomen- intra & extra-hepatic bile duct dilatation to the level of
the hepatic hilium. Suggestion of 2cm mass at hilium-
?cholangiocarcinoma-(Klatskin tumour)
1/17/20188

PRESENTATION
 CC seen in advanced unresectable stage
 Early diagnosis unusual
 Typically elderly- average age 60-65years though
Klatskin slightly younger age group
 Abnormal LFTs / Jaundice-90%
 Abdominal pain / Weight loss- in (30-50%) of
cases -Patel et al 2006
 Pruritus seen in 66% of patients
1/17/20189

PRESENTATION
 Fever- 20%
 Diarrhoea, anorexia, changes in urine & stool
colour and weight loss.
 Liver may be enlarged and smooth-25-40%
 Distended and non tender gallbladder 10%
 Epigastric tenderness.
1/17/201810

DIAGNOSIS
 History / physical examination
 Labouratory-CEA and CA19.9 –sensitivity of 66%
and a specificity of 100% in diagnosing CC in pt
with PSC.
 Imaging-tumours are generally small-USS/ CT
may fail to show the lesion.
 Cholangiography via a transhepatic or
endoscopic approach reqired to define biliary
anatomy and extent of the lesion.
1/17/201813

DIAGNOSIS
 Cholangiographic appearance of Klatskin tumour
is characteristic.
 PTC preferred over ERCP for demonstrating
ductal anatomy-PTC-almost 100% sensitivity &
specificity.
 MRCP non-invasive and now more available.
 Histology –a well defferentiated
adenocarcinoma-short annular constricting
lesion 75%, diffusely infiltrating with long
strictures 15%& intraluminal polypoid mass-3-5%
1/17/201814

TREATMENT
 Management challenging with relatively poor
prognosis.
 Surgery continues to be the mainstay of therapy with
5year survival of 10-40%.
 Complete resection with negative histologic margins
–long -term survival.
 Yang WL et at.. 2007 reported in a study of 185 cases
(1972-2006) a median survival of 37 months following
radical resection, 17months for palliative resection
and death within 1.5years if no resection.
 Hepatic resection- a critical component of operative
approach.
1/17/201817

TREATMENT
 Adjuvant chemoradiotherapy-no benefit.
 Liver transplant for unresectable tumour remains
controversial, tumour recurrence >90%.
 Advances in interventional Radiology and
endoscopy- facilitate non surgical option.
 Benefit of external beam radiotherapy for
palliation of proximal CC uncertain.
 Photodynamic therapy a new palliative treatment
modality for failed stent. Thomas Zoepf et al
concluded in a series in 2008 -offers similar
survival time as incomplete resection.
1/17/201818

Problems
 RT is uncommonly done in these diseases, hence
even more uncommonly discussed
 Lack of awareness of the role of RT in hepato-biliary
tumors
 Lack of technology to safely deliver RT in hepato-
biliary tumors
 Lack of randomised data
1/17/201819

cholangiocarcinoma: Where does RT fit?
 Adjuvant RT +/- CT
 Neo-adjuvant RT + CT
 Palliative RT
1/17/201820

Carcinoma Biliary Tree
 Few trials, compared
 Most trials include both cholangiocarcinoma &
carcinoma gall bladder
 Adjuvant and neo-adjuvant protocols are similar to
that of Ca pancreas (except that Gemcitabine alone
has less of a role in standard therapy)
 Encouraging results with IG-IMRT and SBRT in
recent years.
1/17/201821

SEER Database
Adjuvant RT for Extrahepatic Cholangiocarcinoma
 1988-2003 (4758 patients): Significant difference in
overall survival between Surgery +RT vs Surgery
alone (p<0.001) & between RT/Surgery/both vs
none (p<0.001)
 1973-2003 (2323 patients): Adjuvant RT is not
associated with any improvement in OS/DFS.
1/17/201822

Todoroki et al
 N=63 (cholangiocarcinoma)
 49 patients had curative resection, of which 29 patients
received adjuvant RT.
 IORT + p/o EBRT (n=17) vs p/o EBRT alone (n=6) vs
IORT alone (n=6)
 5-yr survival rates were 39.2% vs 0% vs 16.7%.
 Statistically significant improvement in 5-yr survival rates
for IORT+EBRT vs resection alone (39.2% vs 13.5%)
Int J Radiat Oncol Biol Phys 2000;46:581.1/17/201823

Ben-David et al
 N=28 (biliary malignancies)
 Adjuvant RT (54Gy median dose) +/-CT (54%
cases).
 Significant survival differences between patients with
R0 and R1 resections (24.1 vs 15 months) but NOT
between those with R1 and R2 resections.
Int J Radiat Oncol Biol Phys 2006;66:772.
1/17/201824

IMRT
 Divides each treatment field
into multiple segments
 Modulates beam intensity,
giving discrete dose to each
segment
 Uses multiple, shaped beams
(~9) and thousands of
segments
IMRT Initiated in
1995
Reached the clinic in 2000

RTOG contouring guidelines for adjuvant RT
CTV must include:
1/17/201830

IMRT for pancreatico-biliary cancers
1/17/201833

Dose constraints
Conventional RT
 Liver: 1/3 vol <50 Gy
2/3 vol<35 Gy
3/3 vol<30 Gy
 Kidney: 1/3 vol<50 Gy
2/3 vol<28 Gy
3/3 vol<23 Gy
 Stomach: 1/3 vol<60 Gy
2/3 vol<55 Gy
3/3 vol<50 Gy
 Spine: Max <45 Gy
For conventionally
fractionated
3DCRT/IMRT, the
dose constraint
used is Normal
Liver V30Gy<33%
1/17/201834

Side effects of external beam radiation therapy
 Skin changes, ranging from redness to
blistering and peeling (in the area being
treated)
 Nausea and vomiting
 Diarrhea
 Fatigue (tiredness)
 Hair loss (on the skin in the area being treated)
 Low blood counts
 Nausea, vomiting, and diarrhea are more
common if the abdomen (belly) is being treated
1/17/201835

Radiation Induced Liver Disease (RILD)
Classic RILD
 Occurs 2-3 months
post-RT
 Associated with
hepatomegaly,ascites
+/- jaundice
 Due to veno-occlusive
disease
 Seen in healthy livers
Non-classic RILD
 Occurs 1wk-3 months
post-RT
 Seen in cirrhotic livers
 Rise of SGOT/SGPT
with worsening of liver
function
 Without features of
classic RILD
Treatment: Once established, RILD is difficult to manage
and is invariably fatal in the absence of transplant therapy.
Medical management with diuretics, etc is only symptomatic1/17/201836

BRACHYTHERAPY IN HEPATOBILLIARY SYSTEM

 MALIGNANT STRICTURES
 KLATSKIN TUMORS
1/17/201837

Pictorial presentation
LEFT DUCT CANNULATION
RIGHT DUCT CANNULATION
1/17/201838

Stage IV: Metastatic cholangiocarcinoma
1/17/201840

METASTASIS
-please do not watch crying
1/17/201841

METASTASIS- give a smiling death
1/17/201842

Palliative radiation
Skeletal X-Ray
Bone scan
MRI
PET-CT
1/17/201843

Whole brain radiotherapy
1/17/201848

Choroidal metastasis
1/17/201849

Superscan-extensive bone mets
1/17/201850

Hemibody radiation
1/17/201851

Prophylactic radiation
1/17/201853

Take Home Messages
 Despite conflicing data, adjuvant chemoradiotherapy
is viable and rational for pancreatico-biliary
malignancies
 GEM-based protocols are superior to 5FU-based
protocols
 Neo-adjuvant chemoradiotherapy is viable for locally
advanced disease
 Dose-escalation is possible for conformal techniques
1/17/201854

BILLIARY TRACT CANCER RADIOTHERAPY

More Related Content

What's hot(20)

Similar to BILLIARY TRACT CANCER RADIOTHERAPY(20)

More from Kanhu Charan(20)

Recently uploaded(20)

BILLIARY TRACT CANCER RADIOTHERAPY