Radiation Oncology/Bile duct/Unresectable Disease/Brachytherapy

• Ohio State 1989-02 ASTRO Abstract Long Term Follow-Up of Patients of Intrahepatic Malignancies Treated with Iodine-125 Brachytherapy (2005 Nag S, ASTRO 2005 #2086)
  • Retrospective. 64 patients (54 mets CRC, 2 mets non-CRC, 4 CCA) treated with permanent BT 160 Gy; R1 59%, R2 41%; median follow-up 13.2 years
  • Median survival (5-year OS): 20 months (5%). Higher for small implants and without prior resection
  • Local control (5-year): median 9 months (22%)
  • Conclusion: "Permanent I-125 brachytherapy is a safe and effective adjuvant treatment for unresectable intrahepatic malignancies. It is a simple technique with morbidity and mortality rates comparable to liver resection alone. Patients considered good candidates for I-125 brachytherapy include those with small volume implants, those without prior liver resection, and those with solitary liver metastases.

• Bologna Italy PMID 15675480 -- Unresectable hilar cholangiocarcinoma: multimodality treatment with percutaneous and intraluminal plus external radiotherapy. (2004 Golfieri R, J Chemother. 2004 Nov;16 Suppl 5:55-7.)
  • Protocol report. 11 patients treated with bilateral percutaneous drainage + BT + EBRT; 6 patients completed protocol.
  • Mean survival: 10.5 months, better tahn control group with stenting (2.7 months) or drainage (1.7 months)

• Hong Kong PMID 15918211 -- Long-term survival after intraluminal brachytherapy for inoperable hilar cholangiocarcinoma: a case report. (2005 Chan SY, World J Gastroenterol. 2005 May 28;11(20):3161-4.)
  • Case report. 1 patient. Unresectable hilar CCA survival >6 years

• Berlin Germany PMID 15525748 -- Liver malignancies: CT-guided interstitial brachytherapy in patients with unfavorable lesions for thermal ablation. (2004 Ricke J, J Vasc Interv Radiol. 2004 Nov;15(11):1279-86.)
  • Phase II. 20 patients (19 liver mets, 1 cholangiocarcinoma) treated with CT-guided HDR. Group A (n=11, liver tumors >5cm), Group B (n=9, liver tumors <5cm adjacent to hilum). Average dose 17 Gy (12-25 Gy). Median follow-up 13 months
  • Severe side effects 2 patients (10%): obstructive jaundice from tumor edema, intra-abdominal hemorrhage. Frequent LFT elevation without clinical symptoms
  • 1-year local tumor control: Group A 40%, Group B 71%. After CT-guided HDR retreatment 93% overall control
  • Conclusion: "CT-guided brachytherapy based on individual dose plans and 3D CT data sets generated encouraging results in large liver malignancies as well as in tumors located adjacent to the liver hilum."

• Asahikawa Japan 1988-98 PMID 14630274 -- Intraluminal low-dose-rate 192Ir brachytherapy combined with external beam radiotherapy and biliary stenting for unresectable extrahepatic bile duct carcinoma. (2003 Takamura A, Int J Radiat Oncol Biol Phys. 2003 Dec 1;57(5):1357-65.)
  • Retrospective. 93 patients treated with definitive RT. EBRT (50 Gy) + ILRT (mean 39.2 Gy at 0.5 cm)
  • Median survival: 12 months; impact of tumor length, hepatic invasion, DM
  • Mild-to-severe GI complications in 34%, related to length of ILRT and activity
  • Conclusion: "Our combined-modality therapy provided reasonable local control and improved the quality of life of patients with extrahepatic bile duct carcinoma. Because none of the treatment characteristics had any impact on survival or biliary patency, lower dose levels and/or a localized target volume are recommended to minimize morbidity.

• Yonsei Korea 1986-95 PMID 12909222 -- Combination of external beam irradiation and high-dose-rate intraluminal brachytherapy for inoperable carcinoma of the extrahepatic bile ducts. (2003 Shin HS, Int J Radiat Oncol Biol Phys. 2003 Sep 1;57(1):105-12.)
  • Retrospective. 31 patients with EBRT (median 50.4 Gy), 17 EBRT alone vs. 14 EBRT + ILRT (15 Gy at 1.5cm).
  • Locoregional failure most common, no difference in recurrence rates (53% vs. 36%, p=NS)
  • With EBRT dose >50 Gy, most experienced GI symptoms
  • Overall 2-year survival: 0% EBRT vs 21% EBRT + ILRT (p=0.02)
  • Conclusion: "Given these observations, we believe that the combined use of EBRT and high-dose-rate ILBT is a beneficial, relatively safe, and effective method of improving the treatment outcome in selected patients with inoperable carcinoma of the extrahepatic bile ducts."

• Graz Austria PMID 12558559 -- Palliative treatment of unresectable bile duct tumours. (2003 Mayer R, Acta Med Austriaca. 2003;30(1):10-2.)
  • Retrospective. 14 patients treated with HDR BT (10 Gy), 5 patients additional EBRT (45-50.4 Gy)
  • Median survival: 6.5 months, BT alone 4.5 months vs. BT+EBRT 6.5 month (p=NS)
  • Conclusion: "Patients with advanced unresectable bile duct cancer face a dismal prognosis; however, biliary drainage, and intraluminal brachytherapy with or without external RT, seem to be able to improve quality of life in the remaining time span."

• Aachen Germany PMID 12491056 -- Combined external beam and intraluminal radiotherapy for irresectable Klatskin tumors. (2002 Schleicher UM, Strahlenther Onkol. 2002 Dec;178(12):682-7.)
  • Retrospective. 30 patients with proximal tumors. 18 treated with EBRT (median 30 Gy) vs. 12 treated with EBRT (median 30 Gy) + ILRT (median 40 Gy). 24 patients received low dose 5-FU
  • Median survival: EBRT only 3.9 months vs. EBRT/ILRT 9.1 months
  • Significant (p<0.05) improvement in ILRT >30 Gy and patients without jaundice
  • Conclusion: "The poor prognosis in patients with advanced Klatskin's tumors may be improved by combination therapy, with the role of brachytherapy and chemotherapy still to be defined. Our results suggest that patients without jaundice should be offered brachytherapy, and that a full dose of more than 30 Gy should be applied."

• FNHK Czech Republic
  • PMID 12143240 -- Intraluminal high dose rate brachytherapy in the treatment of bile duct and gallbladder carcinomas. (2002 Dvorak J, Hepatogastroenterology. 2002 Jul-Aug;49(46):916-7.)
    • Retrospective. 13 patients with BD and GB treated with HDR BT via diahepatal drain or PTBD
    • Control of jaundice in all patients. Well tolerated. Mean survival 9.2 months
    • Conclusion: "The addition of intraluminal brachytherapy may be beneficial to patients with carcinomas causing biliary obstruction in whom bile drainage can be established."

• • PMID 12143198 -- Transduodenal intraluminal high dose rate brachytherapy in the treatment of carcinomas of the subhepatic region. (2002 Dvorak J, Hepatogastroenterology. 2002 Jul-Aug;49(46):1045-7.
    • Retrospective. 12 patients with inoperable BD and pancreatic head
    • Mean survival 9.4 months
    • Conclusion: "Transduodenal intraluminal brachytherapy is technically feasible. The addition of intraluminal brachytherapy may be beneficial to patients in whom drainage can be established. Transduodenal insertion of brachytherapy is not competitive to the percutaneous approach but spreads the possibilities of the treatment of bile duct carcinoma. Intraluminal brachytherapy of pancreatic head carcinoma is feasible only via transduodenal approach."

• Miami 1991-98 PMID 11895206 -- High-dose-rate remote afterloading intracavitary brachytherapy for the treatment of extrahepatic biliary duct carcinoma. (2002 Lu JJ, Cancer J. 2002 Jan-Feb;8(1):74-8.)
  • Phase I/II. 18 patients treated with 45 Gy EBRT + HDR BT (52 Gy vs. 59 Gy vs. 66 Gy)
  • Median survival 12.2 months
  • Dose response suggested: 9 months vs. 12.2 months vs. 20.3 months survival (p=NS), 25% CR/PR vs. 80% CR/PR responses
  • Conlusion: "High dose rate brachytherapy of 21 Gy in three divided weekly treatments, plus 45 Gy of external beam radiation is well tolerated. A dose response is shown with significant increase of PR and CR rate for dose >59 Gy. This modality of treatment appears to be safe and effective for inoperable extrahepatic biliary duct carcinoma."

• Prague Czech Rep PMID 11462891 -- Intraluminal brachytherapy and selfexpandable stents in nonresectable biliary malignancies--the question of long-term palliation. (2001 Bruha R, Hepatogastroenterology. 2001 May-Jun;48(39):631-7.)
  • Retrospective. 32 patients with nonresectable CA (17 Klatskin, 11 GB, 4 papula) treated with stent implant and ILRT (30Gy)
  • Median survival: Klatskin 11.9 months, GB 7.0 months, papulla 42.5 months. No stent complications
  • Conclusion: "Intraluminal brachytherapy combined with stent implantation is a safe method and appears to prolong survival in inoperable patients with Klatskin's tumor and carcinoma of papilla Vateri compared with nontreated patients in previous studies. In contrast no similar effect should be expected in patients with gallbladder carcinoma."

• Asahikawa Japan 1988-99 PMID 10884992 -- [Management of hilar bile duct carcinoma with high-dose radiotherapy and expandable metallic stent placement] - [Article in Japanese] (2000 Saito, Nippon Geka Gakkai Zasshi. 2000 May;101(5):423-8.)
  • Retrospective. 107 patients treated with metallic stent and EBRT + HDR BT (59-98 Gy)
  • 2-year (5-year) OS: RT 23% (8%) vs. no RT 0% (0%)
  • Conclusion: "High-dose radiotherapy, consisting of ILRT and EBRT, appears to be feasible in the management of hilar bile duct carcinoma, and it offers a survival advantage for patients not suited for surgical resection. The placement of EMS assists the internal bile flow and lengthens survival after high-dose radiotherapy."

• Amsterdam 1985-97 PMID 10436826 -- Role of radiotherapy, in particular intraluminal brachytherapy, in the treatment of proximal bile duct carcinoma. (1999 Gonzalez Gonzalez D, Ann Oncol. 1999;10 Suppl 4:215-20.)
  • Retrospective. 109 patients received RT, 71 patients surgery + preop RT (19) or + post-op RT (52). Of these, 41 received 10 Gy ILRT boost. Median dose 50-55 Gy. 38 patients palliative RT, 19 received 22-25 ILRT Gy boost. Median dose 60-68 Gy.
  • Median survival: surgery + RT 24 months vs. palliative 10.4 months
  • Surgical patients: dose > 55 Gy had *lower* survival, and no benefit to brachytherapy
  • Palliative patients: no benefit to brachytherapy
  • Conclusion: "The role of radiotherapy either as adjuvant or as primary treatment remains to be demonstrated in prospective randomised studies. From our results, it seems that high radiation doses could be dangerous and could detriment prognosis. Brachytherapy boost was not superior to treatment with external beam irradiation alone."

• Turin Italy 1980-96 PMID 9824998 -- Interventional radiology and radiotherapy for inoperable cholangiocarcinoma of the extrahepatic bile ducts. (1998 Milella M, Tumori 1998; 84:467-71.)
  • Retrospective. 130 patients treated with palliative percutaneous transhepatic biliary drainage (PTBD), 19 excluded after short PTBD survival (<30 days), 111 analyzed. No RT 80% vs. EBRT 9% vs. EBRT + ILRT 11%
  • Median OS: 4.2 months; no RT 3.6 months vs. EBRT 11.5 months vs. EBRT + ILRT 14.3 months
  • Conclusion: "The combination of ERT plus BRT improves survival and quality of life of the patients submitted to PTBD for cholangiocarcinoma."

• Osaka Japan PMID 9638416 -- Endoscopic irradiation and parallel arrangement of Wallstents for hilar cholangiocarcinoma. (1998 Kubota Y, Hepatogastroenterology. 1998 Mar-Apr;45(20):415-9.)
  • Case report. HDR BT followed by placement of 2 Wallstents in parallel
  • Conclusion: "This endoscopic technique seems to be simple, safe, and reliable in obtaining bilateral hepatic drainage with Wallstents in patients with hilar cholangiocarcinoma."

• Mayo Jacksonville PMID 9369143 -- External radiation therapy and transcatheter iridium in the treatment of extrahepatic bile duct carcinoma. (1997 Foo ML, Int J Radiat Oncol Biol Phys. 1997 Nov 1;39(4):929-35.)
  • Retrospective. 24 patients, median EBRT dose 50.4 Gy, median transcatheter boost at 1 cm radius was 20 Gy. 9 pts received concomitant 5-FU
  • Median survival 12.8 months, 5-year OS 14.1%
  • Conclusion: "External beam irradiation combined with a transcatheter boost can result in long-term survival of patients with EHBD cancer. Both distant metastases and local recurrence develop in 25-30% of patients despite irradiation. Survival may be improved by using chemotherapy in combination with EBRT to impact disease relapse (local and distant). Because there may be a dose response with irradiation, survival may also be improved by increasing the dose of radiation delivered by transcatheter boost."

• Minnesota PMID 9274796 -- Biliary tree malignancies: the University of Minnesota experience. (1997 Lee CK, J Surg Oncol. 1997 Aug;65(4):298-305.)
  • Retrospective. 15 patients, most perihilar treated with BT or EBRT
  • Median survival 8 months, 3 long term survivors

• Adelaide Australia 1983-93 PMID 9153812 -- Intraluminal brachytherapy in the treatment of bile duct carcinomas. (1997 Leung JT, Australas Radiol. 1997 May;41(2):151-4.)
  • Retrospective. 15 patients transhepatic BT; 11 LDR, 4 HDR
  • Median survival: 12.5 months
  • Conclusion: "We conclude that the addition of intraluminal brachytherapy after biliary drainage prolongs survival and is a safe and effective treatment, but patients still have a high rate of local failure, and further studies will be needed to address this problem."

• Sydney Australia 1989-94 PMID 8602818 -- Intraluminal brachytherapy in bile duct carcinomas. (1996 Leung J, Aust N Z J Surg. 1996 Feb;66(2):74-7.)
  • Retrospective. 16 patients transhepatic BT, 1 +EBRT
  • Median survival: 23 months
  • Conclusion: "We conclude that iridium-192 brachytherapy is a safe effective treatment for biliary tract carcinoma but a comparison between surgery and stenting would be of value. However, the cost of brachytherapy is not cheap and its value in this regard should be carefully analysed."

• Hokkaido Japan 1983-91 PMID 8598352 -- The role of radiotherapy in the management of extrahepatic bile duct cancer: an analysis of 145 consecutive patients treated with intraluminal and/or external beam radiotherapy. (1996 Kamada T, Int J Radiat Oncol Biol Phys 1996; 34:767-74.)
  • Retrospective. 145 patients, 6 pre-op RT, 59 post-op RT, 54 radical RT, 23 palliative RT.
  • RT: ILRT mean dose 42.2 Gy (20-95 Gy @ 0.4 Gy/hr), EBRT mean dose 42.2 Gy (7.5-80 Gy). Total mean dose 67.8 Gy
  • Mean survival (5-year survival): Preop RT 8.4 mo (11%) vs. postop RT 21.5 mo (18%) vs. radical RT 12.4 mo (6%) vs. palliative RT 4.3 mo (0%)
  • Post-op RT MST: Stage I/II 32.0 months vs. Stage III/IV 18.6 months (p<0.05)
  • Post-op RT: mean survival EBRT 14.4 mo vs. ILRT 24.7 mo (p=0.05)
  • Adjuvant RT: EBRT vs. ILRT (p=NS)
  • No dose response, but trend in post-op RT group (MST 17 mo vs. 26 mo)
  • Total dose > 90 Gy showed higher incidence of hemorrhagic gastroduodenal ulceration
  • Conclusion: "High-dose radiotherapy, consisting of ILRT and EBRT, appears to be feasible in the management of EHBD cancer, and it offers a survival advantage for patients not suited for surgical resection [compared with historical controls] and patients with positive margins in the resected end of the hepatic side bile duct. Expandable metallic biliary endoprosthesis assists the internal bile flow and may lengthen survival after high dose radiotherapy."

• Rome Italy
  • PMID 8638018 -- Role of intraluminal brachytherapy in extrahepatic bile duct and pancreatic cancers: is it just for palliation? (1996 Montemaggi P, Radiology. 1996 Jun;199(3):861-6.)
    • Retrospective. 31 patients (BD 18, pancreas 13) treated with BT (17 alone at 50 Gy, 14 at 30 Gy + EBRT 45 Gy + 5-FU)
    • Toxicity: no acute, 3 late GIB
    • Conclusion: "ILBT is an effective palliative treatment of unresectable extrahepatic bile duct and pancreatic cancers. Results suggest a possible "curative" role in specific clinical settings when properly integrated with other treatments."

• • PMID 7538501 -- Intraluminal brachytherapy in the treatment of pancreas and bile duct carcinoma. (1995 Montemaggi P, Int J Radiat Oncol Biol Phys. 1995 May 15;32(2):437-43.)
    • Retrospective. 12 patients, 5 billiary and 7 pancreatic CA with obstructive jaundice. 4 CCA patients stent + BT (50 Gy @ 1cm), 1 CCA patient stent + BT 48 Gy + EBRT 28 Gy. 4 pancreatic patients 5-FU
    • Cholangitis 25%, stent occlusion 25%. 1 gastric ulcer (BT+EBRT+5FU pancreatic pt)
    • Median OS 14 months
    • Conclusion: "The results in the EHBD patients suggest that the addition of ILBT after biliary drainage prolongs survival." [compared to previous series]

• Emory PMID 7784581 -- Definitive radiation therapy for extrahepatic bile duct carcinoma. (1995 Tsujino K, Radiology. 1995 Jul;196(1):275-80.)
  • Retrospective. 27 patients, 7 pts EBRT (median 50.4 Gy) only and 20 pts EBRT (median 45 Gy) + BT (LDR 25 Gy until 1987, HDR 7.5 Gy thereafter). BT indicated for +SM and all palliative cases. 4 patients 5-FU
  • Median survival (2-year OS): 13 months (10%)
  • EBRT > 45Gy, men, BD confined tumors significantly better outcomes
  • Complications: cholangitis 61%, gastric obstruction 9%
  • Conclusion: "Patients with locally advanced EHBD carcinomas have a low survival rate. Certain factors, however, appear to have prognostic significance."

• MSKCC PMID 8535808 -- Palliation of irresectable hilar cholangiocarcinoma with biliary drainage and radiotherapy. (1995 Kuvshinoff BW, Br J Surg 1995; 82:1522-5.)
  • 12 pts treated with internal drainage followed by ILRT
  • Median survival: 14.5 months, all patients survived >6 months
  • Conclusion: "Internal biliary drainage, in conjunction with radiotherapy, appears to be safe and effective palliation of irresectable or recurrent hilar cholangiocarcinoma. Patients can maintain a reasonable quality of life with an acceptable incidence of cholangitis, without the hindrance of external drainage devices."

• Heidelberg Germany PMID 8040034 -- Combined external beam radiotherapy and intraluminal high dose rate brachytherapy on bile duct carcinomas. (1994 Fritz P, Int J Radiat Oncol Biol Phys. 1994 Jul 1;29(4):855-61.)
  • Retrospective. 30 patients (18 perihilar, 12 distal) treated with EBRT (30-45 Gy) and ILRT (20-45 Gy)
  • Median survival (5-year OS): 10 months (8%)
  • Palliative resection significantly better survival (12.1 months) than RT only (7.9 months)
  • Brachytherapy: Max 20 Gy boost best tolerated, decrease in cholangitis (8% vs. 23%)
  • Conclusion: "The present standard treatment schedule 40 Gy for the external beam and 20 Gy (fourfold 5 Gy) for the afterloading boost seems to be appropriate and well tolerated. After radiotherapy, a permanent supply of drainage should be made with a stent.

• Turin Italy PMID 7520594 -- [Percutaneous treatment of hilar cholangiocarcinoma completed by high-dose rate brachytherapy. Experience in the first 5 cases] - [Article in Italian] (1994 Righi D, Radiol Med (Torino). 1994 Jul-Aug;88(1-2):79-85.
  • Case report. 5 patients.

• Mayo Jacksonville PMID 1312319 -- Analysis of failure after curative irradiation of extrahepatic bile duct carcinoma. (1992 Buskirk SJ, Ann Surg 1992; 215:125-31.)
  • Retrospective. 34 pts treated with 5-FU, EBRT 45 Gy + 17 pts 5-15 Gy EBRT boost vs. 10 pts ILRT vs. 7 pts IORT
  • Median survival: 12 months

• Lyon France 1980-88 PMID 1866463 -- Radiation therapy in extrahepatic bile duct carcinoma. (1991 Mahe M, Radiother Oncol. 1991 Jun;21(2):121-7.)
  • Retrospective. 51 patients, 4 radical resection, 10 positive margins, 12 palliative resection, 10 biopsy, 15 no surgery
  • RT curative (mean EBRT 45 Gy, ILRT 50-60 Gy) for radical/positive margin surgery, palliative (mean EBRT 35 Gy, ILRT 30 Gy)
  • Median survival (3-year OS): 12 months (15%)

• Rotterdam PMID 2153649 -- The role of radiotherapy in the treatment of bile duct carcinoma. (1990 Veeze-Kuijpers B, Int J Radiat Oncol Biol Phys. 1990 Jan;18(1):63-7)
  • Retrospective. 42 patients (11 microscopic positive margins after surgery, 31 unresectable) given EBRT (40 Gy) + ILRT (25 Gy in 1 session)
  • Median survival 10 months, 3 patients > 30 months
  • Resection + RT better than RT alone (p=0.06)

• Duke 1980-87 PMID 3344584 -- Internal radiation for bile duct cancer. (1988 Meyers WC, World J Surg. 1988 Feb;12(1):99-104.)
  • Retrospective. 27 patients (3 resected), treated with stent followed by BT and 22 also EBRT
  • Average survival: 13.5 months (2-58 months)
    • No surgical decompression 5.8 months vs. decompression 14.1 months
    • BT only 11 months vs. BT + EBRT 21 months
  • All patients had symptoms attributed to cholangitis, 21 severe
  • Conclusion: "Heterogeneity of patient material, pretreatment methods, and lack of controls preclude any statement concerning effectiveness of RT for bile duct cancer"

• Utah 1980-1985 PMID 2843489 -- Definitive radiation therapy in bile duct carcinoma. (1988 Hayes JK, Int J Radiat Oncol Biol Phys. 1988 Sep;15(3):735-44.)
  • Retrospective. 24 patients, 75% proximal. 40% palliative/no RT and 60% definitive RT (EBRT, LIRT, or combination)
  • Median survival: palliative 2.0 months vs. definitive 12.8 months (p<0.005)
  • Complications were common, including bacterial sepsis (58%), cholangitis (38%), gastrointestinal bleeding (46%), intra or extrahepatic abscesses (33%), and recurrent biliary obstruction (25%)

• Perth Australia PMID 2831118 -- Transpapillary iridium-192 wire in the treatment of malignant bile duct obstruction. (1988 Levitt MD, Gut. 1988 Feb;29(2):149-52.)
  • 24 patients with malignant bile obstruction (pancreas and CCA)
  • BT (median 60 Gy) via endoscopic catheter. One early death from CVA. Cholangitis 30%, stent blockage 40%
  • Median survival CCA 10 months, pancreas 8.3 months
  • Conclusion: "The ability of intraluminal irradiation to improve palliation or lengthen survival in patients with malignant bile duct obstruction remains uncertain."

• Duarte CA PMID 3338957 -- Intracatheter hyperthermia and iridium-192 radiotherapy in the treatment of bile duct carcinoma. (1988 Wong JY, Int J Radiat Oncol Biol Phys. 1988 Feb;14(2):353-9.)
  • Case report. Locally advanced BD CA, EBRT 45 Gy + hyperthermia to 43-45C x 1 hr + BT 50 Gy over 72 hours
  • Pt asymptomatic 6 months after therapy. Duodenal ulcer.
  • Conclusion: "We believe the use of intracatheter hyperthermia in conjunction with external and/or intracatheter radiotherapy in selected patients with unresectable bile duct carcinomas warrants further study."

• Wash U 1975-83 PMID 3104245 -- Carcinoma of the extrahepatic biliary system--results of primary and adjuvant radiotherapy. (1987 Fields JN, Int J Radiat Oncol Biol Phys. 1987 Mar;13(3):331-8.)
  • Retrospective. 20 patients with GB (3 pts) or billiary duct CA (17 pts). 9 pts EBRT (44 - 63.6 Gy) alone vs. 8 pts EBRT (21.6 - 50.4 Gy) + BT (19.5 - 25.7 Gy)
  • Median survival: EBRT alone 7 monts vs. EBRT + BT 15 months (p=0.06)
  • Conclusion: "Although numbers are small, these results appear to support the use of adjuvant radiotherapy in patients with microscopic residual GB cancer. Aggressive local and regional radiotherapy can add to the quality and length of survival in both patient groups, that is, those with resectable lesions with high likelihood of microscopic residual, and also those with unresectable or gross residual disease after surgery."

• Munich Germany PMID 2448132 -- Endoprosthesis and local irradiation in the treatment of biliary malignancies. (1987 Classen M, Endoscopy. 1987 Nov;19 Suppl 1:25-30.)
  • "Non-surgical drainage procedures can be combined with endoscopic or transhepatic irradiation employing 192-iridium for intraluminal irradiation; further studies are, however, needed"

• King's College Hospital PMID 2998683 -- Internal biliary drainage and local radiotherapy with iridium-192 wire in treatment of hilar cholangiocarcinoma. (1985 Karani J, Clin Radiol. 1985 Nov;36(6):603-6.)
  • Retrospective. 30 patients. BT 40-50 Gy
  • Mean survival 16.8 months (1-66 months). 21 survived >1 year
  • Conclusion: "We report a significant increase in mean survival to 16.8 months in patients treated with internal biliary drainage when combined with local irradiation to the tumour with iridium-192."

• Lyon France PMID 6207904 -- Radiotherapy of high bile duct carcinoma using intra-catheter iridium 192 wire. (1984 Mornex F, Cancer. 1984 Nov 15;54(10):2069-73.)
  • Retrospective. 7 patients. BT 10-60 Gy at 1cm; 4 also EBRT 20-50 Gy
  • Mean survival 8.2 months (2-23 months). No systemic or local complications.
  • Conclusion: "This well-tolerated procedure permits symptomatic palliation without excessive side effects for the patient."

• Mayo 1980-82 PMID 6436203 -- Analysis of failure following curative irradiation of gallbladder and extrahepatic bile duct carcinoma. (1984 Buskirk SJ, Int J Radiat Oncol Biol Phys. 1984 Nov;10(11):2013-23.)
  • Retrospective. 20 pts (16 BD, 4 GB) treated with curative RT (45-50 Gy to tumor and LNs). 10 pts 10-15 Gy boost +/- 5-FU, 8 pts ILRT 20-25 Gy, 2 pts IORT 15-20 Gy
  • Conclusion: "Further experience is necessary to determine whether this aggressive treatment will result in long-term disease-free survival in these patients."

• Germany PMID 6697900 -- [Endoscopic intraductal radiotherapy of high bile-duct carcinoma] - [Article in German] (1984 Phillip J, Deutsch Med Wochenschr. 1984 Mar 16;109(11):422-6.)
  • Case report, 3 patients. Endoscopic BT (60 Gy @ 0.5 cm, 0.85 Gy/min x 70 hours)
  • Conclusion: "The advantage over previously described methods (percutaneous transhepatic, surgical after installation of U-drainage) lies in a smaller complication rate and improved follow-up treatment as change of the endoprosthesis or repeat irradiation is not associated with renewed tissue trauma."

• PMID 7053662 -- Diagnosis and treatment of primary extrahepatic bile duct tumors. (1982 Chitwood WR, Am J Surg. 1982 Jan;143(1):99-106.
  • Retrospective. 10 patients EBRT 30-50 Gy + BT 50 Gy.
  • 5 aliver 1-12 months post RT, 5 died after 3-4 months

• PMID 7330164 -- Newer techniques in the diagnosis and treatment of proximal bile duct carcinoma--an analysis of 41 consecutive patients. (1981 Wheeler PG, Q J Med. 1981 Summer;50(199):247-58.)
  • 41 patients
  • Median survival: surgical drainage/bypass 9 months vs. no drainage 3 months
  • RT performed in 9 patients, improved survival compared with tube drainage alone
  • Conclusion: "The new percutaneous techniques offer a useful alternative to surgery for palliative drainage and radiotherapy."

• King's College Hospital PMID 6114244 -- Treatment of high bile duct carcinoma by internal radiotherapy with iridium-192 wire. (1981 Fletcher MS, Lancet. 1981 Jul 25;2(8239):172-4.)

• PMID 7208926 -- Irradiation of biliary carcinoma. (1981 Herskovic A, Radiology. 1981 Apr;139(1):219-22.)
  • Case report. 6 patients. 50 Gy BT
  • Tumor disappeared in 1, reduced in 5

• Minnesota Papillary colloid adenocarcinoma of the extrahepatic bile ducts. (1935 Walters, W.; Olsen, P. F. Minn. Med. 18:460-462;

=Animal Model

• Freiburg Germany PMID 8284744 -- [Radiation sensitivity of the normal bile duct during high dose rate afterloading irradiation with Iridium 192. Experimental studies in pigs] - [Article in German] (1993 Brambs HJ, Strahlenther Onkol. 1993 Dec;169(12):721-8.)
  • 16 pigs, ILRT 7.5 Gy and 15 Gy using an iridium-192 source. Significant lesions
  • Conclusion: "Single intraluminal high-dose-rate afterloading doses of 7.5 and 15 Gy cause significant lesions and complications at the bile ducts. As the intact bile duct is the Achilles heel of intraductal therapy, considerably lower single doses are recommended for a fractioned treatment."