A novel endoscopic approach to brachytherapy in the management of Hilar cholangiocarcinoma.
OBJECTIVE
Traditionally, biliary brachytherapy sources are placed percutaneously via transhepatic drains or endoscopically via nasobiliary tubes (NBT). Another ERCP is needed for stent replacement after NBT removal. The aim of this study was to determine the feasibility and safety of endoscopic transpapillary insertion of irradiation sources through 10-Fr stents.


METHODS
Medical records of Mayo Clinic Rochester patients undergoing biliary brachytherapy for hilar cholangiocarcinoma (CCA) were reviewed. Patients were part of a treatment protocol with curative intent including external beam radiation therapy (4,500 cGy), radiation sensitization (5-FU), and low dose rate (LDR) brachytherapy (<3,000 cGy) followed by liver transplantation. The 10-Fr biliary stent placed across the malignant biliary stricture was directly cannulated using a radiopaque (192)Ir embedded ribbon within a 300-cm long, 5.1-Fr plastic sheath. After withdrawal of the endoscope, the external end of the brachytherapy catheter was rerouted transnasally and secured. Each patient was hospitalized in a shielded room up to 24 h after which the brachytherapy catheter was removed by hand.


RESULTS
Between 1999 and 2004, 32 patients underwent biliary brachytherapy via endoscopically placed 10-Fr plastic stents (mean age 50.6 yr, 69% PSC, bilateral brachytherapy catheters 28.1%). The technical complication observed was immediate brachytherapy catheter displacement (7 of 32, 22%) managed by prompt brachytherapy catheter repositioning.


CONCLUSIONS
LDR biliary brachytherapy administration via endoscopically placed biliary stents is technically feasible and appears reasonably safe in select patients with unresectable perihilar CCA. Unlike NBTs, stents can potentially be placed in bilateral ductal systems to accommodate dual brachytherapy catheters when indicated.
Simmons
Dia T
DT
Department of Medicine, Division of Gastroenterology & Hepatology, Mayo Clinic College of Medicine, Rochester, Minnesota 55905, USA.
Baron
Todd H
TH
Petersen
Bret T
BT
Gostout
Christopher J
CJ
Haddock
Michael G
MG
Gores
Gregory J
GJ
Yeakel
Peter D
PD
Topazian
Mark D
MD
Levy
Michael J
MJ
D001650:Bile Duct Neoplasms / Q000000981:diagnostic imaging / Q000532:radiotherapy* / Q000628:therapy; D001918:Brachytherapy / Q000379:methods*; D016009:Chi-Square Distribution; D018281:Cholangiocarcinoma / Q000000981:diagnostic imaging / Q000532:radiotherapy* / Q000628:therapy; D002758:Cholangiography; D003131:Combined Modality Therapy; D016145:Endoscopy, Digestive System; D005240:Feasibility Studies; D005260:Female; D006801:Humans; D007496:Iridium Radioisotopes / Q000627:therapeutic use; D008297:Male; D020360:Neoadjuvant Therapy; D010166:Palliative Care; D011879:Radiotherapy Dosage; D015607:Stents; D016896:Treatment Outcome
D007496:Iridium Radioisotopes