Combined modality treatment in unresectable extrahepatic biliary carcinoma

Purpose: Cancers of the extrahepatic biliary tract are rare. Surgical resec tion is considered the standard treatment, but is rarely feasible. Several reports of combined modality therapy, including external beam radiation, of ten combined with chemotherapy and intraluminal brachytherapy, have been pu blished. The purpose of this study was to evaluate the effect of chemoradia tion plus intraluminal brachytherapy on response, local control, survival, and symptom relief in patients with unresectable or residual extrahepatic b iliary carcinoma. Methods and Materials: From February 1991 to December 1997, 20 patients (14 male, 6 female; mean age 61 +/- 12 years; median follow-up 71 months) with unresectable (16 patients) or residual (4 patients), nonmetastatic extrahe patic bile tumors (common bile duct, 8; gallbladder, 1; Klatskin, 11) recei ved external beam radiation (39.6-50.4 Gy); in 19 patients, 5-fluorouracil (96-h continuous infusion, days 1-4 at 1,000 mg/m(2)/day) was also administ ered. Twelve patients received a boost by intraluminal brachytherapy using Ir-192 wires of 30-50 Gy, prescribed 1 cm from the source axis. Results: During external beam radiotherapy, 8 patients (40%) developed grad e 1-2 gastrointestinal toxicity. Four patients treated with external-beam p lus intraluminal brachytherapy had a clinical response (2 partial, 2 comple te) after treatment. For the total patient group, the median survival and t ime to local progression was 21.2 and 33.1 months, respectively. Distant me tastasis occurred in 10 (50%) patients. Two patients who received external beam radiation plus intraluminal brachytherapy developed late duodenal ulce ration. Two patients with unresectable disease survived more than 5 years. Conclusion: Our data suggest that chemoradiation plus intraluminal brachyth erapy was relatively well-tolerated, and resulted in reasonable local contr ol and median survival. Further follow-up and additional research is needed to determine the ultimate efficacy of this regimen. New chemoradiation com binations and/or new treatment strategies (neoadjuvant chemoradiation) may contribute, in the future, to improve these results. (C) 2000 Elsevier Scie nce Inc.