RESUMEN
Deprivation of portal blood flow decreases the hepatic function, thus hepatobiliary cancer patients with total occlusion of the main portal vein (PV) are usually not indicated for major hepatectomy. We herein present a 37-year-old male patient with advanced intrahepatic cholangiocarcinoma, in whom right trisectionectomy was indicated. However, the main PV was nearly completely occluded by tumor invasion, thus resolution of jaundice was markedly slow. To restore the liver function through PV recanalization, a wall stent was inserted percutaneously. Jaundice resolved progressively after PV stenting. Right trisectionectomy, caudate lobectomy, bile duct resection, and en bloc PV segmental resection with iliac vein homograft interposition were performed. However, PV thrombosis developed at the site of PV stent removal, thus a new wall stent was inserted during the operation. The pathology report presented that the tumor was a 5.2 cm-sized well-differentiated adenocarcinoma of periductal infiltrating type with lymph node metastasis. During the follow-up, the interposed PV segment with a wall stent was gradually occluded with development of portal collaterals. At 5 years after surgery, the PV stent was completely occluded and collaterals developed. The patient experienced repetition of febrile episodes of unknown causes. He is currently alive for 8 years with no evidence of tumor recurrence. The detailed surgical procedures were presented with a supplementary video clip of 5 minutes.
RESUMEN
PURPOSE: Selective internal radiation therapy (SIRT) appears to be an interesting treatment possibility for locally-advanced intrahepatic cholangiocarcinoma (ICC), yet the appropriate dosimetry has never been evaluated in this context. METHODS: We retrospectively studied data from 40 patients treated at our institution with 90Y-loaded glass microsphere SIRT combined with chemotherapy for inoperable ICC as first-line treatment. Macroaggregated albumin (MAA)-based single-photon emission computed tomography (SPECT)/computed tomography (CT) quantitative analysis was used to calculate the tumor dose (TD), healthy-injected liver dose (HILD), and injected liver dose (ILD). Response was evaluated at 3 months using the European Association for the Study of the Liver criteria. Factors associated with response and toxicity were analyzed using univariate analysis. RESULTS: We assessed a total of 35 patients (five excluded) receiving 55 injections. Mean TD was 322 ± 165Gy and mean HILD was 74 ± 24Gy for a mean ILD of 128 ± 28Gy. All but two lesions responded, with a minimal TD for responding lesions of 158Gy. Six Grade 3-4 permanent liver toxicities were observed. Mean HILD was not associated with liver toxicity (73.2 ± 25.8Gy for patients with liver toxicity and 77.8 ± 16.9Gy for patients without, ns). Only underlying Child-Pugh status (p = 0.0014) and underlying cirrhosis (p = 0.0021) were associated with liver toxicity. Median progression-free survival was 12.7 months and median overall survival (OS) was 28.6 months. Median OS was 52.7 months for patients with Child-Pugh A5 status. CONCLUSIONS: When combined with chemotherapy, SIRT is highly effective, with a TD > 158Gy. Tolerance was good except for the few patients with cirrhosis or Child-Pugh status ≥A6, who exhibited some liver toxicity. Prospective studies are warranted to confirm.