Comparison of intraluminal brachytherapy combined with and without stent placement for treatment of obstructive jaundice induced by tumor thrombus.

PURPOSE: To compare the safety and efficacy of intraluminal brachytherapy with iodine-125 (125I) seed strand implantation combined with and without stent placement to treat patients with obstructive jaundice induced by tumor thrombus. METHODS: Between January 2018 and June 2022, 42 patients with malignant obstructive jaundice (MOJ) induced by tumor thrombus were included. 20 patients received 125I seed strand implantation and stent placement (group A). The remaining 22 patients, implanted 125I seed strands only, served as control (group B). The two groups' overall survival and jaundice-free survival were compared using the Kaplan-Meier method and log-rank test. RESULTS: During the follow-up period, the mean survival time of group A was 38.0 ± 4.1 months (95%CI, 30.0-46.1 months), while that of group B was 25.1 ± 2.8 (95% CI, 19.5-30.6 months) (p = 0.406). The mean survival rates of 12 months for all patients, group A, and group B was 66.7%, 65%, and 68%, respectively. The mean jaundice-free survival of group A and group B were 34.0 ± 3.6 months (95% CI, 27.9-41.2months) and 22.9 ± 2.7 months (95%CI, 17.5-28.2months) (p = 0.254), respectively. Two PTBD drainage tube infection cases occurred in group A and group B separately. CONCLUSIONS: 125I intraluminal brachytherapy is an effective and safe therapy for treating patients with obstructive jaundice induced by tumor thrombus.

Study of Percutaneous Stent Placement with Iodine-125 Seed Strand for Malignant Biliary Obstruction.

PURPOSE: To evaluate the effectiveness and safety of simultaneous placement of a self-expandable metallic stents (SEMS) and iodine-125 seed strand in the management of malignant obstructive jaundice (MOJ). MATERIALS AND METHODS: This study included 132 patients with MOJ treated from November 2015 to October 2017. Forty-five patients underwent insertion of SEMS with iodine-125 seed strands (Seeds group); the remaining 87 patients underwent SEMS placement alone (Control group). Technical success was defined as accurate, successful deployment of SEMS with or without iodine-125 seed strand; clinical success was defined as 20% reduction in serum bilirubin within 1 week after the procedure, compared with baseline. Complications, duration of primary stent patency, and overall survival were evaluated. RESULTS: Technical success was achieved in all patients in both groups. In the Seeds group, an average of 14 seeds (range 8-22) were implanted in the bile duct as a strand. Clinical success rates were similar between the groups (Seeds group, 93.3%; Control group, 95.4%). Major complications occurred in only one patient, in the Control group. The median period of primary stent patency was significantly longer in the Seeds group (194 days) than in the Control group (86 days; P = 0.049). The median overall survival was also significantly longer in the Seeds group (194 days) than in the Control group (96 days; P = 0.031). CONCLUSION: SEMS combined with iodine-125 seed strands is effective and safe in the management of MOJ and can improve stent patency and patient survival.

A Systematic Review and Meta-analysis of Intraluminal Brachytherapy Versus Stent Alone in the Treatment of Malignant Obstructive Jaundice.

OBJECTIVES: To evaluate therapeutic outcomes of intraluminal brachytherapy (ILBT) for malignant obstructive jaundice (MOJ) against stent alone. METHODS: The PubMed, EMBASE, Cochrane Library, CNKI, Wan Fang, VIP and ClinicalTrials.gov databases were searched for all relevant comparative studies from the earliest available date up to 1 May 2017. Subgroup analyses were performed according to the type of study design and type of stent. RESULTS: Twelve studies that compared ILBT versus stent alone were eligible. A total of 641 participants with MOJ were included in our meta-analysis. A total of 340 participants were treated with intraluminal brachytherapy (ILBT); the other 301 participants were treated with biliary stent alone (stent group). ILBT was associated with lower risk of stent occlusion (OR 0.19; 95% CI 0.13-0.28; P < 0.00001) and better mean survival (MD = 3.15; 95% CI 2.64-3.66; P < 0.00001) compared with stent alone. However, the two groups were similar in number of complications (OR 0.84; 95% CI 0.45-1.56; P = 0.578), post-treatment reduced level of total bilirubin (TBIL) (MD = 22.71; 95% CI - 7.24-52.65; P = 0.14), post-treatment reduced level of direct bilirubin (DBIL) (MD = - 3.67; 95% CI - 14.09-6.75; P = 0.49), post-treatment reduced level of alanine aminotransferase (ALT) (MD = 21.09; 95% CI - 5.09-47.28; P = 0.11) and post-treatment reduced level of aspartate aminotransferase (AST) (MD = 20.86; 95% CI - 45.86-87.58; P = 0.54). CONCLUSIONS: ILBT was significantly superior to stent alone in terms of stent occlusion and mean survival. Meanwhile, ILBT had comparable outcomes to stent alone in terms of complications and post-treatment reduced levels of TBIL, DBIL, ALT and AST. Therefore, ILBT may be considered a preferable technique for MOJ.

Radioterapia como tratamiento paliativo de la obstrucción biliar tumoral / Radiotherapy as palliative treatment of malignant biliary obstruction

OBJETIVOS: La ictericia obstructiva es un síntoma frecuente en los tumores irresecables de la vía biliar. Presentamos un caso clínico con diagnóstico de colangiocarcinoma recurrente con ictericia obstructiva tratada con radioterapia externa. Caso clínico: Paciente con diagnóstico de colangiocarcinoma recurrente metastásico que a pesar de la colocación de dos endoprótesis biliares continúa con ictericia y mal estado general. Se decide tratamiento con radioterapia externa paliativa sobre la lesión tumoral que comprime la vía biliar administrando una dosis total de 20Gy en 5 fracciones de 400 cGy. Tras la finalización del tratamiento las cifras de bilirrubina se estabilizan y comienzan a descender de forma progresiva hasta niveles normales, resolviéndose la ictericia y mejorando la calidad de vida del paciente. CONCLUSIONES: La radioterapia externa puede ser un tratamiento paliativo efectivo para descomprimir la vía biliar y mejorar la sintomatología en pacientes con tumores irresecables

OBJECTIVES: Obstructive jaundice is a frequent symptom in unresectable tumours of the bile duct. The case is reported of a patient diagnosed with recurrent cholangiocarcinoma with obstructive jaundice treated with external radiotherapy. Clinical case: A 47 year- old male diagnosed with recurrent and metastatic cholangiocarcinoma. Despite placing two biliary stents, the patient continued have high bilirubin levels, jaundice and a poor condition overall. With these findings, the proposed treatment was palliative external radiotherapy over the tumour lesion that compressed the bile duct, with a total dose of 20Gy in 5 fractions of 400 cGy. After completing the treatment, the bilirubin values began to descend gradually to normal levels, the jaundice disappeared and the quality of life of the patient improved. CONCLUSIONS: External radiotherapy can be an effective palliative treatment to decompress the bile duct and improve the symptoms in patients with unresectable tumours

Damage to pig bile duct caused by intraluminal brachytherapy using a (125)I ribbon.

BACKGROUND: Stent occlusion by tumor ingrowth or overgrowth is the main cause of jaundice recurrence after metal stent insertion in patients with malignant obstructive jaundice (MOJ). The application of intraluminal brachytherapy (ILBT) in patients with MOJ results in local control of malignant tumors, which prolong stent patency. PURPOSE: To evaluate the safety of ILBT in pig bile ducts using ribbons of iodine-125 ((125)I) seeds. MATERIAL AND METHODS: Sixteen healthy pigs were randomly assigned to four groups of four pigs each. A (125)I seed ribbon was implanted into the common bile duct of each animal through an incision in the duct wall, and was fixed by suturing. The four groups of animals were sacrificed at 15, 30, 60, and 120 days after ribbon implantation, respectively. Serum bilirubin concentrations, alanine aminotransferase concentrations, and white blood cell counts before and after implantation were compared within each group. Pathological changes to the bile duct wall were observed using a light microscope. Morphological changes in biliary epithelial cells and organelles were observed with electron microscopy. RESULTS: (125)I ribbons were successfully implanted in all animals without surgery-related death. We found no significant difference in pre- and post-implant serum bilirubin, alanine aminotransferase, or white blood cell counts. Light and electron microscopy showed that the most severe bile duct damage occurred in the 15-day group, which exhibited necrosis and detachment of numerous epithelial cells, and infiltration of inflammatory cells. Repair and proliferation of the bile duct epithelium began 30 days after implantation and was nearly complete at 60 days. CONCLUSION: This study demonstrated the safety of ILBT using a (125)I ribbon in the pig bile duct. (125)I seed ribbons may be used in the treatment of MOJ in humans.

The use of ¹²5I seed strands for intraluminal brachytherapy of malignant obstructive jaundice.

This study is sought to evaluate the feasibility and safety of using ¹²5I seed strands for intraluminal brachytherapy (ILBT) in the treatment of malignant obstructive jaundice (MOJ), and its clinical effect on stent patency. A total of 34 patients found to have MOJ were randomly assigned to an ILBT treatment group or a control group before biliary stent insertion. For the ILBT group, ¹²5I seed strands were implanted into the obstructive segment of the bile duct after stent insertion. For the control group, only the biliary stent was inserted. Alimentary and hematologic complications were examined for patients in the ILBT group. The stent patency of the two groups were compared. In the ILBT group, the number of ¹²5I seeds per strand varied from 6 to 16 (mean, 10.9), and were successfully implanted in 17 patients. Serum levels of bilirubin, alanine aminotransferase, granulocytes, and platelets assayed 2 and 4 weeks following the procedure demonstrated no significant difference between the ILBT group and the control group. The mean stent patency for ILBT group (10.2 months) was significantly longer than that of the control group (7.2 months, p=0.032). ¹²5I seed strands for ILBT is a feasible and safe palliative therapy for the treatment of MOJ, and may prolong stent patency.

[Palliative treatment of nonresectable pancreatic cancer complicated by obturation jaundice].

There are presented the results of palliative treatment of 411 patients, suffering pancreatic cancer, complicated by obturation jaundice. To all the patients the four-staged treatment, including preoperative preparation, draining operation, chemoradiation and subsequent symptomatic operation, was applied. While performing draining operation there were applied the methods of choledochoduodenoanastomosis formation, elaborated in the clinic. Postoperative complications rate and lethality after application of elaborated method of choledochoduodenoanastomosis formation is lesser than after formation of cholecystojejunoanastomosis and external drainage.

Intraluminal brachytherapy without stenting in intrahepatic papillary cholangiocarcinoma: a case report.

A 46-year-old female patient, with mild cholestasis by a large papillary cholangiocarcinoma involving the left hepatic duct, received intraluminal brachytherapy (50 Gy at 1 cm from the source axis) with the aim to relieve biliary obstruction without stent positioning. The patient presented with haemobilia and vegetant lesions in the left main biliary duct, and thus she had a high risk of early stent obstruction. Eighteen months after the treatment the patient presented tumour progression in the controlateral hepatic lobe, but had a patent left hepatic duct, without signs of cholestasis and/or cholangitis. Based on this and other published reports, intraluminal brachytherapy may be tested in a setting different from standard setting with the aim to safely palliate jaundice in patients with intraductal tumour growth in the biliary tract.

HDR-192Ir intraluminal brachytherapy in treatment of malignant obstructive jaundice.

AIM: To determine the feasibility and safety of intraluminal brachytherapy in treatment of malignant obstructive jaundice (MOJ) and to evaluate the clinical effect of intraluminal brachytherapy on stent patency and patient survival. METHODS: Thirty-four patients with MOJ were included in this study. Having biliary stent placed, all patients were classified into intraluminal brachytherapy group (group A, n = 14) and control group (group B, n = 20) according to their own choice. Intraluminal brachytherapy regimen included: HDR-192Ir was used in the therapy, fractional doses of 4-7 Gy were given every 3-6 d for 3-4 times, and standard points were established at 0.5-1.0 cm. Some patients of both groups received transcatheter arterial chemoembolization (TACE) after stent placement. RESULTS: In group A, the success rate of intraluminal brachytherapy was 98.0%, RTOG grade 1 acute radiation morbidity occurred in 3 patients, RTOG/EORTC grade 1 late radiation morbidity occurred in 1 patient. Mean stent patency of group A (12.6 mo) was significantly longer than that of group B (8.3 mo) (P<0.05). There was no significant difference in the mean survival (9.4 mo vs 6.0 mo) between the two groups. CONCLUSION: HDR-192Ir intraluminal brachytherapy is a safe palliative therapy in treating MOJ, and it may prolong stent patency and has the potentiality of extending survival of patients with MOJ.

Relief of jaundice by external beam radiotherapy and intraluminal brachytherapy in patients with extrahepatic cholangiocarcinoma: results without stenting.

BACKGROUND/AIMS: To clarify whether external beam radiotherapy combined with intraluminal brachytherapy without stenting provides long-term relief of jaundice in extrahepatic cholangiocarcinoma patients. METHODOLOGY: Twenty-five patients with unresectable hilar or distal cholangiocarcinoma were treated by external beam radiotherapy (30 or 50 Gy) combined with intraluminal brachytherapy (24 to 40 Gy). After radiotherapy, we removed the biliary drainage tubes from the patients who responded, and we did not perform stenting in these patients. RESULTS: In 19 (76%) patients, full patency was achieved at the treated lesion, and they were tube-free thereafter. The tube-free survival time in the 19 patients ranged from 7 to 468 days (median: 76 days). Cholangitis and gastroduodenal ulcer developed in 10 (40%) and 2 (8%) patients, respectively, as adverse events after the combined radiotherapy. The median survival time of all patients was 9.3 months, and their 6- and 12-month survival rates were 75.3% and 29.3%, respectively. The ratios of tube-free to overall survival in the 19 patients ranged from 2.4% to 79.4% (median: 26.8%). Eight patients died tube-free. CONCLUSIONS: Although there were limitations to the long-term relief of jaundice by this combined radiotherapy alone, tube-free status was achieved in some patients without stenting.

Role of radiology in the treatment of malignant hilar biliary strictures 2: 10 years of single-institution experience with percutaneous treatment.

We reviewed the results of percutaneous intervention of hilar biliary malignancy over a 10-year period at a single institution: the Royal Melbourne Hospital. Ninety-nine patients (100 treated in total) were included. Information was retrieved by retrospective examination of patient notes and radiology, combined with interviews with family and relevant physicians. Sixty-nine patients were treated with insertion of semipermanent stents, 19 had external drain tubes, and 25 received percutaneous access for Iridium brachytherapy. Adequate drainage was achieved in 87% of the patients stented, and percutaneous access was successful in 96% of patients planned for brachytherapy. Of those patients undergoing endoprosthesis insertion, early complications occurred in 39% and late complications in 23%. Average survival for the entire patient population was 227.3 days, with a median of 167 days. Longer survival times (213 vs 142 days) and lower complication rates (44 vs 64%) are observed with metal stents in comparison with plastic stents. Percutaneous intervention is an important treatment option in hilar biliary malignancy, particularly in patients unfit for surgery. Reasonable survival with good palliation is the most common outcome, and most patients do not require further intervention.