This document discusses the use of radiotherapy to treat biliary tract cancers. It begins by describing biliary tract anatomy and types of biliary cancers like cholangiocarcinoma. It then covers diagnosis, staging, surgical and non-surgical treatment options. It emphasizes that complete surgical resection offers the best chance of long-term survival. The document also discusses the role of radiotherapy as adjuvant or palliative treatment. Newer radiation techniques like IMRT allow safer delivery of higher radiation doses to tumors while minimizing doses to surrounding healthy organs.

1. BILLIARY TRACT CANCERS
HELPING THROUGH
RADIOTHERAPY
DR KANHU CHARAN PATRO
MD,DNB[RT], FAROI[USA], PDCR [CLINI.RESEARCH]
CEPC[PALL.CARE], CBB[HOSP.MX]
EX-RESIDENT TATA MEMORIAL HOSPITAL
HOD,RADIATION ONCOLOGY
DEPARTMENT OF RADIOTHERAPY
MAHATMAGANDHI CANCER HOSPITAL RESEARCH INSTITUTE
1/17/20181

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3. 1/17/20183

4. Anatomically, biliary tree is divided into 3 parts,
upper 3rd-55%, middle 3rd 15% and lower 3rd 10%.Of
these tumours, 10% are diffuse
1/17/20184

5. Cholangiocarcinoma
 Also called bile duct carcinoma
 10% of primary liver cancers
 High prevalence in southeast and eastern Asia
 10-20% are associated with
 Diagnosis of exclusion (must rule out metastatic
adenocarcinoma)
 Usually age 60+ years; no gender preference
 Laboratory: normal AFP
 Poor prognosis; death usually within 6 months
 50-75% metastasize to regional lymph nodes, lungs,
vertebrae, adrenals, brain, elsewhere at autopsy
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6. Etiology
 Cholangitis due to autosomal dominant polycystic
disease,
 congenitally dilated hepatic ducts
 (Caroli’s disease),
 Congenital hepatic fibrosis,
 Infection by liver flukes,
 Thorotrast, anabolic steroids,
 Intrahepatic lithiasis (5-10% of these patients),
 Primary sclerosing cholangitis (7-42% of these
patients)
1/17/20186

7. PATHOPHYSIOLOGY
 Bile duct tumours cause bile duct obstruction -
biliary stasis and alteration of liver function tests
 Prolonged obstruction then leads to-
 Hepatocellular dysfunction, renal dysfunction
 Progressive malnutrition, Pruritus, coagulopathy
 Cholangitis- esp if previous endoscopic,
percutaneous or surgical biliary interventions
have been performed.
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8. CT- abdomen- intra & extra-hepatic bile duct dilatation to the level of
the hepatic hilium. Suggestion of 2cm mass at hilium-
?cholangiocarcinoma-(Klatskin tumour)
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9. PRESENTATION
 CC seen in advanced unresectable stage
 Early diagnosis unusual
 Typically elderly- average age 60-65years though
Klatskin slightly younger age group
 Abnormal LFTs / Jaundice-90%
 Abdominal pain / Weight loss- in (30-50%) of
cases -Patel et al 2006
 Pruritus seen in 66% of patients
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10. PRESENTATION
 Fever- 20%
 Diarrhoea, anorexia, changes in urine & stool
colour and weight loss.
 Liver may be enlarged and smooth-25-40%
 Distended and non tender gallbladder 10%
 Epigastric tenderness.
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13. DIAGNOSIS
 History / physical examination
 Labouratory-CEA and CA19.9 –sensitivity of 66%
and a specificity of 100% in diagnosing CC in pt
with PSC.
 Imaging-tumours are generally small-USS/ CT
may fail to show the lesion.
 Cholangiography via a transhepatic or
endoscopic approach reqired to define biliary
anatomy and extent of the lesion.
1/17/201813

14. DIAGNOSIS
 Cholangiographic appearance of Klatskin tumour
is characteristic.
 PTC preferred over ERCP for demonstrating
ductal anatomy-PTC-almost 100% sensitivity &
specificity.
 MRCP non-invasive and now more available.
 Histology –a well defferentiated
adenocarcinoma-short annular constricting
lesion 75%, diffusely infiltrating with long
strictures 15%& intraluminal polypoid mass-3-5%
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17. TREATMENT
 Management challenging with relatively poor
prognosis.
 Surgery continues to be the mainstay of therapy with
5year survival of 10-40%.
 Complete resection with negative histologic margins
–long -term survival.
 Yang WL et at.. 2007 reported in a study of 185 cases
(1972-2006) a median survival of 37 months following
radical resection, 17months for palliative resection
and death within 1.5years if no resection.
 Hepatic resection- a critical component of operative
approach.
1/17/201817

18. TREATMENT
 Adjuvant chemoradiotherapy-no benefit.
 Liver transplant for unresectable tumour remains
controversial, tumour recurrence >90%.
 Advances in interventional Radiology and
endoscopy- facilitate non surgical option.
 Benefit of external beam radiotherapy for
palliation of proximal CC uncertain.
 Photodynamic therapy a new palliative treatment
modality for failed stent. Thomas Zoepf et al
concluded in a series in 2008 -offers similar
survival time as incomplete resection.
1/17/201818

19. Problems
 RT is uncommonly done in these diseases, hence
even more uncommonly discussed
 Lack of awareness of the role of RT in hepato-biliary
tumors
 Lack of technology to safely deliver RT in hepato-
biliary tumors
 Lack of randomised data
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20. cholangiocarcinoma: Where does RT fit?
 Adjuvant RT +/- CT
 Neo-adjuvant RT + CT
 Palliative RT
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21. Carcinoma Biliary Tree
 Few trials, compared
 Most trials include both cholangiocarcinoma &
carcinoma gall bladder
 Adjuvant and neo-adjuvant protocols are similar to
that of Ca pancreas (except that Gemcitabine alone
has less of a role in standard therapy)
 Encouraging results with IG-IMRT and SBRT in
recent years.
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22. SEER Database
Adjuvant RT for Extrahepatic Cholangiocarcinoma
 1988-2003 (4758 patients): Significant difference in
overall survival between Surgery +RT vs Surgery
alone (p<0.001) & between RT/Surgery/both vs
none (p<0.001)
 1973-2003 (2323 patients): Adjuvant RT is not
associated with any improvement in OS/DFS.
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23. Todoroki et al
 N=63 (cholangiocarcinoma)
 49 patients had curative resection, of which 29 patients
received adjuvant RT.
 IORT + p/o EBRT (n=17) vs p/o EBRT alone (n=6) vs
IORT alone (n=6)
 5-yr survival rates were 39.2% vs 0% vs 16.7%.
 Statistically significant improvement in 5-yr survival rates
for IORT+EBRT vs resection alone (39.2% vs 13.5%)
Int J Radiat Oncol Biol Phys 2000;46:581.1/17/201823

24. Ben-David et al
 N=28 (biliary malignancies)
 Adjuvant RT (54Gy median dose) +/-CT (54%
cases).
 Significant survival differences between patients with
R0 and R1 resections (24.1 vs 15 months) but NOT
between those with R1 and R2 resections.
Int J Radiat Oncol Biol Phys 2006;66:772.
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29. IMRT
 Divides each treatment field
into multiple segments
 Modulates beam intensity,
giving discrete dose to each
segment
 Uses multiple, shaped beams
(~9) and thousands of
segments
IMRT Initiated in
1995
Reached the clinic in 2000

30. RTOG contouring guidelines for adjuvant RT
CTV must include:
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31. 3DCRT plan
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32. IMRT plan
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33. IMRT for pancreatico-biliary cancers
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34. Dose constraints
Conventional RT
 Liver: 1/3 vol <50 Gy
2/3 vol<35 Gy
3/3 vol<30 Gy
 Kidney: 1/3 vol<50 Gy
2/3 vol<28 Gy
3/3 vol<23 Gy
 Stomach: 1/3 vol<60 Gy
2/3 vol<55 Gy
3/3 vol<50 Gy
 Spine: Max <45 Gy
For conventionally
fractionated
3DCRT/IMRT, the
dose constraint
used is Normal
Liver V30Gy<33%
1/17/201834

35. Side effects of external beam radiation therapy
 Skin changes, ranging from redness to
blistering and peeling (in the area being
treated)
 Nausea and vomiting
 Diarrhea
 Fatigue (tiredness)
 Hair loss (on the skin in the area being treated)
 Low blood counts
 Nausea, vomiting, and diarrhea are more
common if the abdomen (belly) is being treated
1/17/201835

36. Radiation Induced Liver Disease (RILD)
Classic RILD
 Occurs 2-3 months
post-RT
 Associated with
hepatomegaly,ascites
+/- jaundice
 Due to veno-occlusive
disease
 Seen in healthy livers
Non-classic RILD
 Occurs 1wk-3 months
post-RT
 Seen in cirrhotic livers
 Rise of SGOT/SGPT
with worsening of liver
function
 Without features of
classic RILD
Treatment: Once established, RILD is difficult to manage
and is invariably fatal in the absence of transplant therapy.
Medical management with diuretics, etc is only symptomatic1/17/201836

37. BRACHYTHERAPY IN HEPATOBILLIARY SYSTEM

 MALIGNANT STRICTURES
 KLATSKIN TUMORS
1/17/201837

38. Pictorial presentation
LEFT DUCT CANNULATION
RIGHT DUCT CANNULATION
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40. Stage IV: Metastatic cholangiocarcinoma
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41. METASTASIS
-please do not watch crying
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42. METASTASIS- give a smiling death
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43. Palliative radiation
Skeletal X-Ray
Bone scan
MRI
PET-CT
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44. Spinal metastasis
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46. Brain metastasis
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48. Whole brain radiotherapy
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49. Choroidal metastasis
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50. Superscan-extensive bone mets
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51. Hemibody radiation
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52. svco
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53. Prophylactic radiation
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54. Take Home Messages
 Despite conflicing data, adjuvant chemoradiotherapy
is viable and rational for pancreatico-biliary
malignancies
 GEM-based protocols are superior to 5FU-based
protocols
 Neo-adjuvant chemoradiotherapy is viable for locally
advanced disease
 Dose-escalation is possible for conformal techniques
1/17/201854

55. THANKS