RADIATION THERAPY IN BILIARY TRACT CANCER

1. 1
Biliary tract cancers
Role of Chemoradiotherapy

2. Organ
Gall bladder
Cholangiocarcinoma
• Intrahepatic
• Extrahepatic
• Hilar
• Distal

3. 2/26/2024 3

4. 2/26/2024 4

5. 2/26/2024 5

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)
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7. Cholangiocarcinoma-
CCA
2/26/2024
• 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
7

8. PATHOPHYSIOLOGY
2/26/2024
• 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.
8

9. 2/26/2024 9

10. PRESENTATION
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• 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.
10

11. 11

12. 2/26/2024 12

13. 13

14. Surgery is the
mainstay
traetment
14

15. Radiation Settings
15
Radical – Unresectable
Adjuvant
Palliative

16. Radiation therapy
16
Chemoradiotherapy
Radiotherapy alone

17. Concurrent chemotherapy
• 5-fluorouracil
– Infusion
– Toxicity
• Capecitabine
– Oral
– Easy
17

18. Radiation
18
•Conformal
•SBRT
EBRT
Brachytherapy

19. 19

20. 20

21. 21

22. Evidences as
adjuvant
22

23. BILCAP
STUDY
23

24. Result
24

25. Japanese study
25

26. 26

27. 27

28. Hogan metaanalysis
28

29. Adjuvant chemoradiation
29

30. 30

31. 31

32. 32

33. 33

34. Summary - adjuvant
• R0- chemo
• R1/R2- chemo-RT
• Node positive- CHEMO RT
• CAPECIATABINE ALONE
– Based on the negative results of the randomized phase III PRODIGE 12-
ACCORD 18 trial gemcitabine/oxaliplatin was removed as a
recommended regimen for resected BTC
• CAPECITABINE as CONCURRENT
34

35. Evidences as
neoadjuvant
35

36. Neoadjuvant gall bladder
36

37. Ongoing study
37

38. Inclusions
38

39. Outcome
39

40. Neoadjuvant summary
• Very few studies
• Biliary stricture and leak issue
• There is insufficient data regarding the use of
RT in the neoadjuvant setting
40

41. Evidences as
RADICAL
41

42. GALL BLADDER
42

43. Intrahepatic Cholangiocarcinoma
43

44. Extrahepatic Cholangiocarcinoma
44

45. PGI POOLED DATA
45

46. Radical RT conclusion
• Chemoradiation in the setting of advanced BTCs can provide control of symptoms due to
local tumor effects and may prolong OS.
• However, there are limited clinical trial data to define a standard regimen or definitive
benefit.
• In a retrospective analysis of 37 patients treated with chemoradiation for unresectable
extrahepatic CCA, the actuarial OS rates at 1 and 2 years were 59% and 22%,
respectively, although effective local control was observed in most patients during this time
period (actuarial local control rates of 90% and 71% at 1 and 2 years, respectively).
• The most extensively investigated chemotherapeutic agent for use in concurrent
chemoradiation in the treatment of BTCs has been fluorouracil, although capecitabine has
been substituted for fluorouracil in some studies.
• The panel recommends that concurrent chemoradiation (RT guided by imaging) should be
limited to either fluorouracil or capecitabine, and that such treatment should be restricted
topatients without evidence of metastatic disease.
• Concurrent chemoradiation with gemcitabine is not recommended due to the limited
experience and toxicity associated with this treatment.
• Evidence supports the consideration of RT for treatment of unresectable and metastatic
intrahepatic CCA but there is little evidence to support this treatment option for gallbladder
cancer and extrahepatic CCA without concurrent chemotherapy and in patients with
unresected disease
46

47. Evidences as
PALLIATIVE
47

48. 48
Palliative
Local
• Pain
• Primary
• Nodal
• Hyper bilirubinemia
• Whole liver
• Ductal obstruction
Metastatic site

49. BRACHYTHERAPY IN HEPATOBILLIARY SYSTEM
•
• MALIGNANT STRICTURES
• KLATSKIN TUMORS
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50. 50

51. Brachytherapy
51

52. Nasobilliary catheter
52

53. Procedural details
53

54. Pictorial presentation
LEFT DUCT CANNULATION
RIGHT DUCT CANNULATION
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55. 2/26/2024 55

56. 56

57. 57

58. 58

59. 59

60. 60

61. Whole liver Radiotherapy
61

62. 62

63. 63

64. Changes in blood values
64

65. RADIATION THERAPY- ADJUVANT
65

66. RADIATION THERAPY- Radical
66

67. RADIATION THERAPY- Dosing
67

68. SBRT
68

69. 69

70. 70

71. 71

72. 72

73. 73

74. PUSH AND PULL BUSINESS
OA
R
TARGET
74

75. SYSTEMATIC ERROR
75

76. Delineation
• OAR
• TARGET
76

77. Where is the Target?
77

78. ITV
CONCEPT
• GTV- CTV- PTV
• GTV-ITV-CTV-PTV
78

79. REDUCTION IN PTV
• Custom immobilization
• Respiratory management
• Image guidance
PTV PTV
79

80. panc
D
THE VOLUME CONCEPT
80

81. Which is better?
• Which motion management system is better?
• Which phase is better?
• Empty stomach/filled stomach is better?
• DIBH/DEBH is better?
• Which immobilization is better?
• Contrast/water is better?
81

82. 82
1. Analyze the tumor in all phases of triple
phase CT
2. See the greatest resolution
3. Try to synchronization with breath hold

83. 83
ARTERIAL VENOUS DELAYED
S
T
A
R
T
S
T
A
R
T
S
T
A
R
T
BREATHHOLD SYNCHRONIZATION
0 sec 20 sec 40 sec

84. IMAGING
• Plain
• Contrast
I. ORAL
II. IV
•Arterial
•Venous
•Delayed 84

85. BARIUM CONTRAST
85

86. ORAL NON-IONIC CONTRAST
86

87. GCP volume – Biliary tract
87

88. NODAL VOLUME- Biliary tract
88

89. Target lymph node for biliary tract
cancer
89

90. CTV - intrahepatic cholangiocarcinoma
90

91. Intrahepatic cholangiocarcinoma
91

92. CTV - extrahepatic cholangiocarcinoma
92

93. Extrahepatic cholangiocarcinoma
93

94. CTV – Gallbladder carcinoma
94

95. Gall bladder
95

96. OAR
96

97. BOWEL BAG
VS
INDIVIDUAL BOWEL LOOP
97

98. 98

99. 99

100. For liver contouring
• Gallbladder should be excluded
• IVC should be excluded when it is discrete from the liver
• Portal vein (PV) should be included in the liver contour
when Segment (Seg) I (caudate lobe) is seen to the left
of PV
100

101. 101

102. 102

103. Side effects of
external beam
radiation therapy
2/26/2024
• 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
103

104. 104

105. SUMMARY
• DATA IS RARE
• INDIVIDUALIZE THE TREATMENT
• ADJUVANT CHEMO IF R0
• R1/R2/NODE - CTRT
IF THERE IS NO OPTION THINK OF RADIATION
ANY WHERE FROM RADICAL TO PALLIATION
105

106. Thank You.
106

107. 107

108. 108

109. Billiary tract
109

110. 110

111. 111

112. 112

113. Common Bile Duct
• CBD contour should start at the first bifurcation or at its entry
to the portal triad inferiorly to the first portion of duodenum
• It passes posterior and medial to the duodenum and joins with
the pancreatic duct
• Irradiation of caudate lobe liver tumors may lead to high
radiation doses being received by the CBD
113

114. 114

115. 115

116. 116

117. Cholangiocarcinoma
117

118. 11
8

119. 119

120. 120

121. Imaging pictures
• The lesion has the following characteristics:
• The lesion is hypodense in the arterial and portal venous phase with
some peripheral enhancement.
• The lesion is hyperdense in the equilibrium phase indicating dens
fibrous tissue.
• The lesion causes retraction of the liver capsule
• The finding of an infiltrating mass with capsular retraction and
delayed persistent enhancement is very typical for a
cholangiocarcinoma.
121

122. Delayed phase enhancement
• Small cholangiocarcinoma not visible in portal venous phase (left)
but seen as relative hyperdense lesion in the delayed phase
(right).
122

123. 123

124. 124

125. 125

126. Cholangiocarcinoma
With glandular stroma

127. 127
INTRAHEPATIC CHOLANGIO CA

128. EXTRAHEPATIC CHOLANGIO CA
128

129. 129
HILAR CHOLANGIO CA

130. MACROSCOPIC EXTRAHEPATIC
130

131. MACROSCOPIC GALLBLADDER
131

132. MACROSCOPIC AMPULARY TYPE
132

133. BILILARY TUMOR
HISTO
CLASSIFICATION
133

134. When you are in peak
You will feel a kick
It is important what you speak
Take care of the weak
134