Researchers from the University of Virginia have reported that photodynamic therapy (PDT) and stent placement was more effective than stent placement alone for patients with inoperable cholangiocarcinoma. The details of this study appeared in an early online publication in the March 2008 issue of Clinical Gastrointestinal Hepatology.

Cholangiocarcinama (cancer of the bile ducts) is a relatively rare cancer, with an annual incidence of 1–2 cases per 100,000 in the United States. There is evidence that the rates of cholangiocarcinoma have been rising worldwide over the past several decades. Risk factors for cholangiocarcinoma include primary sclerosing cholangitis (an inflammatory disease of the bile ducts), congenital liver malformations, infection with the parasitic liver flukes, and exposure to Thorotrast (a chemical previously used in medical imaging). Surgery is the only potentially curative treatment, but most patients have advanced and inoperable disease at the time of diagnosis. After surgery, adjuvant chemotherapy or radiation therapy may be given to increase the chances of cure. Patients with advanced and inoperable cholangiocarcinoma are generally treated with chemotherapy and palliative care measures, such as stent placement to improve bile flow. More recently, photodynamic therapy (PDT) has been explored for treatment of unresectable cholangiocarcinoma. PDT involves the administration of a photosensitizer, such as aminolevulinic acid or methyaminolevulinate, followed by exposure to a light source. Cells that are sensitized to light are then selectively destroyed. Stent placement and PDT are usually accomplished via endoscopic retrograde cholangiopancreatography (ERCP).

The current study involved ERCP and stent placement with or without PDT in 48 patients with unresectable cholangiocarcinoma. Twenty-nine patients were treated with stent placement only and 19 with PDT and stent placement. Analysis included additional factors such as stage of cancer, age, treatment with chemotherapy or radiation, as well as the number of ERCP and PDT procedures each patient underwent.

• Survival of patients following stent placement and PDT was 16.2 months compared with 7.4 months for patients treated only with stents.
• Death rates occurring in the PDT group at three, six, and twelve months were 0%, 16%, and 56%, respectively, compared with 28%, 52%, and 82% among patients treated with stents alone.
• On multivariate analyses only the number of ERCP procedures and the number of PDT treatments were significant variables for survival.
• Side effects occurred only in PDT patients and included skin toxicities, which were treated topically.

Researchers concluded that ERCP with PDT improved survival compared with ERCP alone in patients who are not candidates for surgery.

Comments: These are interesting findings, but the number of patients treated is very small and this was not a randomized trial. However, future research would help determine if this benefit was the result of the addition of PDT or the number of ERCP procedures.

Reference: Kahaleh, M., Mishra, R., Shami, VM., et al. Unresectable cholangiocarcinoma: comparison of survival in biliary stenting alone versus stenting with photodynamic therapy. Clinical Gastrointestinal Hepatology 2008;6:290-7.