Multimodality Treatment With Helical Tomotherapy Intensity Modulated Radiotherapy, Capecitabine, and Photodynamic Therapy is Feasible and Well Tolerated in Patients With Hilar Cholangiocarcinoma

Abstract

Background and purpose: Unresectable cholangiocarcinoma is an intractable disease marked by recurrent bouts of biliary obstruction and infection. Traditional treatment methods provide only symptomatic relief and no proven survival advantage. We assessed the tolerability of helical tomotherapy intensity modulated radiotherapy (IMRT) with concurrent capecitabine and photodynamic therapy (PDT) in patients with unresectable hilar cholangiocarcinoma.

Methods: Ten patients with unresectable hilar cholangiocarcinoma were treated with helical tomotherapy IMRT. An accelerated dose of 50 Gy in 20 fractions (2.5 Gy/fraction) was used. Planning target volume (PTV) consisted of a 1.5 cm radial expansion and a 2 cm craniocaudal expansion of the magnetic resonance imaging and/or contrast enhanced computed tomography-defined gross target volume. PTV ranged from 123 cc to 693 cc (mean 349 cc). Concurrent chronomodulated capecitabine was administered on days of irradiation. Six patients received PDT.

Results: All patients developed side effects, including grade 2 nausea, and 9 of 10 experienced mild fatigue. Patients lost 3% of their body weight on average. Three patients required brief hospital admission and stent revision for cholangitis during chemoradiotherapy. Capecitabine was discontinued in one patient and decreased in dose for another due to increasing liver enzymes. Median overall survival was 13 months, and median disease-free survival was 10 to 11 months. One patient underwent successful cadaveric liver transplant after chemoradiotherapy and remains disease free 2 years later.

Conclusions: Concurrent chemoradiotherapy with helical tomotherapy IMRT and capecitabine in conjunction with PDT is well tolerated in patients with hilar cholangiocarcinoma.

Figure 1

An example of dosimetry for a patient in this study. This patient later underwent cadaveric liver transplantation.

Figure 2

Panel A shows MRI images of a patient who received cadaveric liver transplantation after chemoradiotherapy. Tumor is highlighted by dotted white rectangle. Refer to Figure 1 for dosimetric coverage of this tumor. Panel B shows histology of the postresection tumor specimen, as evaluated by hematoxylin and eosin staining. Panel C shows histology of the nonirradiated liver from the same specimen.

Figure 3

Kaplan-Meier curves for overall survival and local disease control.