Long-term results of ERCP- or PTCS-directed photodynamic therapy for unresectable hilar cholangiocarcinoma

Abstract

Background: Photodynamic therapy (PDT) can be performed as palliative therapy for cholangiocarcinoma, while there is currently insufficient evidence for the efficacy. The aim of this study was to explore the clinical efficacy and safety of endoscopic retrograde cholangiopancreatography (ERCP)- or percutaneous transhepatic cholangioscopy (PTCS)-directed PDT combined with stent placement for unresectable hilar cholangiocarcinoma.

Methods: A retrospective analysis was conducted on 62 patients with unresectable hilar cholangiocarcinoma. Thirty patients received PDT using hematoporphyrin combined with biliary stent placement (PDT+stent group), including 22 receiving ERCP-directed PDT and 8 receiving PTCS-directed PDT. Survival time, quality of life, and postoperative adverse events were compared to 32 patients receiving biliary stent placement alone (Stent-only group).

Results: After 42 months of follow-up, median survival time was significantly longer in the PDT+stent group than the Stent-only group (14.2 vs. 9.8 months, P = 0.003). In the PDT+stent group, the median survival time was longer in the 6 patients with recurrence after surgical resection than the 24 patients without prior surgical resection (20.0 vs. 13.0 months, P = 0.017). The QOL total scores was significantly higher in the PDT+stent group than the Stent-only group at postoperative 6, 9, and 12 months (P<0.05). There was no significant difference in the incidence of postoperative adverse events between the two groups (24 [38.7%] vs. 20 [29.0%], P = 0.239).

Conclusion: ERCP- or PTCS-directed PDT + stent placement can prolong the survival of patients with unresectable hilar cholangiocarcinoma, especially those with recurrence and improve quality of life without increasing adverse events.

Keywords: Cholangiocarcinoma; ERCP; PTCS; Photodynamic therapy.

Conflict of interest statement

All authors including Zongyan Li, Xiaofeng Jiang, Hua Xiao, Shaoyi Chen, Wenfeng Zhu, Haiwu Lu, Liangqi Cao, Ping Xue, Haiyan Li, Dawei Zhang have no conflicts of interest or financial ties to disclose.

© 2020. The Author(s).

Figures

Fig. 1

ERCP-directed PDT procedure for hilar cholangiocarcinoma. A Cholangiography showing the location of tumor stenosis. B As directed by the sphincterotomy knife, the fiberoptic columnar diffuser was positioned at the site of tumor stenosis (arrows indicate the marker of the sphincterotomy knife head end and the columnar diffuser). C The sphincterotomy knife was withdrawn, the fiberoptic column diffuser was left in place (arrow), and PDT irradiation was initiated. D Two months post-treatment, a balloon was used to remove necrotic and exfoliated tissue to clear the bile duct. E Two plastic biliary stents were placed to ensure biliary drainage

Fig. 2

PTCS-directed PDT procedure. A Percutaneous transhepatic cholangial drainage. Cholangiography showing the location of tumor stenosis. B, C As directed by a rigid guidewire, the skin and bile duct were expanded step-by-step using a percutaneous dilatation tube, and the 16Fr sheathing canal was retained. D, E After inserting the rigid choledochoscope from the sheathing canal, the tumor was visualized directly under choledochoscopy, and the fiberoptic column diffuser was placed at the tumor location for PDT. F Internal and external drainage catheter were placed in the bile duct to ensure biliary drainage

Fig. 3

Flow chart showing participant selection and exclusion

Fig. 4

Kaplan–Meier survival curves of the study patients. A Comparison of survival times between the PDT + stent group and Stent-only group. B Comparison of survival rates between PDT + stent group and Stent-only group at different post-treatment time points. C Comparison of survival times between patients with recurrence after surgical resection and patients without surgical resection in the PDT + stent group. D Comparison of survival times between patients with non-postsurgery recurrence from the PDT + stent and Stent-only groups

Fig. 5

Example of therapeutic response by PTCS-directed PDT. A 56-year-old female was admitted to hospital for obstructive jaundice. Ten months previously, the patient received left hemi-hepatectomy + right hepatic duct-Jejunostomy for hilar cholangiocarcinoma (type III b). A Bile duct tumors were seen under choledochoscopy and confirmed by biopsy as tumor recurrence. B PDT under choledochoscopy 48 h after injection of the photosensitizer. C Choledochoscopy showing inflammatory changes in the wall of bile duct 48 h after PDT. D Two months after PDT, tumor necrosis and exfoliated tissue were observed in the bile duct and removed under choledochoscopy. E After removal of the necrotic tissue, the bile duct was unobstructed, the inflammatory reaction disappear, and the tube wall was smooth