Simmons DT et al. (2006) A novel endoscopic approach to brachytherapy in the management of hilar cholangiocarcinoma. Am J Gastroenterol 101: 1792–1796

Patients with cholangiocarcinoma generally have 5-year survival of <40% for resectable and <10% for unresectable disease, and most present with unresectable disease. By contrast, the Mayo Clinic previously reported post-transplantation 5-year survival of 82% for patients with cholangiocarcinoma (their sequential treatment protocol comprised external-beam radiation therapy, radiation sensitization with 5-fluorouracil, low-dose-rate biliary brachytherapy and, for eligible patients, liver transplantation).

A new, retrospective, Mayo Clinic study demonstrates that low-dose-rate biliary brachytherapy can be administered by transpapillary insertion of a brachytherapy catheter, through an endoscope. The 32 patients (aged 31–81 years) with unresectable hilar cholangiocarcinoma underwent endoscopic, retrograde cholangiopancreatography, during which biliary stricture(s) were internally bridged with indwelling, plastic 10 Fr stent(s). A brachytherapy catheter loaded with 192Ir seeds embedded in plastic ribbon was passed through the endoscope and positioned within these stent(s) under fluoroscopic guidance (the catheter can also pass through an 8.5 Fr stent). The endoscope was withdrawn and the free end of the brachytherapy catheter rerouted transnasally and secured. In seven patients (22%), catheter slippage necessitated its repositioning—Simmons and colleagues emphasize the importance of radiographic confirmation of correct catheter positioning during placement, after endoscope withdrawal, and after securing the catheter's free end.

This brachytherapy procedure has several advantages: it can be performed in the endoscopy suite, and does not require temporary nasobiliary tube placement, or cumbersome stent removal and replacement. Importantly, bilateral hepatic ducts can be treated simultaneously while maintaining biliary drainage, which is not possible with nasobiliary tubes.