Role of Intraductal Treatment and Endoscopic Oncologists in the Management of Unresectable Extrahepatic Cholangiocarcinoma

September/October 2021, Vol 2, No 3

Although cholangiocarcinoma (CCA) is a rare cancer that originates in the bile ducts, its incidence rate continues to rise in the United States, and many patients are diagnosed late, with unresectable tumor and poor prognosis. The majority of patients with extrahepatic CCA, including the perihilar subtype, require referral to a center with expertise in endoscopic retrograde cholangiopancreatography (ERCP) and interventional radiology, because of the complexities in obtaining a definitive diagnosis and durable biliary drainage.

In a recent editorial, Srinivas Gaddam, MD, MPH, Assistant Professor of Medicine, Division of Digestive and Liver Diseases, Cedars-Sinai Medical Center, Los Angeles, CA, and Gregory A. Coté, MD, MS, Associate Professor, Division of Gastroenterology and Hepatology, Department of Medicine, Medical University of South Carolina, Charleston, reviewed the role of intraductal therapies and the importance of integrating the endoscopic oncologist into the treatment plan for patients with nonresectable CCA.

Because successful and sustained “biliary drainage is associated with prolonging life and is required for the administration of systemic chemotherapy, it follows that the interventional endoscopist may be considered an ‘endoscopic oncologist’ in the treatment of patients with extrahepatic CCA,” explained Dr Gaddam and Dr Coté.

Once cholestasis has been palliated, maintaining endobiliary stent patency is another challenge. Intraductal interventions, such as radiofrequency ablation and photodynamic therapy, may extend the durability of endobiliary stents. Initial clinical trials of photodynamic therapy showed improved survival, but later studies raised concerns regarding photodynamic therapy–specific issues, including photosensitivity-related burns and secondary bile duct strictures.

Radiofrequency ablation, by contrast, is easier to implement than photodynamic therapy during ERCP. No administration of light-sensitizing chemicals is required, and the catheter technology is simpler and more durable. Intraductal radiofrequency ablation has not been shown to extend life; however, the most likely mechanism for radiofrequency ablation to prolong survival in patients with CCA is its impact on maintaining biliary drainage.

Dr Gaddam and Dr Coté also discussed where radiofrequency ablation should fall in the treatment algorithm. They suggested that given the reduced risk and cost of this treatment, and the low probability that it will have a negative impact on biliary drainage, endoscopists should be comfortable with this procedure and consider its use in patients with unresectable extrahepatic CCA who have a good performance status (ie, survival of 6 months or longer).

“Given the complexity of the disease biology, heterogeneity in biliary obstruction at presentation, and variability in baseline performance status/ability to tolerate systemic therapies, randomized trials of endoscopic interventions for unresectable extrahepatic cholangiocarcinoma must be designed with input from medical and surgical oncologists, radiologists, and interventional radiologists,” Dr Gaddam and Dr Coté noted. “It’s time to move the field from plastic versus metal and pilot studies of intraductal ablation to a concerted effort to better integrate the endoscopic oncologist into a personalized approach to treatment.”

Source: Gaddam S, Coté GA. The importance of the “endoscopic oncologist” in the treatment of nonoperable cholangiocarcinoma. Gastrointest Endosc. 2020;92:1213-1215.

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