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. 2019 Aug 21;5(1):77-84.
doi: 10.1016/j.adro.2019.08.003. eCollection 2020 Jan-Feb.

Stereotactic Body Radiation Therapy for Cholangiocarcinoma: Optimizing Locoregional Control With Elective Nodal Irradiation

Margaret M Kozak  1 , Diego A S Toesca  1 , Rie von Eyben  1 , Erqi L Pollom  1 , Daniel T Chang  1
Affiliations

Stereotactic Body Radiation Therapy for Cholangiocarcinoma: Optimizing Locoregional Control With Elective Nodal Irradiation

Margaret M Kozak et al. Adv Radiat Oncol. .

Abstract

Purpose: To review our institutional experience of treating cholangiocarcinoma using stereotactic body radiation therapy (SBRT).

Methods and materials: A total of 40 patients with intrahepatic (n = 25) or perihilar (n = 15) cholangiocarcinoma treated with SBRT were retrospectively reviewed. SBRT was delivered in 1 to 5 fractions with median dose of 40 Gy. Competing risk analysis was used to estimate cumulative incidence of local in-field, local out-of-field, regional, and distant failure. Kaplan-Meier and log-rank tests were used to calculate overall survival (OS). Toxicity was scored using Common Terminology Criteria for Adverse Events, version 4.0.

Results: The median follow-up time was 18 months. The 1-year incidence of local in-field, local out-of-field, regional, and distant failure was 8%, 23%, 13%, and 22%, respectively. Median OS was 23 months and 1- and 2-year OS rates were 69% and 39%, respectively. Patients with perihilar tumors had a 1-year incidence of regional failure of 24% and worse OS (P = .013). Patients with regional failure were more likely to develop distant metastases, 32% versus 19% at 1 year (P = .11). Acute grade 3 + hepatobiliary toxicity developed in 15 patients (36%).

Conclusions: In this series of cholangiocarcinoma patients treated with definitive SBRT, patterns of failure reveal that regional failures are not insignificant, particularly for perihilar tumors. Elective nodal irradiation of regional lymphatics should be considered when using SBRT. A prospective study of elective nodal irradiation in patients with perihilar tumors would further clarify whether this approach improves outcomes without increasing hepatobiliary toxicity.

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Figures

Figure 1
Figure 1
(a-f) Overall survival for all cholangiocarcinoma patients (n = 42) treated with stereotactic body radiation therapy (a) and for patients with intrahepatic (n = 26) versus perihilar (n = 16) cholangiocarcinoma, respectively (b). Panels c to f show disease recurrence in patients with cholangiocarcinoma treated with stereotactic body radiation therapy. The image shows cumulative incidence of (c) local in-field, (d) local out-of-field, (e) regional, and (f) distant failure.
Figure 2
Figure 2
(a) Representative schematic showing regions of nodal failure in cholangiocarcinoma patients treated with stereotactic body radiation therapy. Nodal regions are as follows: yellow = porta hepatis, purple = aortocaval, blue = gastrohepatic, green = para-aortic, orange = retrocrural. (b) Representative cross-sectional image of an elective nodal irradiation stereotactic body radiation therapy treatment plan. The image is in colorwash, 23.75 Gy isodose cloud showing coverage of the planning target volume (red), elective nodal region (blue), liver (dark green), and duodenum (light green).
See this image and copyright information in PMC

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