Our next case study comes from Dr Hemchand Ramberan from the Program in Advanced Therapeutic and Interventional Endoscopy at Erlanger Hospital in Chattanooga TN.  

PATIENT PROFILE:

A 49 year old Caucasian male presented with jaundice, puritus and RUQ discomfort. He was noted with obstructive jaundice on liver profile with Total bilirubin 9.6 MG/DL, Alkaline phosphatase 440 U/L, AST 180 U/L, ALT 165 U/L, Platelets 45,000 TH/MM3, WBC 2400 TH/MM3 and INR 1.5.  A RUQ US and CAT scan demonstrated a markedly distended gallbladder and dilated bile ducts without any obvious stones. ERCP at his local hospital described a distal CBD stricture and brushings for cytology were non-diagnostic. He also had clinical features and a history that were consistent with cirrhosis related to alcohol.

He underwent a follow up EUS/FNA and ERCP with cholangioscopy and biliary plastic stent placement.  EUS revealed focal abnormal irregular hypoechoic thickening of the terminal bile duct. Cytology from EUS FNA and brushings confirmed adenocarcinoma. ERCP demonstrated an irregular 15 mm terminal CBD obstructing stricture with shouldering. He was also noted with mild portal bilopathy extending from the proximal to distal CBD. A follow up CA 19-9 was 172U/mL and a staging MRI reveals no metastatic or locally advanced disease.  Though he had localized malignancy, he was considered not to be a surgical candidate due to his severe portal hypertension with markedly dilated periportal varices. Chemotherapy was also not an option due to his relative significant pancytopenia.

MRCP with terminal CBD malignant stricture and indwelling CBD stent

MRCP with terminal CBD malignant stricture and indwelling CBD stent

ENDOSCOPIC INTERVENTION:
Given that he was not a candidate for standard treatment options by curative surgery or palliative chemotherapy, he was offered the option of intraductal RFA with the Habib Endo HPB catheter.  Three sessions of intraductal RFA were performed at 8 week intervals with standard application with an ERBE ICC 200 electrosurgical generator utilizing 10 Watts for 120 seconds and with plastic stent replacement at the patient request.  There was mild self limited intraductal bleeding noted after the first two sessions of RFA but no other immediate or delayed complications from the procedure.

ERC showing distal CBD stricture

ERC showing distal CBD stricture

EUS FNA of terminal CBD stricture

EUS FNA of terminal CBD stricture

EUS FNA of terminal CBD stricture Diff Quik with cluster of Atypia

EUS FNA of terminal CBD stricture Diff Quik with cluster of Atypia

Cellblock with malignant cell (adenocarcinoma)

Cellblock with malignant cell (adenocarcinoma)

Spyglass Cholangioscopy of terminal CBD revealing abnormal neoplastic raised epithelia

Spyglass Cholangioscopy of terminal CBD revealing abnormal neoplastic raised epithelia

ERC with intraductal RFA of terminal cholangiocarcinoma using the Habib EndoHPB catheter

ERC with intraductal RFA of terminal cholangiocarcinoma using the Habib EndoHPB catheter

Spyglass cholangioscopy after intraductal RFA, note the ablation of the raised neoplatic epithelia

Spyglass cholangioscopy after intraductal RFA, note the ablation of the raised neoplatic epithelia

PATIENT OUTCOME:
Six months and a year later after his last treatment with intraductal RFA, there has been no progression of his malignant stricture and follow up MRI reveals no evidence of locally advanced or metastatic disease. His CA 19-9 has significantly decreased from 172 U/mL to 42 U/mL though he remains pancytopenic and with compensated cirrhosis. He continues to prefer plastic stent service at 3 to 4 months intervals rather than a permanent biliary self expandable metal stent.

DISCUSSION:
Though the standard of care for cholangiocarcinoma is surgical resection with curative intent and possibly adjuvant or palliative chemotherapy, this case is an example of favorable response that appears to be sustained a year after treatment for a pathology that is known to be notorious for rapid spread and metastasis within a short period from the time of diagnosis and sometimes even with palliative chemotherapy.
The objective findings in this case demonstrate neither progression of the known malignant stricture nor any evidence of local spread or distant metastasis after intraductal RFA with the Habib EndoHPB catheter. It raises questions as to whether this is truly an effective modality of treatment in this particular case or it represents a different tumor biology that was responsive to RFA when the patient had no other therapeutic options despite localized disease but was not an acceptable candidate for surgery.

 

Posted
AuthorFrancois Poulin