Tumours of the hepatic hilum: Radiochemotherapy and photodynamic therapy

The therapeutic management of patients with tumours of the hepatic hilum is still a challenge for all involved in their care. Complete surgical resection is the only curative treatment option. But most of these tumours are not curatively resectable at the time of diagnosis. Median survival of patients with non-resectable hilar cholangiocarcinoma is only about 6 months, even after successful endoscopic or percutaneous biliary drainage. Palliative treatment modalities are therefore needed for most of the patients. Cancers of the bile ducts are moderately chemotherapy-sensitive tumours with objective response-rates from 10% to 30% only in phase-H studies. There is no proven impact on survival. The use of external beam radiotherapy is limited because of the potential for bile duct injury and toxicity to the surrounding tissues. Brachytherapy applied by iridium wires may be helpful to facilitate higher doses to the tumour area, but its effect on survival is contradictory. Data about combination radio-chemotherapy are limited to smaller studies in highly selected patients, e.g. before orthotopic liver transplantation. Photodynamic therapy (PDT) is a new modality for the treatment of patients with non-resectable hilar cholangiocarcinoma. Encouraging results front prospective, single-arm phase-II studies and a randomized trial using photodynamic therapy indicates considerable benefit on survival with a good quality of life. A recently published study with a 5-year follow-tip of patients after PD T for tumours of the hepatic hilum confirms that this treatment option is safe and effective. The optimal approach for patients with non-resectable hilar cholangiocarcinoma is still to be defined. Endoscopic drainage is the accepted palliative treatment of choice. PDT-in combination with endoscopic approach - seems to offer the best treatment results with a proven benefit on survival and acceptable quality of life.