Endoskopische ablative Verfahren bei Gallengangstumoren – Effektivität der photodynamischen Therapie und der Radiofrequenzablation

Zusammenfassung

Nur etwa 20–30 % der Patienten mit hilärem cholangiozellulären Karzinom (CCC) können bei Diagnosestellung kurativ operiert werden, da erst bei fortgeschrittenem Tumorstadium Symptome auftreten [3]. Daher können den meisten Patienten mit dieser Tumorentität lediglich palliative Therapiekonzepte angeboten werden. Die Effektivität der photodynamischen Therapie (PDT) wurde in 2 kontrolliert randomisierten sowie in weiteren kontrollierten Studien nachgewiesen. Eine endoskopische Drainage in Kombination mit einer intraluminalen PDT stellte bislang das beste palliative Therapiekonzept dar [1, 3]. Die Radiofrequenzablation (RFA) ist ein neues endoskopisches Verfahren im Rahmen des palliativen Therapiesettings maligner Gallengangsobstruktionen. Das Verfahren der Radiofrequenzablation scheint der etablierten photodynamischen Therapie bezüglich mittlerer Überlebensdauer, Komplikationsrate bzw. Drainageerfolg maligner Gallengangsobstruktionen nicht unterlegen zu sein. Die RFA scheint eine sichere Therapiealternative zur palliativen Behandlung maligner Gallengangsobstruktionen darzustellen [1] [4] [18]. Für eine endgültige Bewertung langfristiger Wirkungen sowie der mittleren Überlebensdauer ist eine kontrollierte Vergleichsstudie mit photodynamischer Therapie erforderlich.

Summary

Only about 20–30 % of patients presenting with symptoms caused by hilar cholangiocarinomas are curative resectable [3]. Therefore, in most patients with this type of bile duct cancer, only palliative concepts could be offered. Effectiveness of photodynamic therapy (PDT) was demonstrated in two randomized controlled and a few controlled studies. Endoscopic drainage in combination with intraluminal PDT was the best palliative concept that patients could be offered [1] [3]. Radiofrequency ablation represents a new endoscopic procedure for palliative therapy of malignant bile duct obstructions. The procedure of radiofrequency ablation seems to be not underlaid to the established photodynamic therapy concerning median survival, complication rate and drainage success of malignant bile duct obstructions. RFA seems to represent a safe alternative therapy for palliative treatment of malignant bile duct obstructions [1] [4] [18]. To provide a definitive evaluation of the long-term effects and of overall median survival, a controlled trial with PDT must follow.

Key words

Biliary cancer - radiofrequency ablation - endoscopy - biliary drainage - bile duct cancer - Klatskin tumor

• Literatur

• 1 Khan SA, Davidson BR, Goldin RD et al. Guidelines for the diagnosis and treatment of cholangiocarcinoma: an update. Gut 2012; 61: 1657-1669
• 2 Rerknimitr R, Angsuwatcharakon P, Ratanachu-ek T et al. Asia-Pacific consensus recommendations for endoscopic and interventional management of hilar cholangiocarcinoma. J Gastroenterol Hepatol 2013; 28: 593-607
• 3 Goenka MK, Goenka U. Palliation: Hilar cholangiocarcinoma. World J Hepatol 2014; 6: 559-569
• 4 Rustagi T, Jamidar PA. Intraductal radiofrequency ablation for management of malignant biliary obstruction. Dig Dis Sci 2014; 59: 2635-2641
• 5 Steel AW, Postgate AJ, Khorsandi S et al. Endoscopically applied radiofrequency ablation appears to be safe in the treatment of malignant biliary obstruction. Gastrointestinal endoscopy 2011; 73: 149-153
• 6 Figueroa-Barojas P, Bakhru MR, Habib NA et al. Safety and efficacy of radiofrequency ablation in the management of unresectable bile duct and pancreatic cancer: a novel palliation technique. Journal of oncology 2013; 2013: 910897-910897
• 7 Roque J, Ho SH, Reddy N, Goh KL. Endoscopic ablation therapy for biliopancreatic malignancies. Clin Endosc 2015; 48: 15-19
• 8 Ortner ME, Caca K, Berr F et al. Successful photodynamic therapy for nonresectable cholangiocarcinoma: a randomized prospective study. Gastroenterology 2003; 125: 1355-1363
• 9 Zoepf T, Jakobs R, Arnold JC et al. Palliation of nonresectable bile duct cancer: improved survival afterphotodynamic therapy. Am J Gastroenterol 2005; 100: 2426-2430
• 10 Hartmann B, Hartmann D, Eickhoff A et al. Verlängertes Überleben durch Photodynamische Therapie bei Cholangiozellulärem Karzinom. Z Gastroenterol 2010; 48: 374-374
• 11 Witzigmann H, Berr F, Ringel U et al. Surgical and palliative management and outcome in 184 patients with hilar cholangiocarcinoma: palliative photodynamic therapy plus stenting is comparable to r1/r2 resection. Ann Surg 2006; 244: 230-239
• 12 Wiedmann M, Caca K Berr et al. Neoadjuvant photodynamic therapy as a new approach to treating hilar cholangiocarcinoma: a phase II pilot study. Cancer 2003; 97: 2783-2790
• 13 Atsushi N, Hiroyuki Y, Shinichi S et al. Adjuvant photodynamic therapy for bile duct carcinoma after surgery: a preliminary study. J Gastroenterol 2004; 39: 1095-1101
• 14 Mi JinHong, Young KoogCheon, Eung JunLee et al. Long-Term Outcome of Photodynamic Therapy with Systemic Chemotherapy Compared to Photodynamic Therapy Alone in Patients with Advanced Hilar Cholangiocarcinoma. Gut and Liver 2014; 8: 318-323
• 15 Dolak W, Schreiber F, Schwaighofer H et al. Endoscopic radiofrequency ablation for malignant biliary obstruction: a nationwide retrospective study of 84 consecutive applications. Surgical endoscopy 2014; 28: 854-860
• 16 Mizandari M, Pai M, Xi F et al. Percutaneous intraductal radiofrequency ablation is a safe treatment for malignant biliary obstruction: feasibility and early results. Cardiovasc Intervent Radiol 2013; 36: 814-819
• 17 Alis H, Sengoz C, Gonenc M et al. Endobiliary radiofrequency ablation for malignant biliary obstruction. Hepatobiliary Pancreat Dis Int 2013; 12: 423-427
• 18 Strand DS, Cosgrove ND, Patrie JT et al. RCP-directed radiofrequency ablation and photodynamic therapy are associated with comparable survival in the treatment of unresectable cholangiocarcinoma. Gastrointest Endosc 2014; 80: 794-804