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Endoscopic radiofrequency ablation of cholangiocarcinoma: newpalliative treatment modality (with videos)

Amitabh Monga, MRCP, Rajesh Gupta, DM, Mohan Ramchandani, DM, Guduru V. Rao, MS,Darisetty Santosh, DA, D. Nageshwar Reddy, DM

Hyderabad, India

Placement of self-expandable metal stents (SEMSs) ishe standard of care for patients with malignant obstructiveaundice if their life expectancy is �3 months.1,2 However,n �50% of patients with SEMSs, stent blockage developsithin 6 to 8 months,3 and newer endoscopic palliative

reatment modalities are needed.Recently, endobiliary radiofrequency ablation (RFA)

as been used in patients with unresectable malignantbstructive jaundice. We present the first cholangioscopicmages of the use of an endoscopic radiofrequency proben a patient with unresectable cholangiocarcinoma.

ETHODS AND RESULTS

A 56-year-old patient presented with a 1-month historyf jaundice and weight loss. He also had severe ischemiceart disease with a low left ventricular ejection fraction.

His serum bilirubin level was 277 mmol/L (normalange, 5-25 mmol/L), aspartate transaminase level 77 U/Lnormal range, 6-34 U/L), alanine transaminase level 67/L (normal range, 8-56 U/L), alkaline phosphatase level18 U/L (normal range, 30-120 U/L), and internationalormalized ratio 2.29 (normal range, 0.8-1.2). A CT scan ofhe abdomen revealed a dilated proximal common bileuct (CBD), intrahepatic biliary dilation, and a lymphode at the porta hepatis.

ERCP showed a 1.5-cm tight mid-CBD stricture withpstream biliary dilation. Brush cytology confirmed theuspicion of adenocarcinoma. The patient refused to con-ider a surgical option in view of the high operative risk.fter discussion by the Institutional Review Board, pri-ary endobiliary RFA was offered to the patient before

tenting. Informed consent was obtained.An Olympus TJF-Q180V duodenoscope and CHF B260

aby endoscope (Olympus America, Center Valley, PA)ere used for the procedure. Figure 1 shows the stricture

n the mid-CBD and Video 1 (available online at ww-.giejournal.org) shows the cholangioscopic images of

he tumor revealing a nodular lesion with irregular mu-osa. Narrow-band imaging demonstrated the thick, circu-tous, irregular vessels characteristic of a malignancy.

A wire-guided Habib EndoHPB (Emcision, London,

K) catheter was placed under fluoroscopic guidance

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across the biliary stricture (Fig. 2). This bipolar RFA probehas 2 ring electrodes 8 mm apart with the distal electrode5 mm away from the leading edge (Fig. 3). It is 8F indiameter and 1.8 m long and produces coagulative necro-sis over 2.5 cm. Ablation was performed by using an RFAgenerator (1500 RF generator; RITA Medical Systems, Fre-mont, Calif) delivering electrical energy at 400 kHz set at 5W for 2 minutes. The use of a 5-W current for 2 minuteswas based on earlier animal studies4 and the productbrochure. Immediate posttreatment cholangioscopic im-ages showed an ablated tumor with whitish coagulatedmucosa (Video 2, available online at www.giejournal.org).A 10F 10-cm plastic stent was placed across the tumor.

The patient was discharged the next day without anycomplications. Two weeks later, cholangioscopy (Video 3,available online at www.giejournal.org) demonstratedpersistent whitish charred mucosa with well defined prox-imal and distal ablated edges. The 11F cholangioscope

Figure 1. Cholangiogram before endoscopic RFA.

could easily pass across the stricture, and a cholangiogram

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onfirmed its significant resolution (Fig. 4). A plastic stentas inserted again with a plan to place an SEMS at a laterate.

ISCUSSION

In a recent pilot study of 21 patients, Steel et al (per-onal communication) demonstrated the safety and effi-acy of RFA within the bile duct by using a similar bipolarFA catheter in patients with malignant obstructive

aundice without any major complication. After RFAblation, an SEMS was deployed in all patients. Ours is

igure 2. Endoscopically placed Habib EndoHPB (catheter next to thetricture).

Figure 3. Habib EndoHPB catheter.

he first report presenting the cholangioscopic video

GASTROINTESTINAL ENDOSCOPY Volume xx, No. x : 2010

images both before and after the use of endoscopic RFAfor cholangiocarcinoma.

Although it is likely that tumor ablation will improveSEMS patency, it will be interesting to know whetherendobiliary RFA can completely obviate the need for anSEMS.

Until now, photodynamic therapy was the only evidence-based endoscopic treatment other than stenting that im-proved the quality of life and survival of such patients.5

Endobiliary RFA adds to the endoscopic armamentariumfor the treatment of these subjects. However, further ran-domized controlled trials are needed to establish im-proved SEMS patency, cost-effectiveness, and survival ad-vantages, if any.

In conclusion, endobiliary RFA seems to be a user-friendly and effective palliative treatment modality for pa-tients with unresectable bile duct cancer.

DISCLOSURE

All authors disclosed no financial relationships relevantto this publication.

Abbreviations: CBD, common bile duct; RFA, radiofrequency ablation;SEMS, self-expandable metal stent.

ACKNOWLEDGMENTS

The authors thank Dr. N. A. Habib (Imperial CollegeHealthcare, National Health Service Trust, London, UK) for

Figure 4. Cholangiogram obtained 2 weeks after the use of endoscopicRFA.

sharing the results of the pilot EndoHPB clinical study

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efore publication, which encouraged us to use this tech-ique in our patient.

EFERENCES

. Shepherd HA, Royle G, Ross AP, et al. Endoscopic biliary endoprosthesisin the palliation of malignant obstruction of the distal common bile duct:a randomized trial. Br J Surg 1988;75:1166-8.

. Andersen JR, Sorensen HM, Kruse A, et al. Randomised trial of endoscopicendoprosthesis versus operative bypass in malignant obstructive jaun-dice. Gut 1989;30:1132-5.

. Loew BJ, Howell DA, Sanders MK, et al. Comparative performance of un-

coated, self-expandable metal biliary stents of different designs in 2 di-

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ameters: final results of an international multicenter, randomizedcontrolled trial. Gastrointest Endosc 2009;70:445-53.

4. Khorsandi SE, Zacharoulis D, Vavra P, et al. The modern use of radiofre-quency energy in surgery, endoscopy and interventional radiology. EurJ Surg 2008;40:204-10.

5. Ortner MA. Photodynamic therapy for cholangiocarcinomas: overviewand new developments. Curr Opin Gastroenterol 2009;25:472-6.

Current affiliation: Asian Institute of Gastroenterology, Hyderabad, India.

Reprint requests: D. Nageshwar Reddy, DM, Asian Institute ofGastroenterology, 6-3-661, Somajiguda, Hyderabad 500 082, India.

Copyright © 2011 by the American Society for Gastrointestinal Endoscopy0016-5107/$36.00

doi:10.1016/j.gie.2010.10.018

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