Radiofrequency Ablation Plus Stent Placement for Extrahepatic Cholangiocarcinoma Shows Benefit Over Stenting Alone
Bret T. Petersen, MD, MASGE, reviewing Gao DJ, et al. Gastrointest Endosc 2020 Dec 23.
The optimal treatment for cholangiocarcinoma (CCA) or ampullary carcinoma (AC) is surgery. When deemed unresectable and not amenable to neoadjuvant therapy followed by liver transplantation, endoscopic placement of stents plus radiation and/or chemotherapy are common uses for palliation.
In this randomized controlled trial, investigators at 3 centers compared overall survival (OS) among 174 patients with extrahepatic CCA (excluding Bismuth Type IV) or AC. The patients were randomly selected for treatment with either stent placement alone (ST Only, n=87) versus stent placement with endoscopic bipolar radiofrequency ablation (RFA, n=87). Dual interventions were performed 3 months apart.
Although there were no significant differences in control of jaundice or stent patency, the RFA group experienced significantly prolonged OS (14.3 vs 9.2 months; hazard ratio, 0.488; 95% confidence interval, 0.351-0.678; P<.001) and significantly better postprocedural Karnofsky performance scores for 9 months (all P<.001), according to Kaplan-Meier analysis. The survival benefit was present for hilar CCA (P=.004), distal CCA (P=.038), and AC (P+.032). Overall adverse events were comparable (27.6% [RFA] vs 19.5% [ST Only], P=.211), but acute cholecystitis was more common in the RFA group (9 vs 0, P=.003).
COMMENTSeveral reports have described the benefit of intraductal therapies, such as photodynamic therapy or RFA, when directed at focal cancers of the bile duct wall. Given the lack of differences for jaundice and stent patency, the mechanism of benefit from biliary RFA is not well understood. Some RFA catheters deliver electrothermal effects from the delivery of a fixed wattage, whereas others dynamically adjust the intensity of therapy based on the temperature of the probe, thereby potentially attaining optimal benefit while minimizing the depth and severity of injury.
Note to readers: At the time we reviewed this paper, its publisher noted that it was not in final form and that subsequent changes might be made.
CITATION(S)
Gao DJ, Yang JF, Ma SR, et al. Endoscopic radiofrequency ablation plus plastic stent placement versus stent placement alone for unresectable extrahepatic biliary cancer: a multicenter randomized controlled trial. Gastrointest Endosc 2020 Dec 23. (Epub ahead of print) (https://doi.org/10.1016/j.gie.2020.12.016)
