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Objectives: To evaluate therapeutic outcomes of intraluminal brachytherapy (ILBT) for malignant obstructive jaundice (MOJ) against stent alone., Methods: The PubMed, EMBASE, Cochrane Library, CNKI, Wan Fang, VIP and ClinicalTrials.gov databases were searched for all relevant comparative studies from the earliest available date up to 1 May 2017. Subgroup analyses were performed according to the type of study design and type of stent., Results: Twelve studies that compared ILBT versus stent alone were eligible. A total of 641 participants with MOJ were included in our meta-analysis. A total of 340 participants were treated with intraluminal brachytherapy (ILBT); the other 301 participants were treated with biliary stent alone (stent group). ILBT was associated with lower risk of stent occlusion (OR 0.19; 95% CI 0.13-0.28; P < 0.00001) and better mean survival (MD = 3.15; 95% CI 2.64-3.66; P < 0.00001) compared with stent alone. However, the two groups were similar in number of complications (OR 0.84; 95% CI 0.45-1.56; P = 0.578), post-treatment reduced level of total bilirubin (TBIL) (MD = 22.71; 95% CI - 7.24-52.65; P = 0.14), post-treatment reduced level of direct bilirubin (DBIL) (MD = - 3.67; 95% CI - 14.09-6.75; P = 0.49), post-treatment reduced level of alanine aminotransferase (ALT) (MD = 21.09; 95% CI - 5.09-47.28; P = 0.11) and post-treatment reduced level of aspartate aminotransferase (AST) (MD = 20.86; 95% CI - 45.86-87.58; P = 0.54)., Conclusions: ILBT was significantly superior to stent alone in terms of stent occlusion and mean survival. Meanwhile, ILBT had comparable outcomes to stent alone in terms of complications and post-treatment reduced levels of TBIL, DBIL, ALT and AST. Therefore, ILBT may be considered a preferable technique for MOJ.

Background: Endoscopic placement of a iodine-125 radioactive stent is useful to treat obstructive jaundice with unresectable periampullary tumors. This study aimed to retrospectively evaluate the obstructive component of biliary radioactive stents and discuss the different obstructive mechanism with common plastic stents., Patients and Methods: Twenty consecutive patients with malignant obstruction underwent insertion of stents into the common bile duct, including 10 radioactive stents and 10 polyethylene stents. The radioactive stents were withdrawn after ∼3 months or earlier if clinical signs suggested stent clogging. Polyethylene stents were withdrawn after physical signs suggested stent clogging. Bacteriologic analyses included identification of aerobic and anaerobic bacteria. Stent surfaces were observed by scanning electron microscopy. Stent deposition was identified by Fourier-transformed infrared spectroscopy and pyrolysis derivatization/gas chromatography/mass spectrometry., Results: Radioactive stent group and polyethylene stent group stents were placed for 86 days (interquartile range 62, 114) and 146 days (interquartile range 105, 181) respectively. The placement duration of the two types of stents was statistically significant. A variety of microorganisms were cultured from the stent deposits. Scanning electron microscope images showed a thicker necrotic layer on the external surface of polyethylene stent than the radioactive stent group. The proportions of obstructive components in each stent were different, but none of them were statistically significant. Necrotic tumor tissue was found in the radioactive stent group., Conclusion: Similar clogging events occurred in both radioactive stents and polyethylene stents. The median duration time of the radioactive stent was shorter, probably because of the smaller inner diameter, and the radioactive seeds exerted no beneficial effect in inhibiting microorganisms.

Because of increased toxicity, full doses of gemcitabine and radiation therapy cannot routinely be given concurrently. The purpose of the present study was to determine the toxicity and response to treatment with full-dose gemcitabine given between cycles of split-course radiation therapy (nonconcurrent treatment) for inoperable periampullary adenocarcinoma. Treatment consisted of 3 6 week courses for a total of 18 weeks: 1000 mg/m gemcitabine intravenous bolus once a week x 2 weeks; 1 week break; 2 weeks of radiation therapy (1.8 Gy per fraction); 1 week break x 3. The total dose of radiation consisted of 45 Gy to the tumor + regional nodes followed by a 5.4-Gy boost. Patients were restaged at week 15 and at the completion of all treatment. Patients underwent resection if there was sufficient response. A total of 42 patients (40 pancreatic, 1 gallbladder, 1 biliary tract) were enrolled between March 1999 and July 2002. All but 2 medically inoperable patients had evidence of major vessel involvement. Median age was 63 years (range, 40-80 years). All patients were evaluable for response. There were 10 objective partial responses (24%). Six responders underwent resection with a mean survival of 18 months. Mean survival for all 42 patients was 10.3 months (range, 2.0-32.5 months; median, 9.5 months). Four patients experienced grade 3 or 4 gastrointestinal toxicity. Alternating cycles of split-course radiotherapy and gemcitabine chemotherapy permits the delivery of full doses of both modalities with acceptable tolerance. Despite the prolongation in radiation treatment time because of split-course treatment, patients with sufficient response were able to undergo resection.

Background: The rationale for combining cytotoxic agents, such as gemcitabine, and radiotherapy is based on their ability to act as radiation sensitizers and to improve overall response rate. Several studies on pancreatic or biliary carcinoma evaluated the maximum tolerated dose (MTD) of gemcitabine when combined with irradiation of the macroscopic tumor. However, most of these neoplasms metastasize to the regional lymph nodes. Aim of this report is to determine the MTD of weekly gemcitabine when combined with extended field irradiation (tumor plus nodal irradiation)., Patients and Method: 15 patients entered the study. Of these 5 patients were treated with chemoradiation after radical surgical resection. External beam radiation (ERT) was delivered to the tumor (or tumor bed) and regional lymph nodes by using a three-field technique. The initial dose of gemcitabine was 100 mg/m(2) administered as short intravenous infusion once a week. At each dose level 3 patients were treated, and if no grade 3-4 toxicity (considered as dose-limiting toxicity, DLT) was recorded, dose escalation was applied with 50 mg/m(2) increments until the MTD was established., Results: All patients were evaluable for acute toxicity. There were no treatment-related deaths. No DLT occurred at the first 4 dose levels (100-250 mg/m(2)). At the 5th dose level (300 mg/m(2)), 3 patients experienced DLT: 1 had grade 3 gastrointestinal toxicity (painful erosion of gastric mucosa), 1 had uncomplicated grade 3 leukopenia and 1 grade 3 change in liver biochemistry tests. In addition, all 10 unresected patients were evaluated for response, 4 of whom had progressive disease (1 local; 2 distant; 1 local and distant) and 6 had no change. The median follow-up was 21 months., Conclusion: Based on this study, the recommended dose for weekly short infusional gemcitabine combined with radiation therapy to the tumor and lymph nodes is 250 mg/m(2). This value is suggestive of a correlation between acute toxicity and inclusion of lymph nodes in the irradiated volume. Moreover, different infusion modalities, as continuous infusion gemcitabine, should be tested more accurately., (Copyright 2003 S. Karger GmbH, Freiburg)

Fifteen patients with malignant biliary obstruction from carcinoma of the bile ducts, gallbladder, and pancreas (Group I) or metastatic disease (Group II) were treated with intraluminal radiation therapy (ILRT) at Memorial Sloan-Kettering Cancer Center. In 11 cases ILRT was used as a central boost in combination with 3000 cGy external beam radiation therapy (ERT). No significant treatment toxicity was observed. Cholangiographic response was observed in 2 of 12 evaluable patients. In no patient was long-term relief of jaundice without indwelling biliary stent achieved. Survival from treatment in eight Group I patients treated with ILRT +/- ERT was 3 to 13 months (median, 4.5). Survival in seven similarly treated Group II patients was 0.5 to 8 months (median, 4.0). Additional data for ten similar patients referred for ILRT but treated with ERT alone are presented. Analysis of this and other reports indicate the need for prospective controlled trials of the role of this regimen in the management of malignant biliary obstruction before wider application can be recommended.