Weismüller Tobias J
Department of Medicine 1, University Hospital Bonn, Bonn, Germany.
Visc Med. 2021 Feb;37(1):39-47. doi: 10.1159/000513970. Epub 2021 Jan 7.
Patients with irresectable perihilar cholangiocarcinoma (PHC) have a limited prognosis with median survival times still less than 1 year. In addition to the current standard first-line systemic chemotherapy (gemcitabine and a platinum derivate), endoscopic treatment aims to ensure adequate drainage of the biliary system by placing biliary plastic or metal stents. Local ablative procedures like intraluminal biliary brachytherapy (ILBT) or photodynamic therapy (PDT) are used to improve local tumor control and to optimize the stent patency.
Intraductal radiofrequency ablation (RFA) is another promising tool in the therapeutic armamentarium for the endoscopic management and tumor ablation of extrahepatic cholangiocarcinoma (eCCA). By applying thermal energy to the tissue through high-frequency alternating current, RFA induces coagulative necrosis and causes local destruction of the tumor. It is established as a first line percutaneous treatment of solid liver tumors, and since 2011 an endoscopic catheter is available that allows intraductal RFA in the biliary or pancreatic ducts. While the first pilot studies primarily evaluated this new method in patients with distal eCCA, there is now evidence accumulating also for PHC. Two retrospective and two prospective studies demonstrated a significantly improved overall survival and a longer stent patency with intraductal RFA, which overall had a favorable safety profile and was not associated with a significant increase in adverse events. However, prospective studies comparing the efficacy and safety of intraductal RFA, PDT, and/or ILBT are lacking.
Recent studies suggest that intraductal RFA is an effective and well-tolerated additional treatment option with regard to stent patency but also overall survival. Since RFA has fewer systemic side effects and requires less logistical effort when compared to ILBT and PDT, intraductal RFA should be considered as another safe and feasible adjuvant method for the palliative care of patients with advanced PHC. Since comparative studies are lacking, the choice of the local ablative method remains in each case an individual decision.
不可切除的肝门部胆管癌（PHC）患者预后有限，中位生存时间仍不足1年。除了当前标准的一线全身化疗（吉西他滨和铂类衍生物）外，内镜治疗旨在通过放置胆管塑料或金属支架确保胆道系统充分引流。腔内胆管近距离放射治疗（ILBT）或光动力疗法（PDT）等局部消融手术用于改善局部肿瘤控制并优化支架通畅性。
导管内射频消融（RFA）是肝外胆管癌（eCCA）内镜管理和肿瘤消融治疗手段中的另一种有前景的工具。通过高频交流电向组织施加热能，RFA诱导凝固性坏死并导致肿瘤局部破坏。它已成为实体肝肿瘤的一线经皮治疗方法，自2011年以来有一种内镜导管可供使用，可在胆管或胰管中进行导管内RFA。虽然最初的试点研究主要在远端eCCA患者中评估这种新方法，但现在也有越来越多关于PHC的证据。两项回顾性研究和两项前瞻性研究表明，导管内RFA可显著提高总生存率并延长支架通畅时间，总体安全性良好，且与不良事件显著增加无关。然而，缺乏比较导管内RFA、PDT和/或ILBT疗效和安全性的前瞻性研究。
最近的研究表明，导管内RFA是一种有效且耐受性良好的额外治疗选择，不仅关乎支架通畅性，还关乎总生存率。由于与ILBT和PDT相比，RFA的全身副作用较少且所需后勤工作较少，导管内RFA应被视为晚期PHC患者姑息治疗的另一种安全可行的辅助方法。由于缺乏比较研究，局部消融方法的选择在每种情况下仍需个体化决定。
