Endoscopic radiofrequency ablation of cholangiocarcinoma: new palliative 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) is the standard of care for patients with malignant obstructive jaundice if their life expectancy is 3 months.1,2 However, in 50% of patients with SEMSs, stent blockage develops within 6 to 8 months,3 and newer endoscopic palliative treatment modalities are needed. Recently, endobiliary radiofrequency ablation (RFA) has been used in patients with unresectable malignant obstructive jaundice. We present the rst cholangioscopic images of the use of an endoscopic radiofrequency probe in a patient with unresectable cholangiocarcinoma.

METHODS AND RESULTS

A 56-year-old patient presented with a 1-month history of jaundice and weight loss. He also had severe ischemic heart disease with a low left ventricular ejection fraction. His serum bilirubin level was 277 mmol/L (normal range, 5-25 mmol/L), aspartate transaminase level 77 U/L (normal range, 6-34 U/L), alanine transaminase level 67 U/L (normal range, 8-56 U/L), alkaline phosphatase level 318 U/L (normal range, 30-120 U/L), and international normalized ratio 2.29 (normal range, 0.8-1.2). A CT scan of the abdomen revealed a dilated proximal common bile duct (CBD), intrahepatic biliary dilation, and a lymph node at the porta hepatis. ERCP showed a 1.5-cm tight mid-CBD stricture with upstream biliary dilation. Brush cytology conrmed the suspicion of adenocarcinoma. The patient refused to consider a surgical option in view of the high operative risk. After discussion by the Institutional Review Board, primary endobiliary RFA was offered to the patient before stenting. Informed consent was obtained. An Olympus TJF-Q180V duodenoscope and CHF B260 baby endoscope (Olympus America, Center Valley, PA) were used for the procedure. Figure 1 shows the stricture in the mid-CBD and Video 1 (available online at www.giejournal.org) shows the cholangioscopic images of the tumor revealing a nodular lesion with irregular mucosa. Narrow-band imaging demonstrated the thick, circuitous, irregular vessels characteristic of a malignancy. A wire-guided Habib EndoHPB (Emcision, London, UK) catheter was placed under uoroscopic guidance
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Figure 1. Cholangiogram before endoscopic RFA.

across the biliary stricture (Fig. 2). This bipolar RFA probe has 2 ring electrodes 8 mm apart with the distal electrode 5 mm away from the leading edge (Fig. 3). It is 8F in diameter and 1.8 m long and produces coagulative necrosis over 2.5 cm. Ablation was performed by using an RFA generator (1500 RF generator; RITA Medical Systems, Fremont, Calif) delivering electrical energy at 400 kHz set at 5 W for 2 minutes. The use of a 5-W current for 2 minutes was based on earlier animal studies4 and the product brochure. Immediate posttreatment cholangioscopic images showed an ablated tumor with whitish coagulated mucosa (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 any complications. Two weeks later, cholangioscopy (Video 3, available online at www.giejournal.org) demonstrated persistent whitish charred mucosa with well dened proximal and distal ablated edges. The 11F cholangioscope could easily pass across the stricture, and a cholangiogram
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Figure 4. Cholangiogram obtained 2 weeks after the use of endoscopic RFA. Figure 2. Endoscopically placed Habib EndoHPB (catheter next to the stricture).

Figure 3. Habib EndoHPB catheter.

images both before and after the use of endoscopic RFA for cholangiocarcinoma. Although it is likely that tumor ablation will improve SEMS patency, it will be interesting to know whether endobiliary RFA can completely obviate the need for an SEMS. Until now, photodynamic therapy was the only evidencebased endoscopic treatment other than stenting that improved the quality of life and survival of such patients.5 Endobiliary RFA adds to the endoscopic armamentarium for the treatment of these subjects. However, further randomized controlled trials are needed to establish improved SEMS patency, cost-effectiveness, and survival advantages, if any. In conclusion, endobiliary RFA seems to be a userfriendly and effective palliative treatment modality for patients with unresectable bile duct cancer. DISCLOSURE All authors disclosed no nancial relationships relevant to this publication.
Abbreviations: CBD, common bile duct; RFA, radiofrequency ablation; SEMS, self-expandable metal stent.

conrmed its signicant resolution (Fig. 4). A plastic stent was inserted again with a plan to place an SEMS at a later date.

DISCUSSION
In a recent pilot study of 21 patients, Steel et al (personal communication) demonstrated the safety and efcacy of RFA within the bile duct by using a similar bipolar RFA catheter in patients with malignant obstructive jaundice without any major complication. After RFA ablation, an SEMS was deployed in all patients. Ours is the rst report presenting the cholangioscopic video
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ACKNOWLEDGMENTS The authors thank Dr. N. A. Habib (Imperial College Healthcare, National Health Service Trust, London, UK) for sharing the results of the pilot EndoHPB clinical study
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before publication, which encouraged us to use this technique in our patient.

REFERENCES
1. Shepherd HA, Royle G, Ross AP, et al. Endoscopic biliary endoprosthesis in the palliation of malignant obstruction of the distal common bile duct: a randomized trial. Br J Surg 1988;75:1166-8. 2. Andersen JR, Sorensen HM, Kruse A, et al. Randomised trial of endoscopic endoprosthesis versus operative bypass in malignant obstructive jaundice. Gut 1989;30:1132-5. 3. Loew BJ, Howell DA, Sanders MK, et al. Comparative performance of uncoated, self-expandable metal biliary stents of different designs in 2 di-

ameters: nal results of an international multicenter, randomized controlled trial. Gastrointest Endosc 2009;70:445-53. 4. Khorsandi SE, Zacharoulis D, Vavra P, et al. The modern use of radiofrequency energy in surgery, endoscopy and interventional radiology. Eur J Surg 2008;40:204-10. 5. Ortner MA. Photodynamic therapy for cholangiocarcinomas: overview and new developments. Curr Opin Gastroenterol 2009;25:472-6. Current afliation: Asian Institute of Gastroenterology, Hyderabad, India. Reprint requests: D. Nageshwar Reddy, DM, Asian Institute of Gastroenterology, 6-3-661, Somajiguda, Hyderabad 500 082, India. Copyright 2011 by the American Society for Gastrointestinal Endoscopy 0016-5107/$36.00 doi:10.1016/j.gie.2010.10.018

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