Iodine-125 biliary stent for palliative treatment of locally advanced gallbladder cancer

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The management of primary carcinoma of the gallbladder remains a challenging clinical problem. Intraluminal brachytherapy (ILBT) and interstitial brachytherapy (IBT) have been found to be effective in improving local control in patients with the advanced unresectable carcinoma. Our previous research demonstrated that the combination of radioactive stents and normal metallic or plastic stents was technically feasible and well tolerated by patients with advanced tumors around the pancreatic-head area [1].

A 74-year-old man was presented to our hospital with a 2-week history of abdominal distension and jaundice. A magnetic retrograde cholangiopancreatography (MRCP) scan showed a mass in the gallbladder neck, with calculi and gallstones in the common bile duct. A computed tomographic (CT) scan showed carcinoma of gallbladder infiltrating the common bile duct ([Fig. 1]).

Fig. 1 Computed tomographic (CT) scan showing carcinoma of the gallbladder infiltrating the common bile duct.

The results of the laboratory investigations were as follows: white blood cell count 6.40 × 10⁹/L; red blood cell count 4.02 × 10¹²/L; platelet count 197 × 10⁹/L; total bilirubin 448.5 µmol/L, direct bilirubin 339.8 µmol/L, alanine aminotransferase 36 U/L, aspartate aminotransferase 33 U/L; and γ-glutamyltransferase 288 U/L. Renal function, alpha-fetoprotein, and carcinoembryonic antigen were normal, while the serum level of CA19-9 was 344.7 U/mL. An endoscopic retrograde cholangiopancreatography (ERCP) showed that the lower common bile duct was filled with stones. The ERCP also demonstrated irregular stenosis in the upper common bile duct and dilatation of the proximal intrahepatic duct. Endoscopic sphincterotomy was performed and the stones were successfully removed. An endoscopic retrograde brush was used during the operation, and a few days later, the cytology results confirmed the presence of adenocarcinoma. We then placed a special iodine-125 stent, in which the iodine-125 seeds were inserted into a customized plastic stent, and a normal plastic stent in the common bile duct ([Fig. 2]).

Fig. 2 Endoscopic retrograde cholangiopancreatography (ERCP) showing a special iodine-125 stent and a normal plastic stent in the common bile duct.

The jaundice subsided in 3 days, and 3 months later a CT scan showed resolution of the intrahepatic cholangiectasis ([Fig. 3]).

Fig. 3 Computed tomographic (CT) scan showed resolution of intrahepatic cholangiectasis and no progression of the lesion after 3 months of the implantation of the iodine-125 stent.

Following this, the combination of the iodine-125 stent and a normal plastic stent was replaced five times at intervals of 4 – 5 months. The implantation was considered to be safe in this patient as there were no significant procedure-related complications such as acute pancreatitis or early cholangitis. During the fourth implantation, we collected specimens from the bile duct after the removal of the iodine-125 stent and pathological examination also showed the specimen to be an adenocarcinoma ([Fig. 4]).

Fig. 4 Histologic section showing features of adenocarcinoma.

After 2.5 years, the patient remains under regular follow-up; a recent examination revealed that liver and kidney function was normal and a CT scan showed no remarkable increase in tumor volume ([Fig. 5]).

Fig. 5 Computed tomographic (CT) scan showed no significant increase in tumor volume as well as no metastasis.

We are unaware of any previous reports similar to the present case [2] [3]. We conclude on the basis of this report that the placement of radioactive stents and plastic stents for the palliative treatment of malignant lesions such as adenocarcinoma is technically feasible, well tolerated in patients with advanced tumors of carcinoma of gallbladder, and should be safe and effective.

Competing interests: None

Endoscopy_UCTN_Code_TTT_1AR_2AF

References

• 1 Liu Y, Lu Z, Zou D. et al . Intraluminal implantation of radioactive stents for treatment of primary carcinomas of the peripancreatic-head region: a pilot study.  Gastrointest Endosc. 2009;  69 1067-1073
• 2 Zhu A X, Hong T S, Hezel A F. et al . Current management of gallbladder carcinoma.  Oncologist. 2010;  15 168-181
• 3 Fuller C D, Dang N D, Wang S J. et al . Image-guided intensity-modulated radiotherapy (IG-IMRT) for biliary adenocarcinomas: Initial clinical results.  Radiother Oncol. 2009;  92 249-254

1 Y. Guo and J. Chen are co-first authors.