Brachytherapy Boost to Tumor Bed Prior to Adjuvant Chemoradiation in Margin Positive Resected Cholangiocarcinoma
Importance: The role of adjuvant therapy in resected cholangiocarcinoma patients is unproven despite poor survival rates even in completely resected patients. Most relapses occur locally and within a relatively short window from time of resection. R1 resection and lymph node positive patients are particularly at high risk for local relapse. Observation: Adjuvant modalities have not been compared head to head against one another in cholangiocarcinoma patients. The recent phase III PRODIGE 12-ACCORD 18 trial assessing adjuvant chemotherapy with gemcitabine and oxaliplatin in this group of patients was a negative study. Adjuvant radiation has been shown in some retrospective series to improve overall survival in R1 resected and lymph node positive patients. Other retrospective studies suggest adjuvant chemoradiation also carries an overall survival benefit in this setting. Interestingly some of these latter studies suggest the negative prognosis of undergoing an R1 resection may be overcome with adjuvant chemoradiation with regards to overall survival. Two R1 resected cholangiocarcinoma patients at our institution achieved exceptional PFS after receiving brachytherapy boosts prior to external beam chemoradiation with infusional 5-fluorouracil. The first patient was progression free for 91 months prior to succumbing to an unrelated illness while the second patient remains progression free at 65 months currently.