Cholangiocarcinoma: Endoscopic therapies

Cholangiocarcinoma (CCA) is a difficult-to-treat biliary malignancy with significant morbidity and mortality because of its typically late symptomatic presentation. Though curative surgical options do exist, most patients with perihilar CCA are deemed unresectable at the time of diagnosis. Furthermore, the efficacy of chemoradiation for tumor control is limited. However, advances in endoscopic technology and techniques have enabled improved symptom palliation via internal biliary decompression, which is associated with improved quality of life. The introduction of radioactive, intraductal brachytherapy for the management of unresectable CCA has resulted in prolonged biliary stent patency and it has the ability to provide local tumor control. Endoscopic retrograde cholangiopancreatography (ERCP)-directed photodynamic therapy (PDT) and radiofrequency ablation (RFA) for the palliative treatment of patients with unresectable CCA have recently been added to the armamentarium of the biliary endoscopist. Patients now have these nonradioactive, minimally invasive endoscopic treatment options at their disposal, which can help to reduce the rate of biliary infections and might also offer survival benefit. Moreover, ERCP-directed PDT has been used in lieu of intraductal brachytherapy for locoregional tumor control in patients with unresectable perihilar CCA who are awaiting liver transplantation. Despite the studies supporting the use of endobiliary PDT and RFA, the optimal timing, treatment locations (in bilateral disease), and frequency for these ablative therapies have yet to be established. Although endobiliary PDT and RFA both have their respective advantages and disadvantages, attention to patient education and providing detailed informed consent remains paramount to their proper use. This is a point of emphasis given the ongoing technological maturation of these endoscopically delivered ablative therapies and the evolving ways in which they are used.