Complete Resolution of a Malignant Biliary Stricture Using Combined Neoadjuvant Chemoradiation and Brachytherapy Boost Prior to Orthotopic Liver Transplantation

Complete Resolution of a Malignant Biliary Stricture Using Combined Neoadjuvant Chemoradiation and Brachytherapy Boost Prior to Orthotopic Liver Transplantation

To limit recurrence and intra-operative tumor dissemination at the time of transplant, there is increasing evidence that neoadjuvant chemoradiation and brachytherapy boost helps facilitate successful liver transplantation in patients with earlystage unresectable hilar cholangiocarcinoma. In published reports, a complete response to neoadjuvant therapy frequently limits the ability to detect residual disease in the hepatectomy specimen, thereby inviting criticism over whether published results are due to the neoadjuvant protocol per se, or selection of patients with earlystage or pre-malignant disease. In this report, a 41 year old male with a malignant biliary stricture received 45 Gy external beam radiation in conjunction with 5-fluoruracil as a prelude to transplant. This was followed by a transluminal boost of radiation (2000 cGy) using an Iridium-192 brachytherapy wire inserted through percutaneously-placed biliary catheters. Using this approach, we document the complete resolution of the patient’s malignant stricture, thereby objectively quantifying tumor response prior to orthotopic liver transplantation.