Evaluation of high-dose-rate intraluminal brachytherapy by percutaneous transhepatic biliary drainage in the palliative management of malignant biliary obstructiondA pilot study Rupali Aggarwal 1, * , Firuza Darius Patel 1 , Rakesh Kapoor 1 , Mandeep Kang 2 , Pankaj Kumar 1 , Suresh Chander Sharma 1 1 Department of Radiotherapy and Oncology, Postgraduate Institute of Medical Education and Research, Chandigarh, India 2 Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh, India ABSTRACT PURPOSE: To evaluate the role of high-dose-rate intraluminal brachytherapy (ILBT) through percutaneous transhepatic biliary drainage (PTBD) in patients with malignant biliary obstruction, in terms of improvement in symptoms, quality of life (QOL), and survival. METHODS AND MATERIALS: From August 2004 to October 2006, 18 patients aged 30e70 years, who were found unsuitable for surgical resection or were inoperable because of poor general condition, were taken up for palliative ILBT through PTBD. All patients underwent PTBD followed by internaleexternal drainage. After a gap of 1 week, high-dose-rate ILBT was performed by deliv- ering a dose of 800 cGy prescribed at 1 cm from the central axis of the catheter. Two such sessions were given 1 week apart. RESULTS: The mean fall in bilirubin was 11.37 mg% after PTBD and further 2.94 mg% after ILBT. The overall response rates were 100% and 80% for pruritus and icterus, respectively. Improvement in appetite and weight gain was seen in 93.3% and 86.7% patients, respectively, at last followup. The median followup and survival duration were 7.3 and 8.27 months, respectively. Actuarial survival at 6 months was 61.11%. Treatment-related major complications were not seen in any of the patients. QOL showed significant improvement in global health status and most func- tional and symptom scales. CONCLUSIONS: This prospective pilot study demonstrated that PTBD followed by ILBT is a feasible procedure with good symptom control, definite impact on QOL, and minimal complica- tions in such patients. A prospective randomized study is required to more accurately assess the benefit of ILBT compared with biliary drainage alone. Ó 2013 American Brachytherapy Society. Published by Elsevier Inc. All rights reserved. Keywords: Malignant biliary obstruction; High dose rate; Intraluminal brachytherapy; Percutaneous transhepatic biliary drainage; Quality of life Introduction Malignant obstruction of biliary tree can be caused by primary cholangiocarcinomas, local obstruction because of tumors of gall bladder or pancreas, or from metastatic disease to nodes at porta hepatis (1). At the time of diagnosis, only 7e20% of these patients are suitable for radical surgical resection and have a median survival time approaching 17e20 months. Approximately 65e70% of malignant biliary obstruction patients with unresectable disease are severely disabled because of jaundice, intense pruritus, loss of appetite, loss of weight, acholic stools, painful hepato- megaly, change in bowel habits, nausea, vomiting, and coa- gulopathies. Such patients have a median survival time of 2.7 months if no further therapy is given (2, 3). In this setting, given a short life expectancy, the therapeutic goal is often palliation of symptoms with major emphasis on quality of life (QOL). This is possible by drainage of the biliary system surgically, radiologically, or endoscopically. Received 12 April 2012; received in revised form 13 June 2012; accepted 22 June 2012. * Corresponding author. Department of Radiotherapy and Oncology, Postgraduate Institute of Medical Education and Research, Sector-12, Chandigarh 160012, India. Tel.: þ91-9872255667; fax: þ91-1722749338. E-mail addresses: rupali_agg@yahoo.co.in or drpankajarora@ gmail.com (R. Aggarwal). 1538-4721/$ - see front matter Ó 2013 American Brachytherapy Society. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.brachy.2012.06.002 Brachytherapy 12 (2013) 162e170