A fifty-four years
old Marwari patient from Assam presented with progressive jaundice and
intermittent episodes of abdominal pain for three months. CT scan of abdomen
showed a small (1.5 x 1.5 cm) mass in the bifurcation of common bile duct which
is causing biliary tract obstruction and hence jaundice. Portal nodes were not
enlarged and there was no lesion in the liver parenchyma. At presentation,
serum bilirubin level was high (14.7 mg/dl). Endoscopic biopsy and brushing
cytology was adenocarcinoma and clinic-radiological diagnosis was ‘Klatskin
tumour’.
Metallic stenting was
done to relieve jaundice and after stenting serum bilirubin level came down
rapidly. PET scan showed increased uptake in the biliary duct region mass
without any sign of metastasis. He was evaluated and planned for treatment with
robotic radiosurgery. He was treated using robotic radiosurgery (CyberKnife)
with high precision radiotherapy technique after fiducial placement (gold
seeds) near the tumour. After one year, the patient had no obvious complain, liver
function (no jaundice) was normal and CT scan evaluation showed completed
resolution of the mass.
Klatskin tumour is an
uncommon tumour that arises from the bifurcation of common bile duct in the
abdomen (duct that drains bile from liver). Patients usually present with
progressive (increasing) persistent jaundice followed by pain in the upper
abdomen. Surgical excision is the mainstay of treatment. However, surgery is
not possible in majority of the patients owing to the location of the tumour, high
jaundice and medical condition. Chemotherapy may not be an optimal option in
majority of the patients as they present with high jaundice. Majority of such
patients with poor medical condition are treated with only supportive care and
prognosis is dismal (survival for a few months only).
Patients with
metallic stent have relief from jaundice but unfortunately in a few weeks time,
the stent gets blocked with tumour growth. Patients again present with high
jaundice and have severely impaired quality of life. They complain of severe
itching of entire body, loss of appetite and succumb due to impaired liver
function from high jaundice/obstruction. The treatment is to have a longer
‘jaundice-free period’ which in turn improves quality of life and possibly
survival function as well.
Stereotactic body
radiation therapy’s high dose radiation ‘sterilizes’ the metallic stent and
bile duct region. It is assumed that with radiation therapy, blockage of bile
duct and stent is delayed and patients have longer jaundice-free period.In
Klatskin tumour, CyberKnife allows to deliver high dose of radiation in a short
duration to the target without significant morbidity.
Article by Dr.Debnarayan Dutta
To know more about cyberknife kindly blog your comments or you can write to me at lakshmipriya_b@apollohospitals.com or call 9940675877
