125I interstitial implant, precision high-dose external beam therapy, and 5-FU for unresectable adenocarcinoma of pancreas and extrahepatic biliary tree

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Abstract
Twelve patients with adenocarcinoma of the pancreas and two patients with carcinoma of the extrahepatic biliary tree received combined therapy with 125I implant, precision high-dose (PHD) photon external beam therapy, and systemic 5-fluorouraciI (5-FU). The 125I implant delivered 120 to 210 Gy (median 140 Gy). PhD external beam therapy was given with high-energy photons (10, 15 or 45 meVp) and was initiated 4 to 6 weeks postimplant. A dose of 48.6 to 63 Gy was delivered over 5.5 to 7 weeks in 1.8 Gy increments. Six patients received 5-FU, 500 mg/m2 via weekly intravenous bolus injection. No patient was lost to follow-up (range, 3.5–57 months). Acute postoperative morbidity included pancreatic fistula in two patients and gastrointestinal tract bleeding, pulmonary embolism, and cholangitis in one patient each. No patient died of radiation complications. Median survival of the patients with pancreas cancer was 15 months. One patient is alive at 41 months with hepatic metastasis. Satisfactory palliation was observed in patients with pancreas cancer treated with 125I interstitial implant followed by PhD external beam photon therapy and 5-FU. Patient survival did not seem superior to that of patients treated with PhD external beam therapy ± chemotherapy, a less morbid procedure. Two cases of bile duct cancer treated in similar fashion are presented.