To date, no randomized, controlled, trial study has clearly demonstrated long-term survival benefit for EBRT with or without ILB, or chemoradiation, over biliary drainage in patients with biliary tract neoplasms (1). A recent retrospective study showed that the combination of EBRT and ILB in 93 patients with unresectable extrahepatic bile duct carcinoma resulted in a median survival of 12 months, at the expense of mild-to-severe gastroduodenal complications in 32 patients (34%) (44). In another retrospective study, median time to tumor recurrence (nine months vs. five months; P = 0.06) and two-year survival rate (0% vs. 21%; P = 0.015) was significantly better with EBRT and ILB than with EBRT alone, without enhancement in treatment

FIGURE 2 Hilar cholangiocarcinoma (Klatskin tumor) with infiltrative aspect of the hilar region and stent in the right part of the biliary tree (white arrow).
FIGURE 3 Same patient as in Figure 2 showing stent in the main bile duct and right liver metastasis {white arrow).

morbidity; however, no statistically significant difference was found in the recurrence rates between those who did and did not receive ILB (45) (evidence level 4).

A homogeneous systematic approach with metallic stent implantation followed by ILB was evaluated in 32 patients with various biliary malignancies. Mean survival was 457, 237, and 850 days in patients with Klatskin's tumor, gallbladder carcinoma, and carcinoma of the papilla of Vater, respectively. ILB appears to prolong survival in inoperable patients with Klatskin's tumor and carcinoma of the papilla compared with nontreated patients in previous studies. In contrast, no similar effect was noted in patients with gallbladder carcinoma (46) (evidence level 4).

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