ESTABLISHING A COLLABORATIVE AND EFFECTIVE IMAGE-GUIDED HEPATOBILIARY BRACHYTHERAPY PROGRAM: A MODEL FOR BROADER IMPLEMENTATION

Abstract

Purpose:

Cholangiocarcinoma is a rare malignancy and the leading cause of malignant biliary tract obstruction (MBTO), a condition associated with significant morbidity, including abdominal pain, jaundice, and eventual liver failure. Surgical resection is only feasible for a limited subset of patients, and elevated bilirubin levels often preclude systemic therapy. This study outlines the logistics and workflow of a successful image-guided bile duct intraluminal brachytherapy (ILBT) program designed to improve the quality of life (QOL) and clinical outcomes for patients with MBTO.

Materials and Methods:

We describe the essential steps for implementing a successful image-guided ILBT program. Additionally, we retrospectively reviewed the first 40 patients enrolled in a prospective registry who underwent ILBT treatment.

Results:

The successful establishment of a brachytherapy program relies on three key components: (1) a dedicated team with brachytherapy expertise, (2) appropriate infrastructure and resources, and (3) strong multidisciplinary collaboration. Cancer centres with existing high-dose-rate (HDR) brachytherapy programs for prostate and gynecological malignancies already possess the necessary major equipment, including HDR afterloaders, treatment planning systems, shielded treatment room, and imaging modalities (CT/MRI/C-arm) for treatment planning and delivery. Therefore, the primary requirement for developing an ILBT program is fostering collaboration between hepatobiliary surgeons, medical oncologists, and interventional radiologists (IRs) to identify suitable patients. Given that most cancer centres are affiliated with hospitals that offer IR services, routine procedures such as stent placement and percutaneous drain insertion can facilitate ILBT delivery. Once a patient is deemed eligible, Interventional Radiology can place hilar biliary stents or a common bile duct stent, with preservation of percutaneous catheter access, enabling safe and effective brachytherapy administration (Figure 1). At our institution, the first two key components for establishing an ILBT program were already in place. A gastrointestinal radiation oncologist with expertise in brachytherapy played a pivotal role in fostering interdisciplinary collaboration among hepatobiliary surgeons, interventional radiologists, medical oncologists, and radiation oncology teams. The ILBT program was successfully implemented in March 2021, with an initial goal of treating one patient per month. As of December 2024, 42 patients have undergone image-guided ILBT. The median age was 77 years (range: 45–89). Tumour locations included the hilar region (n=21), common hepatic duct (n=5), mid bile duct (n=7), and distal common bile duct (n=5). The prescribed dose was 25 Gy, delivered in five daily fractions.

Conclusions:

Image-guided ILBT is a feasible and effective treatment modality for patients with MBTO, particularly in centres with established HDR brachytherapy programs. The key to successful implementation lies in interdisciplinary collaboration, leveraging existing infrastructure, and ensuring personnel expertise. Given the prevalence of IR capabilities in most cancer centres, this approach can be widely adopted to improve patient outcomes. Standardizing workflows and fostering institutional partnerships will be critical in expanding access to this valuable treatment modality across cancer centres globally.