The addition of radiation to chemotherapy may be associated with a deleterious effect in the R0 population.37

There are only a few studies evaluating the benefit of adjuvant chemoradiotherapy in cholangiocarcinomas.

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Two studies support the use of chemoradiotherapy as adjuvant approach in cholangiocarcinoma. Kim et al evaluated its role in 72 patients with extrahepatic cholangiocarcinoma, among them 25 patients had positive margins. The patients underwent postoperative external beam radiotherapy (40 Gy) and concomitant boluses of 5-FU. Five-year survival rates were 36% after R0 resection, 35% in R1, and 0% following R2.52

Another small study showed again improved survival with chemoradiotherapy in hilar cholangiocarcinoma.53

SWOG trial, a phase II, single-arm, using chemoradiotherapy in node or margin positive patients, has shown good tolerance and promising efficacy.

Patients received four cycles of a combination with gemcitabine and capecitabine followed by concurrent capecitabine and radiotherapy.54

Ramirez-Merino et al concluded in their review that patients with localized and locally advanced cholangiocarcinomas must be treated in a multidisciplinary team, being surgery the main therapeutic option. However, it is necessary to improve survival but it is still difficult to clarify the role of adjuvant treatment.

Adjuvant therapy is widely recommended for intrahepatic or extrahepatic cholangiocarcinomas with microscopically positive resection margins and for those with a complete resection but node-positive disease.

Gemcitabine plus cisplatin has been shown to be superior to gemcitabine alone, but this regimen has not been compared head to head with other gemcitabine-based combinations.55

Others: conventional transarterial chemoembolization

A retrospective analysis has reported that adjuvant conventional transarterial chemoembolization (cTACE) after curative surgery did not delay recurrence but may prolong the OS of patients with early recurrence.56

A prospective study has evaluated the feasibility, safety, and efficacy of conventional cTACE with mitomycin-C and of irinotecan-eluting beads (iDEB-TACE) and to retrospectively compare them with conventional chemotherapy with oxaliplatin and gemcitabine.

These authors report that the treatment with iDEB-TACE is safe in patients with normal liver function, prolongs progression-free survival (PFS) and OS. Local tumor control, PFS, and OS are similar to those achieved by chemotherapy with oxaliplatin and gemcitabine but superior to cTACE.57

Photodynamic therapy

Photodynamic therapy is a local ablative method of treating dysplasia or neoplasia. It consists of selective accumulation of a photoactive drug (photosensitizer) in tumor tissue followed by light activation of the retained photosensitizer. This results in tumor necrosis mediated by cytotoxic radicals, mainly singlet oxygen.58

In an uncontrolled study, adjuvant photodynamic therapy of residual tumor after surgical resection in a few patients was promising.59

Tumor ablation with photodynamic therapy combined with biliary stenting reduces cholestasis and significantly improves median survival in selected patients with bile duct cancers.60

Further studies are necessary to get solid conclusions about the real role of this therapy in the adjuvant setting.