We report the first successful photodynamic therapy for biliary adenomatosis without any serious side effects. Photodynamic therapy is an established intervention in the treatment of Barret’s esophagus[6
], lung cancer[7
] and bile duct cancer[8
]. It was reported that photodynamic therapy can improve the quality of life and the survival of such patients[8,10,15,16
Our patient survived ten years after the diagnosis of biliary papillomatosis was established, exceeding the average survival time of biliary adenomatosis patients ranging from 28[1
] to 32 mo[2
]. Yeung et al[2
] reviewed 78 cases of biliary papillomatosis and postulated a median survival of 28 mo after radical resection irrespective of the histological signs of dysplasia, while the median survival time was only 11 mo when no radical resection was performed. Only few cases having a survival time of more than 4 years after the diagnosis of biliary papillomatosis have been reported. In the patient presented here, the first biliary adenoma was diagnosed in 1996 and recurred in 2002, resulting in hemihepatectomy. After initiation of the PDT, the patient survived another four years with a good quality of life until admission for decompensated liver cirrhosis, a few weeks before he died. From the first manifestation of the disease he even survived 10 years.
Depending on the location and extension of the disease so far, the Whipple procedure and hemihepatectomy are the therapies of choice for biliary papillomatosis resulting in an average survival time of approximately 17 mo[2,17
]. Extensive preoperative diagnosis is required to determine the resectability and the extent of the disease by ERCP, CT, cholangioscopy and intraoperative ultrasound studies[18
]. In cases of diffuse hepatic manifestations, liver transplantation should be considered[4
]. Bile duct papillomatosis is a disease of the elderly (mean age at time of diagnosis: 63 years), thus many patients would not be eligible for transplantation limiting the therapeutic options.
Apart from other local palliative procedures (i.e. stenting, drainage), few cases of local ablation have been reported[19,20
], most of them in the palliative setting with advanced disease plus cholangiocarcinoma were treated with a conventional laser. Data on the long term survival of these patients are lacking so far. However, PDT ablation seems to be more specific targeting dysplastic tissue with less harm to the surrounding tissue[11
]. Thus, using PDT in this particular setting might improve the quality of life and prolong life expectation of this group of patients without exposing them to risky procedures. The use of PDT in this setting has not been reported in the literature so far.
Side effects of PDT include fever, abdominal pain, nausea, vomiting and insomnia though rare. Increased photosensitivity of the skin and eyes is observed and precautions should include avoidance of direct sunlight and bright indoor light[11
]. In this case only minor adverse effects are reported including mild inflammatory reaction two days after the PDT and mild skin reaction. The quality of life was significantly improved with relief from cholestasis and cholangitis for months and the patient exceeded the survival rate of most other cases reported in literature[2
In conclusion, PDT might be a therapeutic option for patients with recurrent biliary papillomatosis after resection as well as for those who are not eligible for surgery. Further studies are needed to prove the role of PDT in the treatment of biliary papillomatosis.