Abstract
Background Malignant obstructive jaundice is a challenging complication of advanced hepatobiliary malignancies and is associated with significant morbidity. Endoscopic or percutaneous biliary drainage remains the standard palliative intervention; however, some patients are unsuitable for or fail these procedures. Radiotherapy, particularly stereotactic body radiotherapy (SBRT), may offer a noninvasive alternative for symptom relief and local tumor control in selected cases.
Case Report A 45-year-old female with inoperable intrahepatic cholangiocarcinoma presented with malignant biliary obstruction. She was not a candidate for surgical resection or invasive biliary drainage. The patient underwent SBRT directed at the primary hepatic lesion. Following treatment, the patient demonstrated meaningful biochemical improvement, including reduction in serum bilirubin levels, along with symptomatic relief. Her clinical response facilitated the initiation of systemic therapy. The patient tolerated treatment well, experiencing only grade 1 fatigue and nausea.
Conclusion This case illustrates the potential role of SBRT as a noninvasive palliative modality in selected patients with malignant biliary obstruction who are unsuitable for standard biliary drainage procedures. Radiotherapy may contribute to symptom relief and enable further oncologic management within a multidisciplinary care framework.
INTRODUCTION
Malignant biliary obstruction can result from various gastrointestinal or hepatobiliary malignancies, and cholangiocarcinoma is one of the most common causes. Obstructive jaundice caused by malignancy is typically managed with biliary decompression through endoscopic or percutaneous drainage.1,2 For patients with obstructive distal cholangiocarcinoma, endoscopic drainage is generally preferred.3 For patients with obstructive hilar cholangiocarcinoma, the choice of biliary drainage method is controversial, and multidisciplinary collaboration is needed to determine the optimal biliary drainage method.4,5 When these interventions fail or are not feasible because of anatomic complexity, alternative strategies are needed. External beam radiotherapy may reduce tumor burden and relieve the obstruction noninvasively.6,7 We present a case in which stereotactic body radiotherapy (SBRT) provided effective palliation for malignant biliary obstruction.
CASE REPORT
A 45-year-old female presented with progressive abdominal pain, vomiting, jaundice, pruritus, and fatigue of 2 months’ duration. She had no prior surgical or interventional procedures. Contrast-enhanced computed tomography (CT) revealed a 9.8 × 8.9-cm hypodense mass involving liver segments II, IVa, and IVb and compressing the common hepatic duct. The lesion demonstrated intense arterial phase enhancement with early washout on the venous phase, consistent with a hypervascular tumor (Figure 1).
Baseline contrast-enhanced computed tomography images of the abdomen show an intensely enhancing mass involving liver segments II, IVa, and IVb with (A) arterial phase hyperenhancement and (B) early washout on venous phase imaging.
On examination, the patient was icteric, with a total bilirubin of 6.07 mg/dL (reference range, 0.3-1.2 mg/dL), direct bilirubin of 3.57 mg/dL (reference range, 0.03-0.18 mg/dL), aspartate aminotransferase of 65 IU/L (reference range, 0-35 IU/L), and alanine aminotransferase of 25 IU/L (reference range, 0-35 IU/L).
Ultrasound-guided fine needle aspiration cytology from the liver lesion revealed poorly differentiated adenocarcinoma, confirming the diagnosis of intrahepatic cholangiocarcinoma. However, the patient had presented with symptomatic malignant biliary obstruction and worsening jaundice and was unsuitable for systemic therapy because of elevated bilirubin levels. Both endoscopic retrograde cholangiopancreatography and percutaneous transhepatic biliary drainage were deemed infeasible because of the location and size of the tumor and the lack of accessible biliary ducts. Given the patient's poor performance status (Eastern Cooperative Oncology Group [ECOG] score of 3), external beam radiotherapy was initiated as a palliative measure to relieve biliary obstruction prior to systemic therapy.
A course of SBRT was delivered to the tumor volume. A dose of 30 Gy in 5 fractions was prescribed using the volumetric modulated arc technique and delivered on alternate days over 2 weeks (Figure 2). Organs at risk—liver, kidneys, stomach, duodenum, bowel, and spinal cord—were contoured and appropriately constrained.
Color wash images of the stereotactic body radiotherapy treatment plan in (A) axial, (C) sagittal, and (D) coronal planes with (B) the corresponding dose-volume histogram.
Within 2 weeks postradiotherapy, the patient demonstrated a reduction in icterus on clinical examination and reported improvement of other symptoms including abdominal pain. Liver function tests showed gradual improvement. Total bilirubin decreased to 1.82 mg/dL by week 4, and direct bilirubin decreased to 0.82 mg/dL (Figure 3). Repeat contrast-enhanced CT performed 6 weeks following radiotherapy demonstrated reduction in tumor bulk and partial decompression of the biliary tree compared with the preradiotherapy CT (Figure 4). Treatment was well tolerated, with only grade 1 fatigue and nausea, and the patient's ECOG score improved to 2.
Serum bilirubin levels gradually decreased after stereotactic body radiotherapy. At 4 weeks, total bilirubin had decreased from 6.07 mg/dL at baseline to 1.82 mg/dL and direct bilirubin had decreased from 3.57 mg/dL to 0.82 mg/dL.
Arterial phase computed tomography images show (A) an enhancing intrahepatic mass prior to stereotactic body radiotherapy and (B) a reduction in tumor size 6 weeks following stereotactic body radiotherapy.
The patient was subsequently started on palliative chemotherapy with gemcitabine 1,000 mg/m2 on days 1 and 8 and cisplatin 25 mg/m2 on days 1 and 8 every 3 weeks. However, following the fourth cycle, her general condition deteriorated. Rising bilirubin levels, suggestive of disease progression, precluded further chemotherapy. The patient subsequently succumbed to disease progression 2 months after discontinuation of chemotherapy.
DISCUSSION
This case provides additional evidence for the use of radiotherapy in relieving malignant biliary obstruction. While drainage remains the standard for malignant biliary obstruction, external beam radiotherapy can be a valuable palliative tool in selected cases, especially when invasive procedures are not feasible. Radiation may relieve obstruction by reducing tumor volume around the bile duct.
Prior reports and small series have demonstrated the efficacy of external beam radiotherapy in reducing jaundice and improving outcomes in patients with inoperable hilar cholangiocarcinoma.7-9 In a study by Ohnishi et al, 14 patients with inoperable hilar cholangiocarcinoma were treated with external beam radiotherapy using a 4MeV linear accelerator with parallel opposing fields (field sizes of 7 × 7 cm to 8 × 10 cm).10 Radiation doses ranged from 50 to 60 Gy, delivered in daily fractions of 1.8 to 2.0 Gy. No further biliary decompression was performed following percutaneous transhepatic cholangiography; radiotherapy was initiated immediately after diagnosis. Eleven of 14 patients completed the full radiation course, and total bilirubin levels normalized in 10 of 11 patients (P<0.005), with no episodes of cholangitis reported.10 Ishii et al combined external beam radiotherapy (30 to 50 Gy) with intraluminal brachytherapy (24 to 40 Gy) and reported biliary tube-free survival in 76% of patients with extrahepatic cholangiocarcinoma.11 In another report, intraluminal brachytherapy alone without stenting in intrahepatic papillary cholangiocarcinoma maintained biliary patency for 18 months.12 Kuvshinoff et al reported that combined internal biliary drainage with intraluminal and external beam radiotherapy provided effective palliation with relief of jaundice in 10 of 12 patients, and the median survival was 14.5 months in patients with unresectable or recurrent hilar cholangiocarcinoma.13
Our case highlights the potential palliative role of modern radiotherapy, particularly SBRT, in the management of malignant biliary obstruction when surgery or other invasive options are not feasible. While conclusions are limited because our report is a single case, our experience suggests that radiotherapy may be considered for selected patients, particularly those with borderline performance status and limited interventional alternatives. Early identification of such patients may help optimize supportive and oncologic care.
CONCLUSION
This report demonstrates the feasibility of SBRT as a noninvasive palliative alternative for relieving malignant obstructive jaundice in a patient unsuitable for biliary drainage or stenting procedures. With precise targeting and limited toxicity, SBRT offers symptomatic relief and may improve eligibility for systemic therapies. Prospective studies are warranted to better define the role, optimal dose, and timing of SBRT in this clinical setting.
This article meets the Accreditation Council for Graduate Medical Education and the American Board of Medical Specialties Maintenance of Certification competencies for Patient Care and Medical Knowledge.
ACKNOWLEDGMENTS
The authors have no financial or proprietary interest in the subject matter of this article.
- ©2026 by the author(s); Creative Commons Attribution License (CC BY)
©2026 by the author(s); licensee Ochsner Journal, Ochsner Clinic Foundation, New Orleans, LA. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (creativecommons.org/licenses/by/4.0/legalcode) that permits unrestricted use, distribution, and reproduction in any medium, provided the original author(s) and source are credited.
REFERENCES
- 1.↵BoulayBR, BirgA. Malignant biliary obstruction: from palliation to treatment. World J Gastrointest Oncol. 2016;8(6):498-508. doi: 10.4251/wjgo.v8.i6.498
- 2.↵LorenzJM. Management of malignant biliary obstruction. Semin Intervent Radiol. 2016;33(4):259-267. doi: 10.1055/s-0036-1592330
- 3.↵WangX, BaiY, ChaiN, Chinese national clinical practice guideline on diagnosis and treatment of biliary tract cancers. Chin Med J (Engl). 2024;137(19):2272-2293. doi: 10.1097/CM9.0000000000003258
- 4.↵CoelenRJS, RoosE, WiggersJK, Endoscopic versus percutaneous biliary drainage in patients with resectable perihilar cholangiocarcinoma: a multicentre, randomised controlled trial. Lancet Gastroenterol Hepatol. 2018;3(10):681-690. doi: 10.1016/S2468-1253(18)30234-6
- 5.↵WangL, LinN, XinF, KeQ, ZengY, LiuJ. A systematic review of the comparison of the incidence of seeding metastasis between endoscopic biliary drainage and percutaneous transhepatic biliary drainage for resectable malignant biliary obstruction. World J Surg Oncol. 2019;17(1):116. doi: 10.1186/s12957-019-1656-y
- 6.↵ChiangJS, YuNY, Ertz-ArchambaultNM, KarlinNJ, ShoudisSN, SioTT. Palliative radiotherapy for hepatobiliary obstruction caused by colorectal metastases. J Gastrointest Oncol. 2019;10(6):1157-1161. doi: 10.21037/jgo.2019.09.05
- 7.↵EngineerR, MehtaS, KalyaniN, High dose chemoradiation for unresectable hilar cholangiocarcinomas using intensity modulated external beam radiotherapy: a single tertiary care centre experience. J Gastrointest Oncol. 2017;8(1):180-186. doi: 10.21037/jgo.2017.01.20
- 8.IsayamaH, TsujinoT, NakaiY, Clinical benefit of radiation therapy and metallic stenting for unresectable hilar cholangiocarcinoma. World J Gastroenterol. 2012;18(19):2364-2370. doi: 10.3748/wjg.v18.i19.2364
- 9.↵JohnsonDW, SafaiC, GoffinetDR. Malignant obstructive jaundice: treatment with external-beam and intracavitary radiotherapy. Int J Radiat Oncol Biol Phys. 1985;11(2):411-416. doi: 10.1016/0360-3016(85)90166-x
- 10.↵OhnishiH, AsadaM, ShichijoY, External radiotherapy for biliary decompression of hilar cholangiocarcinoma. Hepatogastroenterology. 1995;42(3):265-268.
- 11.↵IshiiH, FuruseJ, NagaseM, KawashimaM, IkedaH, YoshinoM. Relief of jaundice by external beam radiotherapy and intraluminal brachytherapy in patients with extrahepatic cholangiocarcinoma: results without stenting. Hepatogastroenterology. 2004;51(58):954-957.
- 12.↵MacchiaG, CostamagnaG, MorgantiAG, Intraluminal brachytherapy without stenting in intrahepatic papillary cholangiocarcinoma: a case report. Dig Liver Dis. 2005;37(8):615-618. doi: 10.1016/j.dld.2004.07.022
- 13.↵KuvshinoffBW, ArmstrongJG, FongY, Palliation of irresectable hilar cholangiocarcinoma with biliary drainage and radiotherapy. Br J Surg. 1995;82(11):1522-1525. doi: 10.1002/bjs.1800821122
