CIO 2021-3 Locoregional Therapy for Intrahepatic Cholangiocarcinoma: Case-Based Examples and Educational Review

Purpose: Intrahepatic cholangiocarcinoma (ICC) is the second most common primary liver malignancy; thus, interventional radiologists should be well acquainted with all available locoregional therapies (LRTs). While surgical resection is the only curative treatment, LRTs such as thermal ablation (i.e., microwave ablation [MWA]), transarterial chemoembolization (TACE), and transarterial radioembolization (TARE) play an important role in downstaging and managing advanced disease. This educational presentation will provide a case-based review of the American Joint Committee on Cancer (AJCC) 8th Edition staging system criteria with special emphasis on factors that dictate LRT selection. In addition, a review of the most up-to-date evidence supporting use of LRTs for ICC will also be included.

Material and Methods: Two patients with ICC treated with LRTs were selected from our institution. Case 1: 46-year-old female with history of obesity and non-alcoholic steatohepatitis (NASH) cirrhosis with esophageal varices, portal hypertension, and splenomegaly diagnosed with T1N1M0 biopsy-proven ICC in segment VII/VIII (LI-RADS category LR-M). Case 2: 64-year-old male with history of nasopharyngeal carcinoma, Hodgkin’s lymphoma, and NASH cirrhosis diagnosed with biopsy-proven ICC in segment II.

Results: Case 1: Pre-procedural MRI abdomen showed a 3.1 cm peripherally enhancing lesion in liver segment VII/VIII. TARE was performed with Yttrium-90 (Y90) glass microspheres; 33.24 mCi was delivered to the tumor via the right hepatic artery. No procedural complications. 3-month follow-up CT showed decrease in tumor size with no residual tumor or metastatic lesions. Case 2: Pre-procedural MRI abdomen showed a 2.3 cm rim-enhancing lesion in liver segment II. MWA was performed at 100 Watts for 6 minutes in a 3.9 x 3.4 cm ablation zone. No procedural complications. 14-month follow-up MRI, as compared to earlier imaging, showed stable appearance of ablation zone with no evidence of local recurrence.

Conclusions: Recent studies suggest that TARE may have a more favorable safety profile compared to TACE for ICC. MWA is thought to be superior to radiofrequency ablation as it can generate higher temperatures and produce larger ablation zones, but current evidence remains inconclusive. In summary, strong foundational knowledge of LRTs is necessary to ensure appropriate selection of LRT while managing ICC in a multidisciplinary fashion.