Radiofrequency Ablation in the Treatment of Unresectable Intrahepatic Cholangiocarcinoma: Systematic Review and Meta-Analysis

Survival Outcomes of Radiofrequency Ablation for Intrahepatic Cholangiocarcinoma from the Surveillance, Epidemiology, and End Results (SEER) Database: Comparison with Radiotherapy and Resection

PURPOSE

To determine effectiveness of radiofrequency ablation for treatment of intrahepatic cholangiocarcinoma (iCCA) using a population-based database.

MATERIALS AND METHODS

Data were extracted from Surveillance, Epidemiology, and End Results (SEER) database from 2000 to 2020 to include 194 patients who underwent ablation for iCCA. Data on patient demographics, overall survival (OS), and cancer-specific survival were retrieved. Factors associated with survival were evaluated. Comparison between ablation and surgical resection (n = 2,653) or external beam radiotherapy (n = 1,068) was performed.

RESULTS

In the ablation group, patients diagnosed and treated after 2010 demonstrated improved OS than that in the 2000-2009 subgroup (median OS, 32 vs 21 months; hazard ratio, 0.50; 95% CI, 0.33-0.75; P = .001). Additional factors associated with OS included tumor size (≤3 cm vs >3 cm; P = .049) and tumor stage (P < .001). For patients diagnosed after 2010, the 1-, 3-, and 5-year OS were 82.8% (95% CI, 74.8%-88.4%), 43.5% (95% CI, 33.5%-53.1%), and 23.7% (95% CI, 15.3%-33.5%), respectively. Patients with local disease (1-year OS, 87.8%; 95% CI, 78.6%-93.3%) demonstrated improved OS compared with patients with regional (1-year OS, 81.3%; 95% CI, 52.5%-93.5%) and distant disease (50.2%; 95% CI, 34.0%-78.8%; P < .001). For tumors ≤3 cm, ablation and surgical resection offered comparable survival benefits (P = .561), although both were better than radiotherapy (P < .0001).

CONCLUSIONS

Survival of patients with iCCA who underwent thermal ablation has improved over the last 10 years. For tumors ≤3 cm, ablation could be as effective as resection with careful candidate selection, and may be considered front-line compared with radiotherapy in certain patient populations. Patient selection based on tumor size and disease stage could improve survival outcomes.

Significant response to pembrolizumab plus lenvatinib in Epstein-Barr-virus-associated intrahepatic cholangiocarcinoma: a case report

BACKGROUND

The prognosis for advanced intrahepatic cholangiocarcinoma (iCCA) is poor, and there remains an urgent need to develop efficient systemic therapy. The efficacy of Pembrolizumab immunotherapy combined with lenvatinibin in iCCA is still unclear. The role of Epstein-Barr-virus (EBV) as a biomarker in iCCA for response to immunotherapy needs further exploration.

CASE PRESENTATION

We report a case of a 60-year-old female with EBV-associated advanced iCCA (EBVaiCCA) who progressed after first-line therapy. She accomplished an available response to the combination therapy of pembrolizumab with lenvatinib, with overall survival of 20 months.

CONCLUSIONS

As far as we know, this is the first case report about the application of Pembrolizumab with lenvatinib for EBVaiCCA patients. This case indicates that the combination of immunotherapy and antiangiogenic therapy provides a glimmer of hope for advanced EBVaiCCA patients.

Percutaneous liver-directed therapies of intrahepatic cholangiocarcinoma

Cholangiocarcinoma is a hepatobiliary malignancy which can manifest anywhere along the biliary tree. Intrahepatic cholangiocarcinoma occurs in the liver within or beyond the second order bile ducts. The prognosis for patients with intrahepatic cholangiocarcinoma is poor, even when successfully resected there is a very high rate of local recurrence. The available systemic therapies are currently limited and have high rates of toxicity. Percutaneous and transarterial liver-directed therapies can be used to treat intrahepatic cholangiocarcinoma with results comparable to current standard of care systemic therapies in some circumstances. This manuscript will review these the techniques and efficacy of percutaneous and transarterial liver-directed therapies for intrahepatic cholangiocarcinoma.

The Recent Trends of Systemic Treatments and Locoregional Therapies for Cholangiocarcinoma

Cholangiocarcinoma (CCA) is a hepatic malignancy that has a rapidly increasing incidence. CCA is anatomically classified into intrahepatic (iCCA) and extrahepatic (eCCA), which is further divided into perihilar (pCCA) and distal (dCCA) subtypes, with higher incidence rates in Asia. Despite its rarity, CCA has a low 5-year survival rate and remains the leading cause of primary liver tumor-related death over the past 10-20 years. The systemic therapy section discusses gemcitabine-based regimens as primary treatments, along with oxaliplatin-based options. Second-line therapy is limited but may include short-term infusional fluorouracil (FU) plus leucovorin (LV) and oxaliplatin. The adjuvant therapy section discusses approaches to improve overall survival (OS) post-surgery. However, only a minority of CCA patients qualify for surgical resection. In comparison to adjuvant therapies, neoadjuvant therapy for unresectable cases shows promise. Gemcitabine and cisplatin indicate potential benefits for patients awaiting liver transplantation. The addition of immunotherapies to chemotherapy in combination is discussed. Nivolumab and innovative approaches like CAR-T cells, TRBAs, and oncolytic viruses are explored. We aim in this review to provide a comprehensive report on the systemic and locoregional therapies for CCA.

Local Control of Distal Cholangiocarcinoma With Radiofrequency Ablation at Endoscopic Retrograde Cholangiopancreatography

Distal cholangiocarcinoma (CCA) can pose diagnostic and therapeutic challenges, often leading to a poor prognosis. While curative resection is viable for a minority in the early stage, we report a case of successful endoscopic therapy. A 79-year-old patient, diagnosed with early-stage extrahepatic CCA, opted out of surgery and chemotherapy. Instead, he pursued a treatment strategy involving serial radiofrequency ablation with stent exchange at endoscopic retrograde cholangiopancreatography. The patient achieved remission, showcasing the potential for local control of distal CCA through radiofrequency ablation and covered self-expanding metal stents. This alternative becomes particularly relevant for patients unsuitable for surgery or chemotherapy and those who decline it.

Percutaneous microwave ablation for early-stage intrahepatic cholangiocarcinoma: A single-institutional cohort

Objectives

Cholangiocarcinoma (CCA) is the second-most common primary hepatic malignancy with an increasing incidence over the past two decades. CCA arises from the epithelial cells lining the bile ducts and can be classified as intrahepatic, perihilar, or distal based on the site of origin in the biliary tree. Surgical resection is the definitive curative therapy for early-stage intrahepatic CCA; however, only a minority of patients may be ideal surgical candidates. Percutaneous microwave ablation (MWA) is a minimally invasive procedure widely used for hepatocellular carcinoma and colorectal cancer metastases to the liver. Growing evidence suggests MWA can play a role in the management of patients with early-stage intrahepatic CCA. In this study, we aim to describe the safety and efficacy of MWA for the management of intrahepatic CCA.

Material and Methods

A retrospective review of patients with intrahepatic CCA treated with MWA at our tertiary referral medical center was performed. Eight patients were treated between 2014 and 2019. Diagnosis of CCA was made based on histopathological studies of samples obtained by surgical resection or percutaneous liver biopsy. All procedures were performed under computed tomography (CT) guidance using a high-power single antenna MWA system. General anesthesia was used for all procedures. Patient medical history, procedural technical information, outcomes, and follow-up data were reviewed. Progression-free survival was estimated with a Kaplan-Meier curve.

Results

A total of 25 tumors with an average size of 2.2 ± 1.7 cm (range 0.5-7.8) were treated with MWA. Our cohort consisted of eight patients (4 males and 4 females) with an average age of 69.3 ± 5.7 years (range 61-79). Three out of eight (3/8, 37.5%) patients were treated initially with surgical resection. NASH-related cirrhosis was documented in 3/8 (37.5%) patients, while 1/8 (12.5%) had alcoholic cirrhosis; the remaining 4 patients (4/8, 50%) did not have cirrhosis. All patients were discharged within 24 h after ablation. Average total follow-up time was 10.6 ± 11.8 months (range 0-41). The incomplete ablation rate and local recurrence rate were 4% (1/25 lesions) and 12% (3/25 lesions), respectively.

Conclusion

In patients who do not qualify for surgical resection, MWA is a safe alternative therapy for the treatment of intrahepatic CCA.

Interventional Radiology Locoregional Therapies for Intrahepatic Cholangiocarcinoma

Surgical resection remains the cornerstone of curative treatment for intrahepatic cholangiocarcinoma (iCCA), but this option is only available to a small percentage of patients. For patients with unresectable iCCA, systemic therapy with gemcitabine and platinum-based agents represents the mainstay of treatment; however, the armamentarium has grown to include targeted molecular therapies (e.g., FGFR2 inhibitors), use of adjuvant therapy, liver transplantation in select cases, immunotherapy, and locoregional liver-directed therapies. Despite advances, iCCA remains a challenge due to the advanced stage of many patients at diagnosis. Furthermore, given the improving options for systemic therapy and the fact that the majority of iCCA patients succumb to disease progression in the liver, the role of locoregional therapies has increased. This review will focus on the expanding role of interventional radiology and liver-directed therapies in the treatment of iCCA.

A Practical Guide for the Systemic Treatment of Biliary Tract Cancer in Canada

Biliary tract cancers (BTC) are rare and aggressive tumors with poor prognosis. Radical surgery offers the best chance for cure; however, most patients present with unresectable disease, and among those receiving curative-intent surgery, recurrence rates remain high. While other locoregional therapies for unresectable disease may be considered, only select patients may be eligible. Consequently, systemic therapy plays a significant role in the treatment of BTC. In the adjuvant setting, capecitabine is recommended following curative-intent resection. In the neoadjuvant setting, systemic therapy has mostly been explored for downstaging in borderline resectable tumours, although evidence for its routine use is lacking. For advanced unresectable or metastatic disease, gemcitabine-cisplatin plus durvalumab has become the standard of care, while the addition of pembrolizumab to gemcitabine-cisplatin has also recently demonstrated improved survival compared to chemotherapy alone. Following progression on gemcitabine-cisplatin, several chemotherapy combinations and biomarker-driven targeted agents have been explored. However, the optimum regimen remains unclear, and access to targeted agents remains challenging in Canada. Overall, this article serves as a practical guide for the systemic treatment of BTC in Canada, providing valuable insights into the current and future treatment landscape for this challenging disease.

Role of Percutaneous Ablation in the Management of Intrahepatic Cholangiocarcinoma

Cholangiocarcinoma (CCA) is an invasive cancer accounting for <1% of all cancers and 10-15% of primary liver cancers. Intrahepatic CCA (iCCA) is associated with poor survival rates and high post-surgical recurrence rates whilst most diagnosed patients are not surgical candidates. There is a growing literature suggesting percutaneous ablative techniques for the management of patients with iCCA measuring ≤3 cm with contraindications to surgery as well as for recurrent or residual tumors aiming to provide local cancer treatment and control. Most used ablative therapies for iCCA include radiofrequency and microwave ablation with irreversible electroporation, cryoablation and reversible electroporation (electrochemotherapy) being less commonly encountered techniques. Due to the infiltrative margins of the lesion, there is a need for larger safety margins and ablation zone; multi-apparatus ablation or other variations of the technique such as balloon-assisted approaches can be utilized aiming to increase size of the zone of necrosis. The present review paper focuses upon the current role of percutaneous ablative techniques for the therapeutic management of iCCA. The purpose of this review is to present the current minimally invasive ablative techniques in the treatment of iCCA, including local control and survival rates.

Interventional Treatment Strategies in Intrahepatic Cholangiocarcinoma and Perspectives for Combined Hepatocellular-Cholangiocarcinoma

cHCC-CCA is an uncommon type of liver cancer that exhibits clinical and pathological characteristics of both hepatocellular carcinoma (HCC) and cholangiocarcinoma (CCA), which are the two main forms of primary liver cancer. The similarity to HCC and CCA makes therapeutical strategies challenging. The poor prognosis of CCA in general, as well as for cHCC-CCA, is mainly attributable to the fact that diagnosis is often at an advanced stage of disease. During the last decade, locoregional therapies usually performed by interventional radiologists and its established role in HCC treatment have gained an increasing role in CCA treatment as well. These comprise a wide range of options from tumor ablation procedures such as radiofrequency ablation (RFA), microwave ablation (MWA), computed tomography high-dose rate brachytherapy (CT-HDRBT), and cryoablation to transarterial chemoembolization (TACE), including the option of intra-arterial administration of radioactive spheres (transarterial radioembolization-TARE), and much attention has focused on the potential of individual concepts in recent years. The purpose of this review is to provide an overview of current radiologic interventions for CCA (excluding options for eCCA), to review and appraise the existing literature on the topic, and to provide an outlook on whether such interventions may have a role as treatment for cHCC-CCA in the future.

Locoregional Therapy for Intrahepatic Cholangiocarcinoma

Intrahepatic cholangiocarcinoma (ICC) has a poor prognosis, and surgical resection (SR) offers the only potential for cure. Unfortunately, only a small proportion of patients are eligible for resection due to locally advanced or metastatic disease. Locoregional therapies (LRT) are often used in unresectable liver-only or liver-dominant ICC. This review explores the role of these therapies in the treatment of ICC, including radiofrequency ablation (RFA), microwave ablation (MWA), transarterial chemoembolization (TACE), transarterial radioembolization (TARE), external beam radiotherapy (EBRT), stereotactic body radiotherapy (SBRT), hepatic arterial infusion (HAI) of chemotherapy, irreversible electroporation (IE), and brachytherapy. A search of the current literature was performed to examine types of LRT currently used in the treatment of ICC. We examined patient selection, technique, and outcomes of each type. Overall, LRTs are well-tolerated in the treatment of ICC and are effective in improving overall survival (OS) in this patient population. Further studies are needed to reduce bias from heterogenous patient populations and small sample sizes, as well as to determine whether certain LRTs are superior to others and to examine optimal treatment selection.

Update on Locoregional Therapies for Cholangiocellular Carcinoma

Locoregional therapy options for CCA are used, in particular, for non-resectable tumors and aim to reduce tumor viability or delay tumor growth and ultimately prolong overall survival. In addition to local ablative procedures such as radiofrequency- or microwave-ablation, transarterial procedures such as transarterial embolization (TAE), transarterial chemoembolization (TACE), or selective internal radiotherapy (SIRT) play a major role. In particular, in combination with advances in molecular medicine and immunotherapy, there has been a further development in the therapy of primary malignant liver tumors in recent years. In this review, we analyze data from recent studies and examine the implications for therapy of CCA, particularly with regard to the combination of locoregional therapies with modern systemic therapies.

Advances in the treatment of intrahepatic cholangiocarcinoma: An overview of the current and future therapeutic landscape for clinicians

Intrahepatic cholangiocarcinoma (ICC) is the second most common primary liver tumor and remains a fatal malignancy in the majority of patients. Approximately 20%-30% of patients are eligible for resection, which is considered the only potentially curative treatment; and, after resection, a median survival of 53 months has been reported when sequenced with adjuvant capecitabine. For the 70%-80% of patients who present with locally unresectable or distant metastatic disease, systemic therapy may delay progression, but survival remains limited to approximately 1 year. For the past decade, doublet chemotherapy with gemcitabine and cisplatin has been considered the most effective first-line regimen, but results from the recent use of triplet regimens and even immunotherapy may shift the paradigm. More effective treatment strategies, including those that combine systemic therapy with locoregional therapies like radioembolization or hepatic artery infusion, have also been developed. Molecular therapies, including those that target fibroblast growth factor receptor and isocitrate dehydrogenase, have recently received US Food and Drug Administration approval for a defined role as second-line treatment for up to 40% of patients harboring these actionable genomic alterations, and whether they should be considered in the first-line setting is under investigation. Furthermore, as the oncology field seeks to expand indications for immunotherapy, recent data demonstrated that combining durvalumab with standard cytotoxic therapy improved survival in patients with ICC. This review focuses on the current and future strategies for ICC treatment, including a summary of the primary literature for each treatment modality and an algorithm that can be used to drive a personalized and multidisciplinary approach for patients with this challenging malignancy.

Clinical Features and Prognostic Models in Patients with Intrahepatic Cholangiocarcinoma: a Population-Based Analysis

BACKGROUND

This study aims to construct a risk classification system and a nomogram in intrahepatic cholangiocarcinomafor patients (ICC).

METHODS

Three thousand seven hundred thirty-seven patients diagnosed with ICC between 2010 and 2015 were selected from the Surveillance, Epidemiology and End Results. The consistency index, time-dependent receiver operating characteristic curve, and the calibration plots were adopted to evaluate the effective performance of nomogram. Decision curve analysis (DCA), net reclassification index (NRI), and comprehensive discrimination improvement (IDI) were used to compare the advantages and disadvantages of two models. Kaplan-Meier curve showed the difference in prognosis among different groups.

RESULTS

Ten variables were selected to establish the nomogram for ICCA. The C-index (training cohort: 0.765, P < 0.05; validation cohort: 0.776, P < 0.05) and the time-dependent AUCs (the training cohort: the values of 1, 3, 5 years were 0.836, 0.873, and 0.888; the validation cohort: the values of 1, 3, 5 years were 0.833, 0.838, and 0.881) showed satisfactory discrimination. The calibration curves also revealed that the nomogram was consistent with the actual observations. The NRI (training cohort: 1-, 3-, 5-year CSS: 0.879, 0.94, 0.771; validation cohort: 1-, 3-, 5-year CSS: 0.905, 0.945, 0.717) and IDI (training cohort: 1-, 3-, 5-year CSS: 0.24, 0.23, 0.22; validation cohort: 1-, 3-, 5-year CSS: 0.24, 0.46, 0.27) (P < 0.05) (compared with AJCC staging). DCA showed that the new model was more practical and had better recognition than AJCC staging.

CONCLUSIONS

A new risk stratification system for ICC patients has been developed, which can be a practical tool for patient management.

The multidisciplinary management of cholangiocarcinoma

Cholangiocarcinoma is a lethal malignancy of the biliary epithelium that can arise anywhere along the biliary tract. Surgical resection confers the greatest likelihood of long-term survivability. However, its insidious onset, difficult diagnostics, and resultant advanced presentation render the majority of patients unresectable, highlighting the importance of early detection with novel biomarkers. Developing liver-directed therapies and emerging targeted therapeutics may offer improved survivability for patients with unresectable or advanced disease. In this article, the authors review the current multidisciplinary standards of care in resectable and unresectable cholangiocarcinoma, with an emphasis on novel biomarkers for early detection and nonsurgical locoregional therapy options.

Emerging Indications for Interventional Oncology: Expert Discussion on New Locoregional Treatments

Interventional oncology (IO) employs image-guided techniques to perform minimally invasive procedures, providing lower-risk alternatives to many traditional medical and surgical therapies for cancer patients. Since its advent, due to rapidly evolving research development, its role has expanded to encompass the diagnosis and treatment of diseases across multiple body systems. In detail, interventional oncology is expanding its role across a wide spectrum of disease sites, offering a potential cure, control, or palliative care for many types of cancer patients. Due to its widespread use, a comprehensive review of the new indications for locoregional procedures is mandatory. This article summarizes the expert discussion and report from the "MIOLive Meet SIO" (Society of Interventional Oncology) session during the last MIOLive 2022 (Mediterranean Interventional Oncology Live) congress held in Rome, Italy, integrating evidence-reported literature and experience-based perceptions. The aim of this paper is to provide an updated review of the new techniques and devices available for innovative indications not only to residents and fellows but also to colleagues approaching locoregional treatments.

Locoregional Therapy in the Management of Intrahepatic Cholangiocarcinoma: Is There Sufficient Evidence to Guide Current Clinical Practice?

PURPOSE OF REVIEW

Intrahepatic cholangiocarcinoma (iCCA) carries a dismal prognosis and, despite increasing incidence, still lacks effective treatments. In this scenario, locoregional therapies (LRT) are gaining interest as they may be effective at local tumor control and complementary to surgical and non-surgical approaches. In this article, we will review the evolving role of LRT performed by interventional radiologists in the management of iCCA.

RECENT FINDINGS

Accumulating retrospective evidence indicates that ablative therapies and transarterial embolizations are of benefit for iCCA with unresectable disease, demonstrating promising safety profiles and prolonged or comparable survival outcomes compared to systemic therapy and surgery. Additionally, for surgical candidates, portal ± hepatic venous embolization can improve the safety of hepatectomy by inducing preoperative hypertrophy of the non-involved liver lobe. LRTs are playing an increasingly important role in the multimodal treatment of iCCA from various perspectives with reduced toxicity relative to traditional treatments. To expand the scope of applications for LRTs in this setting, future prospective randomized studies are needed to confirm their efficacy and advantage.

Locoregional Approaches in Cholangiocarcinoma Treatment

Cholangiocarcinoma (CCA) is a rare hepatic malignant tumor with poor prognosis due to late detection and anatomic factors limiting the applicability of surgical resection. Without surgical resection, palliation is the most common approach. In non-surgical cases contained within the liver, locoregional therapies provide the best chance for increased survival and disease control. The most common methods, transarterial chemoembolization and transarterial radioembolization, target tumors by embolizing their blood supply and limiting the tumor's ability to metabolize. Other treatments induce direct damage via thermal ablation to tumor tissue to mediate their anti-tumor efficacy. Recent studies have begun to explore roles for these therapies outside their previous role of palliation. This review will outline the mechanisms of each of these treatments, along with their effects on overall survival, while comparing these to non-locoregional therapies.

ACR Appropriateness Criteria® Management of Liver Cancer: 2022 Update

The treatment and management of hepatic malignancies can be complex because it encompasses a variety of primary and metastatic malignancies and an assortment of local and systemic treatment options. When to use each of these treatments is critical to ensure the most appropriate care for patients. Interventional radiologists have a key role to play in the delivery of a variety of liver directed treatments including percutaneous ablation, transarterial embolization with bland embolic particles alone, transarterial chemoembolization (TACE) with injection of a chemotherapeutic emulsion, and transarterial radioembolization (TARE). Based on 9 clinical variants, the appropriateness of each treatment is described in this document. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Disparities in curative treatments and outcomes for early stage intrahepatic cholangiocarcinoma in the United States

BACKGROUND

Curative surgical treatments afford the best prognosis for patients with intrahepatic cholangiocarcinoma (iCCA); however, the comparative effectiveness of treatment options and factors associated with curative treatment receipt for early stage iCCA remain unknown.

METHODS

The authors identified patients who were diagnosed with early stage iCCA, defined as a unifocal tumor <3 cm, during 2004-2018 from the National Cancer Database. Multivariable logistic and Cox regression analyses were used to identify the factors associated with curative treatment and overall survival (OS), respectively.

RESULTS

The proportion of patients with early stage iCCA increased from 4.5% in 2004 to 7.3% in 2018, with the odds of early stage detection increasing by 3.1% per year (odds ratio [OR], 1.031; 95% CI, 1.015-1.049). Of 1093 patients who had early stage iCCA, 464 (42.5%) underwent resection, 113 (10.3%) underwent ablation, 62 (5.7%) underwent liver transplantation, and 454 (41.5%) received noncurative treatments. Hispanic patients (adjusted OR [aOR], 0.57; 95% CI, 0.33-0.97) and Black patients (aOR, 0.47; 95% CI, 0.28-0.77) were less likely to receive curative treatments than White patients. Compared with patients who underwent surgical resection, those who underwent liver transplantation had a trend toward improved OS (adjusted hazard ratio [aHR], 0.63; 95% CI, 0.37-1.08), whereas those who underwent local ablation (aHR, 1.39; 95% CI, 1.01-1.92) and noncurative treatments (aHR, 3.97; 95% CI, 3.24-4.88) experienced worse OS.

CONCLUSIONS

More than one third of patients with early stage iCCA did not receive curative treatment, with Hispanic and Black patients being less likely to receive curative treatments than White patients. Surgical resection and liver transplantation were associated with improved survival compared with local ablation. Future studies should investigate disparities in curative treatment receipt and outcomes for early stage iCCA.

Stereotactic radiotherapy for intrahepatic cholangiocarcinoma

Intrahepatic cholangiocarcinoma (iCCA) is an aggressive malignancy with an increasing incidence worldwide and poor prognosis, despite several advances and continuous efforts to develop effective treatments. Complete surgical resection is the mainstay of treatment and offers a potentially curative option, but is only possible in less than a third of patients, owing to advanced disease. Chemotherapy is a well-established treatment in the adjuvant and palliative setting, however, confers limited benefit. Conventional radiotherapy is challenging due to local toxicity. With recent advances in stereotactic ablative radiotherapy (SABR), it is now possible to focus ablative beams of radiotherapy precisely aimed at tumours to minimise damage to surrounding viscera. This review details the history, technical background and application of SABR to iCCA, with directions for future research suggested.

Comparison of Intraductal RFA Plus Stent versus Stent-Only Treatment for Unresectable Perihilar Cholangiocarcinoma—A Systematic Review and Meta-Analysis

Simple Summary

In patients with unresectable perihilar cholangiocarcinoma, adequate biliary drainage is essential. Stent patency remains a challenge in these complex patients, as both plastic and metal stent occlusion may occur, necessitating additional drainage procedures. Radiofrequency ablation (RFA) is a promising local treatment that has already proven its usefulness in other malignancies, such as hepatocellular carcinoma. In this meta-analysis and systematic review, we aimed to compare intraductal RFA with stent placement to stent placement alone in patients with unresectable perihilar cholangiocarcinoma. We found that RFA + stent treatment showed a significantly longer overall survival, in comparison to stent-only treatment. Further research is necessary in order to validate these findings to support the implementation of this promising strategy in clinical practice.

Abstract

Background: One of the cornerstones of palliative treatment for unresectable perihilar cholangiocarcinoma is biliary stent placement in order to restore biliary drainage. In this review, the potential added value of RFA with stent placement in comparison to stent placement alone in patients with unresectable perihilar cholangiocarcinoma is analyzed. Methods: We performed a comprehensive online search for relevant articles in November 2021 (PROSPERO ID: CRD42021288180). The primary endpoint was difference in overall survival. Secondary endpoints included overall survival, stent patency and complications. Only studies comparing survival after RFA + stent placement with stent placement alone were included in the meta-analysis. Non-comparative studies or comparative studies describing stent patency only were included in the systematic review. Results: A total of nine studies, including 217 patients with pCCA who underwent RFA + stent placement and 294 patients who underwent stent-only treatment, met the inclusion criteria for the primary endpoint analysis. Direct comparison between the two treatment groups showed a significantly longer overall survival for RFA + stent treatment, with a pooled HR of 0.65 [95% CI, 0.50–0.84, I² = 38%]. When all eligible studies were included, RFA + stent treatment revealed an overall survival of 9.5 months [95% CI, 6.3–12.6], whereas survival for stent-only treatment was 7.0 months [95% CI, 5.7–8.2]. Due to the heterogeneity of the data, no pooled data analysis could be performed on stent patency or complications. Conclusions: RFA + stent placement displays promising potential to prolong survival. However, further research incorporating confounding factors like use of palliative chemotherapy is necessary in order to validate these findings.

Percutaneous Thermal Segmentectomy: Proof of Concept

AIM

To report the multicenter retrospective experience on combination of balloon-occluded MWA(b-MWA) followed by balloon-occluded TACE(b-TACE) in patients with liver malignancies > 3 cm, focusing on appearance and volume of necrotic area, safety profile and oncological results.

MATERIALS AND METHODS

Twenty-three patients with liver primary malignancies (hepatocellular carcinoma,HCC = 18; intrahepatic cholangiocarcinoma,iCC = 2) and metastasis (colorectal cancer metastasis = 1;sarcoma metastasis = 1;breast metastasis = 1) were treated. Maximum mean diameter of lesions was 4.4 cm (± 1 cm). Treatments were performed using a single-step approach:b-MWA was performed after balloon-microcatheter inflation, followed by b-TACE (with epirubicin or irinotecan). Necrotic area shape and discrepancy with the expected volume of necrosis suggested by vendor's ablation chart were assessed at post-procedural CT. Complications were categorized according to CIRSE classification. Oncological results at 1 and 3-6 months were evaluated using m-RECIST(HCC) and RECISTv1.1(metastasis/iCC).

RESULTS

Mean volume of necrotic area was 75 cm³ (± 36). Discrepancy with vendor chart consisted in a medium percentage of volumetric incrementation of necrotic area of 103.2% (± 99.8). Non-spherical shape was observed in 22/23 patients (95.7%). No complications occurred; Post-embolization syndrome occurred in 12/23patients. Complete response and partial response were, respectively, 91, 3% (21/23) and 8.7% (2/23) at 1 month, 85.7% (18/21) and 9.5% (2/21) at 3-6 months. Progression of disease was 4.7% (1/21) at 3-6 months for extra-hepatic progression. Among partial responders, average percentage of tumor volume debulking was 78.8% (± 9.8%).

CONCLUSION

b-MWA followed by b-TACE in a single-step procedure led to larger necrotic areas than the proposed by vendors ablation chart, non-spherical in shape and corresponded to the vascular segment occluded during ablation. This permitted to safely achieve promising oncological results in patients with > 3 cm tumors.

Liver Transplantation for Intrahepatic Cholangiocarcinoma: Ready for Prime Time?

Cholangiocarcinoma (CCA) represents the second-most common primary liver malignancy after HCC and has risen in incidence globally in the past decades. Intrahepatic cholangiocarcinoma (iCCA) comprises 20% of all CCAs, with the rest being extrahepatic (including perihilar [pCCA] and distal CCA). Though long representing an absolute contraindication for liver transplantation (LT), recent analyses of outcomes of LT for iCCA have suggested that iCCA may be a potentially feasible option for highly selected patients. This has been motivated both by successes noted in outcomes of LT for other malignancies, such as HCC and pCCA, and by several retrospective reviews demonstrating favorable results with LT for a selected group of iCCA patients with small lesions. LT for iCCA is primarily relevant within two clinical scenarios. The first includes patients with very early disease (single tumor, ≤2 cm) with cirrhosis and are not candidates for liver resection (LR). The second scenario is patients with locally advanced iCCA, but where the extent of LR would be too extensive to be feasible. Preliminary single-center reports have described LT in a selected group of patients with locally advanced tumors who have responded to neoadjuvant therapy and have a period of disease stability. Currently, there are three prospective trials underway that will help clarify the role of LT in iCCA. This review seeks to explore the available studies involving LT for iCCA, the challenges of ongoing trials, and opportunities for the future.

Histotripsy for the Treatment of Cholangiocarcinoma in a Patient-Derived Xenograft Mouse Model

Histotripsy is a focused ultrasound ablation therapy being developed for the treatment of liver tumors. A recent study investigating the feasibility of using histotripsy for the ablation of cholangiocarcinoma (CC), bile duct cancer that is difficult to treat with current therapies because of its location near critical structures and fibrous tissue, reported the feasibility of treating CC in an acute mouse model. Here, we investigate histotripsy for the in vivo ablation of CC in a chronic study using a 1-MHz transducer at an applied dose of 500 pulses/point. A pilot study determined that treating the CC tumors plus a 1- to 2-mm margin induced significant injuries to intestinal tissues, thus precluding the use of this strategy. Next, histotripsy was applied to CCs (n = 6) with the treatment contained to the tumor. Post-treatment, the ablation was visualized using ultrasound, and subjects were monitored over time. Histotripsy achieved an average of 73% reduction of tumor diameter 26 d after treatment, with no significant adverse events. Notably, three of six treated tumors were undetectable after 2.5 wk. The treated animals were found to have significantly increased tumor progression-free and overall survival. Overall, results indicate that histotripsy can be used as a safe and effective method for treating CC.

Non-surgical treatment of hilar cholangiocarcinoma

Cancer of the biliary confluence also known as hilar cholangiocarcinoma (HC) or Klatskin tumor, is a rare type of neoplastic disease constituting approximately 40%-60% of intrahepatic malignancies, and 2% of all cancers. The prognosis is extremely poor and the majority of Klatskin tumors are deemed unresectable upon diagnosis. Most patients with unresectable bile duct cancer die within the first year after diagnosis, due to hepatic failure, and/or infectious complications secondary to biliary obstruction. Curative treatments include surgical resection and liver transplantation in highly selected patients. Nevertheless, very few patients are eligible for surgery or transplant at the time of diagnosis. For patients with unresectable HC, radiotherapy, chemotherapy, photodynamic therapy, and liver-directed minimally invasive procedures such as percutaneous image-guided ablation and intra-arterial chemoembolization are recommended treatment options. This review focuses on currently available treatment options for unresectable HC and discusses future perspectives that could optimize outcomes.

Radioembolization of Intrahepatic Cholangiocarcinoma: Patient Selection, Outcomes, and Competing Therapies

Intrahepatic cholangiocarcinoma is the second most common primary hepatic malignancy and poses a therapeutic challenge owing to its late-stage presentation and treatment-resistant outcomes. Most patients are diagnosed with locally advanced, unresectable disease and are treated with a combination of systemic and local regional therapies. Transarterial radioembolization offers a survival benefit and a favorable side effect profile, with a growing body of evidence to support its use. Herein, we review patient selection and detail outcomes of radioembolization for intrahepatic cholangiocarcinoma, together with mention of competing treatments.

Advances in the management of cholangiocarcinoma

Cholangiocarcinoma (CCA) is a primary malignancy of the bile ducts with three anatomically and molecularly distinct entities: Intrahepatic CCA (iCCA), perihilar CCA (pCCA), and distal CCA. As a result of phenotypic and anatomic differences they differ significantly with respect to management. For each type of CCA there have been significant changes in management over the last several years which will be discussed in this review. Although resection remains the standard of care for all types of CCA, liver transplantation has been established as curative treatment for selected patients with pCCA and is being evaluated for iCCA with early success. With respect to systemic therapy capecitabine is now first line adjuvant therapy for all biliary tract malignancies after curative intent resection. Progress in exploiting the pathologic mutations and molecular abnormalities has also yielded regulatory approval of targeted therapy for CCA in patients with acquired alterations in the fibroblast growth factor receptor. There is also increased consensus in managing malignant biliary obstruction associated with CCA where pre-operative biliary stenting is not beneficial while self-expanding metal stents have been shown to be superior to plastic stents in patients who are not surgical candidates.

Metastatic disease to the liver: Locoregional therapy strategies and outcomes

Secondary cancers of the liver are more than twenty times more common than primary tumors and are incurable in most cases. While surgical resection and systemic chemotherapy are often the first-line therapy for metastatic liver disease, a majority of patients present with bilobar disease not amenable to curative local resection. Furthermore, by the time metastasis to the liver has developed, many tumors demonstrate a degree of resistance to systemic chemotherapy. Fortunately, catheter-directed and percutaneous locoregional approaches have evolved as major treatment modalities for unresectable metastatic disease. These novel techniques can be used for diverse applications ranging from curative intent for small localized tumors, downstaging of large tumors for resection, or locoregional control and palliation of advanced disease. Their use has been associated with increased tumor response, increased disease-free and overall survival, and decreased morbidity and mortality in a broad range of metastatic disease. This review explores recent advances in liver-directed therapies for metastatic liver disease from primary colorectal, neuroendocrine, breast, and lung cancer, as well as uveal melanoma, cholangiocarcinoma, and sarcoma. Therapies discussed include bland transarterial embolization, chemoembolization, radioembolization, and ablative therapies, with a focus on current treatment approaches, outcomes of locoregional therapy, and future directions in each type of metastatic disease.

Locoregional Treatments in Cholangiocarcinoma and Combined Hepatocellular Cholangiocarcinoma

Cholangiocarcinoma (CCA) is a primary and aggressive cancer of the biliary tree. Combined hepatocellular cholangiocarcinoma (CHC) is a distinctive primary liver malignancy which has properties of both hepatocytic and cholangiocytic differentiation. CHC appears to have a worse prognosis compared to hepatocellular carcinoma, and similar to that of intrahepatic CCA. While significant advances have been made in understanding the pathophysiology and treatment of these two tumor types, their prognosis remains poor. Currently, liver resection is the primary treatment modality; however, only a minority of patients are eligible for surgery. However, the use of locoregional therapies proves an alternative approach to treating locally advanced disease with the aim of converting to resectability or even transplantation. Locoregional therapies such as transarterial chemoembolization (TACE), selective internal radiation therapy (SIRT), radiofrequency ablation (RFA), and photodynamic therapy (PDT) can provide patients with tumor control and increase the chances of survival. In this review, we appraise the evidence surrounding the use of locoregional therapies in treating patients with CCA and CHC.

Interventional Treatment for Cholangiocarcinoma

Cholangiocarcinoma (CCA) is the second most common type of primary liver malignancy. The latest classification includes intrahepatic cholangiocarcinoma and extrahepatic cholangiocarcinoma, with the latter one further categorized into perihilar and distal cholangiocarcinoma. Although surgical resection is the preferred treatment for CCA, less than half of the patients are actually eligible for radical surgical resection. Interventional treatment, such as intra-arterial therapies, ablation, and brachytherapy (iodine-125 seed implantation), has become an acceptable palliative treatment for patients with unresectable CCA. For these patients, interventional treatment is helpful for locoregional control, symptom relief, and improving quality of life. Herein, in a timely and topical manner, we will review these advances and highlight future directions of research in this article.

Stereotactic radiotherapy in intrahepatic cholangiocarcinoma: A systematic review

Among biliary tract cancers, intrahepatic cholangiocarcinoma (ICC) has different characteristics compared with those in other sites. Current guidelines suggest several treatment options for ICC, including stereotactic body radiation therapy (SBRT). However, the role of SBRT in locally advanced ICC is unclear. The aim of the present study was to present a systematic review on the efficacy and safety of SBRT in ICC. A systematic review based on the PRISMA methodology was performed. Only papers reporting outcomes in terms of overall survival (OS) after SBRT in inoperable patients with ICC were included. Secondary aims were local control (LC), progression-free survival (PFS) and treatment-related toxicity. Six papers (145 patients) were included in the present analysis. SBRT was frequently used as a salvage treatment, since 28.6-66.7% of patients received previous systemic or local treatments. The median SBRT dose was 45 Gy delivered in 3-5 fractions. The median follow-up was 16 months, and median OS time was 14 months (range, 10-48 months). In one of the included studies, SBRT was significantly superior in terms of OS compared with both chemoradiation and trans-arterial-radio-embolization. The 1-year LC rate was 85% in one study, and 1-year PFS rates were 50 and 68% in two studies, respectively. Toxicity was generally not reported in detail or was reported including other sites of biliary cancers. Overall, limited evidence was available on the efficacy of SBRT in ICC, which should be further investigated in prospective studies with a larger number of patients. However, based on the available data, SBRT seems to produce similar results compared with other ICC treatments, with the advantage of being a very short and non-invasive therapy. Therefore, SBRT should be considered in selected patients with ICC.

Percutaneous Radiofrequency Ablation for Recurrent Intrahepatic Cholangiocarcinoma After Curative Resection: Multivariable Analysis of Factors Predicting Survival Outcomes

OBJECTIVE. The purpose of this study was to evaluate the factors associated with local tumor progression (LTP) and overall survival (OS) in patients who have undergone percutaneous radiofrequency ablation (RFA) for recurrent intrahepatic cholangiocarcinoma (iCCA) after curative resection. MATERIALS AND METHODS. Data from 40 patients (mean age, 56.3 years) with 64 recurrent iCCAs (median diameter, 1.5 cm) who underwent percutaneous RFA between 1999 and 2019 were retrospectively analyzed. Patients were included if they had three or fewer metastases, a maximum tumor diameter of 5 cm or less, and disease confined to the liver. RESULTS. Technical success was achieved in all patients, with no procedure-related mortality. During follow-up, local progression of treated lesions was observed in 31.3% of tumors. The median OS and 5-year survival rate from initial RFA were 26.6 months and 18.3%, respectively. Multivariable analysis showed that a larger tumor diameter (> 2 cm, p = .004) was significantly associated with reduced LTP-free survival and that both a larger tumor diameter and less than 1 year from surgery to recurrence (p = .005 and .006, respectively) were statistically significant predictors of reduced OS after RFA. CONCLUSION. Percutaneous RFA may offer a well-tolerated and successful approach to local tumor control in patients with recurrent iCCA after curative surgery. Patients with a small-diameter tumor (≤ 2 cm) and late hepatic recurrence (≥ 1 year after curative resection) benefited most from RFA treatment.

Feasibility of 3D US/CEUS-US/CEUS fusion imaging-based ablation planning in liver tumors: a retrospective study

PURPOSE

To assess the feasibility of ablation planning based on fusion imaging of three-dimensional ultrasound/contrast-enhanced ultrasound (3D US/CEUS) with real-time US/CEUS for liver tumor thermal ablation.

MATERIALS AND METHODS

Between January 2017 and December 2018, 85 hepatic tumors from 82 patients who underwent percutaneous ablation were included. First, intraprocedural 3D US/CEUS imaging was performed for ablation planning. Then, fusion imaging of 3D US/CEUS with real-time US/CEUS was used to guide the implementation of the plan, immediately evaluate the technical success and indicate the need for supplemental ablation. In addition, contrast-enhanced CT/MR imaging was performed 1 month after the procedure to evaluate the presence of residual tumors, and follow-up scans were repeated every 3 months.

RESULTS

The average liver tumor diameter was 28 ± 9 mm (range, 10-55 mm). 3D US/CEUS-based planning was successfully conducted in all 85 tumors with a 100% technical success rate of planning. The immediate evaluation by 3D CEUS/US-CEUS fusion imaging showed a 100% technical success rate of ablation. The 1-month CT/MR scans found a residual tumor in one intrahepatic cholangiocarcinoma patient; the technique efficacy rate was 98.8%. The median follow-up period was 21.5 months (IQR: 4-36 months). During the follow-up period, the local tumor progression rate was 5.9% (5/84), and no major procedure-related complications occurred.

CONCLUSIONS

Ablation planning based on 3D US/CEUS-US/CEUS fusion imaging is feasible for liver tumors.

Rim-arterial enhancing primary hepatic tumors with other targetoid appearance show early recurrence after radiofrequency ablation

OBJECTIVES

To evaluate early (≤ 2 years) local tumor progression (LTP), intrahepatic distant metastasis (IDR), and extrahepatic metastasis (EM) of primary hepatic malignant tumors with arterial rim enhancement (RE) after RFA in comparison with non-RE tumors.

METHODS

Three hundred forty-nine patients who underwent RFA for primary hepatic malignant tumors between January 2009 and December 2016 were included. The patients' tumors were classified into non-RE, RE only (RO), and RE plus other targetoid appearances (REoT). Cumulative LTP, IDR, and EM rates at 1 and 2 years after RFA were calculated using the Kaplan-Meier method and compared using the log-rank test. Prognostic factors for the outcomes were assessed using a Cox proportional hazards model.

RESULTS

There were 303 non-RE, 19 RO, and 27 REoT tumors. The REoT tumors had a significantly higher rate of IDR and EM than non-RE (p = 0.04 for IDR; and p < 0.01 for EM, respectively) at 1 year after RFA. At 2 years, LTP and EM rates were significantly higher for REoT than for non-RE (p = 0.001 for LTP; and p = 0.444 for EM, respectively). The RO tumors did not have different outcomes than non-RE at 1 and 2 years after RFA. Multivariable analysis verified that REoT was a significant factor for IDR (p = 0.04) and EM (p = 0.01) at 1 year and LTP (p = 0.02) at 2 years.

CONCLUSIONS

Tumors with REoT had poor LTP, IDR, and EM within 2 years after RFA than non-RE tumors. However, tumors with RO showed similar results as non-RE tumors.

KEY POINTS

• Tumors with Rim enhancement plus other targetoid appearances (REoT) had a significantly higher rate of recurrence than non-rim enhancing (RE) tumors at 1 and 2 years after RFA. • Tumors with rim enhancement only did not have different outcomes than non-RE at 1 and 2 years after RFA.

Feasibility and Safety of Endoluminal Radiofrequency Ablation as a Rescue Treatment for Bilateral Metal Stent Obstruction Due to Tumor Ingrowth in the Hilum: A Pilot Study

Background. Radiofrequency ablation (RFA) is a palliative method known for its application in the endoscopic treatment of malignant bile duct obstruction. It may be a useful rescue method for metal stent malfunction caused by tumor ingrowth. This study aimed to examine the feasibility and safety of endoluminal RFA for occluded bilateral hilar metal stents due to tumor ingrowth in patients with malignant hilar bile duct obstruction. Methods: From March 2016 to June 2018, 11 patients with unresectable malignant hilar bile duct stricture with occluded bilateral hilar metal stents due to tumor ingrowth were enrolled. Endoluminal RFA was performed through a novel temperature-controlled catheter at a setting of 7 W power for 120 s with a target temperature of 80 °C via endoscopic retrograde cholangiopancreatography (ERCP). The patients’ demographics, clinical outcomes, and adverse events were investigated. Results: The median age was 64 (interquartile range, 54–72) years. All RFA procedures were successful. Clinical success was achieved in eight patients (72.7%). During the follow-up, eight patients (72.7%) showed stent dysfunction, and the median patency after RFA was 50 days (95% confidence interval (CI): 34–not available (NA)). All stent dysfunctions were successfully managed with ERCP. Ten patients died, and the median overall survival was 289 days (95% CI, 107–NA) from RFA to death. There was one case of mild abdominal pain after the procedure without serious adverse events. Conclusions: As a rescue therapy for occluded bilateral hilar metal stents due to tumor ingrowth, endoluminal RFA seemed to be safe and useful in selected patients.

Surgical Treatment of Intrahepatic Cholangiocarcinoma: Current and Emerging Principles

Intrahepatic cholangiocarcinoma (ICC) is a rare, aggressive cancer of the biliary tract. It often presents with locally advanced or metastatic disease, but for patients with early-stage disease, surgical resection with negative margins and portahepatis lymphadenectomy is the standard of care. Recent advancements in ICC include refinement of staging, improvement in liver-directed therapies, clarification of the role of adjuvant therapy based on new randomized controlled trials, and advances in minimally invasive liver surgery. In addition, improvements in neoadjuvant strategies and surgical techniques have enabled expanded surgical indications and reduced surgical morbidity and mortality. However, recurrence rates remain high and more effective systemic therapies are still necessary to improve recurrence-free and overall survival. In this review, we focus on current and emerging surgical principals for the management of ICC including preoperative evaluation, current indications for surgery, strategies for future liver remnant augmentation, technical principles, and the role of neoadjuvant and adjuvant therapies.

Intrahepatic Cholangiocarcinoma

Cholangiocarcinoma is the second most common primary malignancy of the liver. This review will focus on the mass-forming intrahepatic type of this disease and discuss the role of medical, surgical, and radiation oncology in managing this difficult disease. A global understanding to the management of intrahepatic cholangiocarcinoma (ICC) can help the interventional radiologist understand the role of locoregional therapies such as ablation, transarterial chemoembolization, and radioembolization in the management of ICC.

Combination of intraoperative radiofrequency ablation and surgical resection for treatment of cholangiocarcinoma: feasibility and long-term survival

PURPOSE Most patients with intrahepatic cholangiocarcinoma (ICC) are not eligible for surgical resection due to advanced stage. We aimed to evaluate the feasibility, local tumor control, and long-term survival of intraoperative radiofrequency ablation (IORFA) with surgical resection to treat unresectable intrahepatic cholangiocarcinoma (ICC). METHODS From 2009 to 2016, 20 consecutive patients (12 primary ICC, 8 recurrent ICC) underwent curative IORFA with hepatic resection for surgically unresectable ICC. Patients were not qualified to undergo surgical resection due to multiple lesions causing postoperative hepatic insufficiency and undesirable tumor locations for surgical resection or percutaneous RFA. Of the 51 treated tumors (mean, 2.6±0.9 tumors/patient), 24 were treated by IORFA and 27 were surgically removed. The technical success and effectiveness, overall survival, progression-free survival (PFS), and complications were assessed retrospectively. The overall survival and PFS rates were estimated by the Kaplan-Meier method. RESULTS The technical success and effectiveness of IORFA were 100%. The overall survival rates at 6 months, 1, 3, and 5 years were 95%, 79%, 27%, and 14%, respectively. The median overall survival time was 22.0±3.45 months. The PFS rates at 6 months, 1, 3, and 5 years were 70%, 33%, 13%, and 13%, respectively. The median PFS was 9.0±1.68 months. The prognosis was significantly worse for patients with recurrent ICC than for patients with primary ICC. One patient (5%) had major complications due to IORFA such as liver abscess and biliary stricture. CONCLUSION IORFA with surgical resection can be a feasible option for ICC cases that are not amenable to treatment with surgical resection alone. This strategy provides acceptable local tumor control and overall survival.

Intrahepatic cholangiocarcinoma: pathogenesis, current staging, and radiological findings

To this date, it is a major oncological challenge to optimally diagnose, stage, and manage intrahepatic cholangiocarcinoma (ICC). Imaging can not only diagnose and stage ICC, but it can also guide management. Hence, imaging is indispensable in the management of ICC. In this article, we review the pathology, epidemiology, genetics, clinical presentation, staging, pathology, radiology, and treatment of ICC.

Strategies for the delay of surgery in the management of resectable hepatobiliary malignancies during the COVID-19 pandemic

Objective

We aimed to review data about delaying strategies for the management of hepatobiliary cancers requiring surgery during the covid-19 pandemic.

Background

Given the covid-19 pandemic, many jurisdictions, to spare resources, have limited access to operating rooms for elective surgical activity, including cancer, thus forcing deferral or cancellation of cancer surgeries. Surgery for hepatobiliary cancer is high-risk and particularly resource-intensive. Surgeons must critically appraise which patients will benefit most from surgery and which ones have other therapeutic options to delay surgery. Little guidance is currently available about potential delaying strategies for hepatobiliary cancers when surgery is not possible.

Methods

An international multidisciplinary panel reviewed the available literature to summarize data relating to standard-of-care surgical management and possible mitigating strategies to be used as a bridge to surgery for colorectal liver metastases, hepatocellular carcinoma, gallbladder cancer, intrahepatic cholangiocarcinoma, and hilar cholangiocarcinoma.

Results

Outcomes of surgery during the covid-19 pandemic are reviewed. Resource requirements are summarized, including logistics and adverse effects profiles for hepatectomy and delaying strategies using systemic, percutaneous and radiation ablative, and liver embolic therapies. For each cancer type, the long-term oncologic outcomes of hepatectomy and the clinical tools that can be used to prognosticate for individual patients are detailed.

Conclusions

There are a variety of delaying strategies to consider if availability of operating rooms decreases. This review summarizes available data to provide guidance about possible delaying strategies depending on patient, resource, institution, and systems factors. Multidisciplinary team discussions should be leveraged to consider patient- and tumour-specific information for each individual case.

Phase Contrast Imaging Based Microbubble Monitoring of Radiofrequency Ablation: An ex vivo Study

Background

To explore the potential of synchrotron radiation (SR) phase contrast imaging (PCI) for real-time microbubble formation monitoring during radiofrequency ablation (RFA).

Methods

RFA was performed on ex vivo porcine muscle tissue using unipolar and multi-tined expandable electrodes. Images of microbubble formation in the samples were captured by both SR PCI and absorption contrast imaging. The synchronous ablation temperature was recorded. Each RFA electrode type group contained 6 samples. Ablation size was assessed by histologic examination.

Results

Microbubble formation during RFA could be visualized by SR PCI. The diameter of the microbubbles revealed on the image ranged from tens of microns to several millimeters, and these microbubbles first appeared at the edge of the RFA electrode when the target region temperature reached approximately 60°C and rapidly extended outwards. The average microbubble range measured on PCI was 17.66 ± 0.74 mm. The average range of coagulation necrosis measured by histological examination was 17.22 ± 0.38 mm. There was no significant difference between them (P > 0.05). The range of microbubbles corresponded to the ablation zone.

Conclusion

PCI enabled real-time high-resolution visualization of microbubble formation during RFA, indicating a potential for its use in ablation monitoring.

Therapy of Primary Liver Cancer

Primary liver cancer (PLC) is a fatal disease that affects millions of lives worldwide. PLC is the leading cause of cancer-related deaths and the incidence rate is predicted to rise in the coming decades. PLC can be categorized into three major histological subtypes: hepatocellular carcinoma (HCC), intrahepatic cholangiocarcinoma (ICC), and combined HCC-ICC. These subtypes are distinct with respect to epidemiology, clinicopathological features, genetic alterations, and clinical managements, which are thoroughly summarized in this review. The state of treatment strategies for each subtype, including the currently approved drugs and the potential novel therapies, are also discussed.