Interventional Radiology Management of Unresectable Intrahepatic Cholangiocarcinoma

Inoperable intrahepatic cholangiocarcinoma (ICC) carries a dismal prognosis. Transarterial therapies have been shown by numerous small-and medium-sized series to prolong survival in these patients well beyond 1 year. Studies of drug-eluting bead transarterial chemo-embolization (DEB-TACE) and yttrium-90 transarterial radioembolization (TARE) suggest longer survival may be achieved with these newer transarterial modalities. Research to date suggests that patient factors associated with prolonged survival after transarterial therapy include the absence of cirrhosis or the presence of at most Child A cirrhosis, normal or near normal performance status (Eastern Cooperative Oncology Group, ECOG, 0-1), peripheral tumor morphology, tumor hypervascularity, small tumor size, low tumor grade, low tumor burden, and the absence of portal thrombus. The presence of extrahepatic disease has not been found significantly to impact survival, confirming the high mortality from the primary disease. Several studies have directly compared different transarterial therapies. Several have found that transarterial chemoembolic (TACE) therapy is more effective than transarterial chemoinfusion (TACI); however, no study has been conducted to evaluate whether this difference between TACE and TACI persists in the subpopulation of hypovascular tumors. There is evidence that dual-agent conventional TACE with gemcitabine and cisplatin may be more effective than single-agent TACE. In addition to progress being made with transarterial therapies, early results of percutaneous thermal ablation for selected patients with small-to-moderate-sized unresectable ICC are promising. Three recent studies of patients receiving thermal ablation each reported median overall survival of over 30 months post-treatment. Prospective studies of transarterial and percutaneous ablative therapies are needed.