Sonography-guided percutaneous microwave ablation of intrahepatic primary cholangiocarcinoma

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.

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.

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.

Ablative Therapy in Non-HCC Liver Malignancy

Surgical extirpation of liver tumors remains a proven approach in the management of metastatic tumors to the liver, particularly those of colorectal origin. Ablative, non-resective therapies are an increasingly attractive primary therapy for liver tumors as they are generally better tolerated and result in far less morbidity and mortality. Ablative therapies preserve greater normal liver parenchyma allowing better post-treatment liver function and are particularly appropriate for treating subsequent liver-specific tumor recurrence. This article reviews the current status of ablative therapies for non-hepatocellular liver tumors with a discussion of many of the clinically available approaches.

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.

Image-Guided Local Treatment for Unresectable Intrahepatic Cholangiocarcinoma-Role of Interventional Radiology

Intrahepatic cholangiocarcinoma is a highly aggressive malignancy with an increasing incidence in recent years. Prognosis is poor and most patients are not eligible for resection at the time of initial diagnosis due to the anatomic location, inadequate hepatic reserve, limiting comorbidities or metastatic disease. Several locoregional therapies from the field of interventional radiology exist for patients who are not amenable for surgery, or in case of local recurrence as a single treatment modality or combined with systemic treatment. To date, evidence is limited, with most conclusions drawn from single-center studies with small patient cohorts, often treated in the salvage situation or for local recurrence after initial resection. Nevertheless, the results are promising and suggest a survival benefit in selected patients. This narrative review focuses on the use of different locoregional treatment options for intrahepatic cholangiocarcinoma.

Microwave Enabled Physically Cross Linked Sodium Alginate and Pectin Film and Their Application in Combination with Modified Chitosan-Curcumin Nanoparticles. A Novel Strategy for 2nd Degree Burns Wound Healing in Animals

This study reports microwave assisted physically cross-linked sodium alginate and pectin film and their testing in combination with modified chitosan-curcumin nanoparticles for skin tissue regeneration following 2nd degree burn wound. Film was formulated by solution casting method and physically cross-linked using microwave irradiation at frequency of 2450 MHz, power 750 Watt for different time intervals for optimization. The optimized formulation was analyzed for various physiochemical attributes. Afterwards, the optimized film and optimized modified chitosan-curcumin nanoparticles were tested in combination for skin regeneration potential following burn wound in vivo and skin samples extracted and tested for different attributes. The results indicated that the optimized film formulation (5 min microwave treatment) physicochemical attributes significantly enhanced addressing the properties required of a wound healing platform. The vibrational analysis indicated that the optimized film experienced significant rigidification of hydrophilic domains while the hydrophobic domains underwent significant fluidization which also resulted in significant increase in the transition temperatures and system enthalpies of both polymer moieties with microwave treatment. The combined film and nanoparticles application significantly increased protein content in the wounds which were evident from higher absorbance ratios of amide-I and amide-II (2.15 ± 0.001), significantly higher melting transition temperature and enthalpy (∆T = 167.2 ± 15.4 °C, ∆H = 510.7 ± 20.1 J/g) and higher tensile strength (14.65 ± 0.8 MPa) with significantly enhanced percent re-epithelization (99.9934 ± 2.56) in comparison to other treatments. The combined application of film and nanoparticles may prove to be a new novel treatment strategy for 2nd degree burn wound healing.

Thermal ablation in the treatment of intrahepatic cholangiocarcinoma: a systematic review and meta-analysis

OBJECTIVE

To summarize the efficacy and safety of thermal ablation for the treatment of intrahepatic cholangiocarcinoma (ICC).

METHODS

MEDLINE, EMBASE, Cochran Library, and Web of Science databases were searched for studies reporting outcomes in patients with ICC treated with thermal ablation. Meta-analyses of cumulative overall survival (OS) and recurrence-free survival (RFS), Kaplan-Meier survival rates according to time to local tumor progression (TTLTP), technical efficacy, and incidence of complications were analyzed. Pooled hazard ratios of common variables were calculated to explore factors associated with OS.

RESULTS

Twenty observational studies comprising 917 patients were reviewed (primary ICC [n = 502]; post-surgical recurrent ICC [n = 355]; information not available [n = 60]). The pooled proportion of technical efficacy was 91.9% (95% CI, 87.3-94.9%). The pooled 1-, 3-, and 5-year OS rates were 82.4% (95% CI, 75.1-88.9%), 42.1% (95% CI, 36.0-48.4%), and 28.5% (95% CI, 21.2-36.2%). Primary tumors showed higher 3-year OS rates than recurrent ones, with borderline significance (p = 0.072). The pooled 1- and 3-year RFS rates were 40.0% (95% CI, 33.6-46.4%) and 19.2% (95% CI, 8.4-32.7%). The pooled 1-, 3-, and 5-year TTLTP rates were 79.3% (95% CI, 65.1-90.9%), 59.5% (95% CI, 49.1-69.4%), and 58.2% (95% CI, 44.9-70.9%). The pooled incidence of major complications was 5.7% (95% CI, 4.1-7.8%). Tumor size (> 3 cm), multiple tumors, and age (> 65 years) were factors associated with shorter OS.

CONCLUSION

Thermal ablation is a successful alternative with a good safety profile, especially for a single ICC smaller than 3 cm.

KEY POINTS

• The pooled 1-, 3-, and 5-year OS rates following thermal ablation for the treatment of intrahepatic cholangiocarcinoma were 82.4%, 42.1%, and 28.5%. • The pooled incidence of major complications was 5.7%. • A tumor size > 3 cm (HR: 2.12, p = 0.006), multiple tumors (HR: 1.67, p = 0.004), and age > 65 years (HR: 1.67, p = 0.006) were factors associated with shorter OS.

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.

The Role of Conventional and Stereotactic Microwave Ablation for Intrahepatic Cholangiocarcinoma

Background: The incidence and mortality of intrahepatic cholangiocarcinoma (ICCA) is increasing worldwide and curative treatment options are limited due to the aggressive tumor biology and often late diagnosis. Resection of the primary tumor remains the only curative therapy available, as the benefit of palliative chemotherapy and radiotherapy is relatively small. In contrast to hepatocellular carcinoma, minimal-invasive thermal tumor ablation, and in particular stereotactic tumor ablation for small primary cancers or metastases, is not established and data are scarce. Methods: We conducted a literature review in the field of ICCA ablation and retrospective analysis of 10 patients treated by stereotactic microwave ablation (SMWA) for either primary ICCA or liver metastases of ICCA. Results: While current guidelines have no consensus for ablation of primary ICCA, some state that it might be an option in inoperable patients or those with recurrent disease. The literature review revealed 11 studies on microwave ablation for ICCA reporting that MWA for ICCA ≤ 5 cm might be safe and could be a treatment option for patients who are not candidates for surgery. No data has been published on stereotactic microwave ablation (SMWA) for ICCA. The analyses of our own data of 10 patients treated by SMWA for primary ICCA (n = 5) or recurrent ICCA (n = 5) show that the treatment is safe and efficient with short hospital stays and low complication rates. Conclusion: Although thermal ablation, and in particular SMWA, might be a minimally invasive and tissue-sparing curative treatment alternative for small ICCA in the diseased liver and ICCA metastases, the oncologic benefit still needs to be shown in larger studies with longer follow-up.

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.

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.

Italian Clinical Practice Guidelines on Cholangiocarcinoma - Part II: Treatment

Currently, the only curative treatment for cholangiocarcinoma (CCA) is surgical resection, though this treatment is possible in less than 40% of patients. However, recent improvements in preoperative management have led to a higher number of patients who are candidates for this procedure. For unresectable patients, progress is ongoing in terms of locoregional and chemoradiation treatments and target therapies, especially in the definition of patient selection criteria. This is the second part of the Italian CCA guidelines, dealing with CCA treatment, that have been formulated in accordance with Italian National Institute of Health indications and developed according to the GRADE method and related advancements.

Ablative therapies for hepatic and biliary tumors: endohepatology coming of age

Ablative therapies refer to minimally invasive procedures performed to destroy abnormal tissue that may arise with many conditions, and can be achieved clinically using chemical, thermal, and other techniques. In this review article, we explore the different ablative therapies used in the management of hepatic and biliary malignancies, namely hepatocellular carcinoma (HCC) and cholangiocarcinoma (CCA), with a particular focus on radiofrequency ablation (RFA) and photodynamic therapy (PDT) techniques.

Thermal Ablation for Intrahepatic Cholangiocarcinoma in Cirrhosis: Safety and Efficacy in Non-Surgical Patients

PURPOSE

To assess the effectiveness, safety, and overall survival (OS) of thermal ablation as upfront treatment of intrahepatic colangiocarcinoma (ICC) in patients with cirrhosis.

MATERIALS AND METHODS

This was a retrospective analysis of all biopsy-confirmed ICC in cirrhotic patients treated in the authors' unit from 2001 to 2017. Baseline characteristics, ablation procedures, and complications were recorded, and time to recurrence (TTR) and OS were calculated. Twenty-seven patients were identified. Seventy percent had Child-Pugh A disease, and most had clinically significant portal hypertension. Median tumor size was 21 mm. Twenty-one cases were uninodular, and 10 were single ≤ 2 cm.

RESULTS

Complete radiologic necrosis was achieved in 25 cases (92.6%). Median OS was 30.6 months (95% confidence interval [CI], 22.6-46.5), and recurrence was detected in 21 cases (77.8%) with a TTR of 10.1 months (95% CI, 7.7-20.9). In those patients with single ≤ 2-cm ICC, the OS was 94.5 months (95% CI, 11.7-not reached). Differences in OS were statistically significant between patients with single ICC ≤ 2 cm and patients with single ICC > 2 cm (P = .04) and between patients with single ICC > 2 cm and patients with multinodular ICC (P = .02). Only 1 patient had a treatment-related complication.

CONCLUSIONS

Thermal ablation is a safe and effective treatment for ICC in patients with cirrhosis who are not candidates for surgery. The OS is similar to that reported in surgical series, but the initial treatment success is hampered by a high rate of tumor recurrence. Encouraging long-term survival after thermal ablation is achieved in patients with single ≤ 2-cm ICC.

Ablation of Intrahepatic Cholangiocarcinoma

Intrahepatic cholangiocarcinoma is the second most common primary liver cancer but represents only a small portion of all primary liver cancers. At the time of diagnosis, patients are often not surgical candidates due to tumor burden of other comorbidities. In addition, there is a very high rate of tumor recurrence after resection. Local regional therapies, specifically ablative therapies of radiofrequency ablation, microwave ablation, cryoablation, and irreversible electroporation, have proven to be beneficial with other hepatic tumors. The purpose of this review is to provide an overview and update of the medical literature demonstrating ablative therapy as a treatment option for intrahepatic cholangiocarcinoma.

Ablative Therapy for Unresectable Intrahepatic Cholangiocarcinoma: A Systematic Review and Meta-Analysis

BACKGROUND

Intrahepatic cholangiocarcinoma (iCCA) is usually a fatal malignancy with rising incidence globally. Surgical resection currently remains the only curative treatment. However, as only a minority of iCCA is amenable to resection, new therapeutic modalities are needed. Our aims were to systematically review and perform a meta-analysis on the existing literature regarding the use of ablative therapies for iCCA and to assess their efficacy as a treatment modality by calculating pooled survival results and investigate associations between prognostic factors and survival.

METHODS

A comprehensive search of the PubMed database for relevant articles was performed. Studies assessing survival in patients with iCCA undergoing ablation were included. Data were extracted on patient, tumour and treatment characteristics and survival. Random effects meta-analysis was used to pool the data. Galbraith plots were used to investigate heterogeneity; bubble plots were formulated using regression-based meta-analysis.

RESULTS

A total of 10 studies were included in the final analysis, yielding an aggregate of 206 patients (69.5% males, median age: 51.2-72.5) and 320 tumours. Of all patients, 70.4% were recurrent cases of iCCA, and 29.6% were cases of primary iCCA. The median overall survival ranged from 8.7 to 52.4 months. Pooled 1-, 3- and 5-year survival rates were 76% (95% confidence interval: 68-83%), 33% (21-44%) and 16% (7-26%), respectively. No significant association was found between the median age, number of tumours or median tumour size and 1-year survival.

CONCLUSIONS

Ablative therapies display promising potential as treatment modalities for iCCA. However, further research is necessary to validate these findings.

Medical treatment for cholangiocarcinoma

Most of the patients with cholangiocarcinoma (CCA) present with advanced (inoperable or metastatic) disease, and relapse rates are high in those undergoing potentially curative resection. Previous treatment nihilism of patients with advanced disease has been replaced by active clinical research with the advent of randomized clinical trials (RCTs) and a much greater effort at understanding molecular mechanisms underpinning CCA. Three RCTs have recently been reported evaluating adjuvant chemotherapy following curative resection; only one of these has the potential to change practice. The BILCAP study failed to meet its primary endpoint by intention-to-treat analysis; however, a survival benefit was seen in a preplanned sensitivity analysis (predominantly adjusting for lymph nodes status). This, along with the numerical difference in median overall survival has led to the uptake of adjuvant capecitabine by many clinicians. In patients with advanced disease, the only level 1 data available supports the use of cisplatin and gemcitabine for the first-line treatment of patients with advanced disease; there is no established second-line chemotherapy. Previous forays into targeted therapy have proven unfruitful (namely targeting the epithelial growth factor receptor and vascular endothelial growth factor pathways). An increasing number of genomic subtypes are being defined; for some of these on-target therapeutic options are under active investigation. The most developed are studies targeting IDH-1 (isocitrate dehydrogenase) mutations and FGFR-2 (fibroblast growth factor receptor) fusions, with promising early results. Several other pathways are under evaluation, along with early studies targeting the immune environment; these are too premature to change practice to date. These emerging treatments are discussed.

Thermal ablation of intrahepatic cholangiocarcinoma: Safety, efficacy, and factors affecting local tumor progression

PURPOSE

To evaluate the safety and oncologic efficacy of percutaneous thermal ablation of intrahepatic cholangiocarcinoma (ICC) and identify risk factors for local tumor progression (LTP).

MATERIALS AND METHODS

Retrospective review of an institutional tumor ablation registry demonstrated that 20 patients (9 males, 11 females; mean age 62.5 ± 15.8 years) with 50 ICCs (mean size 1.8 ± 1.3 cm) were treated with percutaneous radiofrequency ablation (RFA) or microwave ablation (MWA) between 2006 and 2015. Thirty-eight of the treated ICCs (76%) were metastases that developed after surgical resection of the primary tumor. Patient demographics, procedure technical parameters, and clinical outcomes were reviewed. A Cox proportional hazards model was used to examine the risk of LTP by ablation modality. Survival analyses were performed using the Kaplan-Meier method.

RESULTS

Mean imaging follow-up time was 41.5 ± 42.7 months. Forty-four (88%) ICCs were treated with RFA, and 6 (12%) with MWA. Eleven (22%) cases of LTP developed in 5 (25%) patients. The median time to LTP among these 11 tumors was 7.1 months (range, 2.3-22.9 months). Risk of LTP was not significantly different for ICCs treated with MWA compared to RFA (HR 2.72; 95% CI 0.58-12.84; p = 03.21). Median disease-free survival was 8.2 months (1.1-70.4 months), and median overall survival was 23.6 months (7.4-122.5 months). No major complication occurred.

CONCLUSIONS

Percutaneous thermal ablation is a safe and effective treatment for patients with ICCs and may be particularly valuable in unresectable patients, or those who have already undergone hepatic surgery. Tumor size and ablation modality were not associated with LTP, whereas primary tumors and superficially located tumors were more likely to subsequently recur.

Non-surgical management of patients with intrahepatic cholangiocarcinoma in the United States, 2004-2015: an NCDB analysis

Background

Surgical resection is the standard of care for intrahepatic cholangiocarcinoma (ICC), but only a minority of patients are managed surgically. Other modalities, including external beam radiation (XRT), radiofrequency ablation (RFA), and radioactive implants (RIs) have been employed with significant heterogeneity of prognosis reported in the literature. The aim of this study was to evaluate the demographics of patients with ICC managed non-surgically and compare prognosis in patients managed surgically to those that underwent XRT, RFA, or RI.

Methods

All patients diagnosed with ICC from 2004 to 2015 in the National Cancer Database (NCDB) were reviewed. Patient demographics, treatments, and survival outcomes were analyzed.

Results

Of the 6,140 patients with ICC, 4,374 (71%) did not undergo surgery. Patients managed non-surgically were typically older, treated at community centers, more likely to have severe fibrosis or cirrhosis, and present with higher stage disease. The strongest association to receipt of XRT, RI, or RFA modalities was treatment at an academic center. Increased clinical stage was associated with decreased use of RFA; a significantly higher proportion of patients with stage IV disease were given no local therapy. RFA associated with a statistically significant survival benefit over no local therapy only in stage I disease (2.1 vs. 0.7 years, P=0.012) as well as XRT over no local therapy (1.7 vs. 0.7 years, P=0.009). No survival benefit was realized for any treatment in stage II disease. Patients with stage III disease had a survival benefit from XRT versus no local therapy (0.9 vs. 0.6 years, P=0.029) and RI over no local therapy (1.2 vs. 0.6 years, P=0.013). Patients with stage IV disease only demonstrated survival benefit from RI over no local therapy (0.9 vs. 0.3 years, P=0.014).

Conclusions

The majority of patients with ICC in the United States continue to be managed non-surgically. RFA was associated with improved survival only in stage I disease. XRT was associated with improved survival in stage I & III disease, while RI was associated with improved survival in stage III and IV disease.

Liver-Directed Therapies for Hepatocellular Carcinoma and Intrahepatic Cholangiocarcinoma

Hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (IHC) are primary liver cancers where all or most of the tumor burden is usually confined to the liver. Therefore, locoregional liver-directed therapies can provide an opportunity to control intrahepatic disease with minimal systemic side effects. The English medical literature and clinical trials were reviewed to provide a synopsis on the available liver-directed percutaneous therapies for HCC and IHC. Locoregional liver-directed therapies provide survival benefit for patients with HCC and IHC compared to best medical treatment and have lower comorbid risks compared to surgical resection. These treatment options should be considered, especially in patients with unresectable disease.

Locoregional therapies in cholangiocarcinoma

Cholangiocarcinoma is a rare and aggressive malignancy of the biliary tract. Complete surgical resection can be curative, but the majority of patients are diagnosed with advanced disease and usually die within a year of diagnosis. Most deaths are attributable to local disease progression rather than distant metastases, supporting the use of locoregional therapies. There is evidence that locoregional therapies can provide local tumor control resulting in increased survival while avoiding some of the side effects of systemic treatments, increasing potential treatment options for patients who may be unsuitable for systemic palliative treatments. This review considers the evidence for locoregional therapies in cholangiocarcinoma, which can be classified into endoscopic, vascular, percutaneous and radiation oncological therapies. Current guidelines do not recommend the routine use of locoregional therapies due to a lack of prospective data, but the results of ongoing trials are likely to increase the evidence base and impact on clinical practice.

Management of unresectable intrahepatic cholangiocarcinoma: how do we decide among the various liver-directed treatments?

Intrahepatic cholangiocarcinoma often causes death due to obstruction of the biliary system or interruption of the vascular supply of the liver. This fact emphasizes the critical need for local tumor control in this disease. Successful local tumor control has traditionally been achievable through surgical resection for the small proportion of patients with operable tumors. Technological advances in radiation oncology and in interventional radiology have enabled the delivery of ablative radiation doses or other cytotoxic therapies for tumors in the liver. In some cases, this has translated into substantial prolongation of life for patients with this disease, but the indications for these different treatment options are still the subject of ongoing debate. Here, we review the technological advances and clinical studies that are changing the way intrahepatic cholangiocarcinoma is managed, and discuss ways to achieve individualized treatment of patients.

Locoregional Therapies of Cholangiocarcinoma

BACKGROUND

Cholangiocarcinoma (CC) is the second most primary liver malignancy with increasing incidence in Western countries. Currently, surgical R0 resection is regarded as the only potentially curative treatment. The results of systemic chemotherapy and best supportive care (BSC) in patients with metastatic disease are often disappointing in regard to toxicity, oncologic efficacy, and overall survival. In current practice, the use of different locoregional therapies is increasingly more accepted.

METHODS

A review of the literature on locoregional therapies for intrahepatic cholangiocarcinoma (ICC) was undertaken.

RESULTS

There are no prospective randomized controlled trials. For localized ICC, either primary or recurrent, radiofrequency ablation (RFA) is by far the most commonly used thermal ablation modality. Thereby, a systematic review and meta-analysis reports major complication in 3.8% as well as 1-, 3-, and 5-year overall survival rates of 82, 47, and 24%, respectively. In selected patients (e.g. with a tumor diameter of ≤3 cm), oncologic efficacy and survival after RFA are comparable with surgical resection. For diffuse ICC, different transarterial therapies, either chemotherapy-based (hepatic artery infusion (HAI), transarterial chemoembolization (TACE)) or radiotherapy-based (transarterial radioembolization (TARE)), show extremely promising results. With regard to controlled trials (transarterial therapy versus systemic chemotherapy, BSC or no treatment), tumor control is virtually always better for transarterial therapies and very often accompanied by a dramatic survival benefit and improvement of quality of life. Of note, the latter is the case not only for patients without extrahepatic metastatic disease but also for those with liver-dominant extrahepatic metastatic disease. There are other locoregional therapies such as microwave ablation, irreversible electroporation, and chemosaturation; however, the current data support their use only in controlled trials or as last-line therapy.

CONCLUSION

Dedicated locoregional therapies are commonly used for primary and recurrent ICC as well as liver-only and liver-dominant extrahepatic metastatic disease. Currently, the best evidence and most promising results are available for RFA, HAI, TACE, and TARE. In cohort studies, the overall survival rates are similar to those obtained with surgery or systemic therapies. Prospective randomized controlled trials are warranted to compare safety and efficacy between different surgical, interventional, and systemic therapies, as well as their combinations.

Percutaneous microwave ablation combined with simultaneous transarterial chemoembolization for the treatment of advanced intrahepatic cholangiocarcinoma

Aim

To retrospectively evaluate the safety and efficacy of ultrasound-guided percutaneous microwave ablation (MWA) combined with simultaneous transarterial chemoembolization (TACE) in the treatment of patients with advanced intrahepatic cholangiocarcinoma (ICC).

Methods

All patients treated with ultrasound-guided percutaneous MWA combined with simultaneous TACE for advanced ICC at our institution were included. Posttreatment contrast-enhanced computed tomography and/or magnetic resonance imaging were retrieved and reviewed for tumor response to the treatment. Routine laboratory studies, including hematology and liver function tests were collected and analyzed. Procedure-related complications were reviewed and survival rates were analyzed.

Results

From January 2011 to December 2014, a total of 26 advanced ICC patients were treated at our single institute with ultrasound-guided percutaneous MWA combined with simultaneous TACE. There were 15 males and eleven females with an average age of 57.9±10.4 years (range, 43–75 years). Of 26 patients, 20 (76.9%) patients were newly diagnosed advanced ICC without any treatment, and six (23.1%) were recurrent and treated with surgical resection of the original tumor. The complete ablation rate was 92.3% (36/39 lesions) for advanced ICC. There were no major complications observed. There was no death directly from the treatment. Median progression-free survival and overall survival were 6.2 and 19.5 months, respectively. The 6-, 12-, and 24-month survival rates were 88.5%, 69.2%, and 61.5%, respectively.

Conclusion

The study suggests that ultrasound-guided percutaneous MWA combined with simultaneous TACE therapy can be performed safely in all patients with advanced ICC. The complete ablation rate was high and there was no major complication. The overall 24-month survival was 61.5%.

A simulator for percutaneous hepatic microwave thermal ablation under ultrasound guidance

The purpose of this study was to provide a simulation therapy environment for microwave thermal ablation (MWA) under the guidance of ultrasound, and to present an inexpensive and portable simulator built on real patient-based pre-operative computed tomography (CT) data. We established an experimental simulation system for teaching MWA and present the results of a preliminary evaluation of the simulator's realism and utility for training. The system comprises physical elements of an electromagnetic tracking device and an abdominal phantom, and software elements providing three-dimensional (3D) image processing tools, real-time navigation functions and objective evaluation function module. Details of the novel aspects of this system are presented, including a portable electromagnetic tracking device, adoption of real patient-based pre-operative CT data of liver, operation simulation of MWA, and recording and playback of the operation simulation. Patients with liver cancer were selected for evaluation of the clinical application value of the experimental simulation system. A total of 50 consultant interventional radiologists and 20 specialist registrars in radiology rated the simulator's hardware reality and overall ergonomics. Results show that the simulator system we describe can be used as a training tool for MWA. It enables training with real patient cases prior to surgery, and it can provide a realistic simulation of the actual procedure.

[Stereotactic Radiofrequency Ablation (SRFA) of intrahepatic cholangiocellular carcinomas: a minimal invasive alternative to liver resection]

Up to now resection and liver transplantation are concerned as the only curative treatment options for intrahepatic cholangiocellular carcinomas (ICCs). For patients with inoperable ICCs systemic chemotherapy and various locoregional therapies including transarterial (chemo)embolization (TACE), selective internal radiation therapy (SIRT), radiofrequency ablation (RFA) and microwave ablation (MWA) are applied. Stereotactic RFA (SRFA) allows for precise 3D planning and positioning of multiple RF electrodes. Due to overlapping necroses tumors > 5 cm can be completely ablated in one session. 17 inoperable consecutive patients with 52 ICCs were treated with stereotactic RFA (SRFA). A median overall survival of 60 months was achieved. The two largest tumors with diameters > 10 cm were completely ablated. These SRFA data of irresectable ICCs are superior to the published data on resection. SRFA is a minimal invasive alternative treatment to resection and may be considered as the first-line local treatment of patients with ICCs in selected patients.

Treatment of malignant liver tumors by radiofrequency ablation combined with low-frequency ultrasound radiation with microbubbles

Objective

To explore the therapeutic efficacy and safety of malignant liver tumor treatment by radiofrequency ablation (RA) combined with low frequency ultrasound radiation with microbubbles (LFURM).

Methods

Retrospective analysis of 25 patients with malignant hepatic tumors treated by RA/LFURM in the Department of Hepatobiliary Surgery of Kunming General Hospital affiliated to Chengdu Military District, PLA from January 2010 to June 2011. Ultrasound guided RA was performed, which was followed one week later by LFURM. Basal contrast ultrasound, liver function tests, and serum alpha fetoprotein (AFP) were obtained, and repeated 3 and 6 months after treatment. T-test and chi-square were used to compare parametric and non-parametric variables respectively.

Results

In 17 cases, gross tumor volume was significantly reduced 6 months after treatment while mean tumor showed a reduction of 50% compared to pre-treatment values. In 7 cases gross tumor volumes reduction was partial, but surrounding tumor tissue showed blood flow signals. One patient had no reduction in gross tumor volume. Levels of serum alanine aminotransferase (ALT), aspartate aminotransferase (AST), total bilirubin (TBIL), alpha fetoprotein (AFP) decreased significantly 6 months after treatment (all p<0.05). No tumor recurrence was seen during the 6 month follow-up. Quality of life scores (QOL) were good in 21 patients (84%), improved in 2 patients (8%), unchanged in 1 patient (4%) and got worst in 1 patient (4%). Karnofsky scores (KPS) improved in 19 patients (76%), remained unchanged in 5 patients (2%) and got worst in 1 patient (4%). Both QOL and KPS changes were statistically significant (P<0.05).

Conclusion

RA/LFURM treatment of liver tumors is efficient and safe, and can reduce the gross tumor volumes and protect liver function.

Ultrasound-guided microwave ablation for abdominal wall metastatic tumors: a preliminary study

AIM

To evaluate the feasibility, safety and efficacy of ultrasound-guided microwave (MW) ablation for abdominal wall metastatic tumors.

METHODS

From August 2007 to December 2010, a total of 11 patients with 23 abdominal wall nodules (diameter 2.59 cm ± 1.11 cm, range 1.3 cm to 5.0 cm) were treated with MW ablation. One antenna was inserted into the center of tumors less than 1.7 cm, and multiple antennae were inserted simultaneously into tumors 1.7 cm or larger. A 21 gauge thermocouple was inserted near important organs which required protection (such as bowel or gallbladder) for real-time temperature monitoring during MW ablation. Treatment outcome was observed by contrast-enhanced ultrasound and magnetic resonance imaging (MRI) [or computed tomography (CT)] during follow-up.

RESULTS

MW ablation was well tolerated by all patients. Six patients with 11 nodules had 1 thermocouple inserted near important organs for real-time temperature monitoring and the maximum temperature was 56 °C. Major complications included mild pain (54.5%), post-ablation fever (100%) and abdominal wall edema (25%). All 23 tumors (100%) in this group were completely ablated, and no residual tumor or local recurrence was observed at a median follow-up of 13 mo (range 1 to 32 mo). The ablation zone was well defined on contrast-enhanced imaging (contrast-enhanced CT, MRI and/or contrast-enhanced ultrasound) and gradually shrank with time.

CONCLUSION

Ultrasound-guided MW ablation may be a feasible, safe and effective treatment for abdominal wall metastatic tumors in selected patients.

Percutaneous ultrasound-guided thermal ablation for intrahepatic cholangiocarcinoma

OBJECTIVE

The objective of this study was to evaluate the treatment efficacy and overall survival (OS) of percutaneous ultrasound-guided thermal ablation by means of microwave ablation or radiofrequency ablation for intrahepatic cholangiocarcinoma (ICC).

METHODS

18 patients with 25 ICC nodules underwent ultrasound-guided thermal ablation with curative intention. 8 patients were primary cases and 10 were recurrent cases after curative resection. The local treatment response, complications and survivals were analysed.

RESULTS

Complete ablation was achieved in 23 (92.0%, 23/25) nodules (diameter, 0.7-4.3 cm; mean, 2.5 ± 0.9 cm) and incomplete ablation was found in 2 (8.0%, 2/25) larger tumours (6.4 and 6.9 cm in diameter). No death associated with the treatment was found. The major complication rate was 5.5% (1/18). The follow-up periods ranged from 1.3 to 86.2 months (mean, 20.5 ± 26.3 months; median, 8.7 months). OS rates for all patients at 6, 12, 36 and 60 months were 66.7%, 36.3%, 30.3% and 30.3%, respectively. By univariate analysis, the patient source (primary or recurrent case) was found to be a significant prognostic factor for OS rates (p=0.001). The patient source (p=0.001) and the number of nodules (p=0.038) were found to be significant prognostic factors for recurrence-free survival. OS rates for the primary ICC at 6, 12, 36 and 60 months were 87.5%, 75.0%, 62.5% and 62.5%, respectively.

CONCLUSION

Percutaneous ultrasound-guided thermal ablation is a safe and effective therapeutic technique for ICC. Acceptable survival can be achieved in primary ICCs, whereas the prognosis of recurrent ICCs is relatively poor.