Radiofrequency ablation for incidentally identified primary intrahepatic cholangiocarcinoma

Locoregional therapies in patients with recurrent intrahepatic cholangiocarcinoma after curative resection

BACKGROUND

Hepatectomy is one potential treatment for intrahepatic cholangiocarcinoma (IHCC). Recurrent rate is high after curative resection and most recurrences occur within residual liver parenchyma. The aim of this study was to elucidate the impact of different treatment modalities on recurrent diseases in patients with IHCC after primary liver resection.

METHODS

Between February 1999 and December 2015, we retrospectively identified patients who received curative resection for IHCC. Patients who experienced recurrences were included. Locoregional therapies included re-hepatectomy, radiofrequent ablation, and transhepatic arterial chemoembolization. These patients were categorized into three groups: intrahepatic recurrence without locoregional therapies (group A), intrahepatic recurrence with locoregional therapies (group B) and extrahepatic metastases (group C).

RESULTS

Forty-three patients were included and there were 12, 15, and 16 patients in groups A, B, and C, respectively. The median disease-free survival times were 8.3, 9.1, and 8.7 months in groups A, B, and C (p = 0.099). The median after-recurrence overall survival times (period between recurrence and death/censor) were 6.4, 34.0, and 8.3 months in groups A, B, and C (p = 0.001). Locoregional therapies showed favorable benefit in multivariant analysis (hazard ratio: 0.274, confidence interval: 0.083-0.908, p = 0.010).

CONCLUSION

Locoregional therapies offered favorable benefits for patients with recurrent intrahepatic cholangiocarcinoma.

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.

Selective internal radiotherapy (SIRT) versus transarterial chemoembolization (TACE) for the treatment of intrahepatic cholangiocellular carcinoma (CCC): study protocol for a randomized controlled trial

Background

Cholangiocellular carcinoma is the second most common primary liver cancer after hepatocellular carcinoma. Over the last 30 years, the incidence of intrahepatic cholangiocellular carcinoma has risen continuously worldwide. Meanwhile, the intrahepatic cholangiocellular carcinoma has become more common than the extrahepatic growth type and currently accounts for 10-15% of all primary hepatic malignancies. Intrahepatic cholangiocellular carcinoma is typically diagnosed in advanced stages due to late clinical symptoms and an absence of classic risk factors. A late diagnosis precludes curative surgical resection. There is evidence that transarterial chemoembolization leads to better local tumor control and prolongs survival compared to systemic chemotherapy. New data indicates that selective internal radiotherapy, also referred to as radioembolization, provides promising results for treating intrahepatic cholangiocellular carcinoma.

Methods/Design

This pilot study is a randomized, controlled, single center, phase II trial. Twenty-four patients with intrahepatic cholangiocellular carcinoma will be randomized in a 1:1 ratio to receive either chemoembolization or radioembolization. Randomization will be stratified according to tumor load. Progression-free survival is the primary endpoint; overall survival and time to progression are secondary endpoints. To evaluate treatment success, patients will receive contrast enhanced magnetic resonance imaging every 3 months.

Discussion

Currently, chemoembolization is routinely performed in many centers instead of systemic chemotherapy for treating intrahepatic cholangiocellular carcinoma confined to the liver. Recently, radioembolization has been increasingly applied to cholangiocellular carcinoma as second line therapy after TACE failure or even as an alternative first line therapy. Nonetheless, no randomized studies have compared radioembolization and chemoembolization. Considering all this background information, we recognized a strong need for a randomized controlled trial (RCT) to compare the two treatments. Therefore, the present protocol describes the design of a RCT that compares SIRT and TACE as the first line therapy for inoperable CCC confined to the liver.

Trial registration

ClinicalTrials.gov, Identifier: NCT01798147, registered 16^th of February 2013.

Clinical outcomes and toxicity of proton beam therapy for advanced cholangiocarcinoma

Background

We examined the efficacy and toxicity of proton beam therapy (PBT) for treating advanced cholangiocarcinoma.

Methods

The clinical data and outcomes of 28 cholangiocarcinoma patients treated with PBT between January 2009 and August 2011 were retrospectively examined. The Kaplan–Meier method was used to estimate overall survival (OS), progression-free survival (PFS), and local control (LC) rates, and the log-rank test to analyze the effects of different clinical and treatment variables on survival. Acute and late toxicities were assessed using the National Cancer Institute Common Terminology Criteria for Adverse Events version 4.0.

Results

The median age of the 17 male and 11 female patients was 71 years (range, 41 to 84 years; intrahepatic/peripheral cholangiocarcinoma, n = 6; hilar cholangiocarcinoma/Klatskin tumor, n = 6; distal extrahepatic cholangiocarcinoma, n = 3; gallbladder cancer, n = 3; local or lymph node recurrence, n = 10; size, 20–175 mm; median 52 mm). The median radiation dose was 68.2 Gy (relative biological effectiveness [RBE]) (range, 50.6 to 80 Gy (RBE)), with delivery of fractions of 2.0 to 3.2 Gy (RBE) daily. The median follow-up duration was 12 months (range, 3 to 29 months). Fifteen patients underwent chemotherapy and 8 patients, palliative biliary stent placement prior to PBT. OS, PFS, and LC rates at 1 year were 49.0%, 29.5%, and 67.7%, respectively. LC was achieved in 6 patients, and was better in patients administered a biologically equivalent dose of 10 (BED10) > 70 Gy compared to those administered < 70 Gy (83.1% vs. 22.2%, respectively, at 1 year). The variables of tumor size and performance status were associated with survival. Late gastrointestinal toxicities grade 2 or greater were observed in 7 patients <12 months after PBT. Cholangitis was observed in 11 patients and 3 patients required stent replacement.

Conclusions

Relatively high LC rates after PBT for advanced cholangiocarcinoma can be achieved by delivery of a BED10 > 70 Gy. Gastrointestinal toxicities, especially those of the duodenum, are dose-limiting toxicities associated with PBT, and early metastatic progression remains a treatment obstacle.

Radiofrequency ablation for postoperative recurrences of intrahepatic cholangiocarcinoma

OBJECTIVE

Most recurrent intrahepatic cholangiocarcinoma (RICC) lost the opportunity of radical resection while most nonsurgical management failed to prolong patients' survival. The efficacy and safety of radiofrequency ablation (RFA) as a local treatment for recurrent hepatocellular carcinoma have been confirmed by many clinical studies. The purpose of this study was to evaluate the efficacy, long-term survival and complications of RFA for RICC.

METHODS

A total of 12 patients with 19 RICCs after radical resection were included in this study. The tumors were 1.9-6.8 cm at the maximum diameter (median, 3.2±1.6 cm). All patients were treated with ultrasound guided RFA. There were two RFA approaches including percutaneous and open.

RESULTS

A total of 18 RFA treatment sessions were performed. Ablation was successful (evaluated by 1-month CT after the initial RFA procedure) in 18 (94.7%) of 19 tumors. By a median follow-up period of 29.9 months after RFA, 5 patients received repeated RFA because of intrahepatic lesion recurrence. The median local recurrence-free survival period and median event-free survival period after RFA were 21.0 months and 13.0 months, respectively. The median overall survival was 30 months, and the 1- and 3-year survival rates were 87.5% and 37.5%, respectively. The complication rate was 5.6% (1/18 sessions). The only one major complication was pleural effusion requiring thoracentesis.

CONCLUSION

This study showed RFA may effectively and safely manage RICC with 3-year survival of 37.5%. It provides a treatment option for these RICC patients who lost chance for surgery.

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.

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.

Review article: surgical, neo-adjuvant and adjuvant management strategies in biliary tract cancer

BACKGROUND

The majority of patients with cholangiocarcinoma present with advanced, irresectable tumours associated with poor prognosis. The incidence and mortality rates associated with cholangiocarcinoma continue to rise, mandating the development of novel strategies for early detection, improved resection and treatment of residual lesions.

AIM

To review the current evidence base for surgical, adjuvant and neo-adjuvant techniques in the management of cholangiocarcinoma.

METHODS

A search strategy incorporating PubMed/Medline search engines and utilising the key words biliary tract carcinoma; cholangiocarcinoma; management; surgery; chemotherapy; radiotherapy; photodynamic therapy; and radiofrequency ablation, in various combinations, was employed.

RESULTS

Data on neo-adjuvant and adjuvant techniques remain limited, and much of the literature concerns palliation of inoperable disease. The only opportunity for long-term survival remains surgical resection with negative pathological margins or liver transplantation, both of which remain possible in only a minority of selected patients. Neo-adjuvant and adjuvant techniques currently provide only limited success in improving survival.

CONCLUSIONS

The development of novel strategies and treatment techniques is crucial. However, the shortage of randomised controlled trials is compounded by the low feasibility of conducting adequately powered trials in liver surgery, due to the large sample sizes that are required.

Advances in diagnosis, treatment and palliation of cholangiocarcinoma: 1990-2009

Several advances in diagnosis, treatment and palliation of cholangiocarcinoma (CC) have occurred in the last decades. A multidisciplinary approach to this disease is therefore recommended. CC is a relatively rare tumor and the main risk factors are: chronic inflammation, genetic predisposition and congenital abnormalities of the biliary tree. While the incidence of intra-hepatic CC is increasing, the incidence of extra-hepatic CC is trending down. The only curative treatment for CC is surgical resection with negative margins. Liver transplantation has been proposed only for selected patients with hilar CC that cannot be resected who have no metastatic disease after a period of neoadjuvant chemo-radiation therapy. Magnetic resonance imaging/magnetic resonance cholangiopancreatography, positron emission tomography scan, endoscopic ultrasound and computed tomography scans are the most frequently used modalities for diagnosis and tumor staging. Adjuvant therapy, palliative chemotherapy and radiotherapy have been relatively ineffective for inoperable CC. For most of these patients biliary stenting provides effective palliation. Photodynamic therapy is an emerging palliative treatment that seems to provide pain relief, improve biliary patency and increase survival. The clinical utility of other emerging therapies such as transarterial chemoembolization, hepatic arterial chemoinfusion and high intensity intraductal ultrasound needs further study.

Cholangiocarcinoma: A compact review of the literature

Cholangiocarcinoma (CC) is a devastating cancer arising from biliary epithelia. Unfortunately, the incidence of this disease is increasing in Western countries. These tumors progress insidiously, and liver failure, biliary sepsis, malnutrition and cancer cachexia are general modes of death associated with this disease. To date, no established therapy for advanced disease has been established or validated. However, our knowledge in tumor biology is increasing dramatically and new drugs are under investigation for treatment of this notorious tumor. In clinical practice, there are better diagnostic tools in use to facilitate an earlier diagnosis of CC, at least in those patients with known risk factors. CC is resectable for cure in only a small percentage of patients. Preoperative staging for vascular and biliary extension of CC is very important in this tumor. Laparoscopy and recently endosonography seem to protect against unnecessary laparotomies in these patients. During the last 15 years, aggressive surgical approaches, including combined liver resections and vascular reconstructive surgical expertise, have improved survival in patients with CC. Surgery is contraindicated in CC cases having primary sclerosing cholangitis (PSC). Although CC was previously considered a contraindication to liver transplantation, new cautious protocols, including neo-adjuvant chemoradiation therapies and staging procedures before the transplantation, have made it possible to achieve long-term survival after liver transplantation in this disease. New ablative therapies with photodynamic therapy, intraductal high-intensity ultrasonography and chemotherapy-impregnated plastic biliary endoprosthesis are important steps in the palliative management of extra-hepatic CCs. Radiofrequency and chemo-embolization methods are also applicable for intra-hepatic CCs as palliative modes of treatment. We need more prospective randomized controlled trials to evaluate the role of the new emerging therapies for CC patients.

Cholangiocarcinoma: modern advances in understanding a deadly old disease

Cholangiocarcinomas are tumors that arise anywhere in the biliary tract, presumably of cholangiocyte origin. The global incidence of this rare disease is on the rise. Several known risk factors exist, and link chronic biliary inflammation to the pathogenesis of cholangiocarcinoma. Among these, amplification of the epidermal growth factor receptor, the interleukin-6 signaling pathway, inducible nitric oxide, erb-2, and cyclooxygenase-2 are well defined. Most patients present late, with a median survival of months. Although, imaging studies and clinical context often indicate cholangiocarcinoma, pathologic and cytologic diagnosis is difficult to obtain. Advanced cytologic tests with fluorescence in situ hybridization or digital image analysis can increase diagnostic sensitivity. Surgical resection is the current therapy of choice for both intrahepatic and ductal cholangiocarcinomas. However, the 5-year survival is poor, with 60 to greater than 90% recurrence rates. In a single center experience, liver transplantation with neoadjuvant chemoirradiation, for highly selected patients, has a 5-year disease free survival of greater than 80%. Future targeted therapies will depend on a better understanding of the cellular and molecular biology of cholangiocarcinomas.