At the 2024 CCA Summit, Joshua Kuban, MD, FSIR, discussed interventional radiology (IR) therapies for the treatment of patients with cholangiocarcinoma (CCA), and Eugene Koay, MD, PhD, discussed stereotactic body radiation therapy (SBRT). Dr Kuban discussed that IR can be involved from diagnosis all the way through palliative care and stated that often, morbidity and mortality for patients with CCA is driven by vascular compromise. Major symptoms of venous complications in CCA include ascites, gastrointestinal bleeding from varices, and lower extremity swelling; minor symptoms can include pain, fatigue, and loss of energy; rare symptoms include liver dysfunction and chronic mesenteric ischemia. Dr Kuban discussed how IR techniques can be used for pain from vascular compromise by targeting the celiac plexus. Celiac plexus block is a minimally invasive procedure that injects pain medication into visceral afferent pain fibers from the abdominal viscera.1
Dr Kuban next discussed radioembolization using yttrium-90 (Y90). This is a minimally invasive treatment that uses small radioactive beads called microspheres to deliver radiation directly to cancerous tumors in the liver.1 A study investigated dosimetry of Y90 in 28 consecutive patients with intrahepatic cholangiocarcinoma (iCCA) and a mean tumor dose of 240 Gy. The median progression-free survival (PFS) was 265 days, and the median survival was 22.9 months. The 1-year and 3-year survival rates were 78% and 45%, respectively. There were 10 patients down-staged to resection or transplant.1
Dr Kuban then discussed percutaneous interventional techniques for non-hepatocellular carcinoma liver malignancy with a focus on microwave ablation. Microwave ablation uses the alignment of water molecules to cause agitation and friction to generate heat to destroy tissue.1 A recent study investigated microwave ablation in 52 patients with iCCA with 74 tumors. The study divided patients based on Child-Pugh class A and albumin-bilirubin grades 1 and 2. Results showed a 1-, 3-, and 5-year overall survival (OS) of 87%, 51%, and 35%, respectively, and a 1-, 3-, and 5-year PFS of 69%, 57%, and 57%, respectively.1
Dr Koay addressed the necessity of employing radiation therapy for the treatment of CCA through the application of SBRT techniques. He began his discussion with a case study of a 66-year-old woman with abdominal pain.2 She presented with weight loss, lack of appetite, and elevated liver enzymes. A computed tomography scan showed occlusion of portal vein and right hepatic vein, ascites, and a 10-cm mass. She underwent radiation therapy and as a result, the tumor shrank over the course of 2 years, and she lived a total of 3 years after receiving proton radiation.2
Dr Koay discussed that over two-thirds of patients with iCCA die of biliary complications or vascular complications in the liver within the first year of diagnosis.2 He noted that, if local control of dominant tumors is achieved, it may extend OS. This may be achieved through increased doses of radiation. He discussed key technologies that allow for safe escalation of radiation doses including conformal radiotherapy, image guidance, and motion management.
An investigation involving 150 patients, including 113 patients who had next-generation sequencing, was conducted to examine the outcomes of radiotherapy in individuals diagnosed with iCCA.2 The median OS was 20 months after radiotherapy. Patients experienced mild acute toxicities and had a low incidence of late toxicities. Patients who had the best outcomes had FGFR2 mutations and patients with poor outcomes had mutations in TP53. Additionally, a retrospective study of patients with oligometastatic iCCA demonstrated prolonged survival after radiotherapy. Patients who received liver-directed radiotherapy had a median survival of 21 months versus patients who received chemotherapy only (9 months).2
Dr Koay stated that failures after radiotherapy can occur. Combining radiotherapy with other liver-directed therapies should be explored, as well as the combination of radiotherapy with new systemic therapy.2
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