Armeen Mahvash, MDInterventional RadiologyUT MD Anderson Cancer Center

Locoregional Therapies for Cholangiocarcinoma

Treatment Options

Ablation Radiofrequency Microwave Irreversible Electroporation (abstract)

Transarterial Chemoembolization (TACE) Conventional / Oily TACE Drug Eluting Bead TACE

Selective Internal Radiation Therapy / Yttrium 90 Radioembolization Therasphere / Glass - HCC SIRSpheres / Resin - CRC

Ablative Therapy in ICC

Reference Patients Lesions Type Size/Success Median LPFS Median OS Complication

Kim, 2011 13 17 RFA <5cm/100%

>5cm/0%

32 months 38 months Abscess/ Death

Giorgio, 2011

101 Recurrent9 Primary

12 RFA <3.4cm/100%

>4cm/ 0%

Primary – 83% alive at 5yrs

None

Yu, 2011 15 24 MW <5cm/90%

>5cm/33%

10 months Abscess x 2Seeding

Xu, 2012 1810 Recurrent8 Primary

25 RFA/MW <4.3cm/100%>6.4cm/0%

RFS - months

Recurrent- 6 months Primary –29 months

FeverPartial PVT

Metaanalysis of TACE for ICC

Ray, JVIR, 2013

Conventional TACEReference Patients Chemotherapy Prior Chemo Extrahepatic

DiseaseMedian OS Complications

Herber, 2007 1558 sessions

Mitomycin C 4 None 16 months GI ulcer

Gusani,2008 42199 sessions

Gemcitabine, Cisplatin, OxaliplatinTACI+Embo

NA 45% 9months AMIAbscessBilirubin x 2Platelets x 2

Park, 2011 72 TACE2.5 session/pt83 BSC

Cisplatin NA 72% TACE – 12 mBSC – 3 m

Grade 3 – 24%

Keifer, 2011 62165 session

Cisplatin, Doxorubicin, Mitomycin

29% 31% 15 months Grade 3 – 5 pts

Vogl,2011 115819 session

Various NA None 13 months None

Scheuermann, 2013

32131 session

Mitomycin -29DEB - 3

NA NR 11 months Sepsis x 3

Hyder, 2013 1982 sessions/pt

TACE – 65%DEB – 6%TAE- 6%Y90 – 23%

28% TACE – 13 mDEB – 10 mTAE – 14 mY90 – 11 m

Grade 3 - 8%

Drug Eluting Bead(DEB) TACEReference Patients Chemotherap

yPrior Chemo

Extrahepatic Disease

Median OS Complications

Aliberti, 2008 1129 sessions

Doxorubicin75mg/150mg

No No 13 months Abscess

Poggi, 2009 930 sessions37 cycles

Oxaliplatin 50mg + Oxaliplatin/Gemcitabine Systemic Chemo

No No 30 months Grade 3 – 11%

Kuhlmann, 2012

2641 sessions

Irinotecan 200mg

19% 51% 11.7 months Grade 3 – 9/26Grade 5 - 1

Yttrium 90 Radioembolization

Reference Patients Device Prior Chemo Extrahepatic Mets

Median OS Complications

Saxena, 2010 2525 sessions

SS/resin 72% 48% 9 months Grade 3 – 12%Death x 2

Hoffman, 2012

3334 sessions

SS/resin 79% 24% 22 months Grade 3 - 0%

Mouli, 2013 4692 sessions

TS/glass 35% 35% Peripheral – 15 monthsInfiltrative – 6 months

Grade 3 – 18%

Rafi, 2013 1924 sessions

SS/resin 100% 58% 345 days Grade 3 – 11%

Future Direction

Prospective Trials Needed Combination Therapy

Locoregional + Systemic