Cholangiocarcinoma: Ablation & Intra-arterial Therapies

1

Indications & Contraindications

Patient selection, therapy choice, surgical resectability assessment

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Indications

Unresectable disease — anatomic or technical unresectability (vascular involvement, location, inadequate FLR)
Poor performance status precluding surgical candidacy (ECOG ≤2 appropriate for locoregional therapy)
Recurrent disease after prior surgical resection
Extrahepatic cholangiocarcinoma with liver-dominant metastatic burden
Palliation of mass-related symptoms and refractory biliary obstruction
Downstaging initially unresectable patients toward resection or transplantation (neoadjuvant intent)

Contraindications

Absolute: life-threatening anaphylaxis to iodinated contrast
Absolute: uncorrectable coagulopathy
Relative: ECOG >2 / life expectancy <6 months
Relative: poor hepatic functional reserve
Relative: dominant extrahepatic metastatic disease
Relative: prior biliary-enteric anastomosis or incompetent sphincter of Oddi — very high abscess risk (≥25%); requires aggressive antibiotic prep + bowel decontamination
Relative: uncorrected anemia, leukopenia, or inadequate platelet levels

Therapy Selection Guide

Scenario	Preferred Approach	Rationale
Focal, peripheral, mass-forming <5 cm	Ablation (RFA / MWA / Cryo)	Percutaneous access favorable; best ablation margin achievable
Multicentric or infiltrative disease	Transarterial therapy (TACE / TARE)	Lobar injection covers entire territory; subselective impractical
Central / hilar location	Transarterial therapy preferred	Proximity to major bile ducts increases ablation complication risk
Adjacent to diaphragm	Transarterial therapy preferred	Ablation risks phrenic nerve injury / diaphragm injury
Portal vein thrombosis present	Transarterial therapy safe (Chern 2014)	Hepatic arterial supply still intact; TACE/TARE feasible
Tumor <3 cm, peripheral	Ablation (optimal results)	Median survival up to 33 months reported (Fu et al. JVIR 2012)
Tumor 3–7 cm, peripheral	Ablation (emerging data)	Results intermediate; IRE / MWA for larger zones; Haidu et al. 2012

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Manage Expectations: No locoregional therapy is curative for cholangiocarcinoma. Estimated survival benefit of 2–7 months over systemic chemotherapy historical controls (Ray et al. 2013 meta-analysis). Set appropriate patient and family expectations at the time of consultation.

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Pre-Procedure Planning

Multidisciplinary workup, labs, antibiotics, patient prep

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Imaging & Workup

Meticulous review of cross-sectional imaging (CT and/or MRI): tumor location, centricity, number, proximity to vasculature and bile ducts, arterial supply
Multidisciplinary team discussion: surgery, medical oncology, diagnostic radiology, IR, radiation oncology
Assess surgical resectability (R0 resection) first — IR consultation for unresectable patients
Determine portal venous patency and biliary patency — increased complication risk if either is compromised
Identify percutaneous access windows for ablation planning (CT and/or US targeting)
For TARE: pre-treatment ^99mTc-MAA lobar injection to assess lung shunt fraction; coil-embolize significant extrahepatic collaterals prior to Y90 delivery

Labs & Patient Assessment

CBC, comprehensive metabolic panel, LFTs, coagulation studies (PT/INR, aPTT)
ECOG performance status — ECOG ≤2 appropriate for therapy
Tumor markers: CA 19-9 and CA-125 at baseline — track for treatment response; note: both can be spuriously elevated with biliary infection
Bilirubin elevation — differentiate obstruction (common, may not reflect true hepatocyte reserve) from hepatocellular dysfunction
Type & screen for high-bleeding-risk cases (central tumors, percutaneous ablation)
Creatinine / GFR for contrast nephropathy risk stratification

Antibiotic Prophylaxis (Required)

Cholangiocarcinoma patients require prophylactic antibiotics covering both skin flora and gram-negative biliary colonizers. Duration: 3–7 days typical; up to 14 days in high-risk patients (biliary-enteric anastomosis, prior biliary stenting, immunocompromised).

Ampicillin/sulbactam 1.5–3 g IV (first choice)
Cefazolin 1 g IV + metronidazole 500 mg IV
Ceftriaxone 1 g IV
Penicillin allergy: levofloxacin 500 mg IV or ciprofloxacin 500 mg IV + metronidazole 500 mg IV
Bowel preparation may reduce biliary infection risk, especially with biliary-enteric anastomosis

MDT discussion documented. Surgical unresectability confirmed. Liver-directed therapy endorsed as appropriate.

Imaging reviewed. Tumor location, number, arterial supply, portal vein, and biliary patency assessed. Percutaneous or endovascular access plan confirmed.

ECOG score documented — ECOG ≤2 for procedural candidacy.

Baseline labs obtained: CBC, LFTs, coagulation, CA 19-9, CA-125, creatinine.

Antibiotics ordered with gram-negative coverage. Duration extended to 7–14 days if biliary-enteric anastomosis present.

Bowel prep performed if biliary-enteric anastomosis present or biliary instrumentation anticipated.

IV hydration initiated for contrast nephropathy prophylaxis.

Informed consent obtained. Procedure-specific risks discussed: postembolization syndrome, abscess risk (especially with biliary-enteric anastomosis), biliary injury, liver failure, non-target embolization. Off-label nature of all chemotherapy regimens disclosed.

Postembolization syndrome pre-treatment prepared (for TACE/TARE): dexamethasone 10 mg IV q8h, ondansetron 4–8 mg IV q4h, PCA pump or IV opioid PRN, Ofirmev (acetaminophen 1 g IV — use cautiously with liver disease).

Conscious sedation plan confirmed. Anesthesia notified if MAC required.

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Relevant Anatomy

CCA classification, hepatic arterial supply, biliary considerations

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CCA Classification by Location

Hilar (Klatskin tumor): most common; confluence of right and left hepatic ducts; high surgical complexity; poor percutaneous ablation candidate due to central location
Extrahepatic: distal common bile duct; typically managed surgically (Whipple) when resectable
Gallbladder: treated separately; aggressive biology
Intrahepatic (~10%): primary target for liver-directed IR therapy; mass-forming or infiltrative; derives blood supply from hepatic arterial circulation (analogous to HCC)

Hepatic Arterial Supply

Standard anatomy: celiac axis → common hepatic artery → proper hepatic artery → right and left hepatic arteries
Replaced or accessory right hepatic artery from SMA: present in ~20% of patients — identify on pre-procedure CT
Replaced left hepatic artery from left gastric artery: present in ~10% — may supply left lobe CCA
Intrahepatic CCA: hypovascular relative to HCC — often angiographically occult on standard arteriography; use cone-beam CT (CBCT) for lesion identification and targeting during subselective embolization
Identify cystic artery origin prior to embolization to reduce cholecystitis risk

Biliary Anatomy Considerations

The proximity of intrahepatic CCA to major bile ducts is a critical planning variable for both transarterial and ablative therapy. Central tumors near the hepatic hilum carry increased risk of bile duct injury with thermal ablation and increased risk of biloma or biliary stricture post-embolization. Portal venous patency should be confirmed pre-procedure — compromised portal flow (from tumor invasion or thrombosis) increases risk of hepatic infarction after transarterial embolization, yet TACE and TARE have been demonstrated safe even in the setting of portal vein thrombosis (Chern et al. 2014).

Prior biliary-enteric anastomosis (hepaticojejunostomy, choledochojejunostomy): eliminates the natural antimicrobial barrier of the sphincter of Oddi; biliary tree is colonized with enteric organisms; hepatic abscess rate ≥25% with embolization; aggressive prophylaxis and bowel prep are mandatory
Biliary stents or drains in place: enteric organisms inoculated in bile; treat prophylactically as high-risk patient
Tumor causing biliary obstruction may falsely elevate bilirubin beyond degree attributable to hepatocellular dysfunction — decompress biliary obstruction before embolization if feasible

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Supplies & Setup

Arterial access, chemotherapy agents, ablation probes

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Transarterial Access & Equipment

US + micropuncture access set (transfemoral arterial access)
5F vascular sheath
5F angiographic catheters: Cobra 2, SOS Omni
0.035–0.038 guidewires
Power injector
Microcatheter + microwire (for subselective catheterization in tortuous anatomy)
Cone-beam CT (CBCT) capable angiography suite — essential for occult tumor targeting
Separate chemotherapy preparation tray (chemotherapy safe handling)

Chemotherapy Agents (All Off-Label)

Irinotecan 200 mg
Mitomycin C 2–15 mg
Cisplatin 50 mg or 45–50 mg/m² or 2 mg/kg
Oxaliplatin 50 mg or 85–100 mg/m²
Doxorubicin 50–150 mg or 50 mg/m²
5-FU 450 mg/m²
Gemcitabine 1,000–2,250 mg/m²
Vehicles: drug-eluting beads (soak 2–4 hours prior; reconstitute 50/50 saline/contrast), PVA particles, Gelfoam
⁹⁰Y microspheres (for TARE/radioembolization)

Ablation Probes & Medications

RFA probe (single or cluster, per tumor size; Covidien, RITA, others) — largest published experience
Microwave ablation antenna (expandable applicators for larger zones)
Cryoablation probes ×2–4 (IceSense, Galil; per lesion size)
IRE probes ×2–6 (NanoKnife; newest modality)
CT or US guidance with probe visibility confirmed before placement
Iodinated contrast for single-pass CT injection if poor visibility
Prophylactic antibiotic IV (per regimen above)
IV sedation: midazolam + fentanyl (moderate sedation) or MAC per anesthesia
General anesthesia required for IRE (electrical stimulation causes muscle contractions)

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Procedure Steps

Transarterial therapy and ablative therapy workflows

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Workflow A — Transarterial Therapy (TACE / TARE)

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Transfemoral Arterial Access

Standard transfemoral arterial access with US and micropuncture technique. Advance 5F sheath. Obtain aortogram or selective celiac arteriogram to map hepatic arterial anatomy. Identify standard vs. replaced or accessory hepatic arterial anatomy (replaced right hepatic from SMA in ~20%; replaced left hepatic from left gastric in ~10%). Document cystic artery origin to avoid non-target cholecystitis.

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Select Proper Hepatic Artery

Advance 5F diagnostic catheter (Cobra 2 or SOS Omni) into proper hepatic artery. For TACE: lobar injection generally preferred for multicentric or infiltrative disease; subselective injection for focal disease if safe margin from cystic artery and major bile ducts can be maintained. For TARE: lobar injection standard; bilobar disease treated in sequential sessions.

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Cone-Beam CT for Occult Tumor Targeting

Intrahepatic CCA is frequently hypovascular and angiographically occult on standard DSA. Perform cone-beam CT (CBCT) after selective hepatic artery catheterization to identify tumor blush and correlate with cross-sectional imaging. CBCT is essential for subselective catheterization planning — do not rely on fluoroscopy alone for lesion targeting. If feasible, advance microcatheter to tumor-feeding branch under CBCT guidance.

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Chemotherapy Preparation and Injection (TACE)

Prepare chemotherapy per institutional protocol and pharmacy guidelines (all regimens off-label). For drug-eluting beads: soak beads 2–4 hours prior; reconstitute 50/50 saline/contrast. For conventional TACE: mix chemotherapy agent with Lipiodol and embolic material. Inject slowly under intermittent fluoroscopy. End point: complete drug dose administered OR 2–5 beat stasis of lobar/segmental flow observed. Do not over-embolize in patients with compromised hepatic reserve.

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Radioembolization Delivery (TARE / Y90)

Applicable only after pre-treatment ^99mTc-MAA lung shunt study confirms acceptable shunt fraction (<20% or per institutional threshold). Confirm all significant extrahepatic collaterals coil-embolized at prior session. Deliver ⁹⁰Y microspheres lobar or segmentally per dosimetry prescription. Standard: lobar delivery; bilobar disease treated in sequential sessions 4–6 weeks apart. Follow radiation safety protocols throughout delivery.

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Completion Angiogram and Access Closure

Perform completion DSA to confirm intended distribution and absence of non-target embolization (cholecystitis, GI artery compromise, diaphragmatic vessels). Remove catheter and sheath. Achieve hemostasis by manual compression or vascular closure device. Monitor femoral access site.

Workflow B — Ablative Therapy (RFA / MWA / Cryo / IRE)

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Pre-Procedure Targeting and Probe Selection

Confirm both target tumor AND ablation probe are visible on the planned guidance modality (CT and/or US). No ablation technique has been shown superior to others in CCA. RFA has the largest published experience; microwave achieves larger ablation zones more rapidly; cryoablation provides a visible ice ball; IRE (NanoKnife) is non-thermal and preferred near bile ducts or vessels. Select probe to achieve tumor ablation plus ≥0.5 cm margin (target 1 cm margin when anatomy permits).

2

Patient Positioning, Sedation, and Skin Prep

Position patient for optimal access window to target lesion on CT or US guidance (prone, supine, or lateral decubitus per tumor location). Confirm IV access. Administer moderate sedation (midazolam + fentanyl) or MAC. General anesthesia required for IRE. Apply sterile prep. Infiltrate lidocaine 1% along planned probe trajectory from skin to liver capsule.

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Probe Placement Under Imaging Guidance

Under CT or US guidance, advance probe through the planned trajectory to the target lesion. Confirm tip position within the deepest margin of the tumor prior to ablation. If poor visualization with primary modality: use single iodinated contrast injection under CT to opacify the lesion, or switch to alternative guidance modality. For IRE: place multiple electrode probes in parallel, spaced 1.5–2 cm apart, spanning the tumor. Confirm acceptable probe geometry before energy delivery.

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Energy Delivery

Deploy probe per manufacturer protocol. RFA: active tip deployment if applicable; target tissue temperature 60–100°C; ablate until impedance roll-off or target time reached; overlap ablations for larger tumors. MWA: per system parameters; typically 45–150W, 3–10 min; adjust power and time for tumor size. Cryoablation: freeze-thaw-freeze cycle (typically two 10-min freeze cycles with 5-min passive thaw); ice ball must extend ≥5–10 mm beyond tumor margin. IRE: 90 high-voltage electrical pulses per electrode pair; confirm patient paralysis maintained to prevent movement during pulses.

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Tract Ablation During Withdrawal

During probe removal, ablate the needle tract (for thermal techniques) to reduce risk of tumor seeding along the probe path and to achieve hemostasis at the liver capsule. Apply continuous coagulation energy during slow withdrawal. This is strongly recommended for intrahepatic CCA given its infiltrative biology.

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Post-Ablation Imaging

Obtain immediate post-ablation CT (with and without contrast if feasible) to confirm adequacy of the ablation zone relative to tumor margins and to assess for immediate complications (hematoma, pneumothorax, biloma, biliary injury). An ablation zone extending ≥0.5 cm beyond all tumor margins in all planes is the target. If a margin deficiency is identified, consider immediate re-ablation from the same access. Document for comparison at follow-up imaging 4–6 weeks post-procedure.

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Troubleshooting

Intraoperative problems and solutions

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Angiographically Occult Tumor

Tumor Not Visible on Standard DSA

Intrahepatic CCA is commonly hypovascular and not visible on standard DSA. Do NOT abandon the case — proceed to cone-beam CT (CBCT) after selective hepatic artery injection. CBCT with late arterial or parenchymal phase acquisition typically reveals the lesion. Correlate with pre-procedure cross-sectional imaging for segmental localization. If CBCT is unavailable, a non-selective lobar injection targeting the affected lobe is acceptable for multicentric or infiltrative disease.

Proximity to Bile Duct

Tumor Abutting or Encasing a Major Bile Duct

Thermal ablation within 1 cm of a major bile duct carries high risk of biliary stricture or bile duct necrosis. Consider switching to IRE (NanoKnife), which is non-thermal and preserves bile duct integrity. Alternatively, consider transarterial therapy rather than ablation for central tumors. If ablation must proceed adjacent to a critical bile duct, place a biliary drain beforehand and irrigate with cold saline during ablation to reduce thermal injury (biliary thermoprobe technique).

Poor Probe Visibility

Ablation Probe Not Visible on Guidance Modality

If CT visibility is poor (isodense probe in fatty liver or hepatic parenchyma), perform a single small-volume contrast injection via a separate IV or through the probe if compatible, to mark the probe tip. If US is being used and the probe tip is not visible, switch to CT guidance. Do not proceed with ablation until probe tip position is definitively confirmed — non-target ablation near bile ducts or vessels can cause catastrophic injury.

Biliary-Enteric Anastomosis

Patient Has Prior Biliary-Enteric Anastomosis

This is the single highest-risk feature for hepatic abscess after embolization (≥25% abscess rate). If not already initiated, start aggressive broad-spectrum antibiotics (gram-negative + anaerobic coverage) immediately. Ensure bowel preparation was performed pre-procedure. Consider whether the procedure should proceed at all — in patients with prior biliary-enteric anastomosis, discuss risk-benefit with the referring team and patient. If proceeding: use the minimum embolic load, maintain antibiotic coverage for at least 7–14 days post-procedure, and counsel patient and family on abscess signs to watch for.

Non-target Embolization Risk

Cystic Artery or GI Collateral Origin Near Target Vessel

If the cystic artery arises from the vessel being embolized, consider either: (1) subselective catheterization past cystic artery origin with microcatheter before embolization, or (2) coil-embolizing the cystic artery prior to chemoembolization. For vessels supplying diaphragm or GI tract (right inferior phrenic, gastric branches): identify and preserve these, or if inadvertently embolized, monitor for pleural effusion, cholecystitis, or gastritis.

Incomplete Ablation Zone

Post-Ablation Imaging Reveals Margin Deficiency

If post-ablation CT shows a residual unablated tumor margin, do not withdraw from the room. Immediately re-access the deficient margin with an additional probe pass from the same skin entry site if feasible. Repositioning the probe while the patient remains on the table is far more effective and efficient than scheduling a second session weeks later. Small marginal areas of residual enhancement adjacent to a large ablation zone can be re-targeted at 4–6 week follow-up imaging if immediate re-treatment is not possible.

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Complications

Anticipated side effects vs true complications; abscess risk stratification

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Postembolization Syndrome (Expected)

Fever, nausea, abdominal pain, fatigue — common after TACE/TARE; expected inflammatory response to tumor necrosis; typically 3–7 days duration
Pre-treat with dexamethasone, ondansetron, and analgesics; continue supportively post-procedure
Transient LFT elevation — expected; monitor at 1–2 week follow-up; should trend toward baseline by 4–6 weeks

Hepatic Abscess

Rate ≥25% with prior biliary-enteric anastomosis — far exceeds general population risk; distinguish from expected post-embolization fever by persistent/worsening fever beyond 7 days and imaging
Treatment: percutaneous drainage + IV antibiotics (gram-negative and anaerobic coverage)
Abscess in a non-anastomosis patient: still possible (2–5%); drain if >3 cm or symptomatic

Non-target Embolization

Postembolization cholecystitis: inadvertent cystic artery embolization; most common non-target complication; treat conservatively if mild; cholecystectomy if gangrenous
Pleural effusion: diaphragmatic vessel embolization; usually self-limited; thoracentesis if symptomatic and large
Gastritis / gastric ulceration: embolization of gastric arterial branches; monitor; PPI therapy

Vascular Complications

Arterial dissection at catheterization — usually self-limited with 5F catheter; maintain wire across if dissection extends; convert to contralateral femoral or radial access if needed
Femoral puncture site hematoma — manual compression or vascular closure device; ultrasound assessment if expanding
Portal vein thrombosis (rare) — post-embolization; anticoagulation per hematology/hepatology

Ablation-Specific Complications

Biliary injury / bile duct stricture: especially with thermal ablation near major ducts; IRE preferred in this setting; biliary drain for symptomatic stricture or biloma
Tumor seeding along probe tract: uncommon; prevented by tract ablation during withdrawal; higher risk with infiltrative histology
Pneumothorax: from trans-diaphragmatic or trans-pleural probe approach; monitor post-procedure CT; aspiration or chest tube if >20% or symptomatic
Hemorrhage: subcapsular or intraperitoneal hematoma; monitor with post-procedure imaging; interventional management (embolization) if bleeding is active and significant
Post-cryoablation cryo-shock: rare systemic inflammatory response; supportive care; ICU monitoring if severe

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Post-Procedure Care

Recovery, discharge instructions, follow-up imaging, outcomes

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Immediate Recovery

Routine post-sedation recovery; monitor vital signs per standard protocol
Overnight admission standard for TACE, TARE, and major ablations
Continue antiemetics and analgesics for postembolization syndrome management through recovery
Monitor for fever: low-grade fever expected post-embolization; temp >38.5°C persisting beyond 48h or new fever at 5–7 days should prompt imaging evaluation for abscess
IV fluid support as needed; encourage oral hydration once tolerating POs
Medical consultations as needed (hepatology, oncology if acute liver decompensation concerns)

Discharge Instructions & Follow-up

Discharge next day (standard overnight admission) if stable and pain controlled
Clinic follow-up 1–2 weeks post-procedure: repeat labs (CBC, LFTs, coagulation, CA 19-9)
Follow-up imaging: 4–6 weeks post-procedure (or after final session if multiple sessions planned); typically contrast-enhanced CT or MRI; assess for treatment response, residual/recurrent disease, and complications
Additional sessions planned based on tumor response, residual viable disease, and patient tolerance and performance status
Return precautions: fever >38.5°C, worsening right upper quadrant pain, jaundice, signs of infection → return to ED
Coordinate follow-up care with medical oncology for systemic therapy decisions

Clinical Outcomes Summary

Modality	Key Study	Result
TACE (meta-analysis)	Ray et al. JVIR 2013 (n=542)	76.8% stable disease or response; estimated 2–7 month survival benefit vs. systemic chemotherapy historical controls
TACE (multicenter retrospective)	Hyder et al. Ann Surg Oncol 2013 (n=198)	~75% disease control; OS 13 months; improved vs. historical systemic therapy controls
Radioembolization (Y90)	Mouli et al. JVIR 2013 (n=46)	Up to 15.6-month survival in select subtypes; 11% (5/46) became resectable after treatment
Ablation (RFA, multiple retrospective series)	Fu et al. JVIR 2012 and others	Median survival up to 33 months; best results with tumors <3 cm; intermediate results <5 cm; emerging data up to 7 cm (Haidu et al. CVIR 2012)

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Response Assessment: Use mRECIST or RECIST 1.1 criteria at follow-up imaging. Enhancement at the periphery of a treated lesion is suspicious for residual viable tumor and should prompt repeat treatment planning. CA 19-9 trending downward at 4–6 weeks is a favorable early response marker, bearing in mind that biliary infection can falsely elevate this value.

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References & Resources

Primary sources and related procedures

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Source Chapter

Brown M, Rochon PJ, Gupta RK, Ray CE Jr. Chapter 10: Cholangiocarcinoma: Ablation and Intra-arterial Therapies. In: Faintuch S, Salazar GM, eds. Interventional Oncology: Principles and Practice of Image-Guided Cancer Therapy. Thieme; 2015:155–167.

Primary References

Ray CE Jr et al. (Meta-analysis). Chemoembolization for unresectable intrahepatic cholangiocarcinoma. J Vasc Interv Radiol. 2013;24(8):1218–1226.
Hyder O et al. Intra-arterial therapy for advanced intrahepatic cholangiocarcinoma: a multi-institutional analysis. Ann Surg Oncol. 2013;20(12):3779–3786.
Mouli S et al. Yttrium-90 radioembolization for intrahepatic cholangiocarcinoma: safety, response, and survival analysis. J Vasc Interv Radiol. 2013;24(8):1227–1234.
Fu Y et al. Radiofrequency ablation for intrahepatic cholangiocarcinoma. J Vasc Interv Radiol. 2012;23(5):642–649.
Haidu M et al. Microwave ablation of intrahepatic cholangiocarcinoma: a single-institution experience. Cardiovasc Intervent Radiol. 2012;35(5):1074–1082.
Chern M-C et al. Chemoembolization for intrahepatic cholangiocarcinoma with portal vein tumor thrombus. J Vasc Interv Radiol. 2014;25(1):32–40.
Valle J et al. (ABC-02 Trial). Cisplatin plus gemcitabine versus gemcitabine for biliary tract cancer. N Engl J Med. 2010;362(14):1273–1281.
Razumilava N, Gores GJ. Classification, diagnosis, and management of cholangiocarcinoma. Clin Gastroenterol Hepatol. 2013;11(1):13–21.
Venkatesan AM et al. (SIR Standards of Practice). Quality improvement guidelines for transarterial chemoembolization. J Vasc Interv Radiol. 2010;21(11):1611–1630.
Amini N et al. Downstream staging of cholangiocarcinoma using novel markers. J Surg Oncol. 2014;110(2):163–170.
Rea DJ et al. Liver transplantation with neoadjuvant chemoradiation is more effective than resection for hilar cholangiocarcinoma. Ann Surg. 2005;242(3):451–458.
Park SY et al. Percutaneous radiofrequency ablation of hepatocellular carcinoma and intrahepatic cholangiocarcinoma. AJR Am J Roentgenol. 2011;197(6):W1129–34.
Gates VL et al. Internal pair production dosimetry of yttrium-90 microspheres. J Vasc Interv Radiol. 2014;25(2):266–270.
Patel S et al. Hepatic arterial embolization and chemoembolization for treatment of patients with metastatic carcinoid tumors. J Vasc Interv Radiol. 2006;17(12):1931–1934.
Khan SA et al. (British Society of Gastroenterology). Guidelines for the diagnosis and treatment of cholangiocarcinoma. Gut. 2012;61(12):1657–1669.