University of Chicago interventional radiologists collaborated with several specialties to combine treatment to improve the prognosis of patients with intrahepatic cholangiocarcinoma (iCCA).
The findings of abstract 303, “Combination Yttrium-90 Radioembolization with Concomitant Systemic Gemcitabine, Cisplatin, and Capecitabine as First Line Therapy for Intrahepatic Cholangiocarcinoma (iCCA),” will be presented Wednesday at 3 p.m. as part of Scientific Session 31, Radioembolization: Beyond HCC 3.
The second most common primary liver cancer, iCCA often has poor outcomes. It originates inside the liver and, by the time it is discovered, the tumors are usually very large and invading other structures, said presenter Osman Ahmed, MD, associate professor of radiology, University of Chicago.
“More often than not, these tumors are being incidentally discovered,” Dr. Ahmed said. “The patient may fall and get a CT scan … and we’re lucky [in those cases] because they’re small enough that they could be resected or be treated to get to resection. But overall, they’re usually presenting at a very advanced stage—usually at stage 4—and at a very poor prognosis.”
Dr. Ahmed’s team developed a hospital protocol to treat iCCA using a combination of chemotherapy and yttrium-90 (Y-90) transarterial radioembolization (TARE) to shrink the tumor enough that the patient could then undergo surgical resection. They used the protocol on 13 patients with iCCA who were determined not to be surgical candidates because of the size of the tumor and recurrence risk.
“Our approach was, why don’t we try to shrink and kill the tumor as much as possible, so let’s do a neoadjuvant therapy of a combination of both chemo and radioembolization … so that when you do go in and resect it you’re going to maximize your chances that you’re going to get an R0 resection and hopefully minimizing the chance that they have a recurrence,” Dr. Ahmed explained.
“Oftentimes, we think of our therapies as competing with other specialties, but this is actually a progressive view of treatment in terms of the potential benefits of combination treatment and/or potential synergy,” he added.
Between December 2018 and May 2021, 13 patients were given the treatment. The patients’ mean age was 62. Ten patients had a single lesion, and the average dominant lesion measured 6.3cm.
Patients received intravenous gemcitabine and cisplatin for three cycles, followed by restaging scans. In the absence of disease progression, TARE using glass microspheres was administered with oral capecitabine for one or two cycles. An additional three cycles of gemcitabine and cisplatin were given, followed by restaging scans and evaluation for resectability.
The study showed a median overall survival of 29 months, calculated from the time of diagnosis. From the initial cycle of chemotherapy, median overall survival was 24 months and, from the time of TARE, median overall survival was 10 months. Seven patients were bridged or downstaged to surgery and had a more favorable overall survival.
Previous studies using TARE have mostly focused on the salvage option or large recurrent tumors, said Qian (Clark) Yu, MD, a second-year IR resident at the University of Chicago who was part of the research team. “Our study in comparison is very unique in that we collaborated with clinicians from other fields and added Y-90 as an upfront, first-time treatment,” Dr. Yu said.
The University of Chicago continues to use this protocol with iCCA patients. “As we continue to get more data on this, we’ll hopefully show the added survival benefit of adding radioembolization,” Dr. Ahmed said.
The study also showed that while radioembolization shrinks tumors, it also grows the untreated part of the liver, which is an added benefit to leave more liver behind to potentially improve surgical outcomes, Dr. Ahmed said.
