Curative Radiation as Monotherapy for Intrahepatic Cholangiocarcinoma: A Case Report

Purpose: Intrahepatic cholangiocarcinoma (IHCC) is the second most common primary liver tumor and often presents as advanced disease.1 Resection is considered the only curative treatment, but only 20-30% of patients are surgical candidates.2 First-line therapy for unresectable IHCC is chemotherapy consisting of gemcitabine, cisplatin and durvalumab.4 However, external beam radiation therapy (EBRT) and radioembolization with yttrium-90 (Y-90) are alternatives for patients with unresectable IHCC.1,3 We present a case of an 88 year-old woman diagnosed with intrahepatic cholangiocarcinoma 15 years ago whose only treatment to date has been internal and external radiation.

Methodology: The patient’s case was reviewed as part of an IRB exempt retrospective study. Her clinical record, imaging, dosimetry records, treatment plan, and treatment images were reviewed by the study team.

Results: The patient presented in 2008 with an 8.1 by 7.3 left liver lobe lesion consistent with IHCC for which she received Y-90 radioembolization (146 Gy) followed by right lobe Y-90 radioembolization (103 Gy) at recurrence in 2014. In 2016, imaging showed growth of peripherally enhancing masses adjacent to the previously treated area, so she underwent repeat Y-90 radioembolization of the right hepatic artery (84.1 Gy). In 2019, she had further recurrence in the left lobe for which she was treated with ablative dose EBRT which was well-tolerated aside from radiation-induced pneumonitis/pleural effusion which she recovered from well. At nearly 15 years post treatment, the patient maintains an excellent quality of life and at the time of this report has stable disease on surveillance.

Conclusions: The successful approach of transarterial Y-90 brachytherapy and ablative EBRT for this elderly patient suggests radiosensitivity of IHCC. As less than 10% of IHCC cases have been treated with radiotherapy,1 these therapies are underutilized, and new prospective trials should explore the role of RT in this disease.

References: 1. Avila S, Smani DA, Koay EJ. Radiation dose escalation for locally advanced unresectable intrahepatic and extrahepatic cholangiocarcinoma. Chin Clin Oncol. 2020 Feb;9(1):10. doi: 10.21037/cco.2019.12.05. Epub 2019 Dec 19. PMID: 32008331; PMCID: PMC7277074.
2. Moris D, Palta M, Kim C, Allen PJ, Morse MA, Lidsky ME. Advances in the treatment of intrahepatic cholangiocarcinoma: An overview of the current and future therapeutic landscape for clinicians. CA Cancer J Clin. 2023 Mar;73(2):198-222. doi: 10.3322/caac.21759. Epub 2022 Oct 19. PMID: 36260350.
3. Kis B, Shridhar R, Mhaskar R, Gyano M, Frakes JM, El-Haddad G, Choi J, Kim RD, Hoffe SE. Radioembolization with Yttrium-90 Glass Microspheres as a First-Line Treatment for Unresectable Intrahepatic Cholangiocarcinoma-A Prospective Feasibility Study. J Vasc Interv Radiol. 2023 Sep;34(9):1547-1555. doi: 10.1016/j.jvir.2023.05.026. Epub 2023 May 18. PMID: 37210030.
4. Oh D-Y, He AR, Quin S, Chen L-T, Okusaka T, Vogel A, et al. Durvalumab plus Gemcitabine and Cisplatin in Advanced Biliary Tract Cancer. NEJM Evidence. 2022;1(8):1-11