Interventional Radiology Role in Caring for Primary Sclerosing Cholangitis and Cholangiocarcinoma Dustin Thompson, MD Associate Staff  |  Interventional Radiology Associate Program Director | Interventional Radiology Fellowship Clinical Assistant Professor of Radiology  |  Cleveland Clinic Lerner College of Medicine of Case Western Reserve University Cleveland Clinic  |  9500 Euclid Ave. L10  |  Cleveland, OH 44195 (216) 444-2907

Goals Know what an Interventional Radiologist is Know what bile ducts look like Know some of the interventional radiology procedures available

Biliary anatomy This image has been released as part of an open knowledge project by Cancer Research UK. If re-used, attribute to Cancer Research UK / Wikimedia Commons

CT of dilated bile ducts

Hilar mass on magnetic resonance cholangiopancreatography (MRCP)

When to get more invasive Imaging studies show an abnormality Elevated bilirubin levels Elevated liver enzymes Infection in the biliary system

Endoscopic retrograde cholangiopancreatography (ERCP) versus percutaneous transhepatic cholangiography (PTHC) When ERCP can't reach its goal Altered anatomy due to surgery Difficulty finding ampulla Mass or stricture too tight to pass with ERCP

Initial cholangiogram

Internal external biliary drain

Left sided biliary tube after right hepatectomy for cholangiocarcinoma

Multiple biliary drains required due to hilar mass

Bridging to resection or transplant Portal vein embolization Intra-arterial treatments Bland embolization Transarterial Chemoembolization (TACE) Radioembolization 90Y Ablation

Portal vein embolization Dual blood supply to the liver Hepatic arteries supply bile ducts and are recruited by tumors Portal veins supply majority of blood flow to normal liver Portal vein embolization performed to induce growth of normal liver on the opposite side

Portal vein embolization

Intra-arterial treatments Arterial embolization is performed to target tumors that have recruited blood supply and to preserve normal liver Bland embolization Transarterial Chemoembolization (TACE) Drug eluting beads (DEB-TACE) 90Y Radioembolization (SIR SPHERE, THERASPHERE)

Hepatic angiogram and chemo embolization or radioembolization

Ablation Radiofrequency Microwave

Conclusions Difficult to perform “gold standard” randomized controlled trials due to variability of patients, disease process, and multiple number of available treatments Optimal care depends on multiple consultants Important to have varied approaches to the disease that can be adapted to patient’s specific situation

Goals Know what an Interventional Radiologist is Know what bile ducts look like Know some of the interventional radiology procedures available

To learn more Arellano R, Sahani D. Imaging of cholangiocarcinoma, Dig Dis Interv 2017; 01(01): 008-013 https://www.thieme-connect.com/products/ejournals/html/10.1055/s-0037-1599255 Ierardi, A.M., Angileri, S.A., Patella, F. et al. The Role of Interventional Radiology in the Treatment of Intrahepatic Cholangiocarcinoma. Med Oncol (2017) 34: 11 https://link.springer.com/article/10.1007%2Fs12032-016-0866-1 Ray CE Jr, Edwards A, Smith MT, Leong S, Kondo K, Gipson M, et al. Metaanalysis of survival, complications, and imaging response following chemotherapy-based transarterial therapy in patients with unresectable intrahepatic cholangiocarcinoma. J Vasc Interv Radiol. 2013;24(8):1218–26

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