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Bale et al. Hepatoma Res 2023;9:44 https://dx.doi.org/10.20517/2394-5079.2023.71 Page 9 of 13

Despite the consistently good outcomes, stereotactic approaches are still utilized in only a small number of
[78]
centers worldwide . This is likely due to the requirement for additional investments, such as a 3D
navigation system, a dedicated CT, and the availability of general anesthesia. Additionally, the stereotactic
approach necessitates the training of a specialized team composed of an interventional oncologist, a
radiation technician, and an anesthesiologist.

Combination of thermal ablation with lymph node dissection
The presence of nodal metastasis in iCCA patients is associated with a poor prognosis, with a median
[79]
survival of < 20 months . Therefore, adequate lymphadenectomy (at least 6) during surgical resection is
recommended for accurate staging . However, it is still unclear if the additional morbidity related to
[80]
lymphadenectomy during SR is justified because the impact on survival remains uncertain . We therefore
[81]
recommend combining thermal ablation with laparoscopic LND only in cases with highly suspicious lymph
nodes on cross-sectional imaging and/or PET scan, as there is no clear evidence of a survival benefit to
removing LN in the setting of an ablation.

SUMMARY
Percutaneous image-guided thermal ablation techniques such as RFA and MWA are safe and well-tolerated
local curative treatment options. These treatment modalities are associated with a lower risk of
complications and a shorter hospital stay compared with resection. In addition, these techniques spare
healthy tissue and may also be applied in unresectable patients. The reported median OS after conventional
US- or CT-guided RFA and MWA in patients with unresectable or recurrent iCCA ranges from 10-39
months. For the treatment of patients with primary iCCA, retrospective studies indicate that SR is more
effective than conventional US- and CT-guided thermal ablation. Among patients with recurrent iCCA after
SR, two recent studies reported similar long-term outcomes for thermal ablation and repeated SR, with the
risk of severe complications being in favor of thermal ablation. The number of nodules and tumor size are
relevant prognostic factors. Technical developments such as stereotaxy, image fusion, and robotics improve
the efficacy and outcome of thermal ablation procedures. Multi-needle SRFA with intraprocedural control
of the ablation result by means of image fusion allows for effective and reliable treatment of large and
multiple iCCA nodules within one session with excellent short- and long-term results that are comparable
to resection. With the addition of SRFA as an alternative treatment option for recurrent iCCAs, the rate of
curative re-treatment can be increased significantly.

As a result of the rarity of early iCCA, evidence regarding the efficacy of all different local treatment options
remains scant. There are no prospective studies comparing thermal ablation and SR for the treatment of
primary and recurrent iCCA available. More research, including validation of technical and clinical
predictors and a better understanding of the molecular biology of tumors, should help to stratify patients for
a combination of local and systemic treatments including promising immunotherapies and targeted
[82]
therapies .

DECLARATIONS
Authors' Contributions
Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Supervision, Validation,
Writing-original draft, Writing-review & editing: Bale R
Methodology, Supervision, Validation, Writing-original draft, Writing-review & editing: Pawlik TM