Surgical resection remains the cornerstone of curative treatment for intrahepatic cholangiocarcinoma (iCCA), but this option is only available to a small percentage of patients. For patients with unresectable iCCA, systemic therapy with gemcitabine and platinum-based agents represents the mainstay of treatment; however, the armamentarium has grown to include targeted molecular therapies (e.g., FGFR2 inhibitors), use of adjuvant therapy, liver transplantation in select cases, immunotherapy, and locoregional liver-directed therapies. Despite advances, iCCA remains a challenge due to the advanced stage of many patients at diagnosis. Furthermore, given the improving options for systemic therapy and the fact that the majority of iCCA patients succumb to disease progression in the liver, the role of locoregional therapies has increased. This review will focus on the expanding role of interventional radiology and liver-directed therapies in the treatment of iCCA.

Significant pelvic pain is a fairly common malady in the United States. At the same time, the opioid epidemic has changed how pain is thought about and treated, resulting in a clear call for alternative treatment strategies. One of the promising techniques that has emerged over the last several years is cryoneurolysis. Cryoneurolysis allows for personalization of treatment through targeting of specific peripheral nerves, which correspond to a patient’s pain. In the setting of pelvic pain, several viable targets, namely the pudendal nerve and impar ganglion, have been described. This review delineates the mechanism of action in cryoneurolysis, reviews the pertinent literature and describes patient workup and technique. Finally, future directions are discussed.

SignificanceThe current technology has limited ability to detect lateral thermal spread of injury caused by electrosurgical devices during gynecologic procedures.AimWe aim to assess the feasibility of endoscopic optical coherence tomography (OCT) to detect electrothermal ureteral damage.ApproachElectrothermal energy was externally applied to nine explanted porcine ureters. Three segments of each ureter were treated for 5 s at low (16 W), medium (26 W), and high (36 W) powers (n=27 segments). Volumetric OCT images were acquired using a swept source OCT laser endomicroscopy system. OCT datasets were visually inspected for characterization of normal and electrothermally injured tissue architecture. Ground-truth comparisons were made with histology to validate the presence of lesions and to compare lesion size measurements using Pearson’s correlation coefficient. Three physicians were trained to identify OCT images of normal and injured ureters. Physician lesion detection accuracy was tested with 126 OCT images (63 normal and 63 injured). The effect of treatment power on lesion length as measured with OCT was compared using a one-way analysis of variance.ResultsTransmural electrothermal injury was identified on OCT images for all but one histology-confirmed lesion (22/23, 95.7%). The average sensitivity and specificity for physician lesion detection were 82% and 96%, respectively. The mean lesion size measured on OCT was 3.6±1.9, 4.4±1.3, and 7.0±2.9 mm for low, medium, and high powers, respectively (p=0.024). A comparison of lesion size measured on OCT and histology revealed a moderate positive correlation (r=0.65, p=0.00087).ConclusionsEndoscopic OCT could fulfill the unmet clinical need for the timely detection of electrothermal ureteral injury.