Intrahepatic cholangiocarcinoma: the decisions you may face
7 treatment settings, 5 with more than one named option. Each section lays out the options the standard of care names, what each is for, the trials behind them with their recorded results, the side effects and cautions on record, and questions to ask. Built from the cancer page's standard-of-care rows; nothing here is advice for your case.
Diagnosis
Contrast MRI and CT, biopsy, and comprehensive genomic profiling including RNA-based fusion detection for every patient.
MRI uses a strong magnet and radio waves, with no ionising radiation, to picture soft tissue in finer contrast than CT, so it is the standard scan for brain tumours, prostate, rectal cancer staging, liver lesions and breast screening in high-risk women. It is slow, expensive and blurred by movement.
- No ionising radiation
- Best soft-tissue and brain imaging
- Functional sequences (diffusion, perfusion)
A CT scan is a fast 3D X-ray that shows the size and shape of tumours and whether they have spread.
- Fast, ubiquitous
- Sub-millimetre resolution
- Standard for RECIST response
Sequencing hundreds of cancer genes at once from a biopsy to find the mutations a drug can target.
- One test, all actionable alterations
- Trial matching
No trial record is attached to this row yet. The trials tab lists what is recruiting and the landmark trials for this cancer.
- Slow and expensive
- Motion artefacts
- Gadolinium concerns in renal impairment
- Anatomic only; cannot distinguish scar from live tumour
- Radiation dose
- Poor for brain, marrow, and small peritoneal disease
- Tissue quantity
- VUS interpretation
- 2-3 week turnaround
- Between MRI, CT (computed tomography) and Comprehensive genomic profiling, which do you recommend for me, and what about my case would make you choose differently?Why: Guidelines list several reasonable options; the choice turns on details of your tumour, your health and your priorities.
- What is each option trying to achieve: cure, long control, or relief of symptoms, and over what time?Why: The aim shapes how much side effect and disruption is worth accepting.
- What happens if I delay, or decline this step for now? Is the decision reversible?Why: Some decisions can wait for a second opinion or a trial slot; others cannot. Knowing which is part of the choice.
- For my situation (diagnosis), which of the standard options do you recommend and why?Why: Guideline options include: Contrast MRI and CT, biopsy, and comprehensive genomic profiling including RNA-based fusion detection for every patient.
Add these to your appointment list, or take the full question set for this cancer.
Resectable
Hepatectomy with lymph node dissection followed by six months of adjuvant capecitabine (BILCAP).
Capecitabine (Xeloda) is a tablet form of the chemotherapy fluorouracil. It is a backbone of treatment for bowel cancer and a standard option in advanced breast cancer.
- Adjuvant capecitabine for 6 months vs observation after resection of biliary tract cancer
OS 51.1 vs 36.4 months; ITT HR 0.81 (p=0.097), per-protocol HR 0.75.
Overall survival (ITT) (months): Capecitabine 51.1 (n=223) vs Observation 36.4 (n=224) · HR 0.81 · source
No side-effect rates or interaction flags are recorded for these options yet. The side-effect lookup and interaction checker cover the products that have them.
- Is Capecitabine the only reasonable path for me, or is there a trial, a different sequence or a wait-and-see option?Why: A single standard does not mean a single choice; timing and trials are decisions too.
- What is each option trying to achieve: cure, long control, or relief of symptoms, and over what time?Why: The aim shapes how much side effect and disruption is worth accepting.
- How closely do I match the people in BILCAP, and does that change what the results mean for me?Why: Trial populations are selected; age, fitness, prior treatment and biomarkers all affect how far results carry.
- What happens if I delay, or decline this step for now? Is the decision reversible?Why: Some decisions can wait for a second opinion or a trial slot; others cannot. Knowing which is part of the choice.
- For my situation (resectable), which of the standard options do you recommend and why?Why: Guideline options include: Hepatectomy with lymph node dissection followed by six months of adjuvant capecitabine (BILCAP).
- Am I a candidate for Capecitabine, and what side effects should I expect?Why: Knowing the expected toxicities helps you plan work, family, and supportive care.
- How do the results of BILCAP apply to someone like me?Why: Trial populations differ from individual patients; ask how closely you match.
Add these to your appointment list, or take the full question set for this cancer.
Unresectable, liver-confined
Radioembolisation, stereotactic radiotherapy or hepatic artery infusion in specialised centres, usually with systemic therapy; liver transplantation in trials.
Millions of tiny radioactive glass or resin beads are injected into the liver artery, lodging in the tumour and irradiating it from within.
- Outpatient, single session
- Effective in portal vein thrombosis where TACE is contraindicated
- Radiation segmentectomy can be curative for small tumours
Stereotactic body radiotherapy converges multiple beams with sub-millimetre accuracy to deliver tumour-destroying doses in one to five outpatient sessions, doing the job of surgery for inoperable early lung cancer and for metastases in liver, spine and brain. Tumour size and location limit its use, and late toxicity is a concern near the central airways.
- Ablative doses with minimal recovery
- Outpatient
Replacing the whole diseased liver cures both the cancer and the cirrhosis underneath it, for patients whose tumours are small enough.
- Only therapy that treats cancer and cirrhosis together
- Best long-term survival for early HCC
No trial record is attached to this row yet. The trials tab lists what is recruiting and the landmark trials for this cancer.
- Radioembolisation-induced liver disease
- Failed to beat sorafenib on OS in advanced disease
- Lung shunting excludes some patients
- Size and location limits
- Late toxicity near central airways
- Organ shortage and waiting-list dropout
- Lifelong immunosuppression; checkpoint inhibitors before transplant risk rejection
- Between Radioembolisation (TARE / SIRT, yttrium-90), SBRT / SABR (stereotactic radiotherapy) and Liver transplantation for cancer (Milan criteria and beyond), which do you recommend for me, and what about my case would make you choose differently?Why: Guidelines list several reasonable options; the choice turns on details of your tumour, your health and your priorities.
- What is each option trying to achieve: cure, long control, or relief of symptoms, and over what time?Why: The aim shapes how much side effect and disruption is worth accepting.
- What happens if I delay, or decline this step for now? Is the decision reversible?Why: Some decisions can wait for a second opinion or a trial slot; others cannot. Knowing which is part of the choice.
- For my situation (unresectable, liver-confined), which of the standard options do you recommend and why?Why: Guideline options include: Radioembolisation, stereotactic radiotherapy or hepatic artery infusion in specialised centres, usually with systemic therapy; liver transplantation in trials.
Add these to your appointment list, or take the full question set for this cancer.
Advanced, first line
Gemcitabine and cisplatin with durvalumab (TOPAZ-1) or pembrolizumab (KEYNOTE-966).
Gemcitabine plus cisplatin has been the chemotherapy backbone for bile duct cancer since 2010 and is now given with immunotherapy.
A PD-L1 blocker that became standard after chemoradiation for stage III lung cancer, and now in bladder, biliary, and gastric cancers.
Pembrolizumab is a PD-1 blocking antibody approved in more than 40 settings, from melanoma and lung cancer to the first tumour-agnostic approval for mismatch-repair-deficient tumours in 2017, and before and after surgery in triple-negative breast cancer. A subcutaneous form arrived in 2025, and it is the backbone partner for ADCs and personalised neoantigen vaccines.
- First-line advanced biliary tract cancer: gemcitabine-cisplatin + durvalumab vs + placebo
Show survival figures (1)
Averages across everyone diagnosed, often years ago. Your stage, subtype, age, fitness and the treatment you receive matter more than the average, and the numbers are improving quickly.
- OS HR 0.76; 2-year OS 23.6% vs 11.5%.
Overall survival (updated) (months): Durvalumab + GemCis 12.9 (n=341) vs Placebo + GemCis 11.3 (n=344) · HR 0.76 · source - First-line advanced biliary tract cancer: gemcitabine-cisplatin + pembrolizumab vs + placebo
OS 12.7 vs 10.9 months, HR 0.83.
Overall survival (months): Pembrolizumab + GemCis 12.7 (n=533) vs Placebo + GemCis 10.9 (n=536) · HR 0.83 · source - Tests Gemcitabine + cisplatinLocally advanced or metastatic biliary tract cancer: gemcitabine + cisplatin vs gemcitabine
OS 11.7 vs 8.1 months, HR 0.64.
Overall survival (months): Gemcitabine + cisplatin 11.7 (n=204) vs Gemcitabine 8.1 (n=206) · HR 0.64 · source
| Side effect | Any grade | Grade 3+ |
|---|---|---|
| Pneumonitis (any cause, PACIFIC) · vs 12.8% placebo; 1.1% fatal | 18.3% | - |
Rates from the label or pivotal trial as recorded on the product page; each grade 3+ figure links to its source.
| Side effect | Any grade | Grade 3+ |
|---|---|---|
| Hypothyroidism (immune-mediated) · Pooled monotherapy data, >2,800 patients | 8% | - |
| Pneumonitis (immune-mediated) · Pooled monotherapy data, >2,800 patients | 3.4% | - |
| Colitis (immune-mediated) · Pooled monotherapy data, >2,800 patients | 1.7% | - |
| Hepatitis (immune-mediated) · Pooled monotherapy data, >2,800 patients | 0.7% | - |
- No pharmacokinetic interactions expected (antibody). See the irAE guide for toxicity management.
Rates from the label or pivotal trial as recorded on the product page; each grade 3+ figure links to its source.
- Between Gemcitabine + cisplatin, Durvalumab and Pembrolizumab, which do you recommend for me, and what about my case would make you choose differently?Why: Guidelines list several reasonable options; the choice turns on details of your tumour, your health and your priorities.
- What is each option trying to achieve: cure, long control, or relief of symptoms, and over what time?Why: The aim shapes how much side effect and disruption is worth accepting.
- How closely do I match the people in TOPAZ-1 and KEYNOTE-966, and does that change what the results mean for me?Why: Trial populations are selected; age, fitness, prior treatment and biomarkers all affect how far results carry.
- Which side effects of Durvalumab or Pembrolizumab are most likely for me, which are reversible, and which would make us stop?Why: The recorded rates below come from labels and trials; your own risk depends on dose, other medicines and your health.
- What happens if I delay, or decline this step for now? Is the decision reversible?Why: Some decisions can wait for a second opinion or a trial slot; others cannot. Knowing which is part of the choice.
- For my situation (advanced, first line), which of the standard options do you recommend and why?Why: Guideline options include: Gemcitabine and cisplatin with durvalumab (TOPAZ-1) or pembrolizumab (KEYNOTE-966).
- Am I a candidate for Gemcitabine + cisplatin, Durvalumab, Pembrolizumab, and what side effects should I expect?Why: Knowing the expected toxicities helps you plan work, family, and supportive care.
- How do the results of TOPAZ-1 and KEYNOTE-966 apply to someone like me?Why: Trial populations differ from individual patients; ask how closely you match.
Add these to your appointment list, or take the full question set for this cancer.
Advanced, FGFR2 fusion after chemotherapy
Pemigatinib (FIGHT-202) or futibatinib (FOENIX-CCA2); management of hyperphosphataemia and eye toxicity.
Pemigatinib was the first targeted therapy for bile duct cancer, for tumours with an FGFR2 gene fusion.
Futibatinib is a covalent FGFR inhibitor for FGFR2-fusion bile duct cancer, with the highest response rate of the first-generation drugs.
- Tests PemigatinibPreviously treated cholangiocarcinoma with FGFR2 fusions (cohort A): pemigatinib single arm
ORR 37%; PFS 7.0 months; OS 17.5 months.
- Tests FutibatinibPreviously treated FGFR2-rearranged intrahepatic cholangiocarcinoma: futibatinib single arm
ORR 42%; PFS 9.0 months; OS 21.7 months.
No side-effect rates or interaction flags are recorded for these options yet. The side-effect lookup and interaction checker cover the products that have them.
- Between Pemigatinib and Futibatinib, which do you recommend for me, and what about my case would make you choose differently?Why: Guidelines list several reasonable options; the choice turns on details of your tumour, your health and your priorities.
- What is each option trying to achieve: cure, long control, or relief of symptoms, and over what time?Why: The aim shapes how much side effect and disruption is worth accepting.
- How closely do I match the people in FIGHT-202 and FOENIX-CCA2, and does that change what the results mean for me?Why: Trial populations are selected; age, fitness, prior treatment and biomarkers all affect how far results carry.
- What happens if I delay, or decline this step for now? Is the decision reversible?Why: Some decisions can wait for a second opinion or a trial slot; others cannot. Knowing which is part of the choice.
- For my situation (advanced, fgfr2 fusion after chemotherapy), which of the standard options do you recommend and why?Why: Guideline options include: Pemigatinib (FIGHT-202) or futibatinib (FOENIX-CCA2); management of hyperphosphataemia and eye toxicity.
- Am I a candidate for Pemigatinib, Futibatinib, and what side effects should I expect?Why: Knowing the expected toxicities helps you plan work, family, and supportive care.
- How do the results of FIGHT-202 and FOENIX-CCA2 apply to someone like me?Why: Trial populations differ from individual patients; ask how closely you match.
Add these to your appointment list, or take the full question set for this cancer.
Advanced, IDH1 mutation after chemotherapy
Ivosidenib (ClarIDHy).
The first drug to block a mutant metabolic enzyme in cancer. With azacitidine it tripled survival in IDH1-mutated AML that could not take intensive chemotherapy.
- Tests IvosidenibPreviously treated IDH1-mutant cholangiocarcinoma: ivosidenib vs placebo
PFS HR 0.37; crossover-adjusted OS HR 0.49.
| Side effect | Any grade | Grade 3+ |
|---|---|---|
| Differentiation syndrome · AGILE combination arm | 14% | - |
- Known QT prolongation. Avoid other QT-prolonging drugs where possible; check ECG and correct potassium and magnesium before and during treatment.
Rates from the label or pivotal trial as recorded on the product page; each grade 3+ figure links to its source.
- Is Ivosidenib the only reasonable path for me, or is there a trial, a different sequence or a wait-and-see option?Why: A single standard does not mean a single choice; timing and trials are decisions too.
- What is each option trying to achieve: cure, long control, or relief of symptoms, and over what time?Why: The aim shapes how much side effect and disruption is worth accepting.
- How closely do I match the people in ClarIDHy, and does that change what the results mean for me?Why: Trial populations are selected; age, fitness, prior treatment and biomarkers all affect how far results carry.
- Which side effects of Ivosidenib are most likely for me, which are reversible, and which would make us stop?Why: The recorded rates below come from labels and trials; your own risk depends on dose, other medicines and your health.
- What happens if I delay, or decline this step for now? Is the decision reversible?Why: Some decisions can wait for a second opinion or a trial slot; others cannot. Knowing which is part of the choice.
- For my situation (advanced, idh1 mutation after chemotherapy), which of the standard options do you recommend and why?Why: Guideline options include: Ivosidenib (ClarIDHy).
- Am I a candidate for Ivosidenib, and what side effects should I expect?Why: Knowing the expected toxicities helps you plan work, family, and supportive care.
- How do the results of ClarIDHy apply to someone like me?Why: Trial populations differ from individual patients; ask how closely you match.
Add these to your appointment list, or take the full question set for this cancer.
Second line without a target
FOLFOX (ABC-06); trials.
FOLFOX is the workhorse chemotherapy combination for bowel cancer, used after surgery to cure and in advanced disease as the backbone that targeted drugs are added to.
Cytotoxic chemotherapy drugs (platinums, antimetabolites, microtubule agents and topoisomerase inhibitors) kill rapidly dividing cells by damaging DNA or the mitotic spindle. They still cure testicular cancer, lymphoma and leukaemia, and they are the warhead inside antibody-drug conjugates, but a narrow margin between effective and toxic doses is their limitation.
- Curative in several cancers
- Cheap, generic
No trial record is attached to this row yet. The trials tab lists what is recruiting and the landmark trials for this cancer.
- Narrow therapeutic index
- Resistance via efflux pumps and DNA repair
- Between FOLFOX (5-FU, leucovorin, oxaliplatin) and Cytotoxic chemotherapy, which do you recommend for me, and what about my case would make you choose differently?Why: Guidelines list several reasonable options; the choice turns on details of your tumour, your health and your priorities.
- What is each option trying to achieve: cure, long control, or relief of symptoms, and over what time?Why: The aim shapes how much side effect and disruption is worth accepting.
- What happens if I delay, or decline this step for now? Is the decision reversible?Why: Some decisions can wait for a second opinion or a trial slot; others cannot. Knowing which is part of the choice.
- For my situation (second line without a target), which of the standard options do you recommend and why?Why: Guideline options include: FOLFOX (ABC-06); trials.
- Am I a candidate for FOLFOX (5-FU, leucovorin, oxaliplatin), and what side effects should I expect?Why: Knowing the expected toxicities helps you plan work, family, and supportive care.
Add these to your appointment list, or take the full question set for this cancer.