Ghassan K. Abou-Alfa, MD: I’ll go to Dr Salem. Is there anything we can do in addition, especially imaging-wise, that can help us decipher that further for this patient?

Riad Salem, MD, MBA: There’s some PET [positron emission tomography]–type imaging that one can obtain. It’s not readily available in the United States, but some centers in Asia are using some PET agents to better define that. That continues to be a work in progress. FDG [fluorodeoxyglucose] PET is not generally recommended in this patient population because it’s not actionable. The biopsy, depending on the location, is simple and pretty straightforward. The problem with biopsy, although it didn’t come up, is that I look at every biopsy of a cirrhotic liver and HCC [hepatocellular carcinoma] with caution because you can get some tissue.

I don’t know how much of this information is actionable, but you can have adverse events with a biopsy. That can significantly alter the course of this patient. I’m sure you’re going to talk about what systemic therapy options are available for this patient. You could have some adverse events. I’ve seen them and I’ve managed them, and it’s not as benign as one might think. That’s why I’m happy to see that at least the discussion of the biopsy is still controversial and not resolved. You have to consider significantly whether that’s something you want to do.

Ghassan K. Abou-Alfa, MD: Dr Salem, I’ll challenge that. Data has been reported, and the chance for any further spread of disease based on the biopsy—remember, could be told about systemic disease to begin with—is 0.000002. At the same time, the potential for any bleeding is 0.5, 0.6. These are very subtle risk factors. To make a decision based on those alone might be limited considering the ample amount of data we can get from the biopsy, let alone the diagnostic component. As Dr Yarchoan mentioned, what if it’s a potential combined cholangiocarcinoma HCC? This can happen in 15% of the cases, let alone the genetic analysis. What are your thoughts on that?

Riad Salem, MD, MBA: You bring up great points. I’m certainly not suggesting the effectively nonexistent rate of causing metastatic disease. What I’m suggesting is when you’re thinking about a biopsy and you’re right, the rate of adverse event is low, but sometimes there are locations where you should think twice about the biopsy. It is those cases that will generate some adverse events: a very high dome lesion, a pneumothorax you may cause located in the hilum. By all means, I agree that with modern techniques, we can do it safely. I’m suggesting to take the lesion location into consideration as well, because some can be very challenging. A biopsy is not a biopsy is not a biopsy; the location, the size, and the amount of technical challenge should be a consideration.

Your previous point, about having that conversation on your tumor board, is important. I’ve declined some biopsies because they’re going to be extremely challenging, the yield is going to be low, and I’m putting this patient at risk of not getting their therapy. However, biopsy is a no-brainer—very simple, very straightforward. I’m with you, Ghassan, but sometimes the location is something you should think about and have your IR [interventional radiologist] think, “Are you sure you’ll get some tissue?” If you think you’ll cause an AE [adverse event] or there’s a higher risk, then think twice about it and discuss it. That’s all.

Mark Yarchoan, MD: Can I make 1 other quick comment? One thing we didn’t discuss is that with all these cases, I like to order a CA [cancer antigen] 19-9, which tends to be elevated in cholangiocarcinoma. If there’s an elevated CA 19-9, the patient absolutely should undergo a biopsy.

Ghassan K. Abou-Alfa, MD: I’d be careful here, Mark, because we’re passing on this information in the practice. To really make a CA 19-9, the decision to do a biopsy, I’d be careful about this decision because we don’t drive biomarkers, which are totally unreliable in regard to this. A biopsy seems to be debatable. We agree on that, and this is a conclusion we have to pass on to our colleagues who are listening.

At the same time, however, in the setting of systemic therapy, the fear about spread of the cancer by the biopsy is so minimal that it’s almost nonexistent. The risk of it being an inappropriate and direct intervention, as Dr Salem mentioned, isn’t necessarily in any particular situation. We’re still very good with that biopsy to move forward with. Of course, there’s the issue you mentioned, Dr Yarchoan, of trying to see if it’s a combined cholangiocarcinoma plus HCC, or cholangiocarcinoma to begin with, or let alone the genetic analysis that could be important for the further input. So yes, we recommend it, but there are particular situations that might not need it.

Transcript edited for clarity.