Published online Nov 27, 2023. doi: 10.4240/wjgs.v15.i11.2663
Peer-review started: August 29, 2023
First decision: September 23, 2023
Revised: September 30, 2023
Accepted: October 25, 2023
Article in press: October 25, 2023
Published online: November 27, 2023
Processing time: 90 Days and 6.6 Hours
Perihilar cholangiocarcinoma (pCCA) is a highly malignant tumor arising from the biliary tree. Radical surgery is the only treatment offering a chance of long-term survival. However, limited by the tumor’s anatomic location and peri-vascular invasion, most patients lose the chance for curative treatment. Therefore, more methods to increase the resectability of tumors as well as to improve outcomes are needed.
A 68-year-old female patient had a hepatic hilar mass without obvious symptoms. Laboratory results showed hepatitis B positivity. Magnetic resonance imaging indicated that the mass (maximum diameter: 41 mm) invaded the left and right branches of the main portal vein, as well as the middle, left and right hepatic veins; enlarged lymph nodes were also detected in the hilum. The patient was diagnosed with pCCA, and the clinical stage was determined to be T4N1M0 (stage IIIC). Considering the tumor’s anatomic location and vascular invasion, systematic conversion therapy followed by ex vivo liver resection and autotransplantation (ELRA) was determined as personalized treatment for this patient. Our original systemic sequential therapeutic strategy (lenvatinib and tislelizumab in combination with gemcitabine and cisplatin) was successfully adopted as conversion therapy because she achieved partial response after three cycles of treatment, without severe toxicity. ELRA, anastomotic reconstruction of the middle hepatic vein, right hepatic vein, root of portal vein, inferior vena cava and right hepatic artery, and lymph node dissection were performed at one month after systemic therapy. Pathological and immunohistochemical examination confirmed the diagnosis of pCCA with lymph node metastasis. Although the middle hepatic vein was partially obstructed four months later, hepatic vein stent implantation successfully addressed this problem. The patient has survived for 22 mo after the diagnosis, with no evidence of recurrence or metastasis.
An effective therapeutic strategy for conversion therapy greatly increases the feasibility and efficiency of ELRA.
Core Tip: Limited by tumor’s anatomic location and peri-vascular invasion, most perihilar cholangiocarcinoma patients lose the chance for curative treatment. In this case, we originally put forward systematic conversion therapy followed by ex vivo liver resection and autotransplantation (ELRA). The patient achieved partial response after three cycles of systemic sequential treatment without severe toxicities. Soon afterwards, ELRA, anastomotic reconstruction of the middle hepatic vein, the right hepatic vein, the root of portal vein, inferior vena cava and right hepatic artery, and lymph node dissection were performed with success. The patient achieved long time survival and has survived 22 mo following diagnosis with no evidence of recurrence or metastasis.