Hilar Cholangiocarcinoma with Para-Aortic Lymph Node Metastasis Treated with Chemoimmunotherapy and Conversion Surgery: A Case Report.

Abstract

Introduction: Cholangiocarcinoma (CC) has a poor prognosis and few treatment options. Conversion surgery for unresectable CC has been frequently reported; however, there are almost no reports of conversion surgery after durvalumab plus gemcitabine and cisplatin therapy. In this study, we report the case of a patient with unresectable hilar CC who received durvalumab plus gemcitabine and cisplatin therapy and achieved a pathological complete response after conversion surgery.

Case presentation: A 70-year-old man was diagnosed with hilar CC (cT3N1M0, Stage III C) based on biopsy of the common bile duct stenosis and computed tomography (CT) and magnetic resonance cholangiopancreatography scans. Initially, a right lobe hepatectomy and subtotal stomach-preserving pancreatoduodenectomy were planned. However, there were concerns about an insufficient functional remnant liver volume. Trans-ileocolic portal embolization of the right portal vein branch was performed. On a preoperative CT scan 1 month later for liver volumetry, swelling of the para-aortic lymph nodes was observed, which was judged as distant metastasis, and radical resection could not be performed. After 8 courses of durvalumab plus gemcitabine and cisplatin therapy, vanishing fluorodeoxyglucose accumulation in the para-aortic lymph nodes was observed on positron emission tomography-CT. The possibility of resection was reevaluated, and a right lobe hepatectomy and extrahepatic biliary reconstruction were performed as conversion surgeries. Histological examination confirmed the absence of residual tumors or lymph node metastases. Ten months after surgery, the patient was free of recurrence.

Conclusions: Chemoimmunotherapy with durvalumab as a first-line treatment for unresectable CC has shown promising results. Immunotherapy with durvalumab, followed by conversion surgery, may improve the prognosis of patients with unresectable CC.