Robotic Left Hepatectomy with Hilar Dissection and Portal Lymphadenectomy Following Preoperative Gemcitabine, Cisplatin, and Pembrolizumab for Intrahepatic Cholangiocarcinoma.

Abstract

Background: The historic management of resectable intrahepatic cholangiocarcinoma (ICC) included open resection and portal lymphadenectomy.¹ In the modern era of effective perioperative systemic and immunotherapies, more locally advanced tumors are being converted to resectable disease.² As the surgical limits of safe oncologic resection continue to expand at experienced centers, minimally invasive approaches have also gained traction given the superior intraoperative optics, improved dexterity, and expedited recovery of patients.³ As such, we report a successful robotic resection of a locally advanced left-sided ICC pre-treated with induction chemoimmunotherapy.

Patient and methods: A 40-year-old male patient was found to have a left-sided liver mass during workup for right-sided abdominal pain. Dedicated triphasic computed tomography (CT) revealed a 10 cm mass with two possible ipsilobar daughter satellite lesions as well as tumor thrombus emanating from the left portal vein and bulky periportal lymphadenopathy. Biopsy confirmed ICC without targetable mutations. CA19-9 was elevated at 400 U/mL. After multidisciplinary tumor board review of this patient's locally advanced case, induction therapy with gemcitabine, cisplatin, and pembrolizumab was initiated. After five treatment cycles (roughly 4 months), the patient underwent restaging imaging, which demonstrated a robust radiographic response, including withdrawal of the tumor thrombus deeper into the left portal system as well as reduction in CA19-9 levels. Given the patient's young age, good performance status, and impressive treatment response, we reviewed the risks and benefits of proceeding with robotic left hepatectomy and portal lymphadenectomy. Note that several contingencies were discussed preoperatively, including open conversion and a more extensive resection should the tumor be understaged or progressed off therapy. To ensure sufficient liver remnant, we routinely spare the caudate in left hepatectomies for ICC unless there is compelling evidence of preoperative radiographic involvement. Finally, we planned to address the receding tumor thrombus with intraoperative ultrasound and using intraoperative frozen section. Should this return positive, we discussed with the patient a venous resection and reconstruction to achieve a negative margin.

Results: Operative time was 4 h with an estimated blood loss of 150 cc. Cumulative Pringle time was 30 min. The patient had an uneventful postoperative recovery and was discharged home on postoperative day 3. Final pathology revealed a single 5.7 cm ICC with complete pathologic response and negative margins. Notably, 4 of 11 lymph nodes were involved with tumor for a final TNM staging of T1bN1. After multidisciplinary re-review of this patient's pathology, the patient resumed their preoperative systemic regimen. At most recent 4-month follow-up, there is no evidence of radiographic or biochemical recurrence, and systemic therapy continues to be well tolerated. On the basis of tumor board recommendations, systemic therapy is planned for a total of 6 months in addition to one full year of immunotherapy.

Conclusions: With a combination of preoperative chemoimmunotherapy and robotic left hepatectomy, we describe a successful oncologic outcome for a patient with locally advanced ICC.