Conversion surgery for initially unresectable advanced biliary tract cancer treated with gemcitabine plus cisplatin combination chemotherapy: a case report and literature review

Abstract

Recently, the number of reports describing patients with initially unresectable biliary tract cancer (BTC) who underwent resection in the form of conversion surgery is increasing. Gemcitabine plus cisplatin (GC) combination therapy has been reported to significantly prolong the median survival time from 8.1 to 11.7 months compared with conventional gemcitabine therapy in patients with unresectable BTC. We report the case of a patient with unresectable BTC who underwent conversion surgery with a partial response to GC combination therapy. A 78-year-old woman was diagnosed with unresectable BTC with invasion of the right hepatic artery by lymph node metastasis and liver metastases. The patient received GC combination therapy. After 6 cycles of chemotherapy, the patient achieved a partial response. The radiological findings revealed a marked shrinkage in the primary lesion and the disappearance of lymph node and liver metastases. Therefore, the patient underwent conversion surgery, including biliary tract resection and regional lymph node dissection. For postoperative follow-up, the patient was monitored without receiving adjuvant chemotherapy. The patient had not exhibited recurrence during the 12-month follow-up period. We report the case of a patient with unresectable BTC who underwent conversion surgery with a partial response to GC combination therapy.

Keywords: Biliary tract cancer; Cholangiocarcinoma; Conversion surgery; Gemcitabine plus cisplatin; Spyglass.

Fig. 1

a, b Enhanced abdominal computed tomography (CT) revealed a 45 mm tumor that extended biliary duct cancer from the distal bile duct to the hilar region of the bile duct (arrow). c Swollen lymph node invaded the right hepatic artery (arrowhead)

Fig. 2

a Magnetic resonance cholangiopancreatography (MRCP) showed an irregular stricture from the distal bile duct to the hilar region of the bile duct. b, c Liver metastases were suspected in the hepatobiliary phase and diffusion-weighted image (arrowheads)

Fig. 3

The clinical course, including the schedules of chemotherapy, operation, and radiological examinations, is shown. The patient received 6 cycles of the regimen for 5 months. One month after the final administration of chemotherapy, the patient underwent conversion surgery. Abbreviations: CA19-9 carbohydrate antigen 19-9; CEA carcinoembryonic antigen

Fig. 4

a, b Enhanced abdominal CT revealed that the tumor size was decreased from 45 to 15 mm and was localized in the junction of the cystic and common hepatic ducts (arrow). c Direct invasion of the lymph node to the right hepatic artery was improved (arrowhead)

Fig. 5

Peroral cholangioscopy (The Spyglass Direct Visualization System, Boston Scientific Corp, Natick, MA, USA) showed that the tumor localized in the junction of cystic and common hepatic ducts. In terms of biopsy of the distal bile duct and the hilar region of the bile duct, no malignancy was confirmed. Abbreviations: Bant/post anterior/posterior segmental bile duct; Bl left hepatic duct; Bc caudate lobe bile duct; Bm middle bile duct; Bi inferior bile duct

Fig. 6

a, b Positron emission tomography with 18F-fluoro-D-deoxyglucose (18F-FDG PET)/CT revealed abnormal uptake in the tumor with an SUVmax of 5.8 (arrow), and abnormal uptake in the lymph nodes and liver metastases were not observed

Fig. 7

a Extrahepatic duct resection, choledochojejunostomy and regional lymph node dissection were performed. Abbreviations: RHA right hepatic artery; LHA left hepatic artery; PHA proper hepatic artery; PV portal vein; GDA gastroduodenal artery; CBD common bile duct; GB gallbladder. b Direct invasion of the lymph node to the right hepatic artery was not observed. Abbreviations: CHD common hepatic duct; RHA right hepatic artery; LHA left hepatic artery; PHA proper hepatic artery; PV portal vein; IVC inferior vena cava

Fig. 8

a Macroscopically, a 10 × 10 mm tumor was observed at the junction of the cystic and common hepatic ducts. Resected margins, including hepatic-side and duodenum-side margins, were negative. The precise anatomy of the cystic duct in the lower-right segment was described. b Histopathologically, the tumor displayed well-differentiated tubular adenocarcinoma. c Infiltration of inflammatory cells in the fibrous tissue around the cancer cells was observed, suggesting the presence of necrotic carcinoma cells