Conversion surgery for perihilar cholangiocarcinoma after immune checkpoint inhibitor-combined chemotherapy with the biliary stent-based strategy.

BACKGROUND

Emerging immune checkpoint inhibitor (ICI)-combined chemotherapy may increase the opportunities for conversion surgery in patients with locally advanced (LA) biliary tract cancer. A major challenge in chemotherapy aimed at conversion surgery for LA perihilar cholangiocarcinoma (LA PHCC) is the difficulty in accurately evaluating tumor response on contrast-enhanced computed tomography due to biliary stent-induced inflammation and artifacts. To address this issue, the biliary stent-based strategy was devised and implemented in patients undergoing gemcitabine-cisplatin (GC) with ICI therapy. To improve assessment of tumor spread, this strategy includes repeated endoscopic retrograde cholangiopancreatography during chemotherapy and intentional stent removal when functional biliary patency was achieved. We reviewed the outcomes of treatment combined with the strategy.

METHODS

Patients with LA PHCC who received GC with ICI therapy with the aim of conversion surgery between 2023 and 2025 were retrospectively reviewed. Clinical course and treatment outcomes were evaluated.

RESULTS

Six patients were identified. The biliary stent-based strategy was helpful in preoperative assessment of tumor spread and clinical decision making. Curative-intent resection was performed in 5 patients (83.3%) and R0 resection was achieved in all 3 patients in whom functional biliary patency was confirmed in the strategy.

CONCLUSIONS

The biliary stent-based strategy may have potential clinical utility in the management of patients with LA PHCC receiving GC with ICI therapy with the aim of conversion surgery. The strategy not only facilitates preoperative assessment but also may serve as one criterion for proceeding with conversion surgery.