Conversion surgery after gemcitabine and cisplatin plus durvalumab for advanced intrahepatic cholangiocarcinoma:A case report

BACKGROUND The combination of immune checkpoint inhibitors and chemotherapy has shown promising results for the treatment of advanced biliary tract cancer(BTC).Based on the results of the TOPAZ-1 trial,a gemcitabine and cisplatin plus durvalumab(GCD)regimen was recently approved as first-line therapy for patients with advanced BTC.However,post-GCD conversion surgery has not been previously studied.Herein,we describe a case of advanced intrahepatic cholangiocarcinoma(ICC)successfully treated with radical surgery after GCD.CASE SUMMARY A 65-year-old female diagnosed with advanced ICC with periductal infiltration into the hepatic hilum underwent eight cycles of GCD,followed by durvalumab maintenance treatment,with mild adverse events.Partial response was obtained.Subsequently,a conversion surgery with extended left hepatectomy and bile duct resection was performed.The resection margins were negative,and the pathological diagnosis was compatible with small duct type ICC.The patient remained disease-free for 8 months without adjuvant chemotherapy.CONCLUSION We describe the case of a patient who received successful conversion surgery after GCD treatment for advanced ICC.

Survival outcomes of conversion surgery for metastatic pancreatic ductal adenocarcinoma after neoadjuvant therapy

Objective:To evaluate the survival outcomes of patients who underwent conversion surgery for metastatic pancreatic ductal adenocarcinoma(mPDAC)after neoadjuvant therapy(NAT)and to identify potential candidates that may benefit from this treat-ment strategy.Background:The role and eligibility population of conversion surgery for mPDAC remains controversial in the era of NAT.Methods:A consecutive cohort of patients diagnosed with mPDAC and treated with NAT followed by conversion surgery be-tween 2019 and 2021 were confirmed from a prospective database maintained by the Department of Pancreatic Hepatobiliary Surgery of Changhai Hospital.In accordance with residual metastases and technical resectability after NAT,patients were classi-fied as the complete pathological response of metastases(ypM0)resection group,residual metastases(ypM1)resection group,and exploration group.Median overall survival(mOS)was calculated using the Kaplan-Meier method,uni-and multivariable cox regression was performed to identify clinicopathological predictors of OS.Results:A total of 244 patients with mPDAC were identified from the prospective database,with 19(7.8%)patients who un-derwent ypM0 resection,22(9.0%)underwent ypM1 resection,and 23(9.4%)underwent explorative laparotomy.The mOS was 32.6 months for ypM0 resected patients,15.1 months for ypM1 resected patients,and 13.4 months for those who underwent explorative laparotomy(P<.001).Univariable and multivariable Cox regression analyses confirmed that ypM0 resection,normal-ization of preoperative CA19-9 levels,and continued adjuvant therapy were independent prognostic factors of conversion surgery for mPDAC after NAT.Subgroup analyses revealed that oligometastases and continued adjuvant therapy were associated with improved prognosis in the ypM1 resection group.Conclusion:In patients with mPDAC who underwent NAT followed by conversion surgery,the complete pathological response of metastases,normalization of preoperative CA19-9 levels,and continued adjuvant therapy were independent risk factors for prognosis.Patients with residual oligometastases after treatment were expected to prolong survival through resection.These patients may benefit from conversion surgery and should be potential candidates for this treatment strategy.

Conversion therapy for hepatocellular carcinoma to improve treatment strategies for intermediate and advanced stages

This manuscript is based on a case reported by Song et al published in the World Journal of Clinical Cases.Several challenges remain in the field of hepatocellular carcinoma(HCC)conversion therapy.Consequently,only a limited number of patients with HCC accompanied by portal vein tumor thrombosis(PVTT)and hepatic vein tumor thrombosis(HVTT)are eligible for resection.This clinical case demonstrates that considering the complexity of the disease,a multimodal and multidisciplinary approach is essential for managing HCC accompanied by PVTT and HVTT.However,the outcomes of such surgeries remain controversial.In conclusion,research on HCC conversion therapy is extremely useful for impro-ving treatment strategies for intermediate and advanced HCC,which currently have disappointing clinical outcomes.

Conversion surgery for stage Ⅳ gastric cancer

Gastric cancer with distant metastases,such as para-aortic lymph node metastases,hepatic metastases,and peritoneal dissemination,is classified as stage IV.In this situation,cancer cells have formed micrometastases throughout the body;therefore,according to the algorithm of the Japanese guidelines,stage IV cancer is outside the indication for curative resection.Recent advances in some chemical agents have been remarkable,and some patients have survived for long periods even with stage IV gastric cancer.Thus,even in patients with stage IV gastric cancer,there is a possibility that gastrectomy as conversion surgery could play an important role in the treatment strategy.Gastrectomy as conversion therapy can be safely conducted without perioperative mortality and is considered a sufficiently acceptable treatment strategy.However,the significance of conversion surgery for stage IV gastric cancer remains controversial.In this review,we summarize the treatment strategies and outcomes of conversion surgery for stage IV gastric cancer.

Conversion surgery in patients with initially unresectable pancreatic ductal adenocarcinoma: where do we stand in 2018?

Pancreatic ductal adenocarcinoma(PDAC)continues to have a dismal prognosis,with a 5-year survival rate of<5%.Most(70%-80%)patients are classified as unresectable(UR)disease.Recent progress in chemotherapeutic approaches has provided a high response rate and improved short-term survival.Recently,conversion surgery(CS),which is defined as an additional surgery during multimodal therapy in patients with initially UR-PDAC who respond favorably to anti-cancer treatments,has been successfully introduced as a novel treatment option for locally advanced(UR-LA)and metastatic(UR-M)PDAC.Several studies have demonstrated high resectability rates(UR-LA,20%-57%;UR-M,2%-24%),high margin-negative resection rates(27%-91%),and high negative lymph node rates(29%-83%)in patients who underwent CS.Most studies also demonstrated acceptable mortality and morbidity.Median survival time(MST)varied between 24.9 and 35.3 months for patients with UR-LA,19.5 and 64 months for UR-LA/M,and 26 and 56 months for UR-M,which is better than the MST of patients who did not undergo CS.The presence of M disease did not affect survival in patients who underwent CS.However,the actual clinical benefits of resection have not yet been fully investigated.There are still several issues to be resolved in this area.Therefore,sustained efforts to conduct appropriately designed clinical trials for confirming the efficacy of CS in the subset of patients with initially UR-PDAC are warranted.

HER2-positive adenocarcinoma arising from heterotopic pancreas tissue in the duodenum:A case report

BACKGROUND Adenocarcinoma originating from heterotopic pancreas tissue is a rare disease.Furthermore,to our knowledge,no HER2-positive cases in the duodenum have been reported in the scientific literature nor has the efficacy of trastuzumab treatment for the disease been reported.CASE SUMMARY A 65-year-old woman whose clinical diagnosis was unresectable advanced duodenal cancer with HER2 overexpression responded well to trastuzumab chemotherapy.The main tumor in the duodenum reduced drastically.The patient underwent pancreaticoduodenectomy and lymph node dissection.A small number of cancer cells remained in the submucosal layer of the duodenum and pancreas head.After histological and immunohistochemical examination,the patient was diagnosed with duodenal adenocarcinoma originating from heterotopic pancreas tissue.CONCLUSION Trastuzumab treatment is effective in HER2-positive adenocarcinoma originating from heterotopic pancreas tissue in the duodenum.

Successful hepatic resection for recurrent hepatocellular carcinoma after lenvatinib treatment:A case report

BACKGROUND Lenvatinib has been shown to be noninferior to sorafenib regarding prognosis and recurrence rate in patients with unresectable hepatocellular carcinoma(HCC)who have not received prior systemic chemotherapy.In patients treated with lenvatinib,40%of cases achieved sufficient tumor reduction to make potential surgery possible.However,the outcomes of such surgery are unknown.We report a successful case of hepatic resection for recurrent HCC after lenvatinib treatment.CASE SUMMARY A 69-year-old man underwent right anterior sectionectomy for HCC in segment 8 of the liver.Ten months later,he was found to have an intrahepatic HCC recurrence that grew rapidly to 10 cm in diameter with sternal bone metastases.After confirming partial response to lenvatinib administration for 2 mo,a second hepatectomy was performed.Pathological examination showed that 80%of the tumor was necrotic.The patient did not develop any adverse effects under lenvatinib treatment.He was discharged at 25 d after surgery.Radiation therapy for bone metastases continued to be given under lenvatinib,and the patient has remained alive for 1 year after the second hepatectomy.CONCLUSION The prognosis of patients with recurrent HCC may be improved by liver resection combined with prior lenvatinib therapy.

Downstaging and resection of hepatocellular carcinoma in patients with extrahepatic metastases after stereotactic therapy

Background:A combination of tyrosine kinase inhibitors(TKIs)and anti-PD-1 antibodies with local regional therapy has elicited yield substantial clinical benefits in patients who have hepatocellular carcinoma(HCC)with extrahepatic metastases.Using this treatment strategy to convert HCC patients with extrahepatic metastases from unresectable to resectable has not yet been reported.Methods:Consecutive hepatocellular carcinoma patients with extrahepatic metastases who received first-line therapy with a combination of TKIs and anti-PD-1 antibodies and at least one local regional therapy were analysed.Results:Nine patients with localized disease who received first-line systemic therapy were enrolled.At baseline,all of them had oligometastatic disease,namely,Barcelona Clinic Liver Cancer stage C(or Chinese Liver Cancer stage IIIB).The most common treatment administered was lenvatinib plus anti-PD-1 antibody and transarterial chemoembolization,and the median time span from systemic therapy to surgery was 3.2(IQR,2.8-6.2)months.Three patients achieved a pathological complete response.Six patients underwent laparoscopic surgery,and the other 3 patients underwent open surgery.After a median follow-up of 10.2(IQR,8.6-20.0)months,7 patients survived without disease recurrence,and 2 experienced tumour recurrence.All patients had any-grade AEs,and 55.6%of the patients experienced grade 3 AEs.Fatigue was the most common AE,followed by elevated aminotransferase levels and hypertension.Conclusions:Stereotactic therapy is a feasible conversion therapy for HCC patients with extrahepatic metastases to become resectable.This is the first study to analyse therapeutic outcomes of patients receiving these therapies for HCC with extrahepatic metastases.