EASL Campus

A 63-year-old man presented with painless jaundice, pruritus and a 3 kg weight loss over the previous 4 weeks, ECOG PS 1. The patient had neither history of chronic liver disease, or other significant comorbidities. Blood tests showed a total bilirubin of 14.2 mg/dL, ALP 520 IU/L, gGT 780 U/L, with normal INR and creatinine; Ca 19.9 was 410 U/mL.

Multiphasic contrast-enhanced CT of thorax-abdomen-pelvis and gadolinium-enhanced MRI with MRCP showed a perihilar mass of 2.5 cm in radial diameter, Bismuth-Corlette type IIIa, extending to the right secondary biliary confluence, with encasement of the right hepatic artery and invasion of the right portal vein branch, which also abuts the portal vein bifurcation (AJCC T3). The left hepatic artery and the left portal vein were free. No distant metastases were detected.

EUS showed no suspicious regional or extra-regional lymph nodes. ERCP with brush cytology and endobiliary forceps biopsy revealed atypical cells, not diagnostic for malignancy. CT volumetry estimated the future liver remnant (FLR) after a potential right hepatectomy at 31% of the total liver volume. The case was discussed at the hepatobiliary multidisciplinary team (MDT) meeting of a tertiary referral centre.

Which is the most appropriate management strategy for this patient?

A. Since the tumour is <3 cm and node-negative, the patient should be referred for neoadjuvant chemoradiotherapy followed by liver transplantation (LT), which provides better long-term survival than surgical resection.

B. Upfront right hemihepatectomy within one week, without preoperative biliary drainage, because routine preoperative drainage increases the risk of serious complications.

C. Preoperative biliary drainage of the left liver, followed by right portal vein embolisation to increase the FLR above 40%, and then right hepatectomy with portal vein resection and reconstruction if required to achieve an R0 resection.

D. Surgery is not indicated because a pathological confirmation is lacking and vascular reconstruction would be required: after biliary drainage, first-line gemcitabine-cisplatin plus durvalumab or pembrolizumab should be started, with re-evaluation of resectability after 6 months.