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Open Access Case Report Issue
Salvage robotic associating liver partition and portal vein ligation for staged hepatectomy for advanced hepatocellular carcinoma with insufficient future liver remnant after conversion therapy
iLIVER 2026, 5(3): 100256
Published: 25 August 2026
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Many cases of hepatocellular carcinoma (HCC) are initially considered unresectable. Advances in conversion therapy have enabled some of these patients to subsequently undergo curative resection. However, an insufficient future liver remnant (FLR) prevents patients with HCC undergoing conversion therapy from obtaining the opportunity for surgical resection. Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has been shown to be effective in promoting FLR hypertrophy in patients with HCC. Nevertheless, the safety and feasibility of ALPPS in patients with HCC who have an insufficient FLR after conversion therapy have rarely been reported. Here, we report the first case in which salvage robotic ALPPS enabled a patient with HCC and insufficient FLR after conversion therapy to undergo radical resection. This 56-year-old man was diagnosed with initially unresectable HCC and received five cycles of lenvatinib plus pembrolizumab. Although a partial response was achieved on oncological evaluation, the patient was not eligible for surgical resection because the FLR remained insufficient at 35.5% of the standard liver volume. To promote FLR hypertrophy and achieve radical resection, we performed a two-stage robotic ALPPS after the fifth cycle of systemic therapy. The FLR increased from 35.5% to 49.4% one month after the first stage of ALPPS (robotic cholecystectomy, right portal vein ligation, and liver partition), and subsequent robotic right hemihepatectomy was successfully performed. The patient recovered uneventfully after the two-stage procedure, and no recurrence was observed at the 3-month postoperative follow-up. This case demonstrates that total robotic ALPPS is a feasible bridge to curative resection for selected patients with insufficient FLR after successful conversion therapy. Building upon the concept of salvage ALPPS, this report further highlights the technical advantages of a total robotic platform in facilitating precise, minimally invasive staged hepatectomy.

Open Access Original Article Issue
Bile cell-free DNA shows benefit as a potential sample for somatic mutation detection of resectable cholangiocarcinoma
iLIVER 2025, 4(4): 100206
Published: 07 November 2025
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Background and aims

Cholangiocarcinoma (CCA), a highly aggressive hepatobiliary malignancy, faces significant diagnostic challenges in early stages due to nonspecific clinical manifestations. Although plasma cell-free DNA (cfDNA) analysis via next-generation sequencing (NGS) is widely used for noninvasive cancer detection, its sensitivity in CCA remains suboptimal owing to the low tumor DNA abundance. This study aims to compare bile and plasma as sources for liquid biopsy in CCA genomic profiling, focusing on analytical accuracy and biomolecular stability.

Methods

Ten patients with resectable CCA were prospectively enrolled in this study. DNA extracted from matched plasma, bile, and tumor tissue underwent NGS for somatic mutation, microsatellite stability (MSI), and tumor mutation burden (TMB) analysis.

Results

The concentration of cfDNA in bile was significantly higher than in plasma. Somatic mutations were detected in 100% (10/10) of tumor tissue DNA, 70% (7/10) of bile cfDNA, and 10% (1/10) of plasma cfDNA. Compared to plasma cfDNA, bile cfDNA exhibited higher TMB (median TMB 1.0 vs. 0; p < 0.05) and greater maximum allele fractions (median maxAF 0.057 vs. 0; p < 0.001). While tumor stage significantly influenced plasma cfDNA detection rates, bile cfDNA maintained high detection sensitivity independent of clinical variables. Among CCA patients, bile cfDNA mutation positivity demonstrated sensitivity comparable to CA19-9 serology.

Conclusion

Bile cfDNA outperforms plasma cfDNA in detecting somatic mutations and retains high sensitivity independent of tumor stage, positioning it as a promising tool for early CCA diagnosis and molecular characterization.

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