case_images: PMC11750801_01
case_images: PMC11750801_02
case_images: Imaging manifestations before and after systemic therapy were demonstrated. (A) An enhanced lesion is located at the bile duct near the choledochojejunostomy site in the arterial phase of contrast-enhanced computed tomography and MRCP before PTCD and chemotherapy. (B) The enhanced lesion is located at the bile duct near the choledochojejunostomy site showed no significant changes after PTCD and therapy plus durvalumab for three cycles. (C) The lesion showed no significant changes after three more therapy plus durvalumab and bevacizumab.
case_images: fimmu-15-1520248-g001.jpg
case_images: PMC11750801_02_fimmu-15-1520248-g001.jpg
case_images: f1
case_images: Abdominal enhanced CT, MRI, and MRCP showed hilar cholangiocarcinoma and intrahepatic bile duct dilation ( Figure 1A ). Re-imaging evaluation revealed minimal tumor shrinkage ( Figures 1B, C ).
case_images: The trend change of CA199, CA242 and CA50 were demonstrated at different stages of treatment. Gem, gemcitabine; DDP, cisplatinum; Durva, druvalumab; Bev, bevacizumab.
case_images: fimmu-15-1520248-g002.jpg
case_images: PMC11750801_03_fimmu-15-1520248-g002.jpg
case_images: f2
case_images: Regular follow-up indicated that the patient is currently in a disease-free survival state, with normal levels of tumor markers and no signs of tumor recurrence detected ( Figures 2 ,  4 ).
case_images: PMC11750801_03
case_images: The trend change of CA199, CA242 and CA50 were demonstrated at different stages of treatment. Gem, gemcitabine; DDP, cisplatinum; Durva, druvalumab; Bev, bevacizumab.
case_images: fimmu-15-1520248-g002.jpg
case_images: PMC11750801_03_fimmu-15-1520248-g002.jpg
case_images: f2
case_images: Regular follow-up indicated that the patient is currently in a disease-free survival state, with normal levels of tumor markers and no signs of tumor recurrence detected ( Figures 2 ,  4 ).
case_images: The procedures of space making between biliary tract and intestinal tract were shown. (A) Dismantle the bilioenteric anastomosis, perform T-tube support and drain the left and right hepatic ducts. (B) Free partial greater omentum in strip-type. (C) Roll up the distal 1/2 of the greater omentum. (D) Fill the subhepatic space with the greater omentum. Move the gastric antrum, duodenal bulb, and transverse colon away from the porta hepatis. (E, F). Schematic diagram shows preoperative and postoperative conditions of the patient. (G) Titanium clips were placed around the left and right hepatic ducts for easy of location of proton therapy. White arrow indicated the location of titanium clips.
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case_images: PMC11750801_03_fimmu-15-1520248-g003.jpg
case_images: f3
case_images: To mitigate the adverse effects of proton therapy on the gastrointestinal tract, space-making surgery was performed ( Figure 3 ). The bile-enteric anastomosis was dismantled, and T-tube support and drainage of the left and right hepatic ducts were placed ( Figure 3A ). A partial greater omentum strip was dissected, rolled up, and used to fill the subhepatic space, creating a barrier between the biliary duct and the intestine ( Figures 3B-F ). Titanium clips were placed around the left and right hepatic ducts to facilitate photon therapy localization ( Figure 3G ).
case_images: Imaging follow-up after proton therapy were shown. The irradiation field of proton therapy was showed before and after therapy (A). And original lesion site did not show enhancement in the arterial phase three months after proton therapy (B). The original lesion site did not show enhancement in the arterial phase seven months (C) and ten months (D) after proton therapy.
case_images: fimmu-15-1520248-g004.jpg
case_images: PMC11750801_03_fimmu-15-1520248-g004.jpg
case_images: f4
case_images: Regular follow-up indicated that the patient is currently in a disease-free survival state, with normal levels of tumor markers and no signs of tumor recurrence detected ( Figures 2 ,  4 ).