Background : Radical resection remains the only curative option for intrahepatic cholangiocarcinoma(iCCA). Patients with multifocal tumors,vascular invasion or lymphnode metastasis are considered to have locally advanced disease. Neoadjuvant chemotherapy with gemcitabine and cisplatin as 1st line or with Capecitabine and Irinotecan as 2nd line have shown oncological benefit. An immunotherapy has also showed benefit. Stereotactic Body radiotherapy is safe treatment option in locally advanced tumors. We present a video where combination of modalities was used to achieve downstaging followed by surgery.

Methods : A 64 years old gentleman was diagnosed with locally advanced iCCA involving left lobe with left portal vein thrombosis,left hepatic vein(LHV)encasement and middle hepatic vein(MHV)abutment.CA 19-9 was 1890 U/mL.After 3 cycles of Gemcitabine and Cisplatin,response CT scan showed disease progression and 2nd line chemotherapy with immunotherapy(capecitabine, irinotecan,durvalumab)was started with SBRT.Response CT showed significant size reduction.CA 19-9 dropped to 17 U/mL.Patient was planned for left hepatectomy with portal vein resection(PVR) and segment 8 venous reconstruction. Steps of surgery: 1. Kocherisation,inter-aortocaval nodal sampling and peri-portal dissection. 2. Parenchymal transection with left hepatic duct division,PVR with primary repair 3. Isolation of segment 8 vein,division distal to MHV-LHV confluence,specimen retrieval 4. Reconstruction of segment 8 vein to MHV-LHV confluence using PTFE graft. Final Histopathology report revealed complete pathological response.Patient was planned for two more cycles of same chemotherapy followed by observation.

Results : .

Conclusions : Resection with periportal lymphadenectomy and negative margins remains the only curative option for iCCA.Multimodality options can be utilized to downstage tumor and complex liver resection with vascular reconstruction can achieve excellent oncological outcomes.