Surgical consultation (telephone) — summary

Dr Fedorov — opinion

• MOK approval for surgery means an operation can now be offered: liver resection first, starting with either the left-lobe lesion or the right lobe — an order he discussed with the head of department.
• "Most likely" the proposal will be a right hemihepatectomy first.
• The plan is still to remove both lobes' lesions, but there are risks of the course departing from this plan.
• Two stages, because a one-stage removal would leave too little functional liver for her to survive.
• The operation is possible "this Wednesday" if they agree. INTERPRETATION Wednesday 21.10.2026, computed from the call date (Friday 16.10.2026); the date itself was not stated.
• At the end of the call he confirmed the preliminary plan as summarised by the family: remove the right lobe and, if possible, the tumour of the stomach.

Raised by the family

• Checked that the right lobe is what is being removed; the answer was that the plan is to remove both (above).
• The family said it needs to consider the proposal as quickly as possible.

Dr Fedorov — opinion

Arguments weighed

• For starting with the left lobe: the left-lobe lesion is smaller in volume and has potentially more aggressive growth.
• For starting with the right lobe: the lesion currently fluctuates — a fluid component that could potentially rupture and nullify all treatment efforts.
• Consequences of a rupture (especially spontaneous): an acute emergency; carcinomatosis with a significantly worse prognosis; no surgery radical thereafter.
• For this reason the team leans towards the right lobe as stage one.

Activity of the right-lobe lesion

• Greater activity on the right (as the family suggested) is all the more reason to start there; Dr Latsinnikova had also told him the wall (parietal) component is activating.
• Both lesions are growing, so the right one also threatens life.
• Right lobe first is therefore the best, safer option.

Liver function after a right hemihepatectomy

• Little functional parenchyma would be lost: most of the right lobe is already replaced by tumour that does not perform liver function.
• He currently sees no likelihood of a high risk of post-operative liver failure.
• Functional liver MRI exists, but it "does not work that way" here: given the small functional loss, there is no point in doing such a test now, which would also take time.

Raised by the family

• The family is concerned that wall components are becoming active in different parts of the right-lobe lesion; its impression is that the left lesion is a growing "ball" while the right lobe seems more active.
• The family's understanding that the gastric tumour is currently inactive and not life-threatening; Dr Fedorov answered "yes".
• The family's understanding that the threat to life comes from the left-lobe lesion, which is not treated at first; Dr Fedorov answered "yes" and added the right lobe (above).
• Asked whether a functional MRI showing which part of the liver functions will be done (answer above).

Dr Fedorov — opinion

• The second MOK recommendation is to remove the gastric tumour after all.
• Reason: despite the histology, it is not known with 100% certainty whether viable tumour cells remain in it.
• Removing the right lobe and the gastric tumour in one operation is potentially possible, but only if the stomach does not need a large resection (gastrectomy).
• It appears to lie in the submucosal layer and does not grow inward, so a local gastric resection has a chance; the extent can be stated with 100% certainty only at revision during the operation.
• Even without a large resection, removing the gastric tumour carries its own risks of problems related to gastric resection.

Dr Fedorov — opinion

Risks named

• Drop-out before stage two because of progression: a risk that, unfortunately, cannot be excluded.
• Operative risk assessed as moderate but real: complications and post-operative liver failure may occur.
• Gastric resection adds its own risks (see above).
• Complications, even when successfully managed, lengthen the interval between the operations and so create a risk of progression.
• Progression to unresectability between the stages cannot be ruled out.
• There are risks of departing from the two-stage plan.
• As far as he understands the oncologists, they see no alternative other than this operation with these risks.

Why removing even one stage is worthwhile

• To the Polish clinic's view that treating as much as possible "prolongs", he said "partly so", because this tumour grows slowly; it grows exponentially — slowly at first, then faster.
• For this tumour the total tumour burden in the body really matters.
• Even if only the right lobe is removed and she then drops out of the second stage, that is still a survival benefit from the reduced tumour mass.
• Of course, it is better to remove everything.

Progression versus new metastases

• He distinguished two terms: progression is enlargement of existing metastases; metastasising is the formation of new distant foci.
• She already has metastatic disease: the liver tumour is not primary but a metastasis.
• New metastases are potentially possible, and local treatment of existing ones cannot prevent them.
• Metastasising is a systemic process driven by immune deficit and the activity of the primary tumour; it can be influenced only by systemic therapy.
• What the family probably means is progression (growth of what exists); it is indeed possible and cannot be safely prevented.

Raised by the family

• The family said it fears metastasis.
• Asked whether shrinking the left-lobe lesion by less invasive means during the first operation would lower the risk of metastasis (answers above and in the next section).
• The family summarised the outlook as effectively "50/50": if it spreads, the same situation with a lower tumour burden; if not, a better result. Dr Fedorov answered "yes" — possibly agreement, possibly only acknowledgement (see "Wording unclear").

Dr Fedorov — opinion

Embolisation

• It is unclear what to embolise. Hepatocellular carcinoma is fed mainly by the artery, so embolising the artery works there; this is neither that nor a colorectal metastasis, and this tumour tends, on the contrary, towards necrosis.
• Embolisation during the operation is possible at the Centre, but he does not think it should be done: there is no advantage to doing it intra-operatively.

Ablation

• Local-control methods are either resection (removing everything) or ablation (overheating the tumour).
• There are ablation procedures: in essence a local microwave oven — a radiofrequency antenna overheats the tissue, the burn persists after the current stops, and the result is local aseptic necrosis that usually causes no major intoxication.
• It works well, and is usually effective, for small lesions that one or several electrodes can cover; the field of each electrode is roughly spherical and burns out everything within it.
• Larger lesions need several electrodes placed to cover the whole tumour geometrically, which in her case would be very hard — only a partial, not a complete, ablation.
• Ablation would work only if everything could be burned out at once, which is not possible here; attempting it would most likely be equivalent to the same resection.
• That is exactly where the danger lies.
• Ideally her lesions should be removed surgically, if possible.
• He would regard ablation as a palliative procedure when other options are impossible.

Treating the left lesion during the first operation

• Treating it during stage one usually adds toxic or inflammatory load that could decompensate the liver.
• Not impossible, but risky: an additional risk of immediate post-operative complications.
• He does not think local treatment of the left-lobe metastasis is advisable now, because whatever is done it cannot be treated radically by local means; at most part of it would be ablated.
• Partial necrosis releases pro-inflammatory and aggressive growth factors on a massive scale; the remaining tumour's reaction is unknown.

If the left lesion grows before stage two

• The plan would be palliative ablations or chemoembolisations, or whatever other alternative methods can offer.
• Most likely this would not be radical.
• Asked whether this could buy time until the next operation, he said it could.

Raised by the family

• Asked whether, since the whole liver cannot be operated at once, a partial embolisation of the left part could be done.
• Reported a contact with a clinic in Poland whose message was "come, we will do everything" and which removes "as much as can be removed"; the family said it was a little uneasy about this, in contrast with the option-by-option discussion with Dr Fedorov.
• The Polish doctor reportedly offered "thermo-embolisation" of the left lobe: the part near the vein cannot be treated, but as much as possible would be, which "is already better and prolongs".
• Remarked that ablation suits lesions up to about 3 cm.
• Paraphrased the necrosis concern as "it could trigger growth".
• Asked whether this is necrosis rather than apoptosis; not answered directly.
• Asked whether there is a plan if the left part grows (answer above).

Dr Fedorov — opinion

• Usually the only way to stimulate immunity is immunotherapy (making the tumour visible to the immune system), and it is not indicated in her case.
• General immune activation does not work: immunity cannot be switched on and off or turned up like a dial.
• Immunomodulators: usually unproven drugs causing no change or, worse, unstudied changes.
• Any cancer reflects an imbalance between the immune system's normal clearing of cancer cells (which arise even in healthy people) and the number of such cells and the quality of immune surveillance; surveillance and immunodeficiency have very many subtypes.
• Studying and influencing immunity early would probably solve the problem; no such possibility is known to him today.
• On in-vivo CAR-T: it would be great if something like that appeared.

Raised by the family

• Asked whether the immune system can be stimulated.
• Noted that GIST is a solid tumour for which immunotherapy does not exist.
• Asked whether some general activation of the immune system might help.
• Asked whether she has no immunodeficiency; he did not answer directly (see "Wording unclear").
• Mentioned experimental CAR-T in which a vector reprogrammes the body's own leukocytes in vivo, without growing them outside the body.

Dr Fedorov — opinion

• Asked whether she will take imatinib (Glivec): "not now".
• After the operation she will return to it once her condition allows.
• Imaging after surgery, but not immediately: probably about two weeks later, to assess liver regeneration.
• More frequent imaging: no point in loading the body with contrast and, for CT, extra radiation.
• One CT will be done; CT itself does not treat anything.
• PET includes a CT component, so the two can be compared.

Raised by the family

• Asked whether she will take imatinib.
• Asked whether CT or MRI will be done regularly.
• Noted that CT is hard to compare with PET.

FACT Context from the case file: imatinib 400 mg/day was being taken and continued until the operation, per the family report of 14.10.2026 (current status). Whether "not now" means a pause before surgery was not clarified (see "Wording unclear"). Family report of 20.10.2026: imatinib stopped on 20.10.2026 before the operation; restart a few days after it (timing to be discussed).

Dr Fedorov — opinion

• He cannot comment on the missing slide; he said "they" dealt with the cytology laboratory — who "they" are is not stated.
• The cytology laboratory is a separate unit, not subordinate even to Vladyslav Oleksandrovych (Kropelnytskyi).
• Malignant cells would of course have been on all slides; he thinks the earlier finding was simply over-diagnosis against the background of a cancer diagnosis — "they overdid it". Who "they" are was not stated (presumably the original cytology report).

Raised by the family

• Called it good news that the reviewing laboratory did not see altered (malignant) cells.
• Noted that only 2 of the 3 slides reached the reviewing laboratory.
• Reasoned that malignant cells, if present, would be on all slides.

FACT Context from the written record: the CSD LAB review of 14.10.2026 (2 slides) reads category AUS, malignancy not established; the Shalimov reading of 06.10.2026 was category V (current status).

Dr Fedorov — opinion

• Biobank questions should go to Vladyslav Kropelnytskyi.
• The surgeons' responsibility ends with handing the specimen, unaltered, to pathology; pathology decides whether part of it goes elsewhere.
• Biobanking is something different: a company collects biological samples, de-identifies them and uses them for its own research; it is not part of the patient's treatment, and probably not what the family means.
• Freezing in liquid nitrogen is just a fixation method; the question is what happens to the specimen afterwards.
• Biobanking is a clinical study in which a patient may take part voluntarily, usually for benefits from the company, which might for example cover part of the patient's medical treatment or provide something else.
• Such systems existed "with us" before; he does not know whether they exist now ("with us" = at the Centre or in Ukraine; see "Wording unclear").
• It does not affect treatment; research findings do not come back to the patient.
• Talk to the pathologist; if there are specific requirements for the specimen, the surgical team can meet them.
• On the family's idea of CSD or another private laboratory, he replied only "talk" (to whom not stated).

Raised by the family

• With possible future clinical trials in mind, the family raised (on a suggestion it had received) giving tumour tissue to a biobank, since trials value well-documented patients with banked tumour.
• Noted that CSD (a laboratory in Ukraine) has a biobank.
• Understands, from a conversation with an AI chatbot, that this must be arranged before surgery, because the material must go into liquid nitrogen quickly during the operation.
• Clarified that what was meant is freezing tumour tissue in liquid nitrogen.
• Will talk to CSD and to Dr Kropelnytskyi; Dr Fedorov agreed.
• Hopes to settle tissue preservation before the operation.
• Reported that Dr Kropelnytskyi said they do not freeze in liquid nitrogen; they make paraffin blocks.
• Thinks CSD or another private laboratory might allow liquid-nitrogen freezing.

Dr Fedorov — opinion

• Which medications she will need after the operation cannot be predicted.
• Someone near the patient (ideally a relative) will be needed to fetch medicines that the Centre does not supply, if they are required.
• He suggested her driver could run such errands.
• Drugs the Centre has (e.g. for unforeseen complications) will be given to her directly.
• A sitter can be hired — one of the Centre's nurses or an outside carer.
• One of the Centre's nurses is better, because they know what can and cannot be done with her and whom to alert.
• The family should contact Oleksandr Mykolaiovych, including about the sitter — "I think he will help you".
• Dr Fedorov will tell Oleksandr Mykolaiovych to expect the family's call or message.
• Oleksandr Mykolaiovych will send the promised discharge summary (extract).
• The MOK written conclusion will be ready on Monday and will be sent later. INTERPRETATION Monday 19.10.2026, computed from the call date.
• Further questions can be sent later in writing; he agreed.

Raised by the family

• The patient has only fairly distant relatives (see "Wording unclear").
• Began to say that she will be in a hospital ward; he then explained what the Centre supplies.
• Confirmed she has a driver and will discuss with her what he can do.
• The family can order medicines from pharmacies with courier delivery.
• The family will write to Oleksandr Mykolaiovych to introduce itself.
• Both sides agreed to stay in touch.

Dr Fedorov — opinion

• He asked the family to talk with the patient and explain all of this to her.
• The team's own conversation with her will be the signing of surgical consent; she should be prepared beforehand.
• If she wants more explanation, the team will provide it on request.

Raised by the family

• The family will discuss the proposal with the patient and consider it.
• The family has enough information for now and needs to think about further questions.
• The family said the patient might call Dr Fedorov or Oleksandr Mykolaiovych herself.

• "If the stomach does not need a large resection, a gastrectomy": unclear whether "gastrectomy" restates "large resection" or names a separate option.
• "Latsinnikova": spelling uncertain from the audio.
• "Thermo-embolisation" (Polish clinic): a non-standard term; probably thermal ablation or (chemo)embolisation of the left lobe.
• Ablation field "close to a shar": probably the Russian word for sphere, not "layer".
• Radiofrequency description at 0:15:03: one sentence is garbled; the meaning summarised above is the evident one.
• Immunodeficiency question: he restarted his answer and never said directly whether she is immunodeficient.
• The family's remark about CSD or another private laboratory allowing freezing is garbled.
• "Not now" on imatinib: unclear whether she is to stop it before surgery or is already off it.
• "Such systems existed with us": at the Centre or in Ukraine — both readings fit.
• Cytology: unclear who "they" are in "they dealt with the cytology laboratory" (reviewing laboratory, clinic or the family's contacts) and in "they overdid it" (presumably the original report).
• "One CT": unclear whether one CT in total after surgery or one at the two-week point.
• "Yes" after the family's "50/50" summary: may be agreement or only acknowledgement.
• "Fairly distant relatives": may mean relatives living far away or only distant kin nearby.
• "He will send it later" (MOK conclusion): "he" was not named; the previous sentence was about Oleksandr Mykolaiovych.
• "After that we will do" (imaging): "after that" presumably means after the operation; CT/MRI is implied by the question.

• Open versus laparoscopic approach; anaesthesia; expected length of stay.
• The planned interval between the two stages, and the extent of the second-stage resection.
• Regorafenib or any other systemic therapy besides imatinib.
• Implications of the cytology result for the operation (e.g. peritoneal inspection at the start of surgery).
• Molecular or genetic testing of the operative specimen.