I am so sorry to hear about your latest recurrence. I admire your fighting attitude. I have a little bit of knowledge that I can impart, as I have spoken to several experts about Keytruda trials for my wife Lisa. As you know, Keytruda has shown tremendous promise for the treatment of hematologic malignancies as well as solid tumors such as cholangiocarcinoma. For cholangiocarcinoma, it seems that only a small percentage of patients have a robust response, but it is way too early to draw any conclusions. Researchers are still uncertain as to which populations of patients will have a response. The PD-L1 antibody was previously considered a possible indicator that a particular patient could have a response to Keytruda (or similar class of immunotherapy agents). I have been told that PD-L1 is losing favor as a predictive biomarker; however, a positive PD-L1 result can still qualify some patients for participation in certain Keytruda trials. It seems that other biomarkers such as microsatellite instability (MSI), mutation burden, or the presence of specific mutations such as BRAF may be better indicators of response to treatment, but again, the research is evolving so quickly that this information may already be dated.
I am not aware of Keytruda being used in an adjuvant setting. The clinical trials that I have explored all require measurable disease in order to qualify. However, your oncologist could always prescribe Keytruda off label outside of a trial. The disadvantage of off-label use is that you could be ineligible for future immunotherapy trials. Also, off-label use is not typically covered by insurance, although Merck has provided the drug at no cost to many patients who go this route.
Regarding FOLFOX, I know of many cholangiocarcinoma patients that have done very well on this combination. My wife Lisa had a very good response to folfirinox (similar to folfox with irinotecan added) after failing on the standard gem-cis. In fact, her robust response is the only reason that she was able to have a life-saving resection surgery. Folfirnox did not completely eliminate the tumors, but shrank them enough to make her eligible for surgery.
I agree with you that it would make sense to have surgery immediately if you are eligible rather than wait to see how you respond to chemotherapy. I am sorry I cannot help with this question. I would definitely clarify the reasons with your medical team and possibly seek a second opinion. Clearly all cases are different, but I know that some patients on this board have had more than two resections for multiple recurrences.
Wishing you the best at your appointments today. Please keep us posted.