Adjuvant Therapy for Gallbladder Cancer: an Analysis of the National Cancer Data Base

Big data and RCT's in surgical oncology: Impact on improving hepatopancreatobiliary cancer surgical care on the global stage

Randomized controlled clinical trials (RCTs) are at the heart of "evidence-based" medicine. Conducting well-designed RCTs for surgical procedures is often challenged by inadequate recruitment accrual, blinding, or standardization of the surgical procedure, as well as lack of funding and evolution of the treatment strategy during the many years over which such trials are conducted. In addition, most clinical trials are performed in academic high-volume centers with highly selected patients, which may not necessarily reflect a "real-world" practice setting. Large databases provide easy and inexpensive access to data on a large and diverse patient population at a variety of treatment centers. Furthermore, large database studies provide the opportunity to answer questions that would be impossible or very arduous to answer using RCTs, including questions regarding health policy efficacy, trends in surgical practice, access to health care, the impact of hospital volume, and adherence to practice guidelines, as well as research questions regarding rare disease, infrequent surgical outcomes, and specific subpopulations. Prospective data registries may also allow for quality benchmarking and auditing. There are several high-quality RCTs providing evidence to support current practices in hepatopancreatobiliary (HPB) oncology. Evidence from big data bridges the gap in several instances where RCTs are lacking. In this article, we review the evidence from RCTs and big data in HPB oncology identify the existing lacunae, and discuss the future directions of research in HPB oncology.

Adjuvant chemoradiotherapy in resected gallbladder cancer: A SEER-based study

Background

The prognosis of gallbladder cancer (GBC) is dismal. This study aimed to compare the outcomes of adjuvant chemoradiotherapy (ACR) with those of surgery alone (S) and adjuvant chemotherapy (AC).

Method

The Surveillance, Epidemiology, and End Results (SEER) Program database was used to identify patients diagnosed with GBC and undergoing surgery between 2004 and 2015. The patients were divided into the S, AC, and ACR groups according to their treatment. Categorical variables were compared by Pearson's chi-square test, and a 1:1:1 propensity score matching analysis (PSM) was performed. Overall survival was assessed by Kaplan-Meier curves with log-rank tests. Subgroup analyses were conducted.

Result

A total of 5451 patients were identified in the SEER database. After PSM, the two-year survival among patients who received S, AC, and ACR was 36%, 39%, and 45%, respectively. ACR was associated with improved two-year survival (p < 0.001), while the survival rates were similar in the AC and S groups (p = 0.127) but better in the ACR group than in the AC group (p = 0.012). Subgroup analyses indicated that while the two-year survival rates did not differ significantly in stage II GBC patients between the groups (all p > 0.05), ACR was associated with significantly improved two-year survival in stage Ⅲa (p = 0.008), Ⅲb (p < 0.001), and Ⅳb (p < 0.001) GBC patients.

Conclusion

The combination of surgery and ACR as the treatment modality provided greater survival benefits for GBC patients, particularly for those with advanced tumor staging.

Role of Peri-operative Chemotherapy in Stage II (pT2N0) Gallbladder Cancers

BACKGROUND

Evidence for adjuvant chemotherapy in gallbladder cancer (GBC) is conflicting, with a postulated beneficial effect reported in T2 stage or higher, and node-positive tumours. This study aims to assess the survival benefit of peri-operative chemotherapy in stage II (pT2N0) GBCs.

METHODS

A retrospective analysis of stage II GBCs who underwent curative surgical resection was done. Patients receiving neo-adjuvant therapy (NACT) prior to resection of the gallbladder primary were excluded. Primary endpoint was disease-free survival, and outcomes of patients who received chemotherapy were compared to those who did not. Survival curves were plotted using a Kaplan-Meier analysis and difference between the survival curves was analysed using a log-rank test.

RESULTS

Two hundred seventy-six patients of stage II GBC were included, of whom 188 (68.1%) received chemotherapy and 88 (31.8%) did not. Forty-one (21.8%) patients received chemotherapy in the neo-adjuvant setting. There was no significant difference in the survival of patients who did and did not receive chemotherapy (5-year DFS 67.8% vs 66%, p = 0.795). There was no significant difference in the survival of patients who received chemotherapy in the adjuvant or neo-adjuvant setting (5-year DFS 66.4% vs 71.8%, p = 0.541). There was no statistically significant difference in the survival of patients with high-risk histologic features and who did and did not receive chemotherapy (3-year DFS 72.4% vs 56%; p = 0.379).

CONCLUSIONS

Routine use of chemotherapy, either in the adjuvant or neo-adjuvant setting, offers no survival advantage in stage II (pT2N0) gallbladder cancers.

High-Quality Surgery for Gallbladder Carcinoma: Rare, Associated with Disparity, and Not Substitutable by Chemotherapy

BACKGROUND

Oncologic surgery for T1b-T3 gallbladder carcinoma (GBC) consists of gallbladder fossa resection or bisegmentectomy IVb/V with negative margins and portal/retropancreatic lymphadenectomy. Frequency of high quality oncologic surgery, factors associated with its use, and the ability of chemotherapy to rescue low-quality surgery (LQS) remain unknown.

METHODS

The NCDB was queried for patients diagnosed with stage I-III (T1b-T3) GBC undergoing curative-intent surgery from 2004 to 2016. These patients were divided into two groups based on receiving high quality surgery (HQS) or not; HQS was defined as cholecystectomy with partial hepatectomy, lymph node harvest ≥ 6, and negative margins. Logistic regression and Kaplan-Meier survival analyses were performed.

RESULTS

A total of 3796 patients met inclusion criteria; only 364 (9.6%) met HQS criteria, and 3432 (90.4%) did not achieve HQS and were deemed low-quality surgery (LQS). HQS was associated with improved median overall survival (55.1 vs. 25.5 months, P < .001). Adjuvant chemotherapy (AC) was not able to rescue LQS with poorer survival compared to HQS without AC (27.9 vs 55.1 months, P < .001). Factors associated with HQS included private insurance (OR 1.809, P < .001), higher income (OR 1.380, P = .038), urban/rural residence (vs metropolitan) (OR 1.641, P = .001), higher education (OR 1.342, P = .031), Medicaid expansion states (OR 1.405, P = .005), stage 3 GBC (OR 1.642, P = .020), and reresection (OR 2.685, P < .001). Factors associated with LQS included older age (OR 0.974, P < .001), comorbidities (OR 0.701, P = .004), and laparoscopic approach (0.579, P < .001). Facility type incrementally improved HQS rate (integrated cancer network vs. comprehensive community, 9.8% vs. 6.1%, OR 1.694, P = .003; academic/research center vs. integrated cancer network, 14.9% vs. 9.8%, OR 1.599, P = .003).

CONCLUSION

While HQS for GBC strongly improves survival, it is infrequently practiced. The newly identified factors that improve survival for GBC, such as centralization, open approach, and insurance coverage, are modifiable and, therefore, should be considered to achieve optimal outcomes.

Tumor location and concurrent liver resection, impact survival in T2 gallbladder cancer: a meta-analysis of the literature

Aim of doing this review was to give a uniform consensus on prognostic impact of tumor location (hepatic vs peritoneal), liver resection and adjuvant chemotherapy in gall bladder cancer and, to compare them with previous well-studied factors of survival. We systematically review PubMed, Scopus and Cochrane for relevant articles with no date restrictions, language was restricted to English. Those articles were included that had provided Hazard ratio (HR) of survival for T2 gall bladder cancer. We identified nine retrospective studies published between 2014 and 2020 with 2345 patients. Meta-analysis showed that T2b (hepatic) cancers had higher odds of mortality (HR 3.16 [2.11, 4.74], I² = 0%). Liver resection was associated with significantly higher odds of 5-year overall survival only in T2b (2.20 [1.33, 3.63], I² = 67%), adjuvant chemotherapy was not associated with any significant decrease in mortality risk (0.98 [0.83-1.16]. I² = 20%). Hepatic sided gall bladder tumors carry higher odds for mortality and recurrence. T2a tumors can be managed without hepatic resection. To risk stratify patients we also formulated a scoring system for mortality risk.

Gallbladder cancer who is really cured?

BACKGROUND

Although gallbladder cancer (GBCA) is characterized by a dismal prognosis, there is a proportion of patients who are cured. The aim of this study was to analyze the profile of these patients.

METHODS

A database was queried for patients who underwent curative resection with a follow-up of at least 5 years. Patients were prospectively treated and registered by the same surgical team. A multivariate regression analysis was used to identify factors associated with long-term survival.

RESULTS

From 1988 to 2013, 461 patients were evaluated and 112 who underwent resection were analyzed. Among the patients, five year survival was 57% while lymph node and liver compromise were the only independent factors associated with survival. On the other hand, the elapsed time between the cholecystectomy and the resection, the differentiation grade and the level of wall invasion did not have an independent effect on the prognosis.

CONCLUSION

Despite its poor prognosis, a subset of patients can be cured of GBCA. R0 resection of patients without lymph and liver infiltration are key to GBCA survival.

A comparison of outcomes in patients with intracholecystic papillary neoplasms or conventional adenocarcinomas of the gallbladder

BACKGROUND

Intracholecystic papillary neoplasm (ICPN) of the gallbladder (GB) is an exophytic intraepithelial neoplasm. This study aimed to investigate clinicopathologic findings, prognosis and recurrence patterns of patients with ICPN as compared to those patients with conventional adenocarcinoma of the gallbladder (GBC).

METHODS

Patients who underwent surgical resection for suspected GB cancer between 2000 and 2018 were included. ICPN was defined as an exophytic papillary mass within the GB lumen with a size ≥1.0 cm.

RESULTS

Of 607 patients, 241 patients (40%) were pathologically diagnosed with ICPN. Of the 241 patients with ICPNs, 110 (46%) were T1 or less. Following T stage-matched analysis, the rate of lymph node metastases were comparable (50 [52%] vs. 37 [49%], P = 0.581). The five-year survival rate was higher in ICPN, but after T stage-matching, they were comparable (69.1 vs. 63.2%, P = 0.171). Overall recurrence rates were also comparable, with the exception of lower peritoneal seeding in patients with ICPN.

CONCLUSION

Patients with ICPN who underwent resection were more likely to have an earlier T stage. There was no significant difference in prognosis and recurrence between ICPN and conventional GBC after stage matching. Therefore, the treatment strategy for ICPN should follow the same protocols used for conventional GBC.

Clinical practice guidelines for the management of biliary tract cancers 2019: The 3rd English edition

BACKGROUND

The Japanese Society of Hepato-Biliary-Pancreatic Surgery launched the clinical practice guidelines for the management of biliary tract cancers (cholangiocarcinoma, gallbladder cancer, and ampullary cancer) in 2007, then published the 2nd version in 2014.

METHODS

In this 3rd version, clinical questions (CQs) were proposed on six topics. The recommendation, grade for recommendation, and statement for each CQ were discussed and finalized by an evidence-based approach. Recommendations were graded as Grade 1 (strong) or Grade 2 (weak) according to the concepts of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system.

RESULTS

The 31 CQs covered the six topics: (a) prophylactic treatment, (b) diagnosis, (c) biliary drainage, (d) surgical treatment, (e) chemotherapy, and (f) radiation therapy. In the 31 CQs, 14 recommendations were rated strong and 14 recommendations weak. The remaining three CQs had no recommendation. Each CQ includes a statement of how the recommendations were graded.

CONCLUSIONS

This latest guideline provides recommendations for important clinical aspects based on evidence. Future collaboration with the cancer registry will be key for assessing the guidelines and establishing new evidence.

Patterns of Failure and the Need for Biliary Intervention in Resected Biliary Tract Cancers After Chemoradiation

BACKGROUND

This study assessed patterns of failure and rates of subsequent biliary intervention among patients with resected biliary tract cancers (BTCs) including gallbladder carcinoma (GBC) and extra- and intrahepatic cholangiocarcinoma (eCCA and iCCA) treated with adjuvant chemoradiation therapy (CRT).

METHODS

In this single-institution retrospective analysis of 80 patients who had GBC (n = 29), eCCA (n = 43), or iCCA (n = 8) treated with curative-intent resection and adjuvant CRT from 2007 to 2017, the median radiation dose was 50.4 Gy (range 36-65 Gy) with concurrent 5-fluorouracil (5-FU) chemotherapy. All but two of the patients received adjuvant chemotherapy. The 2-year locoregional failure (LRF), 2-year recurrence-free survival (RFS), and 2-year overall survival (OS), and univariate predictors of LRF, RFS, and OS were calculated for the entire cohort and for a subgroup excluding patients with iCCA (n = 72). The predictors of biliary interventions also were assessed.

RESULTS

Of the 80 patients (median follow-up period, 30.5 months; median OS, 33.9 months), 54.4% had American Joint Committee on Cancer (AJCC) stage 1 or 2 disease, 57.1% were lymph node-positive, and 66.3% underwent margin-negative resection. For the entire cohort, 2-year LRF was 23.8%, 2-year RFS was  43.7%, and 2-year OS was 62.1%.  When patients with iCCA were excluded, the 2-year LRF was 22.6%, the 2-year RFS was 43.9%, and the 2-year OS was 59.2%. In the overall and subgroup univariate analyses, lymph node positivity was associated with greater LRF, whereas resection margin was not. Biliary intervention was required for 12 (63.2%) of the 19 patients with LRF versus 11 (18%) of the 61 patients without LRF (P < 0.001). Of the 12 patients with LRF who required biliary intervention, 4 died of biliary complications.

CONCLUSIONS

The LRF rates remained significant despite adjuvant CRT. Lymph node positivity may be associated with increased risk of LRF. Positive margins were not associated with greater LRF, suggesting that CRT may mitigate LRF risk for this group. An association between LRF and higher rates of subsequent biliary interventions was observed, which may yield significant morbidity. Novel strategies to decrease the rates of LRF should be considered.

Prognostic factors and patterns of loco-regional failure in patients with R0 resected gallbladder cancer

BACKGROUND

In this study, risk factors for loco-regional recurrence in curative R0 resected gallbladder adenocarcinoma were investigated.

METHODS

Patients with gallbladder adenocarcinoma with curative R0 resections between 2000 and 2016 were retrospectively reviewed. Loco-regional failure-free survival (LRFFS) and overall survival (OS) were analyzed using the Kaplan-Meier method; prognostic factors were analyzed using the Cox proportional hazards model. Based on the identified risk factors, patients were grouped for further analysis.

RESULTS

A total of 272 patients were included for analysis; overall, 5-year LRFFS and OS were 83% and 81%, respectively. On multivariate analysis, 3 risk factors for LRFFS were identified; lymphovascular invasion, T3, and N1, by which patients were grouped; group 1 for 0 factor, group 2 for 1 factor and group 3 for 2 to 3 factors. The 5-year LRFFS in groups 1, 2, and 3 were 94%, 73%, and 40%, and the 5-year OS in groups 1, 2, and 3 were 90%, 75%, and 47%, respectively. LRFFS and OS differed significantly among groups (p < 0.05).

CONCLUSION

In patients with R0 resected gallbladder cancer, the presence of >1 risk factor increased the risk of loco-regional recurrence. Additional therapeutic strategy for these patients needs further consideration.

Comparison of overall survival in gallbladder carcinoma at academic versus community cancer centers: An analysis of the National Cancer Data Base

BACKGROUND AND OBJECTIVES

Gallbladder carcinoma (GBC) has a poor prognosis. Studies demonstrated that teaching facilities may provide a lower risk of mortality in patients undergoing pancreatic and colon resection vs nonteaching facilities. We hypothesized that survival rates are higher in academic cancer centers (ACCs) vs community cancer centers (CCCs).

METHODS

Patients with all stages of GBC were identified from the National Cancer Database (2007-2012). Propensity score matching adjusted for selection bias. Descriptive statistics were calculated for all variables. Overall survival (OS) was compared by facility type (ACC vs CCC) and case volume (low vs high) via multivariable Cox proportional hazards regression.

RESULTS

A total of 7967 patients met the inclusion criteria. Following propensity matching, 2801 patients were analyzed from each facility type. Median OS following surgery was higher for ACC (20.99 months, 95% confidence interval [CI], 19.61-22.64, P = .002) than CCC (17.68 months, 95% CI, 16.46-19.25). Following Cox modeling, GBC treatment at ACCs was a protective factor for OS (adjusted hazard ratio 0.876, 95% CI, 0.801-0.958, P = .004).

DISCUSSION

GBC treatment at ACCs is an independent predictor of OS. High volume ACCs are associated with improved OS compared with low volume ACCs. The site of care and case volume in ACCs may contribute to improved survival outcomes.

Disparities in Treatment for Gallbladder Carcinoma: Does Treatment Site Matter?

BACKGROUND AND PURPOSE

Current treatment guidelines for gallbladder cancer range from simple cholecystectomy to regional hepatic resection. Treatment patterns for radical resection and adjuvant chemotherapy vary. We aim to determine if there is any disparity in treatment or difference in survival between academic versus community treatment centers.

METHODS

The National Cancer Database (NCDB) was queried from 2004 to 2014 for gallbladder carcinoma. Cases were stratified into treatment sites as "Community Cancer Center" (CCC) or "Academic Cancer Center" (ACC). Propensity score matching was performed for patient demographics, TNM stage, resection type, and administration of adjuvant chemotherapy. The primary outcome included 30-day mortality, 90-day mortality, and overall survival.

RESULTS

There are similar frequencies of radical versus simple resection and administration of adjuvant chemotherapy between ACC and CCC. When propensity-matched for resection type, cases treated at ACC have lower 30-day mortality (4.1% vs. 6.9%) and 90-day mortality (13.2% vs. 18.5%) and increased 5-year overall survival (26.2% vs. 22.4%) (p < 0.01). After propensity matching for adjuvant chemotherapy, cases at ACC have lower 30-day mortality (4.12% vs. 7.71%) and 90-day mortality (13.22% vs. 19.19%) and increased overall survival (13.6% vs. 11.0%) (p < 0.01).

DISCUSSION AND CONCLUSIONS

While treatment patterns for gallbladder cancer at ACC and CCC were similar, there was a decrease in 30-day and 90-day mortality and improved overall survival associated with patients treated at ACC. Treatment site may have an impact in the surgical outcomes of gallbladder cancer patients. This disparity warrants further research.

Oncologic Outcomes of Extended Lymphadenectomy without Liver Resection for T1/T2 Gallbladder Cancer

PURPOSE

This study provides a standardized operative strategical algorithm that can be applied to patients with T1/T2 gallbladder cancer (GBC). Our aim was to determine the oncologic outcome of radical cholecystectomy with para-aortic lymph node dissection without liver resection in T1/T2 GBC.

MATERIALS AND METHODS

From January 2005 to December 2017, 164 patients with GBC underwent operations by a single surgeon at Severance Hospital. A retrospective review was performed for 113 of these patients, who were pathologically determined to be in stages T1 and T2 according to American Joint Committee on Cancer 7th guidelines.

RESULTS

Of the 113 patients, 109 underwent curative resection for T1/T2 GBC; four patients who underwent palliative operations without radical cholecystectomies were excluded from further analyses. For all T1b and T2 lesions, radical cholecystectomy with para-aortic lymph node dissection was performed without liver resection. There were four GBC-related mortalities, and 5-year disease-specific survival was 97.0%. The median follow-up was 50 months (range: 5-145 months). In all T stages, the median was not reached for survival analysis. Five-year disease-specific survival for T1a, T1b, and T2 were 100%, 94.1%, and 97.1%, respectively. Five-year disease-free survival for T1a, T1b, and T2 were 100%, 87.0%, and 91.8%, respectively.

CONCLUSION

Our results suggest that the current operative protocol can be applied to minimal invasive operations for GBC with similar oncologic outcomes as open approach. For T1/T2 GBC, radical cholecystectomy, including para-aortic lymph node dissection, can be performed safely with favorable oncologic outcomes.

A systematic review of the effectiveness of adjuvant therapy for patients with gallbladder cancer

BACKGROUND

Equipoise exists regarding the benefit of adjuvant therapy (AT) in patients with gallbladder cancer (GBC). The aim of this study was to critically review the available evidence for the effectiveness of AT in patients with GBC following surgery with curative intent.

METHODS

A systematic review was performed. Relevant studies were identified from Trip Database, BIREME-BVS, SciELO, Cochrane Central Register, WoS, MEDLINE, EMBASE and SCOPUS. Adjuvant therapies considered included chemotherapy, chemoradiotherapy, and radiotherapy. The primary outcome was overall survival (OS). Subgorup analysis of patients with positive lymph node disease (PLND), positive surgical margin (PSM), or advanced stage (AS) were performed.

RESULTS

748 related articles were identified; 27 met the selection criteria (3 systematic reviews and 24 observational studies). Evidence provided was moderate, poor and very poor for chemotherapy, chemoradiotherapy, and radiotherapy. Existing evidence is not robust, but suggests certain benefits with AT in improving OS, especially in patients with PLND, PSM and AS.

CONCLUSION

Results do not provide strong evidence that AT is effective in patients who undergo resection for GBC. Subgroups of PLND and PSM may have a survival advantage. Future studies with appropriate internal validity and adequate number of patients are required to better answer this question.

Estimating survival benefit of adjuvant therapy based on a Bayesian network prediction model in curatively resected advanced gallbladder adenocarcinoma

BACKGROUND

The factors affecting the prognosis and role of adjuvant therapy in advanced gallbladder carcinoma (GBC) after curative resection remain unclear.

AIM

To provide a survival prediction model to patients with GBC as well as to identify the role of adjuvant therapy.

METHODS

Patients with curatively resected advanced gallbladder adenocarcinoma (T3 and T4) were selected from the Surveillance, Epidemiology, and End Results database between 2004 and 2015. A survival prediction model based on Bayesian network (BN) was constructed using the tree-augmented naïve Bayes algorithm, and composite importance measures were applied to rank the influence of factors on survival. The dataset was divided into a training dataset to establish the BN model and a testing dataset to test the model randomly at a ratio of 7:3. The confusion matrix and receiver operating characteristic curve were used to evaluate the model accuracy.

RESULTS

A total of 818 patients met the inclusion criteria. The median survival time was 9.0 mo. The accuracy of BN model was 69.67%, and the area under the curve value for the testing dataset was 77.72%. Adjuvant radiation, adjuvant chemotherapy (CTx), T stage, scope of regional lymph node surgery, and radiation sequence were ranked as the top five prognostic factors. A survival prediction table was established based on T stage, N stage, adjuvant radiotherapy (XRT), and CTx. The distribution of the survival time (>9.0 mo) was affected by different treatments with the order of adjuvant chemoradiotherapy (cXRT) > adjuvant radiation > adjuvant chemotherapy > surgery alone. For patients with node-positive disease, the larger benefit predicted by the model is adjuvant chemoradiotherapy. The survival analysis showed that there was a significant difference among the different adjuvant therapy groups (log rank, surgery alone vs CTx, P < 0.001; surgery alone vs XRT, P = 0.014; surgery alone vs cXRT, P < 0.001).

CONCLUSION

The BN-based survival prediction model can be used as a decision-making support tool for advanced GBC patients. Adjuvant chemoradiotherapy is expected to improve the survival significantly for patients with node-positive disease.

Improvement in the diagnosis and treatment of T2 gallbladder carcinoma is pivotal to improvement in the overall prognosis for this disease

Since the American Joint Committee on Cancer (AJCC) subdivided the T2 stage of gallbladder carcinoma (GBC) into T2a and T2b, the diagnosis and treatment of those stages have been a subject of heated discussion and controversy. T2 is a stage of GBC that might be treatable. Based on the extent of lymph node metastasis and distant metastasis, T2 GBC can be classified into various pathological stages such as IIA, IIB, IIIB, and IVB, leading to controversy in clinical settings. This review aims to discuss the effectiveness of and controversies concerning S4b+5 resection, the acceptable extent of lymph node dissection, the timing for treatment of incidental gallbladder cancer, and adjuvant therapy. This review also aims to suggest directions for and recommendations regarding clinical research in the future.

Gallbladder Cancer: Diagnosis, Surgical Management, and Adjuvant Therapies

Gallbladder cancer (GBC) is an often lethal disease, but surgical resection is potentially curative. Symptoms may be misdiagnosed as biliary colic; over half of new diagnoses are made after laparoscopic cholecystectomy for presumed benign disease. Gallbladder polyps >1 cm should prompt additional imaging and cholecystectomy. For GBC diagnosed after cholecystectomy, tumors T1b and greater necessitate radical cholecystectomy. Radical cholecystectomy includes staging laparoscopy, hepatic resection, and locoregional lymph node clearance to achieve R0 resection. Patients with locally advanced disease (T3 or T4), hepatic-sided T2 tumors, node positivity, or R1 resection may benefit from adjuvant chemotherapy. Chemotherapy increases survival in unresectable disease.

Gallbladder cancer with tumor thrombus in the portal vein: A case report

RATIONALE

Gallbladder cancer (GBC) is a highly fatal malignancy. Due to its invasiveness and delayed diagnosis, many GBC patients are diagnosed with synchronous liver and hepatoduodenal ligament involvement. In our case, we report a gallbladder cancer with portal vein thrombus.

PATIENT CONCERNS

A 60-year-old woman presented with persistent upper abdominal dull pain for 2 months.

DIAGNOSES

Ultrasound examination showed gallbladder carcinoma invading liver segment IV, and a tumor thrombus in the left and right main portal trunk. Ultrasonography and contrast-enhanced magnetic resonance imaging (MRI) showed gallbladder carcinoma with invasion of adjacent liver, and tumor thrombus in the right branch of the portal vein and intrahepatic bile duct. Abdominal computed tomography angiography (CTA) revealed no hepatic artery invasion.

INTERVENTIONS

We made a decision to perform extended right lobectomy. Twenty-six days later, the patient underwent intravenous infusion port implantation for S-1 plus oxaliplatin (SOX) therapy.

OUTCOMES

After treatment, the patient has been doing very well and no recurrence has been found for 5 months.

LESSONS

The patient with gallbladder cancer and tumor thrombus in the portal vein described in this report provides a reminder for surgeons of the importance of early diagnosis, and adequate surgical and adjuvant treatment. Multi-disciplinary treatment is significantly beneficial for the overall survival of patients with advanced GBC.

Adjuvant Chemoradiotherapy is Associated with Improved Survival for Patients with Resected Gallbladder Carcinoma: A Systematic Review and Meta-analysis

BACKGROUND

The impact of adjuvant radiotherapy (ART) on survival from gallbladder carcinoma (GBC) remains underexplored, with conflicting results reported. A systematic review and meta-analysis was performed to clarify the impact of ART in GBC.

METHODS

A systematic literature search of several databases was performed following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, from inception to August 2016. Studies that reported survival outcomes for patients with or without ART after curative surgery were included.

RESULTS

All the inclusion criteria was met by 14 retrospective studies including 9364 analyzable patients, but most of the studies had a moderate risk of bias. Generally, the ART group had more patients with unfavorable characteristics than the group that had surgery alone. Nevertheless, the pooled results showed that ART significantly reduced the risk of death (hazard ratio [HR], 0.54; 95% confidence interval [CI] 0.44-0.67; p < 0.001) and recurrence (HR 0.61; 95% CI 0.38-0.98; p = 0.04) of GBC compared with surgery alone. Exploratory analyses demonstrated a survival benefit from ART for a subgroup of patients with lymph node-positive diseases (HR 0.61; p < 0.001) and R1 resections (HR 0.55; p < 0.001), but not for patients with lymph node-negative disease (HR 1.06; p = 0.78). No evidence of publication bias was found (p = 0.663).

CONCLUSIONS

This study is the first meta-analysis to evaluate the role of ART and to provide supporting evidence that ART may offer survival benefits, especially for high-risk patients. However, further confirmation with a randomized prospective study is needed to clarify the subgroup of GBC patients who would benefit most from ART.

Surgical Management of Gallbladder Cancer: Simple Versus Extended Cholecystectomy and the Role of Adjuvant Therapy

OBJECTIVE

To assess if simple cholecystectomy with adjuvant therapy could provide outcomes comparable to extended cholecystectomy.

BACKGROUND

Current guidelines recommend extended/radical cholecystectomy for T2/T3 gallbladder cancer; however, many tumors are discovered incidentally at laparoscopic cholecystectomy.

METHODS

The national Cancer Data Base 2004 to 2014 was queried for patients with pT2/T3 gallbladder adenocarcinoma who underwent resection. Adjuvant therapy was defined as chemotherapy, with or without radiotherapy, within 90 days of surgery. Baseline characteristics and overall survival were compared by χ and Kaplan-Meier method, respectively. One-to-one propensity score matching for receipt of adjuvant therapy was used to account for potential selection bias.

RESULTS

A total of 6825 patients were identified. Diagnosis was made predominantly (78.9%) at the time of surgery or on pathology; 31.8% (2168) received adjuvant therapy. The majority, 88.8% (6060), had a simple cholecystectomy. Patients who received adjuvant therapy versus surgery alone were more likely to: be younger, privately insured, have no comorbidities, pT3 disease, positive lymph nodes, positive resection margins, and extended cholecystectomy. After matching, median survival was significantly longer for extended cholecystectomy with adjuvant therapy (23.3 months) than cholecystectomy with adjuvant therapy (16.4 months), which was significantly longer than either simple (12.4 months) or extended (10.7 months) cholecystectomy alone (all log-rank P<0.001).

CONCLUSIONS

Adjuvant therapy prolongs survival after resection of T2/T3 tumors. Simple cholecystectomy with adjuvant therapy appears to be superior to extended resection alone in the short term and may serve as a potential alternative to re-resection in select high-risk individuals.

The role of surgery and adjuvant therapy in lymph node-positive cancers of the gallbladder and intrahepatic bile ducts

BACKGROUND

Lymph node metastasis is a poor prognostic factor for biliary tract cancers (BTCs). The optimal management of patients who have BTC with positive regional lymph nodes, including the impact of surgery and adjuvant therapy (AT), is unclear.

METHODS

This was a retrospective cohort study of patients who had T1-T3N1M0 gallbladder cancer (GBC) and intrahepatic cholangiocarcinoma (IHC) in the National Cancer Database (2004-2012). Patients were classified by treatment approach (nonoperative, surgery, surgery plus AT). Associations between the overall risk of death and treatment strategy were evaluated with multivariable Cox regression.

RESULTS

Rates of surgical resection were 84.1% for patients with GBC (n = 1335) and 36.6% for those with IHC (n = 1009). The median overall survival of patients in the nonoperative, surgery, and surgery plus AT group was 11.6, 13.3, and 19.6 months, respectively, for those with GBC (log-rank P < .001), and 12.7, 16.2, and 22.6 months, respectively, for those with IHC (log-rank P < .001), respectively. Compared with nonoperative therapy, surgery with or without AT was associated with a lower risk of death from GBC (surgery with AT: hazard ratio [HR], 0.59; 95% confidence interval [CI], 0.48-0.73; surgery without AT: HR, 0.71; 95% CI, 0.56-0.89) and from IHC (surgery with AT: HR, 0.52; 95% CI, 0.42-0.63; surgery without AT: HR, 0.70; 95% CI, 0.56-0.87). AT that included radiation was associated with a lower risk of death relative to surgery alone for patients with GBC regardless of margin status (margin-negative resection: HR, 0.66; 95% CI, 0.52-0.84; margin-positive resection: HR, 0.54; 95% CI, 0.39-0.75), but adjuvant chemotherapy alone was not. For patients with IHC, no survival benefit was detected with adjuvant chemotherapy or radiation for those who underwent either margin-positive or margin-negative resection.

CONCLUSIONS

The best outcomes for patients who have lymph node-positive BTCs are associated with margin-negative resection and, in those who have GBC, the inclusion of adjuvant chemotherapy with radiation regardless of margin status. Cancer 2018;124:74-83. © 2017 American Cancer Society.

Gallbladder Carcinoma in the United States: A Population Based Clinical Outcomes Study Involving 22,343 Patients from the Surveillance, Epidemiology, and End Result Database (1973-2013)

Introduction

Gallbladder carcinoma (GBC) is the most common malignancy of the biliary tract and the third most common gastrointestinal tract malignancy. This study examines a large cohort of GBC patients in the United States in an effort to define demographics, clinical, and pathologic features impacting clinical outcomes.

Methods

Demographic and clinical data on 22,343 GBC patients was abstracted from the SEER database (1973–2013).

Results

GBC was presented most often among Caucasian (63.9%) females (70.7%) as poorly or moderately differentiated (42.5% and 38.2%) tumors, with lymph node involvement (88.2%). Surgery alone was the most common treatment modality for GBC patients (55.0%). Combination surgery and radiation (10.6%) achieved significantly longer survival rates compared to surgery alone (4.0 ± 0.2 versus 3.7 ± 0.1 years, p = 0.004). Overall mortality was 87.0% and cancer-specific mortality was 75.4%.

Conclusions

GBC is an uncommon malignancy that presents most often among females in their 8th decade of life, with over a third of cases presenting with distant metastasis. The incidence of GBC has doubled in the last decade concurrent with increases in cholecystectomy rates attributable in part to improved histopathological detection, as well as laparoscopic advances and enhanced endoscopic techniques. Surgical resection confers significant survival benefit in GBC patients.

Limited Use of Adjuvant Therapy in Patients With Resected Gallbladder Cancer Despite a Strong Association With Survival

Background

There are no randomized data to guide clinicians treating patients with gallbladder cancer (GBC). Several retrospective studies reported the survival benefits of adjuvant radiotherapy (RT) and chemoradiation (CRT). In this paper, we examine whether these publications have impacted the utilization of adjuvant therapies and whether their survival benefits are evident in a contemporary cohort of patients.

Methods

Using the National Cancer Data Base, we identified 5029 patients diagnosed with T1-3N0-1 GBC and treated with surgical resection from 2005 to 2013. We described trends in receipt of adjuvant treatments for three time periods (2005-2007, 2008-2010, 2011-2013) and calculated three-year overall survival (OS) probabilities for 2989 patients treated in 2005-2010. All statistical tests were two-sided.

Results

The percentage of patients who received no adjuvant treatments was unchanged from 2005 to 2013. Adjuvant RT decreased from 4.2% to 1.7% ( P  < .001), adjuvant chemotherapy increased from 8.3% to 13.8% ( P  < .001), and adjuvant CRT remained stable at 15.9% ( P  = .98). Adjuvant treatments were associated with improved three-year OS, with adjusted hazard ratio of 0.47 (95% confidence interval [CI] = 0.39 to 0.58) for CRT, 0.77 (95% CI = 0.61 to 0.97) for chemotherapy, and 0.63 (95% CI = 0.44 to 0.92) for RT. Adjuvant CRT was associated with improved survival in all categories, except T1N0, and in patients with negative and positive margins.

Conclusion

Over the past decade there was no increase in the utilization of adjuvant therapies in the United States for patients with resected GBC. Adjuvant therapy is associated with statistically significantly improved three-year OS. This analysis should form the basis for current clinical recommendations and support future prospective trials.

Chemotherapeutic agents for GI tumor chemoradiotherapy overview of chemotherapeutic agents to be combined with radiotherapy in the GI tract and their potential as radiosensitizers

In the treatment of gastrointestinal tumors, simultaneous radiochemotherapy plays an important role. It is one of the principles of simultaneous radiochemotherapy, applying only chemotherapeutic agents simultaneously to radiation, which are primarily effective in the treated tumor entity, therefore a lot of different agents, like antimetabolites, mostly 5-fluorouracil, platinum derivates (mostly cisplatinum and oxaliplatin), mitomycin C and taxanes are used in simultaneous radiochemotherapy. Most of these have also radiation-intensifying effects. The mechanisms and interactions with ionizing radiation are presented in the article.

Impact of Chemotherapy and External-Beam Radiation Therapy on Outcomes among Patients with Resected Gallbladder Cancer: A Multi-institutional Analysis

BACKGROUND

Use of adjuvant chemotherapy (CTx) and chemoradiation therapy (cXRT) for the treatment of gallbladder cancer (GBC) remains varied. We sought to define the utilization and effect of adjuvant therapy for patients with GBC.

METHODS

Using a multi-institutional national database, 291 patients with GBC who underwent curative-intent resection between 2000 and 2015 were included. Patients with metastasis or an R2 margin were excluded.

RESULTS

Median patient age was 66.6 years. Most patients had a T2 (46.2 %) or T3 (38.6 %) lesion, and 37.8 % of patients had lymph node (LN) metastasis. A total of 186 (63.9 %) patients underwent surgery alone, 61 (21.0 %) received CTx, and 44 (15.1 %) patients received cXRT. On multivariable analysis, factors associated with worse overall survival (OS) included T3/T4 stage [hazard ratio (HR) 1.82], LN-metastasis (HR 1.84), lymphovascular invasion (HR 2.02), perineural invasion (HR 1.42), and R1 surgical margin status (HR 2.06); all P < 0.05). In contrast, receipt of CTx/cXRT was associated with improved OS (CTx, HR 0.38; cXRT, HR 0.26; P < 0.001) compared with surgery alone. Similar results were observed for disease-free survival (DFS) (CTx, HR 0.61; cXRT, HR 0.43; P < 0.05). Of note, only patients with high-risk features, such as AJCC T3/T4 stage (HR 0.41), LN metastasis (HR 0.45), and R1 disease (HR 0.21) (all P < 0.05) derived an OS benefit from CTx/cXRT.

CONCLUSIONS

Adjuvant CTx/cXRT was utilized in 36 % of patients undergoing curative-intent resection for GBC. After adjusted analyses, CTx/cXRT were independently associated with improved long-term outcomes, but the benefit was isolated to only patients with high-risk characteristics.