Use of gemcitabine-platinum in Indian patients with advanced gall bladder cancer

Gallbladder cancer: Progress in the Indian subcontinent

Gallbladder cancer (GBC) is one of the commonest biliary malignancies seen in India, Argentina, and Japan. The disease has dismal outcome as it is detected quite late due to nonspecific symptoms and signs. Early detection is the only way to improve the outcome. There have been several advances in basic as well as clinical research in the hepatobiliary and pancreatic diseases in the West and other developed countries but not enough has been done in GBC. Therefore, it is important and the responsibility of the countries with high burden of GBC to find solutions to the many unanswered questions like etiopathogenesis, early diagnosis, treatment, and prognostication. As India being one of the largest hubs for GBC in the world, it is important to know how the country has progressed on GBC. In this review, we will discuss the outcome of the publications from India highlighting the work and the developments taken place in past several decades both in basic and clinical research.

Second-line treatments in advanced biliary tract cancer: systematic literature review of efficacy, effectiveness and safety

Background: A systematic review was conducted to understand clinical, economic and health-related quality-of-life outcomes in second-line biliary tract cancer. Materials & methods: The review followed established recommendations. The feasibility of network meta-analysis revealed limited networks, thus synthesis was limited to a summary of reported ranges, percentiles and medians. Results: The review included 62 trials and observational studies highly variable with respect to key baseline characteristics. Commonly evaluated second-line treatments included fluoropyrimidine-, gemcitabine- and S-1-based regimens. Across active treatment arms, median overall survival ranged from 3.5 to 15.0 months (median: 6.9), median progression-free survival from 1.4 to 6.5 months (median: 2.9) and objective response from 0 to 36.4%. Outcomes were similar between study types, with a few notable outliers. Treatment-related/-emergent adverse events were infrequently reported; no studies reported economic or health-related quality-of-life outcomes. Conclusions: Biliary tract cancer is a difficult-to-treat disease with poor prognosis. Despite evolving treatment landscapes, more recent studies did not show clinical outcome improvement, highlighting an unmet need among advanced/metastatic patients.

Geographical pattern of carcinoma gallbladder in Bihar and its association with river Ganges and arsenic levels: Retrospective individual consecutive patient data from Regional Cancer Centre

Background:

Indo-Gangetic basin is known to have higher incidence of gallbladder cancer. Proximity to River Ganga and high heavy metal in soil exposure have been postulated as risk factors.

Aim:

This study aims to evaluate the geographical pattern of gallbladder cancer from consecutive patient database enrolled in hospital-based cancer registry (HBCR).

Objectives:

To evaluate demographic profile and districtwise/zonewise dispersion of gallbladder cancer cases registered in HBCR from year 2014 to 2016. To evaluate association of carcinoma gallbladder (CaGB) due to proximity of Ganges, districts of high soil arsenic levels and referral bias.

Materials and Methods:

Demographic profile and district-based location of individual consecutive gallbladder cancer patient registered in Regional Cancer Centre from the year 2014 till 2016 were analyzed. Population data from 2011 census and arsenic soil content data from central groundwater body were obtained. Frequency distribution, cross tabulation, and odds ratio were used to analyze risk of CaGB across population subsets in Bihar.

Results:

A total of 1291 consecutive patients of CaGB were registered from 2014 to 2016. Median age at diagnosis was 55 years (range 18–95 years). Male to female ratio was 0.6. Patna (16%) followed by Vaishali (5.8%), Sitamarhi (5%), Madhubani (4.7%), Gaya (4%), and Samastipur (4%) had highest cases. Districts along main central River Ganga (n = 12) and those exposed to high arsenic soil content (n = 15) had higher odds ratio for CaGB, 1.72 (95% confidence interval [CI]: 1.54–1.91, P = 0.001), and 1.45 (95% CI: 1.30–1.62, P = 0.001), respectively. Districts within 100 km radius of our institute had higher gallbladder cancer cases, odds ratio 1.81 (95% CI: 1.62–2.03, P = 0.001), suggesting significant referral bias predominantly contributed by cases registered under Patna and Vaishali districts.

Conclusion:

CaGB is major public health problem in Bihar. Exposure to high soil arsenic levels and proximity to River Ganga are strongly associated with gallbladder cancer. Systematic population-based longitudinal studies are needed to explore above hypothesis.

Gallbladder cancer: a journey of a thousand steps

This article traces the journey of one of the teams from India that has been actively managing and researching gallbladder cancer for more than a decade, providing insights into the work carried out and highlighting areas that warrant future research in this cancer traditionally known for its dismal outcomes.

Gastrointestinal cancers in India: Treatment perspective

GI cancer is not one cancer but is a term for the group of cancers that affect the digestive system including gastric cancer (GC), colorectal cancer (CRC), hepatocellular carcinoma (HCC), esophageal cancer (EC), and pancreatic cancer (PC). Overall, the GI cancers are responsible for more cancers and more deaths from cancer than any other organ. 5 year survival of these cancers remains low compared to western world. Unlike the rest of the world where organ based specialities hepatobiliary, pancreatic, colorectal and esophagogastric exist, these cancers are managed in India by either a gastrointestinal surgeons, surgical oncologist, or a general surgeon with varying outcomes. The aim of this review was to collate data on GI cancers in indian continent. In colorectal cancers, data from tertiary care centres identifies the unique problem of mucinous and signet colorectal cancer. Results of rectal cancer resection in terms of technique (intersphincteric resection, extralevator aper, minimal invasive approach) to be comparable with world literature. However long term outcome and data regarding colon cancers and nationally is needed. Gastric cancer at presentation are advanced and in surgically resected patients, there is need for a trial to compare chemoradiation vs chemotherapy alone to prevent loco regional recurrence. Data on minimal invasive gastric cancer surgery may be sparse for the same reason. Theree is a lot of data on surgical techniques and perioperatve outcomes in pancreatic cancer. There is a high volume of locally advanced gallbladder cancers with efforts on to decide whether neoadjuvant chemotherapy or neoadjuvant chemoradiotherapy is better for down staging. Considering GI cancers, a heterogeneous disease with site specific treatment options and variable outcomes, the overall data and outcomes are extremely variable. Young patients with pathology unique to the Indian subcontinent (for example, signet ring rectal cancer, GBCs) need focussed attention. Solution for such pathology needs to come from the Indian continent itself. Joint efforts to improve outcomes for GI cancer can be integrated under the national cancer grid program.

Technical Aspects of Gallbladder Cancer Surgery

In this review, the authors present an updated description of gallbladder cancer in 2 sections based on presentation: disease that presents incidentally following laparoscopic cholecystectomy and malignancy that is suspected preoperatively. Elements pertaining to technical aspects of surgical resection provide the critical focus of this review and are discussed in the context of evidence-based literature on gallbladder cancer today.

Indian Council of Medical Research consensus document for the management of gall bladder cancer

The document is based on consensus among the experts and best available evidence pertaining to Indian population and is meant for practice in India.

All postcholecystectomy gallbladder specimens should be opened and examined carefully by the operating surgeon and be sent for histopathological examination.

All “incidental” gall bladder cancers (GBCs) picked up on histopathological examination should have an expert opinion.

Evaluation of a patient with early GBC should include essential tests: A computed tomography (CT) scan (multi-detector or helical) of the abdomen and pelvis for staging with a CT chest or chest X-ray, and complete blood counts, renal and liver function tests. magnetic resonance imaging/positron emission tomography (PET)-CT are not recommended for all patients.

For early stage disease (up to Stage IVA), surgery is recommended. The need for adjuvant treatment would be guided by the histopathological analysis of the resected specimen.

Patients with Stage IVB/metastatic disease must be assessed for palliative e.g. endoscopic or radiological intervention, chemotherapy versus best supportive care on an individual basis. These patients do not require extensive workup outside of a clinical trial setting.

There is an urgent need for multicenter trials from India covering various aspects of epidemiology (viz., identification of population at high-risk, organized follow-up), clinical management (viz., bile spill during surgery, excision of all port sites, adjuvant/neoadjuvant therapy) and basic research (viz., what causes GBC).