A patient with cholangiocarcinoma demonstrating pathologic complete response to chemotherapy: exploring the role of neoadjuvant therapy in biliary tract cancer

Pathological complete response achieved by gemcitabine plus cisplatin therapy for initially unresectable advanced gallbladder cancer: a case report

Background

Conversion surgery for initially unresectable gallbladder cancer is rarely performed due to the low response rate for systemic chemotherapy, and a pathological complete response is seldom achieved.

Case presentation

A 67-year-old woman with jaundice was referred to our hospital and diagnosed with unresectable gallbladder cancer with extra-regional lymph node metastasis after examinations. After biliary decompression, gemcitabine plus cisplatin therapy was started. The tumor marker levels markedly decreased, and imaging studies revealed a reduction in the primary tumor and metastatic lymph nodes. The primary tumor and metastatic lymph node were still shrunk at 4 years after the start of gemcitabine plus cisplatin therapy, so we decided to perform conversion surgery. Gallbladder bed resection and lymph node dissection were performed. The pathological findings of the resected specimen showed only partial fibrosis in the gallbladder wall and no malignant findings in the dissected lymph nodes, indicating a pathological complete response. As of 24 months after the operation, she is alive without recurrence.

Conclusion

Although there have been only a few reports of conversion surgery for initially unresectable gallbladder cancer, it may be worthwhile to perform chemotherapy with the potential goal of subsequent conversion surgery.

The maximum chemiluminescence intensity predicts severe neutropenia in gemcitabine-treated patients with pancreatic or biliary tract cancer

PURPOSE

To assess the predictive ability of the maximum chemiluminescence intensity (CI_max) for severe neutropenia (SN) during neoadjuvant chemo(radio)therapy [NAC(RT)] in patients with advanced pancreatic or biliary tract cancer.

METHODS

Clinicopathological variables and blood test data before NAC(RT) were evaluated in 64 patients with advanced pancreatic or biliary tract cancer who received gemcitabine plus tegafur/gimeracil/oteracil as NAC(RT).

RESULTS

Thirty-nine patients (60.9%) developed Grade 3-4 SN. The median time between commencing NAC(RT) and the onset of SN was 15 (range 10-36) days. SN occurred during the NAC period, not the RT period. The CI_max, neutrophil count, serum interleukin-6 level, C-reactive protein level, complement C3 titer, serum complement titer, and 50.0% hemolytic unit of complement before NAC(RT) were significantly lower in patients with SN than in those without SN (P < 0.05). Multivariate analysis confirmed the CI_max to be the sole independent predictor of SN (P < 0.05). The optimal threshold for the CI_max was 46,000 RLU/s. The sensitivity and specificity were 46.2% and 80.0%, respectively. Majority of the patients (81.8%) with a low CI_max before NAC(RT) experienced SN during NAC(RT).

CONCLUSIONS

CI_max before NAC(RT) predicts SN during NAC(RT) in patients with advanced pancreatic or biliary tract cancer.

A pathological complete response after combined chemotherapy of gemcitabine and S-1 in advanced biliary tract cancer with para-aortic lymph nodes metastasis: a case report

Background

Biliary tract cancer is a rare malignancy that carries poor prognosis. Complete surgical resection is the only curable treatment. However, biliary tract cancer patients are often diagnosed with advanced stages and treated in systemic chemotherapy or palliative treatment settings rather than curative surgery.

Case presentation

This case report describes a pathological complete response of advanced biliary tract cancer achieved after 2 years of intensive combined chemotherapy with gemcitabine and S-1. A 70-year-old female patient who developed severe stenosis in the middle common bile duct with para-aortic lymph nodes swelling was diagnosed with advanced extrahepatic biliary tract cancer that includes metastatic para-aortic lymph nodes and treated with combined chemotherapy of gemcitabine and S-1. After 32 courses of the combined chemotherapy, substantial shrinkage of these enlarged lymph nodes were confirmed and she underwent pylorus-preserving pancreaticoduodenectomy. The pathological examination revealed no viable neoplastic cells in the common bile duct or lymph nodes. She did not receive any further adjuvant chemotherapy. No recurrent lesions have been detected for 48 months after the primary surgery.

Conclusions

This case shed light on the probability of conversion and/or adjuvant surgery for biliary tract cancer with novel systemic chemotherapy regimens.

Impact of adjuvant chemoradiation on survival in patients with resectable cholangiocarcinoma

BACKGROUND

The ideal adjuvant therapy for resected cholangiocarcinoma remains controversial. National guidelines stratify recommendations based on margin status, though few studies are currently available for reference.

METHODS

Data was abstracted on all patients with definitive resections of cholangiocarcinoma at our institution between 2000 and 2013. Adjuvant chemoradiation consisted of 45 Gy delivered to elective nodal regions and 50.4-54 Gy to the surgical bed with concurrent fluoropyrimidine-based chemotherapy. Subgroup analyses were performed delineated by margin status.

RESULTS

Curative resection was performed on 95 patients followed by adjuvant chemoradiation in 23/95 (24%) and observation in 72/95 (76%) with a median follow-up of 21.7 months. For those receiving adjuvant chemoradiation the median overall survival was 30.2 months compared with 26.3 months for those observed (p = 0.0695). In a multivariable model controlling for other prognostic factors, adjuvant chemoradiation was associated with improved disease-free survival (HR 0.50, p = 0.03) and overall survival (HR 0.37, p = 0.004). In multivariable models stratified by margin status, adjuvant chemoradiation was associated with improved overall survival following both margin-negative (HR 0.34, p = 0.035) and margin-positive (HR 0.15, p = 0.003) resections.

CONCLUSIONS

Overall survival was improved with adjuvant chemoradiation following either margin-negative or margin-positive resections, which is not currently reflected in national guidelines.

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.