Abstract
Gall bladder cancer (GBC) usually presents as unresectable or metastatic disease. We conducted a feasibility study to evaluate the effect of neoadjuvant therapy (NAT) on radiologic downstaging and resectability in unresectable GBC cases. Patients with locally advanced disease were treated with chemoradiotherapy [CTRT] ( external radiotherapy (45Gy) along with weekly concurrent cisplatin 35mg/ m2 and 5-FU 500 mg) and those with positive paraaortic nodes were treated with neoadjuvant chemotherapy [NACT (cisplatin 25mg/m2 and gemcitabine 1gm/m2 day 1 and 8, 3 weekly for 3 cycles). Radiological assessment was according to RECIST criteria by evaluating downstaging of liver involvement and lymphadenopathy into complete response (CR), partial response (PR), stable disease (SD) and progressive disease (PD). A total of 40 patients were evaluated from January 2012 to December 2014 (CTRT=25, NACT=15). Pretreatment CT scans revealed involvement of hilum (19), liver infiltration (38), duodenum involvement (n=22), colon involvement (n=11), N1 involvement (n=11), N2 disease (n=8), paraaortic LN (n=15), and no lymphadenopathy (n=6). After neoadjuvant therapy, liver involvement showed CR in 11(30%), PR in 4 (10.5%), SD in 15 (39.4%) and lymph node involvement showed CR in 17 (50%), PR in 6 (17.6%), SD in 4 (11.7 %). Six patients (CTRT=2, NACT=4) with 66.6 % and 83% downstaging of liver and lymphnodes respectively underwent extended cholecystectomy. There was 16.6 % and 83.3% rates of histopathological CR of liver and lymph nodes. All resections were R0. Neoadjuvant therapy in unresectable gall bladder cancer results in a 15% resectability rate. This approach has a strong potential in achieving R0 and node negative disease. Radiologic downstaging (CR+PR) of liver involvement is 40.5% and lymphadenopathy is 67.5%. Nodal regression could serve as a predictor of response to neoadjuvant therapy.
Highlights
Gall bladder cancer is endemic in northern India and often presents as locally advanced or metastatic disease (Randi et al, 2006)
We report radiologic downstaging in a cohort of unresectable Gall bladder cancer (GBC) patients who received neoadjuvant therapy as a part of our prospective feasibility study
Forty patients have been inducted into this study from January 2012 to December 2014.The median age of patients was 52 years, male: female ratio is 9:31.Only 50 % patients underwent diagnostic laparoscopy due to logistic reasons.19 presented with obstructive jaundice and underwent stenting prior to neoadjuvant therapy. 7.5% (n=3) patients progressed on treatment and 15% (n=6) deteriorated on or after completion of treatment and 2 sets of CT scans for response assessment were available for 31 patients only. 62.5% patients (n=25) were treated by CTRT and 37.5% (n=15) by neoadjuvant chemotherapy (NACT). 10% patients with obstructive jaundice treated with CTRT were radiologically suitable for further surgical evaluation, but succumbed to gastrointestinal bleeding after completion of treatment
Summary
Gall bladder cancer is endemic in northern India and often presents as locally advanced or metastatic disease (Randi et al, 2006). Complete surgical resection is the only treatment modality with curative potential. It has a median survival of 9 months after simple cholecystectomy, and 19 months after extended cholecystectomy in patients who are apparently resectable. Gall bladder cancer (GBC) usually presents as unresectable or metastatic disease. We conducted a feasibility study to evaluate the effect of neoadjuvant therapy (NAT) on radiologic downstaging and resectability in unresectable GBC cases. Conclusions: Neoadjuvant therapy in unresectable gall bladder cancer results in a 15% resectability rate. This approach has a strong potential in achieving R0 and node negative disease. Nodal regression could serve as a predictor of response to neoadjuvant therapy
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