Gallbladder cancer and radical surgery

Long-Term Response to Gemcitabine, Cisplatin, and Nab-Paclitaxel Followed by Maintenance Therapy for Advanced Gallbladder Cancer: A Case Report and Literature Review

Background

Gallbladder cancer (GBC) is the most common and devastating tumor type of biliary tract cancer (BTC) with poor outcomes. A new combined regimen of gemcitabine, cisplatin, plus nab-paclitaxel is currently considered an effective option for patients with advanced BTC following the results of a phase II trial. In addition, maintenance therapy after first-line treatment has been shown to improve disease control rate of various solid tumors but has not been evaluated for GBC patients. The scenario we report herein is of a metastatic GBC patient treated with the triple-drug regimen followed by maintenance therapy with capecitabine or S-1, who achieved a long-term survival benefit.

Case Presentation

A 68-year-old man was diagnosed with gallbladder adenocarcinoma with liver, supra-diaphragmatic, and abdominal lymph node metastases (cT3N2M1, stage IVB). Partial response (PR) was achieved after five cycles of gemcitabine and cisplatin chemotherapy. A further three cycles of nab-paclitaxel plus gemcitabine-cisplatin regimen yielded a complete response of all tumor lesions. Subsequent administration of maintenance therapy with capecitabine followed by S-1 achieved a disease-free survival of 15 months for the patient. Moreover, the patient remained responsive to this triple-drug regimen when the disease progressed, achieving PR after two cycles of chemotherapy. Overall, the treatment regimens were well tolerated with no grade 3 or higher adverse effects occurring. Notably, the serum carbohydrate antigen 199 (CA199) levels were closely related to the treatment response and increased before the lesions were found on PET-CT during follow-up.

Conclusion

Our findings suggested that adding nab-paclitaxel into gemcitabine-cisplatin regimen may result in a favorable efficacy in patients with advanced GBC. Further maintenance therapy with capecitabine or S-1 after first-line therapy appeared to be a reasonable option for these patients, and it is valuable to monitor CA199 levels during treatment and follow-up.

Impact of Type of Surgery on Survival Outcome in Patients With Early Gallbladder Cancer in the Era of Minimally Invasive Surgery: Oncologic Safety of Laparoscopic Surgery

Laparoscopic surgery has been widely accepted as a feasible and safe treatment modality in many cancers of the gastrointestinal tract. However, most guidelines on gallbladder cancer (GBC) regard laparoscopic surgery as a contraindication, even for early GBC. This study aims to evaluate and compare recent surgical outcomes of laparoscopic and open surgery for T1(a,b) GBC and to determine the optimal surgical strategy for T1 GBC.The study enrolled 197 patients with histopathologically proven T1 GBC and no history of other cancers who underwent surgery from 2000 to 2014 at 3 major tertiary referral hospitals with specialized biliary-pancreas pathologists and optimal pathologic handling protocols. Median follow-up was 56 months. The effects of depth of invasion and type of surgery on disease-specific survival and recurrence patterns were investigated.Of the 197 patients, 116 (58.9%) underwent simple cholecystectomy, including 31 (15.7%) who underwent open cholecystectomy and 85 (43.1%) laparoscopic cholecystectomy. The remaining 81 (41.1%) patients underwent extended cholecystectomy. Five-year disease-specific survival rates were similar in patients who underwent simple and extended cholecystectomy (96.7% vs 100%, P = 0.483), as well as being similar in patients in the simple cholecystectomy group who underwent open and laparoscopic cholecystectomy (100% vs 97.6%, P = 0.543). Type of surgery had no effect on recurrence patterns.Laparoscopic cholecystectomy for T1 gallbladder cancer can provide similar survival outcomes compared to open surgery. Considering less blood loss and shorter hospital stay with better cosmetic outcome, laparoscopic cholecystectomy can be justified as a standard treatment for T1b as well as T1a gallbladder cancer when done by well-experienced surgeons based on exact pathologic diagnosis.

Surgical treatment of incidental gallbladder cancer discovered during or following laparoscopic cholecystectomy

BACKGROUND

The optimal surgical management of patients with incidental gallbladder cancer (IGBC) and their long-term survival remains unclear.

OBJECTIVE

The purpose of this study was to examine the long-term prognosis of patients with IGBC diagnosed during or after LC.

METHODS

Between January 2002 and January 2012, a total of 7,582 consecutive patients underwent LC for presumed gallbladder benign disease in the Chinese PLA General Hospital, China. Among them, 69 patients (0.91%) were diagnosed to have IGBC. Their medical records, imaging data, surgery records, pathological findings, and survival data were retrospectively reviewed.

RESULTS

Median age was 61 years (range: 34-83). After a median follow-up period of 61 months, the 1-, 3-, and 5-year survival rates of patients were 89.9, 78.3, and 76.8%, respectively. The 5-year survival rates of patients with T1a, T1b, T2, and T3 stages were 95.5, 93.8, 69.2, and 44.4%, respectively. The 5-year survival rates in simple LC (n = 45), converted to open extended cholecystectomy (n = 16), and radical second resection (n = 8) groups were 91.1, 37.5, and 75.0%, respectively. Local port-site tumor recurrence was identified in one patient. Prognostic factors including depth of invasion, lymph node status, vascular or neural invasion, tumor differentiation, extent of resection, bile spillage, and type of surgery were statistically significant (p < 0.05).

CONCLUSIONS

Simple LC is appropriate for T1a patients with clear margin and unbroken gallbladder, whereas extended radical resection is recommended for patients with T1b or more advanced IGBC. An intact surgical specimen and the use of plastic retrieval bags are important to reduce the risk of port-site recurrences and disease relapse. Early diagnosis, meticulous perioperative assessment, and precise surgery are essential factors to obtain good results in IGBC treatment.