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

Panel of serum long non-coding RNAs as potential non-invasive biomarkers for gallbladder carcinoma

Gallbladder carcinoma (GBC) is a common malignancy and is usually diagnosed in the late stages of the disease. The identification of new effective early diagnostic biomarkers could represent an effective approach in reducing mortality in GBC. Altered expression of long non-coding RNAs (lncRNAs) is believed to be associated with the emergence and development of GBC. Our study aims to identify the expression of a range of circulating lncRNAs, including HOTAIR, ANRIL, H19, CCAT1 and MEG3, in matched serum and tissues of GBC for diagnosis and its association with clinicopathological features. The case and control study included matched serum and tissues from 63 GBC, 19 cholecystitis (CC), and 46 normal controls (NC). RNA extraction and cDNA synthesis from serum and fresh tissue match were performed using commercially available kits. Relative expression was assessed using SYBR Green real-time quantitative polymerase chain reaction. Circulating lncRNA levels including HOTAIR, ANRIL and H19 were upregulated in serum samples, while MEG3 and CCAT1 were downregulated in GBC compared to controls. The trend towards upregulation and downregulation was comparable in the tissue. HOTAIR and MEG3 levels were significantly different between serum CC and early-stage GBC (p = 0.0373, 0.0020), while H19 was significantly upregulated comparing early-stage GBC to advanced-stage GBC (p = 0.018). The expression of ANRIL was significant with M stage (p = 0.0488), H19 with stage (p = 0.009), M stage (p=<0.0001) & stage (0.009) and CCAT1 with M stage (0.044). When distinguishing GBC and NC, AUC for HOTAIR was 0.75, ANRIL 0.78, H19 0.74, CCAT1 0.80 and 0.96 for MEG3. The combination sensitivity for lncRNAs ranged from 84.13% (CI: 72.74-92.12%) to 100.0% (CI: 94.31-100.0%). Significant diagnostic value in discriminating pathologic stage was observed for ANRIL and MEG3 (p = 0.022, p = 0.0005). LncRNA show a significant change in expression in GBC and in discrimination of early stage from late-stage disease. The detection of 2 lncRNAs in panels, in coordination with radiology, could represent a potential serum-based biomarker for early-stage GBC diagnosis.

Quantitative tissue proteome profile reveals neutrophil degranulation and remodeling of extracellular matrix proteins in early stage gallbladder cancer

Gallbladder cancer (GBC) is an aggressive malignancy of the gastrointestinal tract with a poor prognosis. It is important to understand the molecular processes associated with the pathogenesis of early stage GBC and identify proteins useful for diagnostic and therapeutic strategies. Here, we have carried out an iTRAQ-based quantitative proteomic analysis of tumor tissues from early stage GBC cases (stage I, n=7 and stage II, n=5) and non-tumor controls (n=6) from gallstone disease (GSD). We identified 357 differentially expressed proteins (DEPs) based on ≥ 2 unique peptides and ≥ 2 fold change with p value < 0.05. Pathway analysis using the STRING database showed, 'neutrophil degranulation' to be the major upregulated pathway that includes proteins such as MPO, PRTN3, S100A8, MMP9, DEFA1, AZU, and 'ECM organization' to be the major downregulated pathway that includes proteins such as COL14A1, COL1A2, COL6A1, COL6A2, COL6A3, BGN, DCN. Western blot and/or IHC analysis confirmed the elevated expression of MPO, PRTN3 and S100A8 in early stage of the disease. Based on the above results, we hypothesize that there is an increased neutrophil infiltration in tumor tissue and neutrophil degranulation leading to degradation of extracellular matrix (ECM) proteins promoting cancer cell invasion in the early stage GBC. Some of the proteins (MPO, MMP9, DEFA1) associated with 'neutrophil degranulation' showed the presence of 'signal sequence' suggesting their potential as circulatory markers for early detection of GBC. Overall, the study presents a protein dataset associated with early stage GBC.

Heterogeneity of management practices surrounding operable gallbladder cancer - results of the OMEGA-S international HPB surgical survey

BACKGROUND

Gallbladder cancer (GBC) is an aggressive, uncommon malignancy, with variation in operative approaches adopted across centres and few large-scale studies to guide practice. We aimed to identify the extent of heterogeneity in GBC internationally to better inform the need for future multicentre studies.

METHODS

A 34-question online survey was disseminated to members of the European-African Hepatopancreatobiliary Association (EAHPBA), American Hepatopancreatobiliary Association (AHPBA) and Asia-Pacific Hepatopancreatobiliary Association (A-PHPBA) regarding practices around diagnostic workup, operative approach, utilization of neoadjuvant and adjuvant therapies and surveillance strategies.

RESULTS

Two hundred and three surgeons responded from 51 countries. High liver resection volume units (>50 resections/year) organised HPB multidisciplinary team discussion of GBCs more commonly than those with low volumes (p < 0.0001). Management practices exhibited areas of heterogeneity, particularly around operative extent. Contrary to consensus guidelines, anatomical liver resections were favoured over non-anatomical resections for T3 tumours and above, lymphadenectomy extent was lower than recommended, and a minority of respondents still routinely excised the common bile duct or port sites.

CONCLUSION

Our findings suggest some similarities in the management of GBC internationally, but also specific areas of practice which differed from published guidelines. Transcontinental collaborative studies on GBC are necessary to establish evidence-based practice to minimise variation and optimise outcomes.

Gallbladder cancer

Gallbladder cancer (GBC) is the most common cancer of the biliary tract, characterized by a very poor prognosis when diagnosed at advanced stages owing to its aggressive behaviour and limited therapeutic options. Early detection at a curable stage remains challenging because patients rarely exhibit symptoms; indeed, most GBCs are discovered incidentally following cholecystectomy for symptomatic gallbladder stones. Long-standing chronic inflammation is an important driver of GBC, regardless of the lithiasic or non-lithiasic origin. Advances in omics technologies have provided a deeper understanding of GBC pathogenesis, uncovering mechanisms associated with inflammation-driven tumour initiation and progression. Surgical resection is the only treatment with curative intent for GBC but very few cases are suitable for resection and most adjuvant therapy has a very low response rate. Several unmet clinical needs require to be addressed to improve GBC management, including discovery and validation of reliable biomarkers for screening, therapy selection and prognosis. Standardization of preneoplastic and neoplastic lesion nomenclature, as well as surgical specimen processing and sampling, now provides reproducible and comparable research data that provide a basis for identifying and implementing early detection strategies and improving drug discovery. Advances in the understanding of next-generation sequencing, multidisciplinary care for GBC, neoadjuvant and adjuvant strategies, and novel systemic therapies including chemotherapy and immunotherapies are gradually changing the treatment paradigm and prognosis of this recalcitrant cancer.

Small-cell carcinoma of the gall bladder: Report of three cases and review of the literature

Gallbladder (GB) Small Cell Carcinoma (SCC) is an uncommon entity with very poor prognosis. There is a paucity of literature regarding its natural history and management, with only 73 prior cases reported in the world literature. In this case report, we present three cases of SCC of the GB with varied presentations, clinical course, management, and outcomes along with a brief review of the available literature on this subject.

Addition of trastuzumab emtansine (T-DM1) in a human epidermal growth factor receptor 2–overexpressed metastatic carcinoma of the gallbladder patient to enhance survival: A case study

Biliary tract cancers are clinically and genetically heterogeneous cancer type with a worst prognosis among gallbladder adenocarcinoma patients. Systemic therapeutic options for metastatic biliary tract cancers are fewer, and there are limited treatment choices for the patients who progress on first line apart from symptomatic treatment. Thus, a biomarker-guided personalized treatment approach needs to be explored among biliary tract cancer subtypes. We encountered a case of 53-year-old male patient with human epidermal growth factor receptor 2 (HER2, ERBB2) positive metastatic gallbladder cancer, treated with first-line gemcitabine and cisplatin combination–based chemotherapy along with trastuzumab followed by second-line treatment with mFOLFIRINOX. On progression in third line, treated with single agent ado-trastuzumab emtansine targeting human epidermal growth factor receptor 2 and got survival benefit of nearly 6 months. This is the first reported case from India that explored the possibility and impact of ado-trastuzumab emtansine in advanced gallbladder cancer after exhausting standard treatment options. It highlights the possibility of exploring ado-trastuzumab emtansine for treatment resilient, human epidermal growth factor receptor 2-positive and advanced gallbladder adenocarcinoma.

Radical surgery for de novo gallbladder carcinoma-Single-center analysis of prognostic factors and survival outcomes from an endemic region

BACKGROUND AND OBJECTIVE

Gallbladder cancer (GBC) is an aggressive malignancy where curative resection is possible in few and survival is poor. There are limited data on outcomes in patients with de novo GBC from endemic regions undergoing surgery for curative intent. We report survival outcomes in this group of patients from a region with high incidence of disease.

METHODS

We reviewed the records of all GBC patients (2014-2018) and included those who underwent radical cholecystectomy (RC) for de novo GBC. Univariable and multivariable analyses were performed to identify factors influencing recurrence and survival.

RESULTS

A total of 649 patients with GBC were evaluated for surgery and curative intent surgery was attempted in 246 (38%) patients. Of these 246 patients, RC was performed in 115 patients, with histologically confirmed de novo GBC. Locally advanced disease (≥stage IIIB) was present in 52 (45.2%) patients. Median time to recurrence and overall survival (OS) were 31 and 36 months, respectively. Lymph node positivity (p = 0.005) and grade significantly influenced OS on multivariable analysis.

CONCLUSION

Satisfactory survival outcomes are possible after RC for de novo GBC. Extended resections performed in high volume centers combined with appropriate adjuvant treatment can offer significant survival benefits, with acceptable morbidity and mortality rates.

Demographic and clinicopathological Profile of Gall Bladder Cancer Patients: Study from a tertiary care center of the Sub-Himalayan region in Indo-Gangetic Belt

INTRODUCTION

Gall bladder cancer (GBC) accounts for 80%-95% of biliary tract malignancies in the world. There is however striking variability in the global incidence of gallbladder cancer, reaching epidemic levels for some regions and ethnicities. The aim of this study was to evaluate the demographic and clinicopathological profile of the gallbladder cancer patients.

MATERIALS AND METHODS

All patients of carcinoma gall bladder presenting to department of surgery in hepatopancreaticobiliary unit from July 2017 to November 2020 were included in this study. A proforma containing all the relevant details including history, examination, blood, radiology, and pathological investigations was filled.

RESULTS

A total of 326 patients of GBC were analyzed. The majority (75%) were found to be females with a mean age of 55 years. Pain abdomen was the most common presenting symptom in 81% of patients. The most common stage of presentation was stage IV and only 6 were in stage I. Two hundred and thirty three (71.4%) patients had metastatic disease at presentation. Liver infiltration at the time of diagnosis was present in 89% of patients. The most common site of metastasis was found in the liver (23.3%). GBC was more common in patients with A blood group. Baseline serum albumin levels were found to be significantly associated with the staging of GBC.

CONCLUSIONS

Due to the non specific symptoms patients of GBC present at very advanced stages, high index of suspicion and health education seems to play an important role in early detection and improvement of survival.

Chronic calculus cholecystitis: Is histopathology essential post-cholecystectomy?

Background

Carcinoma of the gall bladder (GB) is the most common malignancy of the gastrointestinal tract. One percent of cholecystectomy specimens show incidental gall bladder cancers (GBCs).

Aim

Our aim of the study to was evaluate the utility of routine histopathology of cholecystectomy specimens removed with a diagnosis of gall bladder diseases (GBD).

Materials and Methods

A retrospective study was done reviewing the histopathological records of 906 patients who underwent cholecystectomy. Demographic details, gross findings, and microscopic findings noted. All the cases were categorized into two groups, A and B. Group A included the cases with any gross abnormality including wall thickness ≥4 mm and group B included rest of the cases.

Results

Majority of the patients were in the age group of 31-40 years of age. Out of 906 patients studied, majority of them were females with F:M ratio of 6.14:1. Of the 47 cases which were included in group A (with macroscopic abnormality), six cases had gall bladder carcinoma on microscopy. One case from group B with macroscopically normal-appearing GB had invasive carcinoma on microscopy. In our study, we found a sensitivity of 85.71% and specificity of 95.44%, while positive predictive value (PPV) was 91.11% and negative predictive value (NPV) was 99.65% of macroscopic abnormality in the diagnosis of invasive carcinoma.

Conclusion

All cholecystectomy specimens must be examined by histopathologists who must decide whether processing for microscopy is needed. Microscopic examination may be reserved for the specimen with a macroscopic lesion. This will result in a reduction of costs and pathology workload without compromising patient management.

Genomic Landscape and Targeted Treatment of Gallbladder Cancer: Results of a First Ongoing Prospective Study

Background  Prognosis of gallbladder cancer (GBC) has not changed in the past 20 years. Comprehensive genomic profiling (CGP) carries potential to determine the actionability for multiple targets, including ERBB2 , ERBB3 , MET , ROSI , FGFR , and PIK3 . This study evaluates the role of CGP and targeted therapies. Methods  This is a multicenter, prospective, single-arm study. All consecutive patients of unresectable and/or metastatic GBC of age ≥18 years were enrolled. Hybrid capture-based CGP was performed by Foundation Medicine CDx. All patients received first-line chemotherapy with gemcitabine-cisplatin regimen. Patients with ERBB2/3 amplification received trastuzumab with capecitabine or nab-paclitaxel, and patients with MET amplification were treated with crizotinib. For ERBB2/3 mutations, lapatinib plus capecitabine regimen was used. Results  Fifty patients were studied with a median age of 56 years (range 26-83) and a male-to-female ratio of 1:1.6. ERBB2 and ERBB3 amplification was seen in 9 (18%) and 2 (4%) patients, respectively. Four patients with ERBB2 amplification received trastuzumab and/or lapatinib, showed partial response, and maintained response beyond 12 weeks. One patient had mixed response, whereas two patients progressed on trastuzumab and lapatinib. Three patients with ERBB3 mutations showed response to lapatinib-capecitabine. One patient with MET amplification responded to crizotinib for 4 weeks. PIK3 mutations were present in 14% of cases and were independent of ERBB aberrations. Conclusion  GBC is enriched in 28% of patients with ERBB2 and ERBB3 amplifications and/or mutations. Responses are seen with lapatinib in concurrent ERBB2 mutation and amplification. ERBB3 mutation showed response to lapatinib. MET and PIK3 are new findings in GBC, which may be targeted.

Epidemiologic Study of Patients Registered in Oncology Unit at a Hepatobiliary Tertiary Care Center in India

Background: Cancer accounts for about 1 in 7 deaths, worldwide. Primary cancers of the hepatobiliary system are significant health problems worldwide and their management presents great challenges for the hepatobiliary specialist. The incidence of hepatobiliary malignancies is on an increasing trend in India. Study: We did a retrospective study for the epidemiologic, clinical characteristics, and outcomes of patients with cancer registering for treatment in the oncology division at the Institute of Liver and Biliary Sciences, Delhi, India, between January 1, 2017 and December 31, 2017. Results: Atotal of 502 new patients were registered during the study period. The majority of the patients were male (M:F 1.69:1), in the age group of 35–64 years (64.3%) and presented in advanced stages of the disease (72.7% in Stage III and IV). The most common cancers were gallbladder cancer (GBC) (29.7%) and hepatocellular carcinoma (HCC) (17.3%). GBC was the most common in females (M: F 1:1.6), 86.6% were advanced (Stage III and IV), and gallstones were present in 44.3% patients (M: F 1:2.9). Periampullary carcinoma presented in early stages (71% in Stage I and II). Survival at 6 months (n = 110 evaluable patients) was 100% for Stage I, 88% for Stage II, 73.7% for Stage III and 42.1% for Stage IV, and 62.7% overall (P < 0.001). Survival at 6 months (n = 123 evaluable patients) was 56.5% for biliary cancers, 71.4% for HCC, and 75% for nonbiliary cancers (P = 0.15). 217 (43%) patients had one visit to the hospital and 168 (34%) patients had 2–5 visits with no or little follow-up. Conclusions: Most of the disease burden was in the male gender (GBC was more common in females), in the age group 35–64 years and with advanced disease presentation (except periampullary cancer). Survival diminished significantly with increasing stage of disease. Survival was worse for patients with biliary cancers. This could be due to advanced presentation, poor follow-up, and inadequate public health awareness.

Systematic review of management of incidental gallbladder cancer after cholecystectomy

BACKGROUND

Gallbladder cancer is rare, but cancers detected incidentally after cholecystectomy are increasing. The aim of this study was to review the available data for current best practice for optimal management of incidental gallbladder cancer.

METHODS

A systematic PubMed search of the English literature to May 2018 was conducted.

RESULTS

The search identified 12 systematic reviews and meta-analyses, in addition to several consensus reports, multi-institutional series and national audits. Some 0·25-0·89 per cent of all cholecystectomy specimens had incidental gallbladder cancer on pathological examination. Most patients were staged with pT2 (about half) or pT1 (about one-third) cancers. Patients with cancers confined to the mucosa (T1a or less) had 5-year survival rates of up to 100 per cent after cholecystectomy alone. For cancers invading the muscle layer of the gallbladder wall (T1b or above), reresection is recommended. The type, extent and timing of reresection remain controversial. Observation time may be used for new cross-sectional imaging with CT and MRI. Perforation at initial surgery had a higher risk of disease dissemination. Gallbladder cancers are PET-avid, and PET may detect residual disease and thus prevent unnecessary surgery. Routine laparoscopic staging before reresection is not warranted for all stages. Risk of peritoneal carcinomatosis increases with each T category. The incidence of port-site metastases is about 10 per cent. Routine resection of port sites has no effect on survival. Adjuvant chemotherapy is poorly documented and probably underused.

CONCLUSION

Management of incidental gallbladder cancer continues to evolve, with more refined suggestions for subgroups at risk and a selective approach to reresection.

Developing institutions for cancer care in low-income and middle-income countries: from cancer units to comprehensive cancer centres

Global cancer centres operate across different sizes, scales, and ecosystems. Understanding the essential aspects of the creation, organisation, accreditation, and activities within these settings is crucial for developing an affordable, equitable, and quality cancer care, research, and education system. Robust guidelines are scarce for cancer units, cancer centres, and comprehensive cancer centres in low-income and middle-income countries. However, some robust examples of the delivery of complex cancer care in centres in emerging economies are available. Although it is impossible to create an optimal system to fit the unique needs of all countries for the delivery of cancer care, we summarise what has been published about the development and management of cancer centres in low-income and middle-income countries so far and highlight the need for clinical and political leadership.

Surgical treatment for gallbladder cancer - a systematic literature review

OBJECTIVE

To evaluate existing evidence regarding surgical treatments for gallbladder cancer in a Health Technology Assessment. A specific aim was to evaluate whether extended surgery regarding liver, lymph nodes, bile duct, and adjacent organs compared with cholecystectomy alone in the adult patient with gallbladder cancer in early and late stages implies improved survival.

METHODS

In April 2015 and updated in June 2016, a systematic literature search was conducted in PubMed, Embase, and the Cochrane Library. Two authors independently screened titles, abstracts, and full-text articles. The certainty of evidence was evaluated according to GRADE.

MAIN RESULTS

Forty-four observational studies (non-randomised, controlled studies) and seven case series were included. Radical resection, including liver and lymph node resection, compared with cholecystectomy alone showed significantly better survival for patients with stages T1b and above. All studies had serious study limitations and the certainty of evidence was very low (GRADE ⊕○○○). A survival benefit seen in patients with stage T1b or higher with lymph node resection, was most evident in stage T2, but the certainty of evidence was low (GRADE ⊕⊕○○). It is uncertain whether routine bile duct resections improve overall survival in patients with gallbladder cancer stage T2-T4 (GRADE ⊕○○○).

CONCLUSION

Data indicate that prognosis can be improved if liver resection and lymph node resection is performed in patients with tumour stage T1b or higher. There is no evidence supporting resection of the bile duct or adjacent organs if it is not necessary in order to achieve radicality.

Treatment of advanced Gall bladder cancer in the real world-can continuation chemotherapy improve outcomes?

BACKGROUND

Gemcitabine-Platinum doublet chemotherapy is the standard of care in patients with locally advanced inoperable and metastatic (LA/M) Gall bladder cancers (GBC).

METHODS

Consecutive patients with LA/M GBC treated with Gemcitabine-Cisplatin (GC) or Gemcitabine-Oxaliplatin (GO) as first line palliative chemotherapy from January 2013 to June 2015 were retrospectively analysed. Patients who were able to continue chemotherapy beyond 6-8 cycles were separately compared to those who were potential candidates for this approach, but chose not to continue chemotherapy.

RESULTS

A total of 396 patients received first line palliative chemotherapy during the period of analysis, 276 patients (69.6%) were unable to complete 6-8 cycles of chemotherapy, while 120 patients (30.4%) were potential candidates for continuing chemotherapy. Seventy patients (n=120; 58.3%) received a median of 4 cycles of continuation chemotherapy. Median overall survival (OS) for the entire cohort was 7.65 months [95% confidence interval (CI), -7.14 to 8.16], while median event free survival (EFS) was 4.53 months (95% CI, -4.23 to 4.83). Patients receiving continuation chemotherapy had a statistically improved median OS compared to all other patient cohorts, 14.88 months (95% CI, -12.48 to 17.27; P=0.005 on multivariate analysis). Burden/number of sites of metastases, receiving of continuation chemotherapy, fit and able to receive second line chemotherapy (CT2) were identified on multivariate analysis as prognostic factors for OS.

CONCLUSIONS

OS in our study appeared lower than published literature, but a group of patients were identified whose survival could be prolonged by continuing chemotherapy. Easily available factors can predict prognosis of GBC undergoing first line palliative chemotherapy.