Survival analysis of patients with primary gallbladder cancer from 2010 to 2015: A retrospective study based on SEER data

Haematologic biomarkers and survival in gallbladder cancer: a systematic review and meta-analysis

Background

Gallbladder cancer is a rare malignancy characterised by poor survival with lack of durable response to treatment. Thus, novel biomarkers are needed to prognosticate patients. This systematic review and meta-analysis sought to examine the role of neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, monocyte-to-lymphocyte ratio, platelet count (PC) and serum immune inflammation index in predicting the survival of patients with gallbladder cancer.

Materials and methods

A systematic search was done using PubMed, Cochrane, ClinicalTrials.gov and Google Scholar for articles published from inception until 8 February 2022. Hazard ratios (HR) with 95% confidence intervals (CI) were pooled and subgroup analyses were conducted according to treatment, region and cut-offs. The primary outcome of interest was overall survival (OS). Data were summarised using RevMan version 5.4.

Results

Twenty studies comprising 5,183 patients were included in the analysis. High neutrophil-lymphocyte ratio (HR 1.72, 95% CI 1.47-2.02), platelet-lymphocyte ratio (HR 1.51, 95% CI 1.33-1.72), monocyte-lymphocyte ratio (HR 1.96, 95% CI 1.46-1.64), PC (HR 1.20, 95% CI 1.02-1.40) and serum inflammation index (HR 1.73, 95% CI 1.36-2.18) were all associated with worse survival. The association was consistent across most subgroups on race and cut-offs with a trend towards poor survival for PC above 252.5.

Conclusion

High neutrophil-lymphocyte ratio, platelet-lymphocyte ratio, monocyte-lymphocyte ratio, PC and SII are associated with worse OS in gallbladder cancer and are potential biomarkers for prognostication. Prospective studies are recommended to further evaluate their use.

Clinical implication of the geometric location (fundal end versus cystic ductal end) of gallbladder cancer

BACKGROUND

Management of early-stage gallbladder cancer is becoming more important as the rate of early detection is increasing. Although there have been many studies about the clinical implication of the invasion depth or peritoneal/hepatic location of gallbladder cancers, there is no study on the clinical implication of the geometric location of cancer along the longitudinal length of the gallbladder.

METHODS

The location of gallbladder cancer was defined as the geometric center of the primary site of a tumour, which lies on the longitudinal diameter of the surgical specimens. We compared the oncologic outcomes following surgery between gallbladder cancers located on the fundal end and those located on the cystic ductal end. We also analysed patients with stage 1 gallbladder cancer who recurred after surgery.

RESULTS

A total of 575 patients with gallbladder cancer were included in this study. Patients with gallbladder cancer on the cystic ductal end had significantly lower rates of recurrence-free survival (P = 0.016) and overall survival (P = 0.023) compared to those with gallbladder cancer on the fundal end. Among 90 patients with stage 1 gallbladder cancer, three patients had a recurrence, all of whom had cystic ductal end gallbladder cancer and showed cystic duct invasion or concomitant xanthogranulomatous cholecystitis in permanent pathology.

CONCLUSIONS

Gallbladder cancers on the cystic ductal end had worse postoperative oncologic outcomes compared with those on the fundal end.

ELF3 suppresses gallbladder cancer development through downregulation of the EREG/EGFR/mTOR complex 1 signalling pathway

The prognosis of gallbladder cancer (GBC) remains poor, and a better understanding of GBC molecular mechanisms is important. Genome sequencing of human GBC has demonstrated that loss-of-function mutations of E74-like ETS transcription factor 3 (ELF3) are frequently observed, with ELF3 considered to be a tumour suppressor in GBC. To clarify the underlying molecular mechanisms by which ELF3 suppresses GBC development, we performed in vivo analysis using a combination of autochthonous and allograft mouse models. We first evaluated the clinical significance of ELF3 expression in human GBC tissues and found that low ELF3 expression was associated with advanced clinical stage and deep tumour invasion. For in vivo analysis, we generated Pdx1-Cre; KrasG12D ; Trp53R172H ; Elf3f/f (KPCE) mice and Pdx1-Cre; KrasG12D ; Trp53R172H ; Elf3wt/wt (KPC) mice as a control and analysed their gallbladders histologically. KPCE mice developed larger papillary lesions in the gallbladder than those developed by KPC mice. Organoids established from the gallbladders of KPCE and KPC mice were analysed in vitro. RNA sequencing showed upregulated expression of epiregulin (Ereg) in KPCE organoids, and western blotting revealed that EGFR/mechanical targets of rapamycin complex 1 (mTORC1) were upregulated in KPCE organoids. In addition, ChIP assays on Elf3-overexpressing KPCE organoids showed that ELF3 directly regulated Ereg. Ereg deletion in KPCE organoids (using CRISPR/Cas9) induced EGFR/mTORC1 downregulation, indicating that ELF3 controlled EGFR/mTORC1 activity through regulation of Ereg expression. We also generated allograft mouse models using KPCE and KPC organoids and found that KPCE organoid allograft tumours exhibited poorly differentiated structures with mTORC1 upregulation and mesenchymal phenotype, which were suppressed by Ereg deletion. Furthermore, EGFR/mTORC1 inhibition suppressed cell proliferation and epithelial-mesenchymal transition in KPCE organoids. Our results suggest that ELF3 suppresses GBC development via downregulation of EREG/EGFR/mTORC1 signalling. EGFR/mTORC1 inhibition is a potential therapeutic option for GBC with ELF3 mutation. © 2023 The Authors. The Journal of Pathology published by John Wiley & Sons Ltd on behalf of The Pathological Society of Great Britain and Ireland.

Gallbladder Cancer Risk and Indigenous South American Mapuche Ancestry: Instrumental Variable Analysis Using Ancestry-Informative Markers

A strong association between the proportion of indigenous South American Mapuche ancestry and the risk of gallbladder cancer (GBC) has been reported in observational studies. Chileans show the highest incidence of GBC worldwide, and the Mapuche are the largest indigenous people in Chile. We set out to assess the confounding-free effect of the individual proportion of Mapuche ancestry on GBC risk and to investigate the mediating effects of gallstone disease and body mass index (BMI) on this association. Genetic markers of Mapuche ancestry were selected based on the informativeness for assignment measure, and then used as instrumental variables in two-sample Mendelian randomization analyses and complementary sensitivity analyses. Results suggested a putatively causal effect of Mapuche ancestry on GBC risk (inverse variance-weighted (IVW) risk increase of 0.8% per 1% increase in Mapuche ancestry proportion, 95% CI 0.4% to 1.2%, p = 6.7 × 10-5) and also on gallstone disease (3.6% IVW risk increase, 95% CI 3.1% to 4.0%), pointing to a mediating effect of gallstones on the association between Mapuche ancestry and GBC. In contrast, the proportion of Mapuche ancestry showed a negative effect on BMI (IVW estimate -0.006 kg/m2, 95% CI -0.009 to -0.003). The results presented here may have significant implications for GBC prevention and are important for future admixture mapping studies. Given that the association between the individual proportion of Mapuche ancestry and GBC risk previously noted in observational studies appears to be free of confounding, primary and secondary prevention strategies that consider genetic ancestry could be particularly efficient.

Diagnostic performance and safety of endoscopic ultrasound-guided tissue acquisition of gallbladder lesions: A systematic review with meta-analysis

BACKGROUND

Endoscopic ultrasound (EUS)-guided tissue acquisition (TA) is widely used for various target samples, but its efficacy in gallbladder (GB) lesions is unknown. The aim of the present meta-analysis was to assess the pooled adequacy, accuracy and safety of EUS-TA of GB lesions.

METHODS

A literature search from January 2000 to August 2022 was done for studies analyzing the outcome of EUS-guided TA in patients with GB lesions. Pooled event rates were expressed with summative statistics.

RESULTS

The pooled rate of sample adequacy for all GB lesions and malignant GB lesions was 97.0% (95% CI: 94.5-99.4) and 96.6% (95% CI: 93.8-99.3), respectively. The pooled sensitivity and specificity for the diagnosis of malignant lesions were 90% (95% CI: 85-94; I2 = 0.0%) and 100% (95% CI: 86-100; I2 = 0.0%), respectively, with an area under the curve of 0.915. EUS-guided TA had a pooled diagnostic accuracy rate of 94.6% (95% CI: 90.5-96.6) for all GB lesions and 94.1% (95% CI: 91.0-97.2) for malignant GB lesions. There were six reported mild adverse events (acute cholecystitis = 1, self-limited bleeding = 2, self-limited episode of pain = 3) with a pooled incidence of 1.8% (95% CI: 0.0-3.8) and none of the patients had serious adverse events.

CONCLUSION

EUS-guided tissue acquisition from GB lesions is a safe technique with high sample adequacy and diagnostic accuracy. EUS-TA can be an alternative when traditional sampling techniques fail or are not feasible.

Pattern of Care and Outcomes of Gallbladder Cancer Patients: Retrospective Study from a High Incidence Region in India

Lakhan KasyapIntroduction  Gallbladder cancer (GBC) is the 20th most common cancer in India with a crude incidence rate of 2.3 per 100,000 persons. Of note, it is relatively common in states which fall in the Gangetic plains. Patients often present in the advanced stage and have an unfavorable prognosis. Materials and Methods  From January to June 2021, 170 treatment-naive GBC (adenocarcinoma) patients who were registered at a tertiary care cancer center in North India, were included. Data were extracted from electronic medical records and was analyzed with SPSS. Results  Median age was 56 years (range 32-77 years) and 65.5% ( n  = 112) were female. Incidental GBC was found in 20% patient ( n  = 34). Majority of patients (79.4%, n  = 135) had preserved performance status. Advanced GBC was present in 85.8% ( n  = 146) patients (locally advanced = 37.0% and metastatic = 48.8%). Biliary drainage procedure was performed in 24% of patients (68% of patients with obstructive jaundice). More than half of patients (53.5%) were lost to follow-up without any treatment. There were 33 patients (19.4%) who underwent surgery and 20 of them received neoadjuvant chemotherapy. Adjuvant chemotherapy and adjuvant radiotherapy were received by 13 and 2 patients, respectively. Palliative chemotherapy was administered to 46 patients. The most common chemotherapy regimen was gemcitabine-cisplatin. At a median follow-up of 1.7 months (95% confidence interval, 1-2.4 months), 42 patients (24%) progressed and 24 patients (14%) died, with 6 months estimated progression-free survival and overall survival being 60.2 and 79%, respectively. Conclusion  GBC is an aggressive and lethal malignancy predominantly affecting females in the fifth decade with dismal outcomes. Improved access to health care, an aggressive approach in operable cases, and optimization of systemic and adjuvant therapy are the need of the hour.

A Gallbladder Cancer Survival Prediction Model Based on Multimodal Fusion Analysis

BACKGROUND

Gallbladder cancer is the sixth most common malignant gastrointestinal tumor. Radical surgery is currently the only effective treatment, but patient prognosis is poor, with a 5-year survival rate of only 5-10%. Establishing an effective survival prediction model for gallbladder cancer patients is crucial for disease status assessment, early intervention, and individualized treatment approaches. The existing gallbladder cancer survival prediction model uses clinical data-radiotherapy and chemotherapy, pathology, and surgical scope-but fails to utilize laboratory examination and imaging data, limiting its prediction accuracy and preventing sufficient treatment plan guidance.

AIMS

The aim of this work is to propose an accurate survival prediction model, based on the deep learning 3D-DenseNet network, integrated with multimodal medical data (enhanced CT imaging, laboratory test results, and data regarding systemic treatments).

METHODS

Data were collected from 195 gallbladder cancer patients at two large tertiary hospitals in Shanghai. The 3D-DenseNet network extracted deep imaging features and constructed prognostic factors, from which a multimodal survival prediction model was established, based on the Cox regression model and incorporating patients' laboratory test and systemic treatment data.

RESULTS

The model had a C-index of 0.787 in predicting patients' survival rate. Moreover, the area under the curve (AUC) of predicting patients' 1-, 3-, and 5-year survival rates reached 0.827, 0.865, and 0.926, respectively.

CONCLUSIONS

Compared with the monomodal model based on deep imaging features and the tumor-node-metastasis (TNM) staging system-widely used in clinical practice-our model's prediction accuracy was greatly improved, aiding the prognostic assessment of gallbladder cancer patients.

Effects of surgery on survival of elderly patients with gallbladder cancer: A propensity score matching analysis of the SEER database

Background

Surgery is the sole curative therapy for gallbladder cancer (GBC) patients. Confronting an aging society, the demand to treat elderly patients with GBC is increasing. But there are few reports on survival benefit in elderly GBC patients treated with surgery. Therefore, we designed this population-based study to assess the survival benefit of surgery in GBC patients aged 70 years or older.

Methods

GBC patients aged 70 years or older were identified in the surveillance, epidemiology, and end results cancer (SEER) database from 2010 to 2017. A 1:1 propensity score matching (PSM) analysis was conducted to balance the baseline data of patients. Overall survival (OS) and cancer-specific survival (CSS) of patients were evaluated by Kaplan-Meier analysis and compared with log-rank test. Independent risk factors associated with OS and CSS were determined by univariate and multivariate Cox proportional hazard regression analyses and subgroup analysis were performed.

Results

A total of 2055 GBC patients aged 70 years or older were included in our study, with 1734 patients underwent surgery. Before PSM, the age, AJCC stage, TNM stage, and chemotherapy were significantly different between the surgery and no-surgery group (all P<0.05). Patients with surgery had significantly longer OS and CSS than those without surgery (P<0.0001). After 1:1 PSM, the differences in clinicopathological characteristics were reduced (all P>0.05). Kaplan-Meier analysis also showed patients received surgery had significantly better OS and CSS (P<0.0001). Subgroup analysis further indicated that almost all subgroups received surgery had OS and CSS advantage, especially patients aged 70-84 years old. Finally, univariate and multivariate COX regression analyses showed that age, AJCC stage and T stage were independent prognostic factors for OS and CSS in patients undergoing surgery.

Conclusion

Our study found that surgery significantly improved OS and CSS in GBC patients aged 70-84 years, but more prospective studies are needed to prove our findings.

In silico analysis to identify novel ceRNA regulatory axes associated with gallbladder cancer

Competitive endogenous RNA (ceRNA) networks are reported to play a crucial role in regulating cancer-associated genes. Identification of novel ceRNA networks in gallbladder cancer (GBC) may improve the understanding of its pathogenesis and might yield useful leads on potential therapeutic targets for GBC. For this, a literature survey was done to identify differentially expressed lncRNAs (DELs), miRNAs (DEMs), mRNAs (DEGs) and proteins (DEPs) in GBC. Ingenuity pathway analysis (IPA) using DEMs, DEGs and DEPs in GBC identified 242 experimentally observed miRNA-mRNA interactions with 183 miRNA targets, of these 9 (CDX2, MTDH, TAGLN, TOP2A, TSPAN8, EZH2, TAGLN2, LMNB1, and PTMA) were reported at both mRNA and protein levels. Pathway analysis of 183 targets revealed p53 signaling among the top pathway. Protein-protein interaction (PPI) analysis of 183 targets using the STRING database and cytoHubba plug-in of Cytoscape software revealed 5 hub molecules, of which 3 of them (TP53, CCND1 and CTNNB1) were associated with the p53 signaling pathway. Further, using Diana tools and Cytoscape software, novel lncRNA-miRNA-mRNA networks regulating the expression of TP53, CCND1, CTNNB1, CDX2, MTDH, TOP2A, TSPAN8, EZH2, TAGLN2, LMNB1, and PTMA were constructed. These regulatory networks may be experimentally validated in GBC and explored for therapeutic applications.

Gallbladder cancer concomitant with autosomal dominant polycystic kidney disease: A case report

The case is a 67-year-old female with autosomal dominant polycystic kidney disease who was followed up regularly. CT scan showed a mural nodule growing over the past 4 years inside the hypodense region surrounded by hepatic cysts. Surgery was performed and the pathological diagnosis was StageI gallbladder cancer.

Delayed manifestation of needle track metastasis after radical cholecystectomy: is needle track mapping needed?

This surgical perspective paper highlights the importance and rationale of performing a needle biopsy of a gallbladder mass though the future anticipated surgical incision site. It is a simple, and cost-effective technique, requiring close collaboration between the surgeon and the radiologist.

Incidental Findings of Gallbladder and Bile Ducts-Management Strategies: General Aspects, Gallbladder Polyps and Gallbladder Wall Thickening-A World Federation of Ultrasound in Medicine and Biology (WFUMB) Position Paper

The World Federation of Ultrasound in Medicine and Biology (WFUMB) is addressing the issue of incidental findings with a series of position papers to give advice on characterization and management. The biliary system (gallbladder and biliary tree) is the third most frequent site for incidental findings. This first part of the position paper on incidental findings of the biliary system is related to general aspects, gallbladder polyps and other incidental findings of the gallbladder wall. Available evidence on prevalence, diagnostic work-up, malignancy risk, follow-up and treatment is summarized with a special focus on ultrasound techniques. Multiparametric ultrasound features of gallbladder polyps and other incidentally detected gallbladder wall pathologies are described, and their inclusion in assessment of malignancy risk and decision- making on further management is suggested.

Long-term results and prognostic factors after surgical treatment for gallbladder cancer

Objectives

Gallbladder cancer is relatively rare and traditionally regarded as having poor prognosis. There is controversy about the effects of clinicopathological features and different surgical techniques on prognosis. The aim of this study was to investigate the effects of clinicopathological characteristics of the patients with surgically treated gallbladder cancer on long-term survival.

Material and Methods

We retrospectively analyzed the database of gallbladder cancer patients treated at our clinic between January 2003 and March 2021.

Results

Of 101 evaluated cases, 37 were inoperable. Twelve patients were determined unresectable based on surgical findings. Resection with curative intent was performed in 52 patients. The one-, three-, five-, and 10-year survival rates were 68.9%, 51.9%, 43.6%, and 43.6%, respectively. Median survival was 36.6 months. On univariate analysis, poor prognostic factors were determined as advanced age; high carbohydrate antigen 19-9 and carcinoembryonic antigen levels; non-incidental diagnosis; intraoperative incidental diagnosis; jaundice; adjacent organ/structure resection; grade 3 tumors; lymphovascular invasion; and high T, N1 or N2, M1, and high AJCC stages. Sex, IVb/V segmentectomy instead of wedge resection, perineural invasion, tumor location, number of resected lymph nodes, and extended lymphadenectomy did not significantly affect overall survival. On multivariate analysis, only high AJCC stages, grade 3 tumors, high carcinoembryonic antigen levels, and advanced age were independent predictors of poor prognosis.

Conclusion

Treatment planning and clinical decision-making for gallbladder cancer requires individualized prognostic assessment along with standard anatomical staging and other confirmed prognostic factors.

Smartphone-Based and Data-Driven Superstructure State Prediction Method for Highway Bridges in Service

Survival analysis is a data-driven approach that is widely used in various fields of biomedical prognostic research, and it is highly reliable in the processing of time-event data. This study developed a method for evaluating the service performance of bridge superstructures using the built-in acceleration sensor of smartphones and the prediction of survival analysis theory. It will be used to assist in the daily maintenance and repair of small and medium bridges. The effects of the upper load-bearing structure, upper general structure, bearings, deck paving, expansion joints, and frequency ratio on the deterioration of the bridge superstructure were investigated. The results show that the first-order vibration frequency of the bridge can be effectively detected by the built-in acceleration sensor of the mobile phone, but its low sensitivity and high output noise make it impossible to accurately detect the higher-order frequencies of the bridge. The upper load-bearing members, the upper general structure, the bearing, the deck pavement, and the frequency ratio are all related to the changing trend of the technical condition level of the bridge superstructure.

Successful Treatment of Metastatic Gallbladder Carcinoma with PD-L1 Expression by the Combination of PD-1 Inhibitor Plus Bevacizumab with Chemotherapy: A Case Report

Gallbladder cancer (GBC) is the most common type of biliary tract cancer. The GBC is often diagnosed at an advanced stage, which limits surgical intervention due to its aggressive nature, and as a consequence of its insensitivity to chemotherapy, more effective treatments are required. In GBC, the efficacy of chemotherapy combined with anti-PD-L1/VEGF inhibition remains to be clarified. The present case report describes successful treatment by toripalimab in combination with bevacizumab and gemcitabine in a patient with metastatic GBC and PD-L1 combined positive score (CPS) =30. After six courses of therapy, a partial response was observed in the patient’s clinical condition. So far, her PFS has exceeded 15 months. To the best of our knowledge, there was no other case where toripalimab plus bevacizumab were used in combination with gemcitabine as an effective treatment strategy for GBC. The remarkable response is likely to be related to the positive expression of PD-L1. Further, VEGF inhibition in combination with chemotherapy may result in improved clinical outcomes due to increased antitumor immunity. Chemotherapy regimens combined with anti-PD-L1/VEGF inhibition are promising therapies for GBC. Further well-designed prospective clinical trials are needed in order to confirm the efficacy and safety of the three-drug regimen.

Examination of the characteristics of long-term survivors among patients with gallbladder cancer with liver metastasis who underwent surgical treatment: a retrospective multicenter study (ACRoS1406)

Background

Gallbladder cancer (GBC) with liver metastasis is considered unresectable. However, there have been infrequent reports of long-term survival in patients with GBC and liver metastases. Therefore, we examined the characteristics of long-term survivors of gallbladder cancer with liver metastasis.

Methods

A retrospective multicenter study of 462 patients with GBC (mean age, 71 years; female, 51%) was performed. Although patients with pre-operatively diagnosed GBC and liver metastasis were generally excluded from resection, some cases identified during surgery were resected.

Result

In patients with resected stage III/IV GBC (n = 193), the period 2007–2013 (vs. 2000–2006, hazard ratio 0.63), pre-operative jaundice (hazard ratio 1.70), ≥ 2 liver metastases (vs. no liver metastasis, hazard ratio 2.11), and metastasis to the peritoneum (vs. no peritoneal metastasis, hazard ratio 2.08) were independent prognostic factors for overall survival, whereas one liver metastasis (vs. no liver metastasis) was not. When examining the 5-year overall survival and median survival times by liver metastasis in patients without peritoneal metastasis or pre-operative jaundice, those with one liver metastasis (63.5%, not reached) were comparable to those without liver metastasis (40.4%, 33.0 months), and was better than those with ≥ 2 liver metastases although there was no statistical difference (16.7%, 9.0 months). According to the univariate analysis of resected patients with GBC and liver metastases (n = 26), minor hepatectomy, less blood loss, less surgery time, papillary adenocarcinoma, and T2 were significantly associated with longer survival. Morbidity of Clavien–Dindo classification ≤ 2 and received adjuvant chemotherapy were marginally not significant. Long-term survivors (n = 5) had a high frequency of T2 tumors (4/5), had small liver metastases near the gallbladder during or after surgery, underwent minor hepatectomy without postoperative complications, and received postoperative adjuvant chemotherapy.

Conclusions

Although there is no surgical indication for GBC with liver metastasis diagnosed pre-operatively, minor hepatectomy and postoperative chemotherapy may be an option for selected patients with T2 GBC and liver metastasis identified during or after surgery who do not have other poor prognostic factors.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12876-022-02234-9.

Conversion surgery following gemcitabine plus cisplatin therapy for initially unresectable gallbladder cancer with peritoneal carcinomatosis: a case report

Background

Conversion surgery, which is defined as chemotherapy or chemoradiotherapy followed by radical surgery, may improve survival of patients with initially unresectable advanced biliary tract cancer, including gallbladder cancer. However, there are few reports on conversion surgery for advanced gallbladder cancer.

Case presentation

A 69-year-old woman was referred to our hospital with initially unresectable gallbladder cancer with peritoneal carcinomatosis. She underwent gemcitabine plus cisplatin therapy for 9 months. Extended cholecystectomy, resection of the extrahepatic bile duct with regional lymph node dissection, and total omentectomy were then performed as conversion surgery. The patient has survived without recurrence for 19 months postoperatively (31 months after the initial diagnosis) while continuing chemotherapy.

Conclusions

This case suggests that conversion surgery for advanced gallbladder cancer is effective and may be curative for locally advanced disease and distant metastasis such as peritoneal carcinomatosis.

Identification of Circulating lncRNAs Associated with Gallbladder Cancer Risk by Tissue-Based Preselection, Cis-eQTL Validation, and Analysis of Association with Genotype-Based Expression

Long noncoding RNAs (lncRNAs) play key roles in cell processes and are good candidates for cancer risk prediction. Few studies have investigated the association between individual genotypes and lncRNA expression. Here we integrate three separate datasets with information on lncRNA expression only, both lncRNA expression and genotype, and genotype information only to identify circulating lncRNAs associated with the risk of gallbladder cancer (GBC) using robust linear and logistic regression techniques. In the first dataset, we preselect lncRNAs based on expression changes along the sequence "gallstones → dysplasia → GBC". In the second dataset, we validate associations between genetic variants and serum expression levels of the preselected lncRNAs (cis-lncRNA-eQTLs) and build lncRNA expression prediction models. In the third dataset, we predict serum lncRNA expression based on individual genotypes and assess the association between genotype-based expression and GBC risk. AC084082.3 and LINC00662 showed increasing expression levels (p-value = 0.009), while C22orf34 expression decreased in the sequence from gallstones to GBC (p-value = 0.04). We identified and validated two cis-LINC00662-eQTLs (r² = 0.26) and three cis-C22orf34-eQTLs (r² = 0.24). Only LINC00662 showed a genotyped-based serum expression associated with GBC risk (OR = 1.25 per log2 expression unit, 95% CI 1.04-1.52, p-value = 0.02). Our results suggest that preselection of lncRNAs based on tissue samples and exploitation of cis-lncRNA-eQTLs may facilitate the identification of circulating noncoding RNAs linked to cancer risk.

Stepwise correlation of TP53 mutations from pancreaticobiliary maljunction to gallbladder carcinoma: a retrospective study

BACKGROUND

The genetic changes underlying carcinogenesis in patients with risk factors of gallbladder carcinoma (GBC) remains controversial, especially in patients with pancreaticobiliary maljunction (PBM). This study aimed to clarify the association between risk factors of GBC and genetic changes using next-generation sequencing (NGS).

METHODS

We retrospectively analyzed resected tissues of 64 patients who were diagnosed with GBC (n = 26), PBM [with GBC (n = 8), without GBC (n = 20)], and chronic cholecystitis, used as a control group (n = 10). DNA was extracted from tumors and their surrounding tissues, which were precisely separated by laser-capture microdissection. Gene alterations of 50 cancer-related genes were detected by NGS and compared with clinical information, including PBM status.

RESULTS

The most frequent gene alterations in GBC tissues occurred in TP53 (50%), followed by EGFR (20.6%), RB1 (17.6%), and ERBB2 (17.6%). Gene alterations that were targetable by molecular targeted drugs were detected in 20 cases (58.8%). Statistical analysis of gene alterations and risk factors revealed that TP53 alteration rate was higher in GBC patients with PBM than those without PBM (p = 0.038), and the TP53 mutation rates in the epithelium of control patients, epithelium of PBM patients without GBC, peritumoral mucosa of GBC patients with PBM, and tumor tissue of GBC patients with PBM were 10, 10, 38, and 75%, respectively (p <  0.01).

CONCLUSIONS

TP53 alteration more than KRAS mutation was revealed to underlie carcinogenesis in patients with PBM.

Effect of Hyperthermic Intraperitoneal Perfusion Chemotherapy Combined with Radical Surgery and Capecitabine on Stage III Gallbladder Cancer

PURPOSE

The aim of the study was to investigate the effect of hyperthermic intraperitoneal perfusion chemotherapy (HIPEC) combined with radical surgery and capecitabine on stage III gallbladder cancer.

METHOD

Seventy-eight patients with stage III gallbladder cancer treated in our hospital between December 2015 and April 2019 were retrospectively enrolled. Depending on the treatment approach, the patients were divided into the control group (radical surgery and capecitabine) and the HIPEC group (hyperthermic intraperitoneal perfusion chemotherapy combined with radical surgery and capecitabine). The patients were followed up by outpatient or through telephone until April 1, 2020. SPSS 19.0 software was applied for data analysis. Survival analysis was performed using the Kaplan-Meier method and parallel log-rank test.

RESULTS

There were 43 cases in the control group and 35 cases in the HIPEC group. There were no significant differences in operation time, lymph node metastasis, microvascular infiltration, and nerve invasion; there was no significant difference in postoperative complications between the two groups (P > 0.05). The average hospitalization time of the HIPEC group was 23.0 ± 6.9 days, which was longer than the 20.0 ± 5.8 days of the control group (P < 0.05). The body temperatures of HIPEC group patients at 0 h and 6 h after operation were higher than those of patients in the control group (P < 0.05); however, the body temperature of the two groups gradually became the same at 12-24 h after operation. There was no liver and kidney damage in the two groups after surgery. The platelets in the HIPEC group were less than those in the control group (P < 0.05). The median survival time of HIPEC was 19.2 months, which was longer than 15.3 months in the control group. The 1-year survival rates of the two groups were 91.43% vs. 76.71%, and the 2-year survival rates were 26.29% vs. 17.53%, respectively (P < 0.05).

CONCLUSION

HIPEC combined with radical surgery and capecitabine for stage III gallbladder cancer can effectively prolong survival time without increasing surgery-related complications.

IMbrave 151: a randomized phase II trial of atezolizumab combined with bevacizumab and chemotherapy in patients with advanced biliary tract cancer

Background:

Biliary tract cancers (BTCs) are heterogenous, highly aggressive tumors that harbor a dismal prognosis for which more effective treatments are needed. The role of cancer immunotherapy in BTC remains to be characterized. The tumor microenvironment (TME) of BTC is highly immunosuppressed and combination treatments are needed to promote effective anticancer immunity. Vascular endothelial growth factor (VEGF) drives immunosuppression in the TME by disrupting antigen presentation, limiting T-cell infiltration, or potentiating immune-suppressive cells. Many VEGF-regulated mechanisms are thought to be relevant to repressed antitumor immunity in BTC, making dual targeting of VEGF and programmed cell death protein 1 (PD-1)/PD-L1 pathways a rational approach. Gemcitabine and Cisplatin (Gem/Cis) can also modulate anticancer immunity through overlapping and complementary mechanisms to those regulated by VEGF. Anti-PD-L1/VEGF inhibition, coupled with chemotherapy, may potentiate antitumor immunity leading to enhanced clinical benefit.

Methods:

IMbrave 151 is a randomized, double-blind, placebo-controlled, multicenter, international phase II study to evaluate atezolizumab (a PD-L1 inhibitor) in combination with chemotherapy (gemcitabine and cisplatin) and bevacizumab (an anti-VEGF monoclonal antibody) as a first-line treatment for advanced BTC. Approximately 150 patients with previously untreated, advanced BTC will be randomized to either Arm A (atezolizumab + bevacizumab + Gem/Cis) or Arm B (atezolizumab + placebo + Gem/Cis). Randomization is stratified by the presence of metastatic disease, primary tumor location, and geographic region. The primary efficacy endpoint is investigator-assessed progression-free survival (PFS) per RECIST 1.1. Secondary endpoints include objective response rate (ORR), duration of response (DoR), disease control rate (DCR), overall survival (OS), and safety and patient reported outcomes (PROs). Tissue, blood, and stool samples will be collected at baseline and on-treatment in order to perform correlative biomarker analyses.

Discussion:

IMbrave 151 represents the first randomized study to evaluate combined PD-L1/VEGF blockade on a chemotherapy backbone in BTC.

Trial registration:

NCT identifier: NCT04677504; EUDRACT number: 2020-003759-14

Prognostic Nomograms to Predict Survival of Patients with Resectable Gallbladder Cancer: A Surveillance, Epidemiology, and End Results (SEER)-Based Analysis

Background

Gallbladder adenocarcinoma (GBAC) is globally acknowledged as one of the most common malignancies among all gastrointestinal cancers. Despite prognosis of GBAC patients remains poor, patients with early-stage disease can be observed with long-term survival.

Material/Methods

In this study, 2556 patients with pathological GBAC between 2010 and 2015 were derived from the Surveillance, Epidemiology, and End Results (SEER) database. The prognostic nomograms containing all independent prognostic factors for predicting overall survival (OS) and cancer-specific survival (CSS) were constructed to achieve superior prognostic discriminatory ability.

Results

Based on the AJCC 7^th TNM staging system, we found the TNM substaging was not accurate enough to predict the survival and stratify the risk. Based on the results of univariate and multivariate analyses, a more precise prognostic nomogram was constructed containing all significant independent prognostic factors (age, grade, TNM stage, bone metastasis, and chemotherapy) for OS, while age, grade, TNM stage, bone metastasis and radiotherapy significant independent prognostic factors for CSS. The C-index of the constructed nomogram for predicting OS and CSS was 0.740 and 0.737 higher than that of TNM staging alone (0.667 for OS and 0.689 for CSS), respectively. In addition, the calibration curves and decision curve analysis further showed its robust power in survival prediction.

Conclusions

The constructed nomograms showed better discrimination abilities to predict OS and CSS rates at 1, 3, and 5 years. In the future, these constructed models for this disease will assist in risk stratification to guide GBAC treatment.

Validation of the 8th Edition American Joint Commission on Cancer (AJCC) Gallbladder Cancer Staging System: Prognostic Discrimination and Identification of Key Predictive Factors

The scope of our study was to compare the predictive ability of American Joint Committee on Cancer (AJCC) 7th and 8th edition in gallbladder carcinoma (GBC) patients, investigate the effect of AJCC 8th nodal status on the survival, and identify risk factors associated with the survival after N reclassification using the National Cancer Database (NCDB) in the period 2005-2015. The cohort consisted of 7743 patients diagnosed with GBC; 202 patients met the criteria for reclassification and were denoted as stage ≥III by AJCC 7th and 8th edition criteria. Overall survival concordance indices were similar for patients when classified by AJCC 8th (OS c-index: 0.665) versus AJCC 7th edition (OS c-index: 0.663). Relative mortality was higher within strata of T1, T2, and T3 patients with N2 compared with N1 stage (T1 HR: 2.258, p < 0.001; T2 HR: 1.607, p < 0.001; Τ3 HR: 1.306, p < 0.001). The risk of death was higher in T1-T3 patients with Nx compared with N1 stage (T1 HR: 1.281, p = 0.043, T2 HR: 2.221, p < 0.001, T3 HR: 2.194, p < 0.001). In patients with AJCC 8th edition stage ≥IIIB GBC and an available grade, univariate analysis showed that higher stage, Charlson-Deyo score ≥ 2, higher tumor grade, and unknown nodal status were associated with an increased risk of death, while year of diagnosis after 2013, academic center, chemotherapy. and radiation therapy were associated with decreased risk of death. Chemotherapy and radiation therapy were associated with decreased risk of death in patients with T3-T4 and T2-T4 GBC, respectively. In conclusion, the updated AJCC 8th GBC staging system was comparable to the 7th edition, with the recently implemented changes in N classification assessment failing to improve the prognostic performance of the staging system. Further prospective studies are needed to validate the T2 stage subclassification as well as to clarify the association, if any is actually present, between advanced N staging and increased risk of death in patients of the same T stage.