International Journal of Radiation Oncology*Biology*Physics
Clinical investigation: gallbladderAdjuvant external beam radiation therapy with concurrent chemotherapy in the management of gallbladder carcinoma
Introduction
Gallbladder carcinoma (GBC) is the sixth most common gastrointestinal malignancy in the United States and continues to increase in incidence; more than 6,900 new cases were estimated for 2000 (1). In general, the prognosis of patients diagnosed with GBC is poor, with an expected overall 5-year survival rate of less than 10% and a median survival of 6 months (2). The poor survival rate results from 50–70% of patients presenting with advanced disease (Stage III, IV), because the onset of symptoms is insidious, occurring over a period of weeks to months 2, 3. Of the patients who ultimately succumb to GBC, 86% have advanced local-regional disease (4).
Complete surgical resection is the most effective treatment for Stage 0–I GBC, but it offers little chance of durable local control or improved survival in Stage II–IV GBC. The reported 5-year survival rates are as follows: Stage 0–I, 33–100%; Stage II, 9–33%; Stage III, 0–25%; and Stage IV, 0–5% 5, 6, 7, 8, 9, 10, 11, 12.
Attempts have been made to improve local control and survival using adjuvant radiotherapy alone or in combination with chemotherapy. There have been conflicting reports regarding the value of postoperative adjuvant radiotherapy 13, 14, 15, 16, 17, 18, 19. Given the small number of reported series, the benefit of adjuvant radiotherapy has been difficult to assess, because of the different patient selection factors, staging systems, extent of resection, radiation therapy technique, and chemotherapy regimes used in the different series.
Based on the poor overall survival rate and high local recurrence rates after surgery alone, a prospective treatment approach was developed at our institution in an attempt to improve outcome after curative resection, with a combined modality approach of radiation therapy plus concurrent 5-fluorouracil (5-FU) chemotherapy. This report analyzes this multimodality approach to GBC.
Section snippets
Methods and materials
A comprehensive review of the tumor registry within the division of radiation oncology at the Mayo Clinic in Rochester, MN identified 21 patients from 1985 through 1997 with GBC who received adjuvant external beam radiation therapy (EBRT) with concurrent 5-FU-based chemotherapy after an attempt at curative resection. The medical records of these 21 patients were examined in detail as to the individual patient characteristics, tumor stage, pathology, surgical resection, radiation therapy,
Clinicopathologic characteristics
Of the 21 patients evaluated, 15 were female and 6 were male. The median age at diagnosis was 62.4 years and ranged from 45.6 to 78.8 years. Presenting symptoms or signs included the following: pain in 18 of 21 patients (85.7%), jaundice in 5 (23.8%), pruritis in 2 (9.5%), palpable mass in 2 (9.5%), and weight loss of >10% body weight in 1 (4.8%). The median duration of symptoms or signs before diagnosis was 1.8 weeks and ranged from 0.1 to 52.7 weeks.
The extent of surgical resection was
Surgery alone: survival and patterns of relapse
In general, the prognosis of patients diagnosed with gallbladder malignancies is poor, and the overall 5-year survival rate is less than 5–10% (15). The majority of patients, 50–70%, diagnosed with gallbladder malignancies present with advanced disease, Stage III–IV (3). As diagnostic imaging has improved, GBC has been detected at earlier, resectable stages more frequently, and the role of surgical treatment has evolved toward more extensive and radical resections 4, 10, 22, 23, 24, 25.
Conclusion
Based upon the findings of this study and those of the literature, it can be concluded that gallbladder carcinoma is associated with a generally poor prognosis. It is possible that the previous dismal outcome could be improved by noting the factors associated with favorable outcomes and applying these findings to patient care strategies. Surgical resection alone has resulted in relatively poor survival rates. However, performing a complete resection with negative margins seems critical to
Acknowledgements
The authors thank Ms. Lynn Taraski for preparing the manuscript and overseeing the tables and figures.
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