Abstract
Introduction:
Retroperitoneal lymphadenopathy is considered as metastatic disease in GBC, however some surgical series of radical surgery with RPLN dissection have shown results marginally inferior to those with non-RPLN lymph-node dissection. Radiological RPLN comprises a major proportion of advanced non-metastatic GBC (40% ). There is dilemma in the intent of treatment to be offered in such cases. Hence we are reporting our series of GBC treated with first line CT and consolidation CTRT in responders with comparison of outcomes of patients with RPLN versus non-RPLN.
Materials and methods:
Non-metastatic advanced GBC with good performance status (KPS.80) were initiated on first line chemotherapy (CT, cisplatin-gemcitabine) and thereafter responders were evaluated by CT-angiography and PET-CT scan for resectability. If found unresectable, they were offered chemo-radiotherapy (CTRT) to a dose of 45 Gy by conventional fractionation (3D-CRT technique) along with concurrent capecitabine @1250mg/m2 to GBC and regional lymphatics including RPLN. Thereafter boost dose of 9Gy/5# was given to GBC only. Response assessment was done using CT scan abdomen by RECIST criteria. Outcomes (overall survival) between the 2 groups (RPLN vs Non RPLN) were computed with Kaplan-Meier survival curves and chi-square tests using spss v 20.
Results:
Amongst 189 patients of advanced non-metastatic GBC recruited from 2011–2022, 80 had RPLN. The demographic features of both groups were comparable. 68% patients were women, 30% underwent upfront stenting for obstructive jaundice, 90% had T3 and T4 disease and 45%, 30% and 25% had N0, N1, N2 in non-RPLN arm. Only 10% had undergone upfront laparoscopic staging and had pathological proven RPLN. 40% patients received 4 cycles CT only and 50% patients received 6 cycles or more, and 33% received CTRT. By RECIST criteria, 10% vs 16% achieved complete response (CR), 39% vs 41% achieved partial response (PR), 16% vs 15% achieved stable disease (SD), 2.7% vs 6% had disease progression (PD) and 14.5% vs 3.7% were non-evaluable in Non-RPLN vs RPLN group respectively. 12% vs 6% could undergo radical surgery in Non-RPLN vs RPLN group (p = 0.03). The overall median overall survival was 9 months (95% CI 7.6–10.3 months) vs 10 months (95% CI 8-9.8 months) (p = NS) in Non-RPLN vs RPLN group respectively. In those who received CT only, the median OS was 7 months vs 8 months, while in those who received CT followed by CTRT, the median OS was 14 months vs 13 months (p = 0.65) in non-RPLN vs RPLN group respectively.
Conclusions:
Based on this analysis, we conclude that advanced non-metastatic GBC patients with RPLN have outcomes similar to those without RPLN if treated with radical intent.