Gastrointestinal cancer-18-Gall Bladder and Biliary tract

GASTROINTESTINAL CANCER PART-18

Welcome to the 18th part of educational series on GastroIntestinal Cancers. We learned in part 17 about liver transplant, need for multidisciplinary evaluation, options of local therapies like ablation or embolization, and systemic therapy like sorafenib or PIAF chemotherapy, for hepatocellular carcinoma.

Question: Now Dr. Chiragbhai, what about cancers of gall bladder and bile ducts?

Answer: These are comparatively uncommon, with higher incidence in North India. Risk factors are largely unknown, but thought to be chronic inflammation, such as secondary to gall stones, or rarely liver fluke-a parasite. They often present with nonspecific or no symptoms, have tendency for early spread to lymph nodes and liver, resulting in advance stage at diagnosis. Gall bladder cancers are detected incidentally in a large number of patients, as presenting symptoms can be like cholecystitis.

Que: How do you treat them?

Ans: Only curative option is surgical resection. However, few patients present at such a stage. Patients who are detected incidentally at time of cholecystectomy, should be attempted cancer surgery if possible. Those who are diagnosed at pathology review, should be reoperated by a person experienced in such surgery, as about 75% still have residual cancer. This offers the best chance of cure.

Role of adjuvant/postoperative chemotherapy or chemoradiotherapy is not clear. Since there are very few clinical trials, that too with very small number of patients, most of these questions are unanswered. Different centers use different approach, and a multidisciplinary evaluation is important to decide individual patient’s plan, while we await good clinical trials. India has much larger number of patients, and hopefully such data will come from India, rather than West.

Que: What are the options for unresectable patients?

Ans: Palliation is the goal, with prolongation of survival to some extent. Biliary drainage is an important part of palliation, and can be achieved by various means e.g. ERCP, PTC. Even though, overall response rate to chemotherapy not very good, small number of patients respond well and derive significant benefit. A number of options exist, mostly incorporating 5-FU or capecitabine, gemcitabine, oxaliplatin, and few other agents like mitomycin, cisplatin. No targeted agents have been found to be useful, mostly due to lack of data.

In few patients with localized disease, where surgery is not feasible, chemoradiation can occasionally provide good palliation and should be considered in some cases. Concurrent chemotherapy is given using 5-FU or capecitabine. Gemcitabine is not recommended due to toxicity and right dose is not defined.

Dr. Chirag A. Shah; M.D. Oncology/Hematology (USA),
Diplomate American Board of Oncology and Hematology.
Ahmedabad. drchiragashah@gmail.com
Shyam Hem-Onc Clinic. 402 Galaxy, Near Shivranjani, Opp Jhansi ki Rani BRTS, Ahmedabad. 079 26754001 www.shyamhemoncclinic.com