Resection combined with intraoperative radiation therapy (IORT) for stage IV (TNM) gallbladder carcinoma

Abstract

From October 1976 to May, 1990, a total of 86 patients with stage IV (TNM) gallbladder cancer were treated at Tsukuba University Hospital. Twenty-seven of the 86 patients underwent tumor resection; 43 patients received palliative surgery. The remaining 16 were too advanced to have surgery. Of 27 patients who had tumor resection, 9 had resection alone, 17 had intraoperative radiation therapy (IORT) +/- postoperative external radiotherapy (ERT), and 1 had postoperative ERT. The procedures used were: extended right hepatic lobectomy plus hepaticobiliary resection (HBR) (n = 2), hepatic segmentectomy (SIVb, SV) plus HBR (n = 9), hepatic segmentectomy (SIV, V, VI) with HBR (n = 1), hepatic segmentectomy (SIV, V) plus HBR with pancreaticoduodenectomy (PD) (n = 3), PD plus HBR (n = 1), cholecystectomy with wedge resection of the gallbladder fossa plus HBR (n = 3), and cholecystectomy plus HBR (n = 3), and cholecystectomy (n = 4). Regional lymph node dissections were performed in every patient and 17 of 27 patients underwent additional resections of adjacent organs such as the stomach, duodenum, colon, and abdominal wall. A single dose of 20-30 Gy was delivered intraoperatively for 17 patients. A mean total dose of 36.4 Gy (1.8/fraction) was added to IORT for 10 patients. The three-year cumulative survival rate was 10.1% for resection plus IORT but 0% for resection alone. The longest survivor is alive and well at 3 years and 3 patients are alive 16, 13, and 4 months after tumor resection followed by IORT plus ERT.

Carcinoma of the gallbladder

“…In a recently reported series from Japan, 17 of 27 patients with stage IV (TNM) carcinoma of the gallbladder received intraoperative radiation therapy (IORT) with or without external radiotherapy (ERT). The 3-year cumulative survival rate was 10.1% for resection plus IORT compared with 0% for resection alone [38]. Further trials regarding this modality are necessary.…”

“…Preliminary reports on the use of intraoperative radiotherapy indicate that this technique may play a role in the curative and palliative management of gallbladder carcinoma [38,39]. In a recently reported series from Japan, 17 of 27 patients with stage IV (TNM) carcinoma of the gallbladder received intraoperative radiation therapy (IORT) with or without external radiotherapy (ERT).…”

Is External Palliative Radiotherapy for Gallbladder Carcinoma Effective?

“…However, there is no standard technique in the literature due to the small number of series, while the most widely used method is EBRT as in our case. Todoroki [8] and Todoroki et al [3,4,9] reported that in patients with stage IV disease, adjuvant radiotherapy (IORT + EBRT) yielded a significantly (p = 0.0023) higher 5-year survival rate (8.9%) than resection alone (2.9%). The local control rate was significantly (p = 0.0467) higher in the adjuvant radiation group than in the resection-alone group (59.1 vs. 36.1%).…”

“…The local control rate was significantly (p = 0.0467) higher in the adjuvant radiation group than in the resection-alone group (59.1 vs. 36.1%). Also, the 30-day operative mortality rate was 5.9% and the overall 5-year survival rate of stage IV disease patients was 6.3% [3,4,8,9]. However, other problems such as optimal radiation dose, radiation procedure, appropriate timing between surgical resection and radiation therapy, the tolerability of surgically disturbed tissues to radiation, etc., have not been fully answered in the literature and should be further studied.…”

“…Nevertheless, it appears that gallbladder carcinomas are not as radioresistant as was previously thought. In the majority of the cases, radiotherapy has a palliative role in the management of gallbladder carcinoma, as in our case, and occasionally has also an important impact on the cure of this disease in combination with complete surgical resection of the tumor [8,9]. Mainly, in terms of radiotherapy technique, the external-beam radiotherapy (EBRT) is used due to feasibility reasons.…”