Radiological Downstaging with Neoadjuvant Therapy in Unresectable Gall Bladder Cancer Cases

  • Agrawal, Sushma (Department of Radiotherapy, Sanjay Gandhi Post Graduate Institute of Medical Sciences) ;
  • Mohan, Lalit (Department of Radiotherapy, Sanjay Gandhi Post Graduate Institute of Medical Sciences) ;
  • Mourya, Chandan (Department of Radiotherapy, Sanjay Gandhi Post Graduate Institute of Medical Sciences) ;
  • Neyaz, Zafar (Department of Radiotherapy, Sanjay Gandhi Post Graduate Institute of Medical Sciences) ;
  • Saxena, Rajan (Department of Radiotherapy, Sanjay Gandhi Post Graduate Institute of Medical Sciences)
  • Published : 2016.06.01


Background: Gall bladder cancer (GBC) usually presents as unresectable or metastatic disease. We conducted a feasibility study to evaluate the effect of neoadjuvant therapy (NAT) on radiologic downstaging and resectability in unresectable GBC cases. Materials and Methods: Patients with locally advanced disease were treated with chemoradiotherapy [CTRT] ( external radiotherapy (45Gy) along with weekly concurrent cisplatin $35mg/m^2$ and 5-FU 500 mg) and those with positive paraaortic nodes were treated with neoadjuvant chemotherapy [NACT (cisplatin $25mg/m^2$ and gemcitabine $1gm/m^2$ day 1 and 8, 3 weekly for 3 cycles). Radiological assessment was according to RECIST criteria by evaluating downstaging of liver involvement and lymphadenopathy into complete response (CR), partial response (PR), stable disease (SD) and progressive disease (PD). Results: A total of 40 patients were evaluated from January 2012 to December 2014 (CTRT=25, NACT=15). Pretreatment CT scans revealed involvement of hilum (19), liver infiltration (38), duodenum involvement (n=22), colon involvement (n=11), N1 involvement (n=11), N2 disease (n=8), paraaortic LN (n=15), and no lymphadenopathy (n=6). After neoadjuvant therapy, liver involvement showed CR in 11(30%), PR in 4 (10.5%), SD in 15 (39.4%) and lymph node involvement showed CR in 17 (50%), PR in 6 (17.6%), SD in 4 (11.7 %). Six patients (CTRT=2, NACT=4) with 66.6 % and 83% downstaging of liver and lymphnodes respectively underwent extended cholecystectomy. There was 16.6 % and 83.3% rates of histopathological CR of liver and lymph nodes. All resections were R0. Conclusions: Neoadjuvant therapy in unresectable gall bladder cancer results in a 15% resectability rate. This approach has a strong potential in achieving R0 and node negative disease. Radiologic downstaging (CR+PR) of liver involvement is 40.5% and lymphadenopathy is 67.5%. Nodal regression could serve as a predictor of response to neoadjuvant therapy.


Radiologic downstaging;neoadjuvant therapy;unresectable gallbladder cancer


  1. ctcaev3.pdf
  2. de Aretxabala X, Roa I, Burgos L, et al (1999). Preoperative chemoradiotherapy in the treatment of gallbladder cancer, Am Surg, 65, 241-6.
  3. Ed Cancer Staging Manual Part1.pdf
  4. Gangopadhyay A, Nath P, Biswas J (2015). Reduced dose intensity of chemotherapy may not lead to inferior palliation in locally advanced carcinoma of the gall bladder: An experience from a regional cancer center in Eastern India, J Gastrointest Cancer, 46, 297-300
  5. Kato A, Shimizu H, Ohtsuka M, et al (2013). Surgical resection after downsizing chemotherapy for initially unresectable locally advanced biliary tract cancer: a retrospective singlecenter study, Ann Surgical Oncol, 20, 318-24.
  6. Randi G, Franceschi S, La Vecchia C (2006). Gallbladder cancer worldwide:geographical distribution and risk factors, Int J Cancer, 118, 1591-2.
  7. Saxena R, Sikora SS, Kaushik SP (1995). A triple bypass procedure for advanced carcinoma of the neck of the gall bladder. Br J Surg, 82, 394-5.
  8. Sirohi B, Mitra A, Jagannath P, et al (2015). Neoadjuvant chemotherapy in patients with locally advanced gallbladder cancer. Future Oncol, 11, 1501-9.
  9. Therasse P, Arbuck SG, Eisenhauer EA, Kaplan RS, Rubinstein L (2000). New guidelines to evaluate the response to treatment in Solid Tumors. J Natl Cancer Inst, 9, 205-6.

Cited by

  1. Long-Term Survival with Chemoradiation Alone in Locally Advanced Unresectable Gallbladder Cancer: First Case Report of a New Paradigm vol.49, pp.2, 2018,
  2. Prognostic significance of neutrophil–lymphocyte ratio and carbohydrate antigen 19-9 in patients with gallbladder carcinoma vol.98, pp.8, 2019,