Multimodality management of gallbladder cancer can lead to a better outcome: Experience from a tertiary care oncology centre in North India

Table 1 Histopathological and perioperative details of resectable gallbladder patients (n = 172)

Patient characteristic	n (%)
Type of surgery
Wedge resection	93 (54)
Anatomical segment IVb/V resection	66 (38.4)
Modified extended right hepatectomy	12 (7)
Lap cholecystectomy	1 (0.6)
Histology
Adenocarcinoma	160 (93)
Adenosquamous	9 (5.2)
Carcinosarcoma	2 (1.2)
Squamous	1 (0.6)
Histological grade
Well differentiated	33 (19.2)
Moderately differentiated	116 (67.4)
Poorly differentiated	23 (13.4)
pT stage
T1	25 (14.5)
T2	70 (40.7)
T3	73 (42.4)
T4	4 (2.4)
pN stage
N0	117 (68)
N+	55 (32)
LVI positive	54 (31.4)
PNI positive	56 (32.5)
IAC positive	15 (8.7)
R0/R1 resection
R0	161 (93.6)
R1	11 (6.4) [liver (n = 4), cystic duct (n = 4), bile duct (n = 3)]
Final stage (AJCC 8th)
I	21 (12.2)
II	45 (26.2)
III	73 (42.4)
IV	33 (19.2)
Postoperative morbidity
Overall	53 (30.8)
Clavien-Dindo grade III & above	21 (12.2)
Bile leak	14 (8.1)
Clinically significant	5 (2.9)
90 d mortality	8 (4.6)
Adjuvant therapy	117/147 (79.6)
Chemotherapy only	80
Chemoradiotherapy	37
Advised but not taken/incomplete	30
Not indicated	25

AJCC: American Joint Committee on Cancer; IAC: Inter-aortocaval lymphnode; LVI: Lymphovascular invasion; PNI: Perineural invasion.

Table 2 Association between patient and disease characteristics with outcomes

	Overall survival			Disease free survival
Factor	HR	95%CI	P value	HR	95%CI	P value
Sex
Female	0.92	[0.56-1.51]	0.76	0.98	[0.61-1.6]	0.96
Male
Jaundice
Yes	0.9	[0.37-2.16]	0.81	1.19	[0.48-2.93]	0.67
No
Incidental
Yes	0.24	[0.07-0.81]	0.001	0.54	[0.34-0.86]	0.01
No
Neoadjuvant therapy
Yes	2.2	[1.27-3.81]	< 0.001	2.91	[1.64-5.16]	< 0.001
No
Resection
R+	4.08	[1.22-13.64]	< 0.001	4.13	[1.22-13.9]	< 0.001
R0
Lymph node status
Positive	1.91	[1.13-3.25]	0.006	2.44	[1.4-4.17]	0.001
Negative
T stage
T1a-T2
T3-T4	5.01	[3.06-8.18]	< 0.001	4.21	[2.55-6.94]	< 0.001
LVI
Yes	2.08	[1.22-3.5]	0.001	2.12	[1.23-3.64]	0.001
No
PNI
Yes	3.06	[1.75-5.37]	< 0.001	2.54	[1.45-4.45]	< 0.001
No
Poorly differentiated
Yes
No	1.75	[0.81-3.7]	0.07	1.43	[0.66-3.08]	0.28

HR: Hazard ratio; CI: Confidence interval; LVI: Lymphovascular invasion; PNI: Perineural invasion.

Table 3 Clinicopathological characteristics of patients who received adjuvant therapy vs those who did not

Patient characteristic	Adjuvant group (n = 117), n (%)	Non-adjuvant Group (n = 30), n (%)	P value
Age, yr (mean)	54.5	60	0.01
Sex (M:F)	47:70	10:20	0.63
Incidental GBC	55 (47)	7 (23.3)	0.03
Neoadjuvant therapy	33 (28.2)	7 (23.3)	0.76
Type of surgery			0.71
Wedge resection	62 (53)	16 (53.3)
Anatomical segment IVb/V resection	48 (41)	11 (36.7)
Modified extended right hepatectomy	7 (6)	3(10)
Histology			0.91
Adenocarcinoma	108 (92.3)	28 (93.3)
Adenosquamous	7(6)	2 (6.7)
Carcinosarcoma	1	0
Squamous	1	0
Histological grade			0.12
Well differentiated	21 (18)	2 (6.7)
Moderately differentiated	82 (70.1)	21 (70)
Poorly differentiated	14 (11.9)	7 (23.3)
pT stage			0.56
T1	6 (5.1)	2 (6.7)
T2	57 (48.7)	11 (36.7)
T3	52 (44.4)	17 (56.6)
T4	2 (1.7)	0
pN stage			0.47
N0	77 (65.8)	17 (56.7)
N+	40 (34.2)	13 (43.3)
LVI positive	37 (31.6)	13 (43.3)	0.32
PNI positive	40 (34.2)	12 (40)	0.7
R0/R1resection			0.84
R0	109 (93.2)	27 (90)
R1	8 (6.8)	3 (10)
Final stage (AJCC 8th)			0.79
I	3 (2.6)	1 (3.3)
II	36 (30.8)	8 (26.7)
III	56 (47.9)	13 (43.3)
IV	22 (18.1)	8 (26.7)

AJCC: American Joint Committee on Cancer; GBC: Gallbladder cancer; LVI: Lymphovascular invasion; PNI: Perineural invasion.

Table 4 Comparison of the present study with other studies on multimodality management of gallbladder cancer

Parameter	Our study	Patkar et al[4], 2018	Creasy et al[15], 2019
Sample size	274	400	437
Patients who underwent complete resection	172	320	255
Unresectable	102	80	182
Major liver resection, (%)	Yes (7)	No	Yes (24.3)
Incidental GBC, (%)	35	40	60.7
R1 resection, n (%)	11/172 (6.4)	10/320 (3.1)	15/255 (5.9)
Neoadjuvant in resectable group, n (%)	43/172 (25)	83/320 (25.9)	16/255 (6.3)
Final stage III/IV, n (%)	106/172 (61.6)	232/400 (58)	306/437 (70)
LN positivity, n (%)	56/172 (32)	98/320 (30.62)	NA
Residual disease in incidental cases, n (%)	29/73 (39.7)	68/160 (42.5)	172/276 (62.3)
Adjuvant therapy, n (%)	117/147 (79.6)	206/320 (64.4)	78/255 (30.7)
Recurrence, n (%)	71/172 (41.2)	98/320 (30.6)	NA
Dying of disease, n (%)	69/172 (40.1)	45/320 (14)	149/255 (58.4)
Estimated 3 yr OS, (%)	56	64	NA
Estimated 5 yr OS, (%)	43.5	NA	43 (only survivors)
Estimated 3 yr DFS, (%)	49.2	49	36

DFS: Disease free survival; GBC: Gallbladder cancer; LN: Lymph node; NA: Not available; OS: Overall survival.