Kresl John J, Schild Steven E, Henning George T, Gunderson Leonard L, Donohue John, Pitot Henry, Haddock Michael G, Nagorney David
Division of Radiation Oncology, Mayo Clinic and Mayo Foundation, Rochester, MN, USA.
Int J Radiat Oncol Biol Phys. 2002 Jan 1;52(1):167-75. doi: 10.1016/s0360-3016(01)01764-3.
This study was performed to evaluate the outcome of patients with gallbladder cancer who received postoperative concurrent chemotherapy and radiation therapy.
Curative resection followed by adjuvant combined modality therapy with external beam radiation therapy (EBRT) and chemotherapy was attempted in 21 consecutive gallbladder carcinoma (GBC) patients at the Mayo Clinic from 1985 through 1997. All patients received concurrent 5-fluorouracil during EBRT. EBRT fields encompassed the tumor bed and regional lymph nodes (median dose of 54 Gy in 1.8-2.0-Gy fractions). One patient received 15 Gy intraoperatively after EBRT. A retrospective analysis was performed for the end points of local control, distant failure, and overall survival.
After maximal resection, 12 patients had no residual disease on pathologic evaluation, 5 had microscopic residual disease, and 4 had gross residual disease. One patient had Stage I disease, and 20 had Stage III-IV disease. With median follow-up of 5 years (range: 2.6-11.5 years), 5-year survival for the entire cohort was 33%. The 5-year survival rate of patients with Stage I-III disease was 65% vs. 0% for those with Stage IV disease (p < 0.02). For patients with no residual disease, 5-year survival was 64% vs. 0% for those with residual disease (p = 0.002). The median survival was 0.6, 1.4, and 5.1 years for patients with gross residual, microscopic residual, and no residual disease, respectively (p = 0.02). The 5-year local control rate for the entire cohort was 73%. Two-year local control rates were 0%, 80%, and 88% for patients with gross residual, microscopic residual, or no residual disease, respectively (p < 0.01). Five-year local control rates were 100% for the 6 patients who received total EBRT doses >54 Gy (microscopic residual, 3 patients; gross residual, 1 patient; negative but narrow margins, 2 patients) vs. 65% for the 15 who received a lower dose (3, gross residual; 2, microresidual; 10, negative margins).
Patients with completely resected (negative margins) GBC followed by adjuvant EBRT plus 5-fluorouracil chemotherapy had a relatively favorable prognosis, with a 5-year survival rate of 64%. These results seem to be superior to historical surgical controls from the Mayo Clinic and other institutions, which report 5-year survival rates of approximately 33% with complete resection alone. Both tumor stage and extent of resection seemed to influence survival and local control. More aggressive measures using current cancer therapies and integration of new cancer treatment modalities will be required to favorably impact on the poor prognosis of patients with Stage IV or subtotally resected GBC. Additional investigation leading to earlier diagnosis is warranted, because most patients with GBC present with advanced disease.
本研究旨在评估接受术后同步化疗和放疗的胆囊癌患者的治疗结果。
1985年至1997年期间，梅奥诊所对21例连续性胆囊癌（GBC）患者尝试进行根治性切除，随后采用外照射放疗（EBRT）和化疗的辅助联合治疗。所有患者在EBRT期间接受同步5-氟尿嘧啶治疗。EBRT野包括肿瘤床和区域淋巴结（中位剂量54 Gy，每次分割剂量1.8 - 2.0 Gy）。1例患者在EBRT后术中接受了15 Gy照射。对局部控制、远处转移和总生存等终点进行了回顾性分析。
最大程度切除术后，12例患者病理评估无残留病灶，5例有镜下残留病灶，4例有肉眼残留病灶。1例患者为I期疾病，20例为III - IV期疾病。中位随访5年（范围：2.6 - 11.5年），整个队列的5年生存率为33%。I - III期疾病患者的5年生存率为65%，而IV期疾病患者为0%（p < 0.02）。无残留病灶患者的5年生存率为64%，有残留病灶患者为0%（p = 0.002）。肉眼残留、镜下残留和无残留病灶患者的中位生存期分别为0.6年、1.4年和5.1年（p = 0.02）。整个队列的5年局部控制率为73%。有肉眼残留、镜下残留或无残留病灶患者的2年局部控制率分别为0%、80%和88%（p < 0.01）。接受EBRT总剂量>54 Gy的6例患者（镜下残留3例；肉眼残留1例；切缘阴性但狭窄2例）的5年局部控制率为100%，而接受较低剂量的15例患者（肉眼残留3例；镜下残留2例；切缘阴性10例）为65%。
接受根治性切除（切缘阴性）的GBC患者，随后接受辅助EBRT加5-氟尿嘧啶化疗，预后相对较好，5年生存率为64%。这些结果似乎优于梅奥诊所和其他机构的历史手术对照，后者报告单纯根治性切除的5年生存率约为33%。肿瘤分期和切除范围似乎都影响生存和局部控制。需要采用更积极的当前癌症治疗措施并整合新的癌症治疗模式，以改善IV期或次全切除GBC患者的不良预后。鉴于大多数GBC患者就诊时已处于晚期疾病状态，有必要进行进一步研究以实现更早诊断。
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