Department of Radiotherapy, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, 226014, India.
J Gastrointest Cancer. 2024 Oct 19;56(1):7. doi: 10.1007/s12029-024-01124-5.
Retroperitoneal lymphadenopathy is considered a metastatic disease in GBC; however, some surgical series of radical surgery with enlarged RPLN who underwent RPLN dissection have shown results marginally inferior to those without enlarged RPLN. Radiological RPLN comprises a major proportion of advanced non-metastatic GBC. There is dilemma in the intent of treatment to be offered in such cases. We are reporting our series of outcome of GBC with RPLN treated with first-line CT followed by consolidation CTRT.
Non-metastatic locally advanced GBC with good performance status (KPS ≥ 80) were initiated on first-line CT (cisplatin-gemcitabine), and thereafter, responders were evaluated by CECT-angiography and PET-CT scan for resectability. If found unresectable, they were offered consolidation CTRT to a dose of 45 Gy by conventional fractionation (3D-CRT technique) along with concurrent capecitabine at 1250 mg/m to GBC and regional lymphatics including RPLN. Thereafter, boost dose of 9 Gy/5# was given to GBC only. Response assessment was done using CECT abdomen by RECIST criteria v 1.1. Outcomes (overall survival) of the two groups (RPLN vs non-RPLN) were computed with Kaplan-Meier survival curves and chi-square tests using SPSS v 20.
Among 189 patients of advanced non-metastatic GBC recruited from 2011 to 2022, 80 had RPLN. The demographic features of both groups were comparable. Overall, 68% of the patients were women, 30% underwent upfront stenting for obstructive jaundice, and 90% had T3 and T4 disease. Only 10% had undergone upfront laparoscopic staging and had pathologically proven RPLN. Forty percent of the patients received four cycles of CT only and 50% of the patients received six cycles or more and 33% received CTRT. By RECIST criteria, 10% vs 16% achieved complete response (CR), 39% vs 41% achieved partial response (PR), 16% vs 15% achieved stable disease (SD), 2.7% vs 6% had disease progression (PD), and 14.5% vs 3.7% were non-evaluable in non-RPLN group vs RPLN group, respectively. 12% vs 6% could undergo radical surgery in non-RPLN group vs RPLN group (p = 0.03). The median OS was 9 months (95% CI 7.6-10.3 months) vs 10 months (95% CI 8-9.8 months) (p = NS) in non-RPLN group vs RPLN group, respectively. In those who received CT only, the median OS was 7 months vs 8 months, while in those who received CT followed by CTRT, the median OS was 14 months vs 13 months (p = 0.65) in non-RPLN group vs RPLN group, respectively.
Based on this analysis, we conclude that RPLN constitutes a major proportion of advanced non-metastatic GBC and has outcomes similar to those without RPLN if treated with radical intent. RPLN should not be considered a metastatic disease and should be treated with radical intent.
腹膜后淋巴结病被认为是 GBC 的转移性疾病；然而，一些接受根治性手术且扩大的 RPLN 行 RPLN 解剖的手术系列显示，结果略逊于无扩大 RPLN 的患者。放射学上的 RPLN 构成了晚期非转移性 GBC 的主要部分。在这种情况下，治疗意图存在困境。我们报告了我们的一系列结果，即接受一线 CT 治疗后再行巩固性 CTRT 的 RPLN 治疗的 GBC。
无转移的局部晚期 GBC 患者一般情况良好（KPS≥80），接受一线 CT（顺铂-吉西他滨）治疗，然后通过 CECT-血管造影和 PET-CT 扫描评估应答者的可切除性。如果发现不可切除，他们将接受巩固性 CTRT，剂量为 45 Gy，采用常规分割（3D-CRT 技术），同时卡培他滨 1250 mg/m2 用于 GBC 和包括 RPLN 在内的区域淋巴结。此后，仅对 GBC 给予 9 Gy/5# 的推量。使用 RECIST 标准 v 1.1 通过 CECT 腹部评估反应。使用 Kaplan-Meier 生存曲线和 SPSS v 20 中的卡方检验计算两组（RPLN 与非 RPLN）的生存结果（总生存）。
2011 年至 2022 年间共招募了 189 例晚期非转移性 GBC 患者，其中 80 例有 RPLN。两组患者的人口统计学特征无差异。总体而言，68%的患者为女性，30%因阻塞性黄疸而行支架置入术，90%为 T3 和 T4 期疾病。只有 10%的患者接受了腹腔镜分期手术，并经病理证实有 RPLN。40%的患者仅接受了四个周期的 CT 治疗，50%的患者接受了六个周期或更多的治疗，33%的患者接受了 CTRT。根据 RECIST 标准，10%与 16%的患者达到完全缓解（CR），39%与 41%的患者达到部分缓解（PR），16%与 15%的患者达到疾病稳定（SD），2.7%与 6%的患者出现疾病进展（PD），14.5%与 3.7%的患者在非 RPLN 组与 RPLN 组分别无法评估。非 RPLN 组与 RPLN 组中分别有 12%与 6%的患者可接受根治性手术（p=0.03）。非 RPLN 组与 RPLN 组的中位 OS 分别为 9 个月（95%CI 7.6-10.3 个月）与 10 个月（95%CI 8-9.8 个月）（p=NS）。仅接受 CT 治疗的患者中位 OS 为 7 个月，而接受 CT 后再行 CTRT 的患者中位 OS 为 14 个月与 13 个月（p=0.65），分别在非 RPLN 组与 RPLN 组。
基于这项分析，我们得出结论，RPLN 构成了晚期非转移性 GBC 的主要部分，如果采用根治性意图治疗，其结果与无 RPLN 的患者相似。RPLN 不应被视为转移性疾病，应采用根治性意图进行治疗。
