Adjuvant Chemotherapy in Resectable Gallbladder Cancer is Underutilized Despite Benefits in Node-Positive Patients
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LETTER – HEPATOBILIARY TUMORS
Adjuvant Chemotherapy in Resectable Gallbladder Cancer is Underutilized Despite Benefits in Node-Positive Patients Yi-Lei Deng, MD, and Jian Li, MD Department of Hepatopancreatobiliary Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
To the Editor, We read with interest the recent publication by Kemp et al.1 which presents a retrospective, multi-institutional study of 5656 patients with resected pathologic stages 1–3 gallbladder cancer (GBC) conducted from 2006 to 2015. These researchers found that adjuvant chemotherapy likely improves survival in node-positive GBC, but its utility in the treatment of node-negative disease has not been demonstrated. The study is indeed an interesting one in the field, and we congratulate the authors for their clinically relevant contribution. However, several issues need further consideration and discussion. First, Kemp Bohan et al.1 thought adjuvant chemotherapy likely improves survival in node-positive GBC. Indeed, multiple studies have shown that chemotherapy offers benefits to patients with unresectable or metastatic bile duct cancer.2,3 Ghidini et al.4 systematically reviewed 30 studies representing nearly 22,500 patients, 4000 of whom received adjuvant chemotherapy after resection of biliary tract cancer (BTC). The authors found that adjuvant chemotherapy significantly improved survival (hazard ratio [HR], 0.59; 95% confidence interval [CI], 0.49–0.71; p \ 0.001). However, given the quality of the data (mostly from nonrandomized series) included in their analysis, the conclusion should be further confirmed.
Ó Society of Surgical Oncology 2020 First Received: 12 August 2020 Accepted: 27 August 2020 Y.-L. Deng, MD e-mail: [email protected]
The randomized PRODIGE trial (38 patients with gallbladder adenocarcinoma) found that gemcitabine and oxaliplatin (GEMOX) therapy had no benefit in terms of either relapse-free survival (p = 0.47) or overall survival (p = 0.74).5 However, because it included only 38 patients with GBC, this study was underpowered to determine any benefit in GBC. Recently, Ma et al.6 systematically reviewed five randomized studies representing 1192 patients, 125 of whom received adjuvant chemotherapy after resection of GBC. The authors found that adjuvant chemotherapy did not significantly improve the survival of resected GBC patients (HR, 1.06; 95% CI, 0.48–2.37; p = 0.88). Even the patients included in the systematic review of Ma et al.6 were significantly fewer than in the study of Kemp Bohan et al.1 The role of adjuvant chemotherapy in resected GBC needs to be confirmed by a well-designed, large-scale, randomized trial. Second, the authors thought that resected GBC patients with positive lymph nodes may benefit the most from adjuvant therapy. However, the previously reported metaanalysis by Ma et al.6 showed no statistically significant subgroup effect of resection margin status or lymph node status on the survival benefits of adjuvant therapy for resected BTC patients. Only t
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