From the Guidelines
Treatment for T4 gallbladder cancer should primarily involve systemic chemotherapy with gemcitabine combined with cisplatin as the first-line regimen, given the advanced stage and poor prognosis of this disease. This approach is based on the most recent and highest quality evidence available, which demonstrates a clear survival advantage for the combination of gemcitabine and cisplatin in patients with advanced or metastatic biliary tract cancer, as shown in the study by 1.
Key Considerations
- The prognosis for T4 gallbladder cancer remains poor, with 5-year survival rates generally below 5% 1.
- Surgical resection may be considered when possible, but many T4 tumors are unresectable due to extensive invasion.
- Alternative chemotherapy regimens may include gemcitabine with oxaliplatin or 5-fluorouracil-based combinations, as discussed in 1 and 1.
- Radiation therapy might be added for local control or palliative purposes, with options including concurrent chemoradiation and high radiation doses delivered by brachytherapy boost using iridium-192, as mentioned in 1.
Management Approach
- Systemic chemotherapy with gemcitabine and cisplatin should be the primary treatment approach, with administration intravenously every 3 weeks for multiple cycles.
- Palliative care is an essential component of management to address symptoms and improve quality of life.
- Clinical trials investigating targeted therapies or immunotherapies may be considered for eligible patients who have progressed on standard treatments.
- Evaluation of the patient should include magnetic resonance cholangiopancreatography (MRCP) and laparoscopy, as well as biliary drainage for jaundice before instituting chemotherapy, as recommended in 1.
From the Research
T4 Gallbladder Cancer Treatment
- T4 gallbladder cancer is a advanced stage of the disease, and treatment options are limited 2.
- Surgery is the only curative option for early-stage gallbladder cancer, but only 10% of patients are primarily eligible for curative treatment 3.
- For T4 tumors, a more aggressive surgical approach, including resection of the gallbladder, liver, and regional lymph nodes, is advisable 2.
- However, patients with advanced tumors or metastatic disease are not candidates for radical resection and thus should be directed to more suitable palliation 2.
Adjuvant Therapy
- Adjuvant therapy, including radiotherapy, chemotherapy, and systemic chemotherapy, may play a role in improving survival for resected gallbladder cancer patients 4.
- Capecitabine is a standard treatment option for biliary tract cancers, including gallbladder cancer, and is often used as adjuvant therapy 4, 5.
- Current standard of care for adjuvant therapy includes 6 months of oral capecitabine 5.
Palliative Chemotherapy
- For advanced-stage gallbladder cancer, palliative chemotherapy with gemcitabine and cisplatin is the current standard of care 3, 6, 5.
- After the failure of gemcitabine and cisplatin, FOLFOX (5-FU/folinic acid and oxaliplatin) is a recommended chemotherapy regimen 3.
- Recent advances with the PD-L1 inhibitor durvalumab have opened up the therapy landscape for immune checkpoint inhibition in gallbladder cancer 3.