Guidelines for adjuvant therapy in Gall Bladder and Bile duct carcinomas

Biliary tract cancers are rare cancers that arise from epithelial lining of gallbladder and bile ducts. Gallbladder cancer (GBC) is the most common cancer of the biliary tract and accounts for two thirds of the cases, whereas bile duct cancer accounts for the remaining one-third. Although anatomically these malignancies are related and have similar metastatic patterns, each has a distinct clinical presentation, molecular pathology, and prognosis. Radical surgery offers the only chance of cure, given their proximity to the complex anatomy of porta hepatis, only one third of cases at presentation are resectable, after radical resection relapse is often very frequent. Pattern of recurrence is typically local, although first relapse at a distant site is not uncommon. With high rates of relapse, strategy aimed at optimizing local control with postoperative radiation alone or in combination with chemotherapy or optimizing systemic recurrence with chemotherapy have potential to improve treatment outcomes. Evidence for use of adjuvant therapy for these rare tumors is fragmentary and has not been evaluated in prospective randomised controlled trials. On basis of uncontrolled institutional series and registry analyses adjuvant approach is favoured and used in up to 70% of centres worldwide.  However there is lack of consensus regarding optimal use of post operative therapy, in the present article we review and present pertinent data for use of adjuvant radiotherapy, chemo-radiotherapy and chemotherapy for intrahepatic, extrahepatic cholangiocarcinomas and carcinoma of the gall bladder and propose guidelines for use of adjuvant therapy based upon retrospective data.