Computed Tomography-Based Interstitial Brachytherapy for Recurrent Cervical Carcinoma in the Vaginal Apex.

AIMS: To determine the factors influencing the outcomes of patients with recurrences post-hysterectomy for cervical cancers treated with external beam radiotherapy (EBRT) and interstitial brachytherapy. MATERIALS AND METHODS: This prospective study accrued 90 patients between October 2008 and May 2014. All patients had had a prior hysterectomy and were diagnosed with recurrent vaginal apex cancers with squamous cell carcinomas. All underwent EBRT of 50 Gy (2 Gy/fraction) using tomotherapy-based image-guided intensity-modulated radiotherapy with concurrent chemotherapy of weekly cisplatin (40 mg/m2) followed by high dose rate interstitial brachytherapy boost of 20 Gy (4 Gy/fraction twice a day). Local relapse, disease-free and overall survival were determined. RESULTS: At a median follow-up of 74 months (4-123 months), 10/90 (11%) patients had local failure as the first site of relapse and 12/90 (13.3%) had first distant relapse. Only one patient had synchronous local and distant relapse. The 7-year local relapse-free, disease-free and overall survival were 87.6, 68.3 and 68.3%, respectively. Grade 2 and 3 rectal toxicity were seen in 5.6 and 3.1% of patients, respectively. Among these, two (2.2%) patients underwent temporary diversion colostomy due to vaginal sigmoid and rectovaginal fistula. Grade 2 and 3 bladder toxicity were seen in 5.6 and 1.1% of patients, respectively. In summary, the lateral disease extent (P = 0.048) and the presence of nodal disease at diagnosis (P = 0.08) had a statistically significant or borderline impact on local relapse without any impact on disease-free survival. Tumour size in itself did not affect overall survival. CONCLUSION: With the integration of EBRT and interstitial brachytherapy, most vaginal apex recurrences can be salvaged. An excellent local control and survival is achievable using intensity-modulated radiotherapy with image guidance and concurrent chemotherapy followed by high dose rate interstitial brachytherapy.

Minimally invasive versus open pelvic exenterations for rectal cancer: a comparative analysis of perioperative and 3-year oncological outcomes.

BACKGROUND: This study compared the surgical and oncological outcomes of open and minimally invasive pelvic exenteration. METHODS: Patients who underwent pelvic exenterations for primary locally advanced rectal cancers with invasion of the urogenital organs (central and anterior disease) between August 2013 and September 2020 were reviewed retrospectively. Patients were categorized as undergoing open or minimally invasive surgery (MIS) and these groups were compared for perioperative outcomes and 3-year survival (overall, recurrence-free and local relapse-free survival). Multivariable Cox regression analysis was performed to assess the independent influence of approach of surgery and cancer features on recurrence-free survival (RFS). RESULTS: Of the 158 patients who underwent pelvic exenteration, 97 (61.4 per cent) had open exenterations and 61 (38.6 per cent) patients had an MIS resection (44 patients (72 per cent) using laparoscopy and 17 (28 per cent) using robotic surgery). There were 96 (60.8 per cent) total pelvic exenterations and 62 (39.2 per cent) posterior pelvic exenterations. MIS exenterations had significantly longer operative times (MIS versus open: 640 mins versus 450 mins; P < 0.001) but reduced blood loss (MIS versus open: 900 ml versus 1600 ml; P < 0.001) and abdominal wound infections (MIS versus open: 8.2 versus 17.5 per cent; P = 0.020) without a difference in hospital stay (MIS versus open: 11 versus 12 days; P = 0.620). R0 resection rates and involvement of circumferential resection margins were similar (MIS versus open: 88.5 versus 91.8 per cent, P = 0.490 and 13.1 versus 8.2 per cent, P = 0.342 respectively). At a median follow-up of 29 months, there were no differences in 3-year overall survival (MIS versus open: 79.4 versus 60.2 per cent; P = 0.251), RFS (MIS versus open: 51.9 versus 47.8 per cent; P = 0.922) or local relapse-free survival (MIS versus open: 89.7 versus 75.2 per cent; P = 0.491. On multivariable analysis, approach to surgery had no bearing on RFS, and only known distant metastasis, aggressive histology and inadequate response to neoadjuvant radiation (pathological tumour regression grade greater than 3) predicted worse RFS. CONCLUSION: MIS exenterations documented longer procedures but resulted in less blood loss and fewer wound infections compared with open surgeries. In the setting of an experienced centre, the hospital stay, R0 resection rates and oncological outcomes at 3 years were similar to those of open exenterations.

Outcomes of Definitive Treatment of Signet Ring Cell Carcinoma of the Rectum: Is Minimal Invasive Surgery Detrimental in Signet Ring Rectal Cancers?

The outcome of surgery for signet ring adenocarcinoma of rectum is suboptimal with high predilection for locoregional and peritoneal metastases. Lack of intercellular adhesion due to focal loss of epithelial cell adhesion molecule (EpCAM) may account for this. In such patients, whether minimal invasive surgery carries a high risk of dissemination by pneumoperitoneum and tumor implantation remains uncertain. The aim of this study was to compare the outcomes of patients undergoing minimally invasive surgery (MIS) versus open surgery in patients with signet ring cell adenocarcinoma of rectum. A retrospective study was conducted at a tertiary care center over 3 years on 39 patients undergoing open surgery and 40 patients undergoing MIS diagnosed with signet ring cell carcinoma (SRCC) identified from our surgical database. Patient characteristics in terms of demographics, clinicoradiological staging, neoadjuvant therapy, and type of surgery with morbidity were compared in the two groups. Data on patients undergoing adjuvant therapy and 3 years disease-free survival (DFS) and overall survival (OS) were analyzed. Recurrence patterns in both groups were separately identified as locoregional, peritoneal, or systemic. The number of patients undergoing surgery in the two arms was 40 (MIS) and 39 (open). In the MIS arm, mean DFS was 29 months whereas in the open arm, it was 25.8 months. The mean OS was 33.65 months for the MIS arm and that for the open arm was 36.34 months. This retrospective study reveals no significant difference in outcomes of surgery for signet ring cell rectal cancers with either MIS or open approach.

Can Post-Treatment MRI Features Predict Pathological Circumferential Resection Margin (pCRM) Involvement in Low Rectal Tumors.

The MERCURY II study demonstrated the use of MRI-based risk factors such as extramural venous invasion (EMVI), tumor location, and circumferential resection margin (CRM) involvement to preoperatively predict pCRM (pathological CRM) outcomes for lower rectal tumors in a mixed group of upfront operated patients and patients who received neoadjuvant treatment. We aim to study the applicability of results of MERCURY II study in a homogeneous cohort of patients who received neoadjuvant chemoradiation (NACTRT) prior to surgery. After Institutional Review Board approval, post NACTRT restaging MRI of 132 patients operated for low rectal cancer between 2014 and 2018 were retrospectively reviewed by two radiologists for site of tumor, EMVI status, distance from anal verge (< 4 or > 4 cm), and mrCRM positivity. Findings were compared with post surgery pCRM outcomes using Fisher's exact test. Only 9/132(7%) patients showed pCRM involvement on histopathology, 8 of them being CRM positive on MRI (p = 0.01). The positive predictive value (PPV) of mrCRM positive status and pCRM status was 12.7% (95% CI: 9.7-16.5%), while the negative predictive value was 98.5% (95% CI: 91.4-99.8%) (p = 0.01). EMVI positive and anteriorly located tumors showed higher incidence of pCRM positivity but were not found to be significant (15% vs 5.2% and p = 0.13 and 8.6% vs 2.1% and p = 0.28, respectively). Unsafe mrCRM was the only factor significantly associated with pCRM positivity on post neoadjuvant restaging MRI. Tumors less than 4 cm from anal verge, anterior tumor location, and mrEMVI positivity did not show statistically significant results to predict pCRM involvement.

A Retrospective Study of the Dosimetric Parameters and Duodenal Toxicity in Patients With Upper Gastrointestinal and Gynaecological Cancers Treated With Radiation Therapy.

AIMS: The duodenum is a critical organ at risk while planning radiation for gastrointestinal cancers or para-aortic nodes from gynaecological cancers due to the close proximity to the target volumes. The aim of this study was to assess the dosimetric parameters of the duodenum received during radiotherapy to upper gastrointestinal and gynaecological malignancies and their correlation with clinical toxicity. MATERIALS AND METHODS: All adult patients who were treated with radiotherapy for primary upper gastrointestinal cancers (liver, stomach, pancreas, gall bladder) and patients with gynaecological cancers who were treated with extended fields in view of para-aortic nodal involvement from 1 January 2010 to 31 July 2015 were considered for the study. The radiation dose prescription was 45 Gy to the elective clinical target volume and 52.5-60 Gy to the gross nodal volume. The planning computed tomography scan was retrieved and the dose-volume histogram parameters for the duodenum were extracted. The relative volumes of duodenum receiving a dose from 40 to 55 Gy in increments of 5 Gy (V40Gy, V45Gy, V50Gy, V55Gy) were also noted. RESULTS: Of the 258 patients assessed, 30 patients (12.1%) were detected to have grade 2-4 toxicities related to the duodenum as detected on endoscopy. Most had grade 3 toxicity - 18 patients were diagnosed with grade 3 toxicity and four patients had grade 4 toxicity. The most common toxicity noted was duodenal ulceration seen in 16 patients. The other toxicities were duodenal stricture in eight patients, duodenal perforation in five patients and one patient was reported to have duodenal fistula. The patients with duodenum receiving V55Gy ≥ 1 cm3 (7.7% versus 3.8%, P = 0.014) and V50Gy ≥ 4 cm3 (7.7% versus 3.8%, P = 0.014) had higher grade ≥2 duodenal toxicity. CONCLUSION: A threshold level of V55Gy ≥ 1 cm3 and V50Gy ≥ 4 cm3 for the duodenum is predictive of clinically significant grade 2 and higher toxicity and could serve as valid dose constraints for the duodenum.

Clinical Utility of Staging Laparoscopy for Advanced Obstructing Rectal Adenocarcinoma: Emerging Tool.

The multimodal treatment for advanced rectal adenocarcinoma mandates accurate preoperative staging with contrast-enhanced computed tomography (CECT) of the thorax, abdomen, and pelvis, and magnetic resonance imaging (MRI) of the pelvis. Unlike gastric cancer, the role of staging laparoscopy (SL) in advanced colorectal cancer has not been evaluated. This study aims to evaluate the clinical value of SL in treatment decision-making for advanced rectal cancer (RC) with near or complete obstructing tumors. Observational review of colorectal database at Tata Memorial Hospital from January 2013 to December 2016 identified 562 patients diagnosed and treated for advanced RC. Of the 562 cases, 48.7% (274) were clinically and radiologically diagnosed of near or complete obstructing advanced RC. Medical records of 34% (94/274) who underwent SL with diversion stoma (DS) were analyzed. In the absence of ascites, extensive peritoneal deposits, and unresectable liver metastases on SL, a curative treatment was offered, which entailed neoadjuvant chemoradiation (NACTRT), whereas the cohort of patients with extensive peritoneal disease received palliative therapy. Of the 94 patients with advanced RC, conventional imaging studies staged 73.5% (69/94) cohort as non-metastatic locally advanced and 26.5% (25/94) had potentially resectable metastatic RC. Pre-therapeutic SL upstaged the disease by 26% (18/69) and 8% (2/25) in locally advanced and potentially resectable metastatic RC cohorts, respectively. Treatment decision changed in 21.2% (20/94) of the patients, and midline laparotomy was thus avoided. In our observational study, SL was found to be a safe and effective staging modality in RC; it detected occult peritoneal disease and prevented midline laparotomy in 21.2% of the cohort, which was of value to determine treatment strategy in patients with advanced RC before initiating NACTRT. SL and laparoscopic-assisted de-functioning stoma were associated with minimal morbidity and led to early initiation of NACTRT.

Persistent involvement of anterior mesorectal fascia in carcinoma rectum - extended resection of rectum vs total pelvic exenteration: results from a single-centre retrospective study.

AIM: Involvement of the anterior mesorectal fascia (iAMRF) after neoadjuvant treatment leads to either resection of the involved organ alone [extended resection of the rectum (ERR)] or total pelvic exenteration (TPE). The purpose of this study was to compare the rate of recurrence and survival of patients undergoing ERR or TPE for iAMRF after neoadjuvant treatment. The outcome of patients who underwent total mesorectal excision after downstaging was also compared. METHOD: This was a retrospective study of primary rectal cancer patients. RESULTS: Of 237 patients, 61 (21.5%) patients with nonmetastatic carcinoma rectum had iAMRF at baseline. Ten patients defaulted before completion of neoadjuvant chemoradiotherapy. After neoadjuvant chemoradiotherapy, 22 patients (43.1%) developed systemic metastases, seven patients (13.8%) were downstaged to free anterior mesorectal fascia and underwent total mesorectal excision (anterior resection/abdominoperineal resection) and the remaining 22 patients (43.1%) had persistent iAMRF. Thirteen patients with persistent iAMRF underwent ERR, whereas nine patients underwent TPE. The median duration of hospital stay in the TPE group was 13 days (10-26), whereas it was 7 days (5-21) in the ERR group. A clear circumferential resection margin, R0 resection, was achieved in all patients with TPE and ERR. After a median follow-up of 31.6 months, five patients with TPE (55.6%), four patients with ERR (30.7%) and three patients in the downstaged group (42.9%) developed systemic recurrence. None of the patients with TPE and the downstaged group developed local recurrence, whereas three patients with ERR (23.1%) developed local recurrence. Median disease-free survival was 12.3 months in the TPE group, 18.9 months in the ERR group and 10.6 months in the downstaged group, whereas mean overall survival was 36.2, 32.8 and 27.9 months, respectively. CONCLUSION: Although there is no significant difference in the overall survival and disease-free survival, ERR is associated with a high risk of local recurrence compared to TPE and the downstaged group.

Carcinoembryonic antigen directed PET-CECT scanning for postoperative surveillance of colorectal cancer.

AIM: During the follow-up of surgically resected colorectal cancer (CRC), positron emission tomography-contrast-enhanced computed tomography (PET-CECT) is indicated for asymptomatic elevation of carcinoembryonic antigen (CEA) > 5 ng/ml and no obvious site of recurrence on clinical examination and basic imaging. As an institutional policy, a PET-CECT scan was performed at our institute whenever (1) CEA levels rose above 5 ng/ml and (2) CEA values were doubled (even if the CEA level was < 5 ng/ml). Our aim was to correlate the range of CEA elevation with recurrence rates and to evaluate the diagnostic utility of PET-CECT scanning in this setting. METHOD: We retrospectively analysed all cases where a PET-CECT scan was performed for elevated CEA levels during surveillance visits after complete resection of the primary tumour followed by adjuvant therapy. This study was conducted from 1 January 2013 to 31 July 2015. RESULTS: In all, 104 patients underwent a PET-CECT scan for rising CEA values, and 62 patients (59.6%) were found to have recurrent disease. At CEA levels < 5, 5.1-10, 10.1-15, 15.1-50 and > 50 ng/ml, disease recurred in 10%, 45%, 70%, 94% and 100% patients, respectively. Sensitivity, specificity, positive predictive value and negative predictive value of the PET-CECT scan were 92.7%, 95.2%, 96.2% and 90.9%, respectively. Elevation of CEA levels during follow-up was indicative of recurrence in 68% of the secretors and 45% of the non-secretors (based on baseline CEA status). CONCLUSION: In the setting of rising CEA levels during follow-up of patients with CRC, a PET-CECT scan is a valuable tool to detect recurrence, irrespective of the baseline CEA secretor status. The likelihood of recurrence of disease was directly proportional to the value of the raised CEA level.

High nodal positivity rates even in good clinical responders after chemoradiation of rectal cancer: is organ preservation feasible?

AIM: Local excision (LE) is emerging as a treatment option for rectal cancer responding well to chemoradiation. However, it does not address the mesorectal nodal burden. We aimed to identify the factors influencing nodal positivity and subsequently defined a low-risk group by including only patients at low risk. METHOD: A single-centre, retrospective database analysis was carried out of patients with radically resected rectal cancer after neoadjuvant chemoradiation. RESULTS: This study included 524 patients with predominantly low rectal tumours. Nodal positivity among ypT0, T1 and T2 groups was 14.7%, 28% and 30%, respectively. Multivariate analysis with stepwise logistic regression identified the following low-risk features: age ≥ 40 years, nonsignet ring cell carcinoma (SRCC) histology and pathological complete response (pCR). Sixty-nine patients fulfilling all three criteria were analysed and the nodal positivity was found to be 10.1%, which implies that, if these patients had been selected for LE, one in 10 would have had positive mesorectal nodes. CONCLUSION: Even in patients with low-risk criteria (pCR, non-SRCC histology and age ≥ 40 years), the residual positive nodal disease burden is 10%. Whether this high incidence of residual nodal disease translates into a similar risk of locoregional recurrence if an organ-preservation strategy is adopted is unclear.

Multidisciplinary management of colorectal adenocarcinoma associated with anal fistula: an Indian series.

AIM: Adenocarcinomas associated with anal fistula are rare and often present at an advanced stage. They are often mistaken for commonly occurring benign diseases, leading to delayed diagnosis. Previous reports have predicted inferior oncological outcomes for these cases compared with sporadic rectal cancers. We are presenting our series of patients with colorectal adenocarcinoma associated with anal fistula who were treated with multimodality therapy at a tertiary cancer centre in India. METHOD: This was a retrospective review of a prospectively maintained database of patients treated at our centre between 1 July 2013 and 31 March 2015. Of the 15 patients included in the study, 11 had prior intervention in the form of seton placement or fistulotomy. Fourteen patients had circumferential resection margin (CRM) involvement at initial workup and hence were given neoadjuvant chemoradiotherapy (NACRT). None of the patients had distant metastasis and only 15% had regional nodal involvement. RESULTS: All 13 patients included in the final analysis underwent abdominoperineal excision (APE). Ten patients (73%) underwent extralevator APE. Plastic reconstruction in the form of a V-Y advancement flap for perineal closure was required in six patients (46%). On histopathological examination, a mucinous component was found to be present in 11 patients (73%). The quality of total mesorectal excision was complete in 92% patients. The CRM was free in 92% of patients. Median overall survival and disease-free survival were not reached. CONCLUSION: Colorectal adenocarcinomas associated with fistula are locally aggressive malignancies with a low incidence of lymph node involvement and distant metastasis. NACRT, wider resection in the form of extralevator APE, and liberal use of plastic reconstruction may result in favourable outcomes.

Vaginal displacement during course of adjuvant radiation for cervical cancer: results from a prospective IG-IMRT study.

OBJECTIVE: To compare internal target volume (ITV) generated using population-based displacements (ITV_study) with empty and full bladder scan fusion (ITV_EBFB) for organ-at-risk (OAR) doses during adjuvant intensity-modulated radiation therapy (IMRT) for cervical cancer. METHODS: From January 2011 to October 2012, patients undergoing IMRT were included. CT simulation was carried out after inserting vault markers. Planning target volume (PTV)_EBFB received 50 Gy per 25 fractions. Pre-treatment megavoltage CT (MVCT) was performed. MVCTs were registered using bony landmarks with Day 1 MVCT. Displacement of the centre of mass of markers was measured along each axis. Directional ITV was calculated using mean ± 2 standard deviations (SDs) (ITV_study). Replanning was performed using PTV study, and OAR doses were compared with PTV_EBFB using Wilcoxon test. RESULTS: A total of 348/386 data sets were evaluable for 16 patients. The median vaginal displacement was 1.2 mm (SD, 1.3 mm), 4.0 mm (SD, 3.5 mm) and 2.8 mm (SD, 3.3 mm) in the mediolateral, superoinferior and anteroposterior directions, respectively. The ITV margins were 4.1, 10.3 and 10.6 mm. ITV_study and ITV_EBFB were 115.2 cm(3) (87.7-152.2 cm(3)) and 151 cm(3) (95.7-277.1 cm(3)) (p < 0.0001), respectively. PTV_study and PTV_EBFB were 814 and 881 cm(3) (p < 0.0001), respectively. Median doses to the bladder were lower with the PTV_study (46.2 Gy vs 43.2 Gy; p = 0.0001), and a similar trend was observed in the volume of the small bowel receiving 40 Gy (68.2 vs 60.1 cm(3); p = 0.09). CONCLUSION: Population-based PTV margins can lead to reduction in OAR doses. ADVANCES IN KNOWLEDGE: Population-based ITV may reduce OAR doses while executing adjuvant IMRT for cervical cancer.

Evaluation of internal target volume in patients undergoing image-guided intensity modulated adjuvant radiation for gastric cancers.

OBJECTIVE: To evaluate three-dimensional (3D) displacements of gastric remnant during adjuvant radiation. METHODS: From January 2011 to September 2012, patients undergoing adjuvant image-guided intensity-modulated radiation on tomotherapy were included. Megavoltage CT (MVCT) data sets from daily treatment were coregistered with Day 1 MVCT. Residual stomach remnant was delineated on the data set, while the remaining were blinded to previous day contours. Gastric volume and centre of mass (COM) were determined for all data sets. The 3D deviation of COM was calculated for each fraction. Mean 3D and standard deviation (SD) were calculated for each patient and study population, and a 95% confidence interval (CI) was determined. Also, systematic and random errors for patient population and internal target volume (ITV) margin were calculated using the van Herk formula. RESULTS: There were 119 images available for 15 patients. Mean volume of remnant was 319 cm(3) (146-454 cm(3)). Gastric remnant expanded in different directions with no specific directional expansion. Average deviations in mediolateral, superoinferior and anteroposterior directions were 9 mm (3-25 mm; SD, 5 mm), 6 mm (3-16 mm; SD, 4 mm) and 5 mm (1-10 mm; SD, 3 mm), respectively, with 95% CI of 18, 15 and 11 mm, and ITV margins of 19.2, 13.5 and 7.8 mm, respectively. CONCLUSION: There is large variation in gastric remnant volume during the course of radiation. Large displacements observed in the present study necessitate the need to investigate adaptive techniques for optimizing intensity-modulated radiotherapy (IMRT) delivery. ADVANCES IN KNOWLEDGE: An adaptive strategy needs to be developed to optimize IMRT delivery for adjuvant gastric irradiation.

From two-dimensional to three-dimensional conformal radiotherapy in prostate cancer: an Indian experience.

BACKGROUND: Sparse data from India are available regarding the outcome of prostate cancer treatment. We report our experience in treating prostate cancer with radiotherapy (RT). MATERIALS AND METHODS: This study included 159 men with locally advanced cancer treated with RT with or without hormone therapy between 1984 and 2004. The median RT dose was 70 Gy over 35 fractions. Eighty-five patients received whole pelvic RT and prostate boost, and 74 patients were treated with 3-dimensional conformal radiotherapy (3DCRT) to prostate and seminal vesicles alone. RESULTS: The median follow-up was 25 months and the freedom from biochemical failure for all the patients at 5 years was 76%, disease-free survival (DFS) 59.1%, and overall survival (OAS) was 70.1%. The risk stratification (91% vs 52%, P < 0.03) and RT dose (72.8% for dose > 66 Gy vs 43.5% for dose < 66 Gy; P = 0.01) affected the DFS. DFS at 5 years was better in the group receiving 3DCRT to prostate and seminal vesicles (78% vs 51.5%; P = 0.001) and was reflected in OAS as well (P = 0.01). CONCLUSION: CRT technique with dose escalation results in significant benefit in DFS and OAS in locally advanced prostate cancer.

Adjuvant radiation therapy in gall bladder cancers: 10 years experience at Tata Memorial Hospital.

INTRODUCTION AND PURPOSE: In gall bladder cancers, even after curative surgery, survivals are dismal and loco-regional failure accounts for 40-86%. Although these are considered radio-resistant, adjuvant radiation, with or without chemotherapy, has been tried to improve loco-regional control and overall survival rates. With an aim to evaluate the natural history of gall bladder cancers, role of radiation therapy (RT) and prognostication, a retrospective analysis was undertaken. MATERIALS AND METHODS: Between 1991-2000, 60 patients with gall bladder cancer, treated with radical intent, were evaluated. Patients details including history, physical examination, liver function tests, ultrasonography of the abdomen and chest X-ray; and CT scan Abdomen if done, were noted. In patients who underwent surgery, surgical details, histopathology and pathological staging, were recorded. The details of post-operative adjuvant treatment, including radiation therapy details, as well as chemotherapeutic agents, number of cycles and type of infusion [bolus/infusion], were noted. RESULTS: Sixty patients underwent surgery. On histopathological staging, 28 patients (46.5%) had stage II, 19 (32%) had stage III, 12 (20%) had stage-I and 1 patient had stage IV disease. Thirteen (21%) patents did not receive any adjuvant treatment, 32 (53%) patients received adjuvant RT alone, 8(14%) received post-operative CT+RT and 7 (12%) patients received CT alone. With a median follow-up of 18 months (12-124 months), 27 (45%) patients were disease free, 11 (19%) had local failures, 7 (11%) had loco-regional, 7 (11%) loco-regional+distant, 4 (7%) distant and 4 (7%) patients had local+distant failures. The Overall Disease Free Survival (DFS) and overall survival was 30% and 25%, at 5 years, respectively. Stage grouping ('P' = 0.007), Pathological T ('P' = 0.01) had significant impact on DFS on univariate analysis, where as histological grade ('P' = 0.06) showed trend towards significance. CONCLUSION: Gall bladder cancers are aggressive and lethal. Early diagnosis and curative surgery, followed by appropriate adjuvant radiation therapy, may improve survivals, with no established consensus till date. Following curative surgery, pathological T stage and stage grouping, are the significant prognostic factors for outcome.