J Gastrointest Canc (2014) 45 (Suppl 1):S270–S274 DOI 10.1007/s12029-014-9654-3
CASE REPORT
A Report of Sarcomatoid Carcinoma of the Gallbladder Treated with Palliative Deocetaxel and Gemcitabine Chemotherapy Dinesh Chandra Doval & Saud Azam & Anurag Mehta & Ankur Pruthi & Ullas Batra & Kumardeep Dutta Choudhury & Kapil Kumar
Published online: 19 October 2014 # Springer Science+Business Media New York 2014
Introduction Gallbladder carcinoma (GBC) is a disease common in the northern part of India, Chile, and Japan [1]. The commonest histological type of this neoplasm is adenocarcinoma, while sarcomatoid histology is rare [2]. There are a few reports available in the literature on sarcomatoid GBC where it was detected in a surgically resectable stage [3, 4]. The prognosis of this type of neoplasm is very poor [2]. We report a case of metastatic sarcomatoid carcinoma along with its outcome who received palliative deocetaxel and gemcitabine chemotherapy.
Case Report A 42-year-old female had history of pain in the upper abdomen of 3–4 months duration, right neck swelling of 2.5-month D. C. Doval (*) : U. Batra : K. D. Choudhury Department of Medical Oncology, Rajiv Gandhi Cancer Institute and Research Centre, Sector 5, Rohini, Delhi 110085, India e-mail: [email protected] D. C. Doval : S. Azam Department of Research, Rajiv Gandhi Cancer Institute and Research Centre, Sector 5, Rohini, Delhi 110085, India A. Mehta Department of Laboratory Services, Rajiv Gandhi Cancer Institute and Research Centre, Sector 5, Rohini, Delhi 110085, India A. Pruthi Department of Nuclear Medicine, Rajiv Gandhi Cancer Institute and Research Centre, Sector 5, Rohini, Delhi 110085, India K. Kumar Department of Surgical Oncology, Rajiv Gandhi Cancer Institute and Research Centre, Sector 5, Rohini, Delhi 110085, India
duration, and weight loss. She underwent diagnostic laparoscopy on 13 Dec 2011 which was suggestive of a gallbladder mass infiltrating the liver. She presented with these clinical details at our hospital on 19 Dec 2011. Physical examination of the abdomen was soft with physical scar of the laparoscopic surgery and staples. The serum levels of carcinoembryonic antigen (CEA, 0.69 ng/mL) and carbohydrate antigen 19–9 (CA 19–9, 8.34 U/mL) were within the normal reference range. Her hematological findings showed a hemoglobin level of 10.3 g/dL, leukocyte count 8,800/cumm, red blood cells 4.13 mil/cumm and platelets 415,000/cumm. Serum biochemistry revealed a glutamic-pyruvic transaminase (SGPT) level of 256 U/L, glutamic oxaloacetic transaminase (SGOT) 137 U/L, sodium 134 mEq/L, and uric acid 2.4 mg/dL. Other serum biochemical parameters are within the normal range. Review of PET-CT scan, done outside the hospital, showed a hypermetabolic soft tissue mass in gallbladder infiltrating adjacent liver parenchyma and a hypodense lesion in the right lobe of liver. Metabolically active lymphnodes were seen in bilateral supraclavicular, gastrohepatic, periportal, celiac, retropancreatic, right retrocrural, preaortic, left paraaortic, aortocaval, retrocaval, and mesenteric regions. Hyper metabolic soft tissue lesion was seen in the left shoulder and left gluteal regions. A metabolically active nodule was also noted in the right adrenal and head of femur (Figs. 1a, 2a, and 3a). Pathological examination of gallbladder biopsy, reviewed at our hospital, showed spindleshaped cells with abundant eosinophilic cytoplasm and central round hyperchromatic nuclei without any area of necrosis (Fig. 4a, b). On immunohistochemistry, tumor cells strongly and diffusely expressed vimentin (Fig. 4c). Moderate expression of cytokeratin was also seen (Fig. 4d). Tumor was negative for LCA and synaptophysin. The
J Gastrointest Canc (2014) 45 (Suppl 1):S270–S274
S271
Fig. 1 Staging PET-CT (column a) demonstrates hypermetabolic gallbladder mass infiltrating adjacent liver parenchyma, few liver lesions in the right lobe, and hypermetabolic enlarged retroperitoneal lymphnodes. Significant regression in size and metabolic activity in gall bladder mass in interim PET-CT study done post three cycles of palliative chemotherapy (column b) compared with staging PET-CT. PET-CT study done post
six cycles of chemotherapy (column c) showed no further response in gall bladder or liver lesions. However, ascites was a new development. Circular region of interest (ROI) drawn shows the standardized uptake values (SUV), which represents quantitative metabolic activity
pathologist’s final opinion was sarcomatoid carcinoma of the gallbladder. Her Eastern Cooperative Oncology Group (ECOG) performance status was 1. Advanced nature of disease, prognosis, and palliative nature of treatment were explained to the patient and husband. Keeping in view the metastatic and sacromatoid histology of the tumor, she was planned for palliative chemotherapy with injection (Inj) gemcitabine (900 mg/m2, days 1 and 8; Q3 weekly) and Inj docetaxel (100 mg/m2 day 8; Q3 weekly). Informed consent was obtained from the patients before the start of treatment. The chemotherapy was started on 29 Dec 2011. Inj zoledronic acid was added for bone metastasis along with each cycle. During the course of treatment on day 8 of cycle 2, she developed neutropenia which was managed with administration of granulocyte colony-stimulating factors. It was also used during subsequent cycles of treatment. After completion of three cycles of chemotherapy,
PET-CT scan was carried out for the response evaluation according to the Response Evaluation Criteria In Solid Tumor version 1.1 which showed gallbladder mass, soft tissue, right adrenal, lymphnodal, and bone lesions decreased in size as compared to the previous scan (Figs. 1b, 2b, and 3b). Overall, there was partial response (PR) to the treatment with metabolically active significant residual disease. In view of the PR to the treatment, she was continued with the same chemotherapy regimen. Patient developed chemo-port-associated deep vein thrombosis (DVT) post four cycles of chemotherapy for which the chemo-port was removed and DVT was managed with low molecular weight heparin. Fifteen days after the completion of the sixth cycle of chemotherapy, she came to the hospital with bilateral pedal edema, abdominal distention, vomiting, altered sensorium, and back pain. PET-CT scan was carried out post six cycles of treatment and, compared with earlier scans, showed
S272
J Gastrointest Canc (2014) 45 (Suppl 1):S270–S274
Fig. 2 Figure showing significant regression in size and metabolic activity in the right lobe of liver lesion in interim PET-CT study done post three cycles of palliative chemotherapy (column b) compared with staging PET-CT study (column a)
lymphnodal abnormalities which had increased in size and number with persistent metabolic activity. Liver lesions, gallbladder mass, and bony lesions were persistent without any significant change. Ascites and bilateral pleural effusion were new developments. Right adrenal lesion and soft tissue deposits in the left posterior chest were not noted (Figs. 1c, 2c, and 3c). Overall, it was a metabolically active progressive disease. One-time ascitic fluid aspiration was done and pathological examination was positive for the malignant cell. She was admitted for supportive treatment in the hospital. Her general condition deteriorated and she developed hypotension. Despite the best supportive care, patient succumbed to the illness and died in the hospital on 16 May 2012. She survived for 5 months from diagnosis.
Discussion The commonest histological subtype of GBC is adenocarcinoma. The sarcomatoid carcinoma is a rare diagnosis in
the clinical practice and was first reported by Landsteiner in the year 1907. Immunohistochemical analysis of the tumor is required to identify this tumor, since it contains the malignant epithelial as well as sarcomatous component both at the same time. It is not associated with the specific radiological imaging finding as well as tumor makers. The clinical presentation is usually the same as in the case of adenocacinoma. Surgical resection remains the mainstay treatment. There are no clinical trials or any other data available for the palliative systemic chemotherapy in the advanced sarcomatoid carcinoma of the gallbladder. However, a few reports are available for the adjuvant chemotherapy or chemoradiotherapy [3, 5, 6]. Surgically curative and palliative resections are the mainstay of treatment in the earlier reported cases [4, 7–9]. There are reports available for chemotherapy in sarcomatoid carcinoma which have shown good response as well as survival with docetaxel and gemcitabine chemotherapy [10, 11]. Therefore, in our case, gemcitabine and docetaxel doublet
J Gastrointest Canc (2014) 45 (Suppl 1):S270–S274
S273
Fig. 3 Figure showing significant regression in size and metabolic activity in retroperitoneal lymphnodes in interim PET-CT study done post three cycles of palliative chemotherapy (column b) compared with
staging PET-CT study (column a). PET-CT study done post six cycles of chemotherapy (column c) showed mild progression in lymphnodal lesions
chemotherapy was offered keeping in view of sarcomatoid histology and metastatic disease [12]. Treatment resulted in PR achieved post three cycles; however, patient progressed post six cycles of treatment. It could be noted that after six cycles, the primary tumor in the gallbladder and liver remained persistent without any significant change, but the progression was observed in the lymphnodes and other metastatic sites. The toxicities are neutropenia which can easily be managed by GCSFs. The patient responded well to the chemotherapy, however, progresses after the sixth cycle. She survived for 5 months from the diagnosis despite extensive nodal and metastatic disease. The prognosis of the sacomatoid carcinoma of the gallbladder has been poor. The patients usually presented with large tumor size with liver infiltration and lymphnodal disease. Survival of the patient is limited to a few months even after surgical resection. The 3-year overall survival rate was observed as 31 %
with a median survival of 7 months in the patients who underwent surgical resection [13]. Another study that had analyzed the survival of already-reported surgically resecated cases found median overall survival as 5.5 months [2]. There is no standard management of sarcomatoid GBC nor do any clinical trials exist. Almost all reported cases had undergone radical or palliative surgery, and there is lack of information for the survival of patients treated with palliative chemotherapy. The survival of advanced disease of gallbladder cancer remains poor, and in our case, it correlates well with the outcomes of the abovementioned studies even with palliative chemotherapy.
Conclusions Keeping in view the rarity of this tumor subtype, randomized studies are not feasible. In the advanced disease, there are very
S274
J Gastrointest Canc (2014) 45 (Suppl 1):S270–S274
Fig. 4 Representative hematoxyline and eosine staining of tumor tissue ×100, ×400 (a, b). Immunohistochemical positive staining for vimentin, ×200 (c), and cytokeratin, ×400 (d)
limited therapeutic interventions available and a combination of Deocetaxel and Gemcitabine could be beneficial to the patients. It could also be tried in the adjuvant settings with manageable toxicities.
Source of Funding/Support None Conflict of Interest None
References 1. Randi G, Malvezzi M, Levi F, Ferlay J, Negri E, Franceschi S, et al. Epidemiology of biliary tract cancers: an update. Ann Oncol. 2009;20:146–59. 2. Hu ZH, Li ZW, Shen L, Zhang M, Zheng SS. Surgical therapy and prognosis of sarcomatoid carcinoma of the gallbladder. Hepato-Biliary-Pancreat Dis Int. 2010;9:175–9. Desolate. 3. Pu JJ, Wu W. Gallbladder carcinosarcoma. BMJ Case Rep. 2011. 4. Park SB, Kim YH, Rho HL, Chae GB, Hong SK. Primary carcinosarcoma of the gallbladder. J Korean Surg Soc. 2012;82:54–8.
5. Liu KH, Yeh TS, Hwang TL, Jan YY, Chen MF. Surgical management of gallbladder sarcomatoid carcinoma. World J Gastroenterol. 2009;15:1876–9. 6. Zhang L, Chen Z, Fukuma M, Lee LY, Wu M. Prognostic significance of race and tumor size in carcinosarcoma of gallbladder: a meta-analysis of 68 cases. Int J Clin Exp Pathol. 2008;1:75–83. 7. Kataria K, Yadav R, Seenu V. Sarcomatoid carcinoma of the gall bladder. J Surg Case Rep. 2012; 5. 8. Kim MJ, Yu E, Ro JY. Sarcomatoid carcinoma of the gallbladder with a rhabdoid tumor component. Arch Pathol Lab Med. 2003;127: e406–8. 9. Oberoi R, Jena A, Tangri R, Sahria A. Carcinosarcoma of the gallbladder with chondroid differentiation: MRI findings. Ind J Radiol Imaging. 2006;16:491–3. 10. Maki RG, Wathen JK, Patel SR, et al. Randomized phase II study of gemcitabine and docetaxel compared with gemcitabine alone in patients with metastatic soft tissue sarcomas: results of sarcoma alliance for research through collaboration study 002. J Clin Oncol. 2007;25:2755–63. 11. Bay JO, Ray-Coquard I, Fayette J, et al. Docetaxel and gemcitabine combination in 133 advanced soft-tissue sarcomas: a retrospective analysis. Int J Cancer. 2006;119:706–11. 12. Maki RG. Gemcitabine and docetaxel in metastatic sarcoma: past, present, and future. Oncologist. 2007;12:999–1006. 13. Okabayashi T, Sun ZL, Montgomey RA, Hanazaki K. Surgical outcome of carcinosarcoma of the gall bladder: a review. World J Gastroenterol. 2009;15:4877–82.
CASE REPORT
A Report of Sarcomatoid Carcinoma of the Gallbladder Treated with Palliative Deocetaxel and Gemcitabine Chemotherapy Dinesh Chandra Doval & Saud Azam & Anurag Mehta & Ankur Pruthi & Ullas Batra & Kumardeep Dutta Choudhury & Kapil Kumar
Published online: 19 October 2014 # Springer Science+Business Media New York 2014
Introduction Gallbladder carcinoma (GBC) is a disease common in the northern part of India, Chile, and Japan [1]. The commonest histological type of this neoplasm is adenocarcinoma, while sarcomatoid histology is rare [2]. There are a few reports available in the literature on sarcomatoid GBC where it was detected in a surgically resectable stage [3, 4]. The prognosis of this type of neoplasm is very poor [2]. We report a case of metastatic sarcomatoid carcinoma along with its outcome who received palliative deocetaxel and gemcitabine chemotherapy.
Case Report A 42-year-old female had history of pain in the upper abdomen of 3–4 months duration, right neck swelling of 2.5-month D. C. Doval (*) : U. Batra : K. D. Choudhury Department of Medical Oncology, Rajiv Gandhi Cancer Institute and Research Centre, Sector 5, Rohini, Delhi 110085, India e-mail: [email protected] D. C. Doval : S. Azam Department of Research, Rajiv Gandhi Cancer Institute and Research Centre, Sector 5, Rohini, Delhi 110085, India A. Mehta Department of Laboratory Services, Rajiv Gandhi Cancer Institute and Research Centre, Sector 5, Rohini, Delhi 110085, India A. Pruthi Department of Nuclear Medicine, Rajiv Gandhi Cancer Institute and Research Centre, Sector 5, Rohini, Delhi 110085, India K. Kumar Department of Surgical Oncology, Rajiv Gandhi Cancer Institute and Research Centre, Sector 5, Rohini, Delhi 110085, India
duration, and weight loss. She underwent diagnostic laparoscopy on 13 Dec 2011 which was suggestive of a gallbladder mass infiltrating the liver. She presented with these clinical details at our hospital on 19 Dec 2011. Physical examination of the abdomen was soft with physical scar of the laparoscopic surgery and staples. The serum levels of carcinoembryonic antigen (CEA, 0.69 ng/mL) and carbohydrate antigen 19–9 (CA 19–9, 8.34 U/mL) were within the normal reference range. Her hematological findings showed a hemoglobin level of 10.3 g/dL, leukocyte count 8,800/cumm, red blood cells 4.13 mil/cumm and platelets 415,000/cumm. Serum biochemistry revealed a glutamic-pyruvic transaminase (SGPT) level of 256 U/L, glutamic oxaloacetic transaminase (SGOT) 137 U/L, sodium 134 mEq/L, and uric acid 2.4 mg/dL. Other serum biochemical parameters are within the normal range. Review of PET-CT scan, done outside the hospital, showed a hypermetabolic soft tissue mass in gallbladder infiltrating adjacent liver parenchyma and a hypodense lesion in the right lobe of liver. Metabolically active lymphnodes were seen in bilateral supraclavicular, gastrohepatic, periportal, celiac, retropancreatic, right retrocrural, preaortic, left paraaortic, aortocaval, retrocaval, and mesenteric regions. Hyper metabolic soft tissue lesion was seen in the left shoulder and left gluteal regions. A metabolically active nodule was also noted in the right adrenal and head of femur (Figs. 1a, 2a, and 3a). Pathological examination of gallbladder biopsy, reviewed at our hospital, showed spindleshaped cells with abundant eosinophilic cytoplasm and central round hyperchromatic nuclei without any area of necrosis (Fig. 4a, b). On immunohistochemistry, tumor cells strongly and diffusely expressed vimentin (Fig. 4c). Moderate expression of cytokeratin was also seen (Fig. 4d). Tumor was negative for LCA and synaptophysin. The
J Gastrointest Canc (2014) 45 (Suppl 1):S270–S274
S271
Fig. 1 Staging PET-CT (column a) demonstrates hypermetabolic gallbladder mass infiltrating adjacent liver parenchyma, few liver lesions in the right lobe, and hypermetabolic enlarged retroperitoneal lymphnodes. Significant regression in size and metabolic activity in gall bladder mass in interim PET-CT study done post three cycles of palliative chemotherapy (column b) compared with staging PET-CT. PET-CT study done post
six cycles of chemotherapy (column c) showed no further response in gall bladder or liver lesions. However, ascites was a new development. Circular region of interest (ROI) drawn shows the standardized uptake values (SUV), which represents quantitative metabolic activity
pathologist’s final opinion was sarcomatoid carcinoma of the gallbladder. Her Eastern Cooperative Oncology Group (ECOG) performance status was 1. Advanced nature of disease, prognosis, and palliative nature of treatment were explained to the patient and husband. Keeping in view the metastatic and sacromatoid histology of the tumor, she was planned for palliative chemotherapy with injection (Inj) gemcitabine (900 mg/m2, days 1 and 8; Q3 weekly) and Inj docetaxel (100 mg/m2 day 8; Q3 weekly). Informed consent was obtained from the patients before the start of treatment. The chemotherapy was started on 29 Dec 2011. Inj zoledronic acid was added for bone metastasis along with each cycle. During the course of treatment on day 8 of cycle 2, she developed neutropenia which was managed with administration of granulocyte colony-stimulating factors. It was also used during subsequent cycles of treatment. After completion of three cycles of chemotherapy,
PET-CT scan was carried out for the response evaluation according to the Response Evaluation Criteria In Solid Tumor version 1.1 which showed gallbladder mass, soft tissue, right adrenal, lymphnodal, and bone lesions decreased in size as compared to the previous scan (Figs. 1b, 2b, and 3b). Overall, there was partial response (PR) to the treatment with metabolically active significant residual disease. In view of the PR to the treatment, she was continued with the same chemotherapy regimen. Patient developed chemo-port-associated deep vein thrombosis (DVT) post four cycles of chemotherapy for which the chemo-port was removed and DVT was managed with low molecular weight heparin. Fifteen days after the completion of the sixth cycle of chemotherapy, she came to the hospital with bilateral pedal edema, abdominal distention, vomiting, altered sensorium, and back pain. PET-CT scan was carried out post six cycles of treatment and, compared with earlier scans, showed
S272
J Gastrointest Canc (2014) 45 (Suppl 1):S270–S274
Fig. 2 Figure showing significant regression in size and metabolic activity in the right lobe of liver lesion in interim PET-CT study done post three cycles of palliative chemotherapy (column b) compared with staging PET-CT study (column a)
lymphnodal abnormalities which had increased in size and number with persistent metabolic activity. Liver lesions, gallbladder mass, and bony lesions were persistent without any significant change. Ascites and bilateral pleural effusion were new developments. Right adrenal lesion and soft tissue deposits in the left posterior chest were not noted (Figs. 1c, 2c, and 3c). Overall, it was a metabolically active progressive disease. One-time ascitic fluid aspiration was done and pathological examination was positive for the malignant cell. She was admitted for supportive treatment in the hospital. Her general condition deteriorated and she developed hypotension. Despite the best supportive care, patient succumbed to the illness and died in the hospital on 16 May 2012. She survived for 5 months from diagnosis.
Discussion The commonest histological subtype of GBC is adenocarcinoma. The sarcomatoid carcinoma is a rare diagnosis in
the clinical practice and was first reported by Landsteiner in the year 1907. Immunohistochemical analysis of the tumor is required to identify this tumor, since it contains the malignant epithelial as well as sarcomatous component both at the same time. It is not associated with the specific radiological imaging finding as well as tumor makers. The clinical presentation is usually the same as in the case of adenocacinoma. Surgical resection remains the mainstay treatment. There are no clinical trials or any other data available for the palliative systemic chemotherapy in the advanced sarcomatoid carcinoma of the gallbladder. However, a few reports are available for the adjuvant chemotherapy or chemoradiotherapy [3, 5, 6]. Surgically curative and palliative resections are the mainstay of treatment in the earlier reported cases [4, 7–9]. There are reports available for chemotherapy in sarcomatoid carcinoma which have shown good response as well as survival with docetaxel and gemcitabine chemotherapy [10, 11]. Therefore, in our case, gemcitabine and docetaxel doublet
J Gastrointest Canc (2014) 45 (Suppl 1):S270–S274
S273
Fig. 3 Figure showing significant regression in size and metabolic activity in retroperitoneal lymphnodes in interim PET-CT study done post three cycles of palliative chemotherapy (column b) compared with
staging PET-CT study (column a). PET-CT study done post six cycles of chemotherapy (column c) showed mild progression in lymphnodal lesions
chemotherapy was offered keeping in view of sarcomatoid histology and metastatic disease [12]. Treatment resulted in PR achieved post three cycles; however, patient progressed post six cycles of treatment. It could be noted that after six cycles, the primary tumor in the gallbladder and liver remained persistent without any significant change, but the progression was observed in the lymphnodes and other metastatic sites. The toxicities are neutropenia which can easily be managed by GCSFs. The patient responded well to the chemotherapy, however, progresses after the sixth cycle. She survived for 5 months from the diagnosis despite extensive nodal and metastatic disease. The prognosis of the sacomatoid carcinoma of the gallbladder has been poor. The patients usually presented with large tumor size with liver infiltration and lymphnodal disease. Survival of the patient is limited to a few months even after surgical resection. The 3-year overall survival rate was observed as 31 %
with a median survival of 7 months in the patients who underwent surgical resection [13]. Another study that had analyzed the survival of already-reported surgically resecated cases found median overall survival as 5.5 months [2]. There is no standard management of sarcomatoid GBC nor do any clinical trials exist. Almost all reported cases had undergone radical or palliative surgery, and there is lack of information for the survival of patients treated with palliative chemotherapy. The survival of advanced disease of gallbladder cancer remains poor, and in our case, it correlates well with the outcomes of the abovementioned studies even with palliative chemotherapy.
Conclusions Keeping in view the rarity of this tumor subtype, randomized studies are not feasible. In the advanced disease, there are very
S274
J Gastrointest Canc (2014) 45 (Suppl 1):S270–S274
Fig. 4 Representative hematoxyline and eosine staining of tumor tissue ×100, ×400 (a, b). Immunohistochemical positive staining for vimentin, ×200 (c), and cytokeratin, ×400 (d)
limited therapeutic interventions available and a combination of Deocetaxel and Gemcitabine could be beneficial to the patients. It could also be tried in the adjuvant settings with manageable toxicities.
Source of Funding/Support None Conflict of Interest None
References 1. Randi G, Malvezzi M, Levi F, Ferlay J, Negri E, Franceschi S, et al. Epidemiology of biliary tract cancers: an update. Ann Oncol. 2009;20:146–59. 2. Hu ZH, Li ZW, Shen L, Zhang M, Zheng SS. Surgical therapy and prognosis of sarcomatoid carcinoma of the gallbladder. Hepato-Biliary-Pancreat Dis Int. 2010;9:175–9. Desolate. 3. Pu JJ, Wu W. Gallbladder carcinosarcoma. BMJ Case Rep. 2011. 4. Park SB, Kim YH, Rho HL, Chae GB, Hong SK. Primary carcinosarcoma of the gallbladder. J Korean Surg Soc. 2012;82:54–8.
5. Liu KH, Yeh TS, Hwang TL, Jan YY, Chen MF. Surgical management of gallbladder sarcomatoid carcinoma. World J Gastroenterol. 2009;15:1876–9. 6. Zhang L, Chen Z, Fukuma M, Lee LY, Wu M. Prognostic significance of race and tumor size in carcinosarcoma of gallbladder: a meta-analysis of 68 cases. Int J Clin Exp Pathol. 2008;1:75–83. 7. Kataria K, Yadav R, Seenu V. Sarcomatoid carcinoma of the gall bladder. J Surg Case Rep. 2012; 5. 8. Kim MJ, Yu E, Ro JY. Sarcomatoid carcinoma of the gallbladder with a rhabdoid tumor component. Arch Pathol Lab Med. 2003;127: e406–8. 9. Oberoi R, Jena A, Tangri R, Sahria A. Carcinosarcoma of the gallbladder with chondroid differentiation: MRI findings. Ind J Radiol Imaging. 2006;16:491–3. 10. Maki RG, Wathen JK, Patel SR, et al. Randomized phase II study of gemcitabine and docetaxel compared with gemcitabine alone in patients with metastatic soft tissue sarcomas: results of sarcoma alliance for research through collaboration study 002. J Clin Oncol. 2007;25:2755–63. 11. Bay JO, Ray-Coquard I, Fayette J, et al. Docetaxel and gemcitabine combination in 133 advanced soft-tissue sarcomas: a retrospective analysis. Int J Cancer. 2006;119:706–11. 12. Maki RG. Gemcitabine and docetaxel in metastatic sarcoma: past, present, and future. Oncologist. 2007;12:999–1006. 13. Okabayashi T, Sun ZL, Montgomey RA, Hanazaki K. Surgical outcome of carcinosarcoma of the gall bladder: a review. World J Gastroenterol. 2009;15:4877–82.
