Gallbladder cancer worldwide: geographical distribution and risk factors

Betulinic acid induces apoptosis of gallbladder cancer cells via repressing SCD1

Gallbladder cancer (GBC) is the most common and aggressive malignancy of the biliary tract. Betulinic acid (BetA) has been reported to have anti-inflammatory and antitumor effects; however, the effect of BetA on GBC is still unknown. In this study, we investigated the effect of BetA on five GBC cell lines and found that BetA significantly inhibited the proliferation of NOZ cells but had little inhibitory effect on other GBC cells. BetA disturbed mitochondrial membrane potential and induced apoptosis in NOZ cells. Real-time polymerase chain reaction analysis revealed that stearoyl-coenzyme A desaturase 1 (SCD1) was highly expressed in NOZ cells but low expressed in other GBC cells. BetA inhibited SCD1 expression in a concentration-dependent manner in NOZ cells. Downregulation of SCD1 expression by RNA interference inhibited the proliferation of NOZ cells and induced cell apoptosis. Moreover, BetA inhibited the growth of xenografted tumors and suppressed SCD1 expression in nude mice. Thus, our results showed that BetA induced apoptosis through repressing SCD1 expression in GBC, suggesting that BetA might be an effective agent for the treatment of patients with GBC that highly expresses SCD1.

Clinicopathological features and survival outcomes of rare histologic variants of gallbladder cancer

BACKGROUND

Adenocarcinoma (AC) is the most common histological type in gallbladder carcinoma (GBC). Squamous cell carcinoma (SCC), adenosquamous carcinoma (ASC), and papillary carcinoma (PC) are rare histologic variants of GBC.

METHODS

Patients with AC, SCC, ASC, and PC of the gallbladder between 2004 and 2013 were identified from the National Cancer Database. Univariate and multivariate analyses were performed, and Kaplan-Meier curves were used to compare overall survival (OS) based on histological subtype.

RESULTS

A total of 5956 patients ≥18 years of age were included in the final analysis. Most patients (n = 5398; 90.6%) had AC compared with variant histologies. PC (n = 227; 3.8%) was the most common variant, followed by ASC (n = 216; 3.6%) and SCC (n = 115; 1.9%); 70.3% were female and 78.9% Caucasian. The median age was 70 (range, 25-90) years. Surgical resection was performed in 77.7% of AC, 53.0% of SCC, 88.9% of ASC, and 96.9% of PC (P < .001). Systemic therapy after surgery was administered in 25.1% of AC, 18.3% of SCC, 35.7% of ASC, and 19.4% of PC (P = .001). In multivariate analysis, multiagent chemotherapy was associated with improved OS in all histologies except for SCC and PC (p < .001), and adjuvant systemic therapy was associated with improved OS in ASC and AC (P < .001).

CONCLUSION

Survival differs between the gallbladder variants. Except for SCC, GBC variants underwent surgical resection more often than AC. Adjuvant systemic therapy was associated with improved OS in ASC and AC.

Gallbladder histological alterations in patients undergoing cholecystectomy for cholelithiasis

OBJECTIVE

to describe the histological findings of the gallbladders of patients undergoing cholecystectomy and to evaluate the presence of factors associated with gallbladder incidental cancer.

METHODS

we conducted a descriptive, cross-sectional, observational study with 1,278 histopathological exams of gallbladders coming from cholecystectomy for cholelithiasis and of their reports, held from January 2008 to December 2017.

RESULTS

the most common pathological finding was chronic cholecystitis, present in 1,251 patients (97.8%), followed by gallbladder cholesterolosis, in 131 (10.2%). Gallbladder cancer was identified in six patients, with a prevalence of 0.5% in this sample. There was a significant association between the presence of cancer and age ≥60 years and wall thickness ≥0.3cm.

CONCLUSION

there was low prevalence of gallbladder cancer in this population, higher occurrence in the elderly and association of the tumor with gallbladder wall thickness.

Trends of gallbladder cancer incidence, mortality, and diagnostic approach in urban Shanghai between 1973 and 2009

PURPOSE

To describe and interpret secular time trends in gallbladder cancer (GBC) incidence, mortality, and diagnostic approach using 37 years of cancer registry data in urban Shanghai.

METHODS

Data on registration of GBC in urban Shanghai during 1973 and 2009 were collected by the Shanghai Cancer Registry. To describe time trends and to identify specific time points when significant changes occurred, we used joinpoint regression analysis.

RESULTS

The age-standardized rates (ASRs) of incidence increased from 1.1/100,000 (1973-1975) to 2.9/100,000 (2006-2009) in men and from 1.7/100,000 (1973-1975) to 3.9/100,000 (2006-2009) in women. ASRs of incidence increased significantly with estimated annual percent changes (EAPCs) of 2.8% in men and 2.5% in women. The mortality trends increased significantly, with EAPCs of 2.8% in men and 2.5% in women. The increasing incidence and mortality rates were primarily observed in men ⩾60 years of age and in women ⩾70 years of age. Notable downward trends in incidence and mortality were identified among women age 60-69 years over the last decade. The percentage of GBC diagnosed by pathology increased steadily over the years while the percentage of GBC diagnosed by imaging, surgery, and biochemistry sharply increased from 1987 onwards.

CONCLUSIONS

Thirty-seven years of cancer registry data document a tremendous increase in incidence/mortality and a slight decline in incidence/mortality over the last decades for GBC, especially among women, in Shanghai. The development of diagnostic approaches and aging population may play important roles.

The Role of Diabetes Mellitus in Diseases of the Gallbladder and Biliary Tract

BACKGROUND

The increasing prevalence of diabetes mellitus worldwide continues to pose a heavy burden. Though its gastrointestinal impact is appropriately recognized, the lesser known associations may be overlooked.

OBJECTIVE

We aim to review the negative implications of diabetes on the gallbladder and the biliary tract.

METHODS

A MEDLINE® database search of literature was conducted with emphasis on the previous five years, combining keywords such as "diabetes," "gallbladder," and "biliary".

RESULTS

The association of diabetes to the formation of gallstones, gallbladder cancer, and cancer of the biliary tract are discussed along with diagnosis and treatment.

CONCLUSION

Though we uncover the role of diabetic neuropathy in gallbladder and biliary complications, the specific individual diabetic risk factors behind these developments is unclear. Also, in addition to diabetes control and surgical gallbladder management, the treatment approach also requires further focus.

Incidental Carcinoma Gallbladder: Incidence, Risk Factors, and Factors Affecting Survival-5-Year Experience from a Tertiary Care Institute

INTRODUCTION

Carcinoma gallbladder is a very lethal disease. It can get detected incidentally after laparoscopic cholecystectomy. The overall outcome of incidentally detected carcinoma gallbladder is a matter of debate in literature.

AIM

To estimate the overall incidence of the incidental gallbladder carcinoma, the various risk factors associated with it and factors affecting overall survival in patients who underwent laparoscopic cholecystectomy with eventual histology turning out to be carcinoma gallbladder.

METHODS

Data of all the patients undergoing laparoscopic cholecystectomies in one surgical unit under the Department of Surgery at All India Institute of Medical Sciences, New Delhi, India, between January 2014 and December 2018 was retrospectively analyzed. All patients with incidental carcinoma gallbladder were followed up and completion radical cholecystectomy was performed. The demographic profile, preoperative imaging, intra-operative finding, histopathology of primary surgery, and median interval between two surgeries were analyzed to look for various risk factors associated with incidental carcinoma gallbladder and factors affecting overall survival.

RESULTS

Incidence of the incidental carcinoma gallbladder was 0.51% with a female/male ratio of 4:1 and mean age of 47.2 years. Preoperative imaging of most of them was suggestive of chronic cholecystitis; however, one patient had multiple gallbladder polyps. Six patients had uneventful laparoscopic cholecystectomy, while four had bile spillages intraoperatively. All the patients had adenocarcinoma on histopathology. Pathological staging of four patients was pT1b and six patients had pT2 tumor. The median interval between cholecystectomy and completion radical cholecystectomy in this series was 8 weeks. At the end of 19-month median follow-up, overall survival was 55.5%.

CONCLUSION

Incidence of incidental carcinoma gallbladder is 0.51%, most commonly affecting middle-aged females. Risk factors associated with incidental carcinoma gallbladder were found to be multiple gallbladder calculi, single large stone, and gallbladder polyps. Survival is better in males, young patients with uneventful primary surgery and better-differentiated pathology.

Oncologic Outcomes of Extended Lymphadenectomy without Liver Resection for T1/T2 Gallbladder Cancer

PURPOSE

This study provides a standardized operative strategical algorithm that can be applied to patients with T1/T2 gallbladder cancer (GBC). Our aim was to determine the oncologic outcome of radical cholecystectomy with para-aortic lymph node dissection without liver resection in T1/T2 GBC.

MATERIALS AND METHODS

From January 2005 to December 2017, 164 patients with GBC underwent operations by a single surgeon at Severance Hospital. A retrospective review was performed for 113 of these patients, who were pathologically determined to be in stages T1 and T2 according to American Joint Committee on Cancer 7th guidelines.

RESULTS

Of the 113 patients, 109 underwent curative resection for T1/T2 GBC; four patients who underwent palliative operations without radical cholecystectomies were excluded from further analyses. For all T1b and T2 lesions, radical cholecystectomy with para-aortic lymph node dissection was performed without liver resection. There were four GBC-related mortalities, and 5-year disease-specific survival was 97.0%. The median follow-up was 50 months (range: 5-145 months). In all T stages, the median was not reached for survival analysis. Five-year disease-specific survival for T1a, T1b, and T2 were 100%, 94.1%, and 97.1%, respectively. Five-year disease-free survival for T1a, T1b, and T2 were 100%, 87.0%, and 91.8%, respectively.

CONCLUSION

Our results suggest that the current operative protocol can be applied to minimal invasive operations for GBC with similar oncologic outcomes as open approach. For T1/T2 GBC, radical cholecystectomy, including para-aortic lymph node dissection, can be performed safely with favorable oncologic outcomes.

Can we assess the advancements of gallbladder cancer using red blood cell distribution width?

Gallbladder cancer (GBC) is a rare biliary malignancy. The relationship between red blood cell distribution width (RDW) and cancer prognosis has been confirmed by many studies, however, the relationship between RDW and gallbladder cancer is rarely reported. Therefore, we aimed to assess the correlation between RDW and the advancements of GBC in this study.A retrospective study was performed on 108 GBC patients and 119 age and gender-matched individuals who were admitted to the First Affiliated Hospital of Guangxi Medical University from January 2012 to December 2018.The GBC patients had significantly higher RDW(%) levels compared to the healthy controls group (15.7 ± 2.4 vs 13.5 ± 0.6; P = .000). In addition, GBC patients with stage III+IV had higher levels of RDW(%) than stage I+II (16.1 ± 2.5 vs 14.9 ± 2.0, P = .011). Correlation analysis showed that RDW had positive correlations with TNM stage (correlation coefficient = 0.302, P = .002). The cut-off value of RDW was observed to be 14.5% in patients with GBC (area under the curve = 0.757, 95% confidence interval = 0.677-0.838, P = .000). Univariate logistic regression and multivariate logistic regression analysis showed that RDW was an independent risk factor for GBC lymph node metastasis.Our results suggest that elevated levels of RDW are independently associated with GBC patients and may serve as potential markers for the advancements of GBC.

Expression and Clinical Implications of Cysteine Cathepsins in Gallbladder Carcinoma

Background: Gallbladder carcinoma (GBC) exhibits poor prognosis due to its detection at an advanced stage. Upregulation of lysosomal cysteine proteases cathepsin L (CTSL) and cathepsin B (CTSB) has been implicated in several tumorigenic processes. However, no such information in GBC was available. Therefore, the present study was planned to investigate the expression and clinical significance of these cathepsins in GBC.

Methods: Activities of CTSL and CTSB were assayed in the gallbladder (GB) tissues obtained from GBC patients (n = 43) and control subjects (n = 69). Protein and mRNA levels were quantified using immunohistochemistry and real-time PCR (qPCR), respectively. Finally, serum levels of CTSL and CTSB were estimated by ELISA. Receiver operating characteristic (ROC) curve analysis was used for the assessment of sensitivity, specificity, and diagnostic accuracy of these cysteine cathepsins in GBC. The association of combined CTSL and CTSB activity with overall survival was assessed using Kaplan Meier survival analysis.

Results: The expression and activity of both CTSL and CTSB were significantly increased (p < 0.050) in tumors of GBC patients as compared to controls. Enzymatic activity of CTSL+B and CTSB exhibited a strong positive association with tumor stage and lymph node involvement in GBC (p < 0.050). Interestingly, the elevated activity of combined CTSL+B was also associated with increased mortality in these patients. Furthermore, significantly enhanced levels of serum CTSL and CTSB were also observed in GBC (p < 0.050) as compared to controls. ROC analysis revealed high diagnostic significance of serum CTSB and CTSL for distinguishing GBC patients from controls with an area under the curve (AUC) of 82 and 77%, respectively.

Conclusion: This study, for the first time, demonstrates the clinical significance of CTSL and CTSB overexpression in GBC. Our findings may help improve the clinical management of this carcinoma.

Re-resection in Incidental Gallbladder Cancer: Survival and the Incidence of Residual Disease

Background

Re-resection for incidental gallbladder cancer (iGBC) is associated with improved survival but little is known about residual disease (RD) and prognostic factors. In this study, survival after re-resection, RD, and prognostic factors are analyzed.

Methods

Patients with iGBC were identified from the Netherlands Cancer Registry, and pathology reports of re-resected patients were reviewed. Survival and prognostic factors were analyzed.

Results

Overall, 463 patients were included; 24% (n = 110) underwent re-resection after a median interval of 66 days. RD was present in 35% of patients and was most frequently found in the lymph nodes (23%). R0 resection was achieved in 93 patients (92%). Median overall survival (OS) of patients without re-resection was 13.7 (95% confidence interval [CI] 11.6–15.6), compared with 52.6 months (95% CI 36.3–68.8) in re-resected patients (p < 0.001). After re-resection, median OS was superior in patients without RD versus patients with RD (not reached vs. 23.1 months; p < 0.001). In patients who underwent re-resection, RD in the liver (hazard ratio [HR] 5.54; p < 0.001) and lymph nodes (HR 2.35; p = 0.005) were the only significant prognostic factors in multivariable analysis. Predictive factors for the presence of RD were pT3 stage (HR 25.3; p = 0.003) and pN1 stage (HR 23.0; p = 0.022).

Conclusion

Re-resection for iGBC is associated with improved survival but remains infrequently used and is often performed after the optimal timing interval. RD is the only significant prognostic factor for survival after re-resection and can be predicted by pT and pN stages.

Electronic supplementary material

The online version of this article (10.1245/s10434-019-08074-4) contains supplementary material, which is available to authorized users.

Remarkable Response of Metastatic Gallbladder Carcinoma to Apatinib After Failed Multiline Chemotherapies: A Case Report and Literature Review

Gallbladder carcinoma (GBC) is a relatively rare and aggressive malignant tumor with a poor prognosis. A systematic review of current clinical studies illustrates an extreme paucity of second-line therapeutic options following the failure of standard-of-care cisplatin-gemcitabine chemotherapy. The efficacy of apatinib, an highly potent and selective oral inhibitor of VEGFR-2 tyrosine kinase, for refractory advanced GBC has not yet been clarified. Herein, we report a case of advanced GBC that presented a durable partial response to apatinib used as monotherapy after the failure of multiline chemotherapies including S-1 monotherapy, capecitabine monotherapy, gemcitabine plus capecitabine, and irinotecan plus oxaliplatin. The patient achieved an efficacy of partial response within 2 months. By September 23, 2019, the duration of treatment had extended for almost 1 year with a satisfactory quality of life, and the administration of apatinib was continued. Dose reduction of apatinib occurred at week four due to grade 2 hypertension and hand-foot skin reaction (HFSR). No fatigue, proteinuria, mucositis, or thrombocytopenia occurred. To the best of our knowledge, this is the first case of a successful use of apatinib monotherapy for heavily pretreated GBC. Further prospective studies are warranted to confirm the efficacy and safety of apatinib in GBC.

Eukaryotic translation initiation factor 6 overexpression plays a major role in the translational control of gallbladder cancer

BACKGROUND

Gallbladder cancer (GBC) is a rare neoplasia of the biliary tract with high mortality rates and poor prognosis. Signs and symptoms of GBC are not specific and often arise at late stage of disease. For this reason, diagnosis is typically made when the cancer is already in advanced stages, and prognosis for survival is less than 5 years in 90% of cases. Biomarkers to monitor disease progression and novel therapeutic alternative targets for these tumors are strongly required. Commonly, dysregulated protein synthesis contributes to carcinogenesis and cancer progression. In this case, protein synthesis directs translation of specific mRNAs, and, in turn, promotes cell survival, invasion, angiogenesis, and metastasis of tumors. In eukaryotes, protein synthesis is regulated at its initiation, which is a rate-limiting step involving eukaryotic translation initiation factors (eIFs). We hypothesize that eIFs represent crossroads in the development of GBC, and might serve as potential biomarkers. The study focus was the role of eIF6 (an anti-association factor for the ribosomal subunits) in GBC.

METHODS

In human GBC samples, the expression of eIF6 was analyzed biochemically at the protein (immunohistochemistry, immunoblot analyses) and mRNA levels (qRT-PCR).

RESULTS

High levels of eIF6 correlated with shorter overall survival in biliary tract cancer (BTC) patients (n = 28). Immunohistochemical data from tissue microarrays (n = 114) demonstrated significantly higher expression levels of eIF6 in GBC compared to non-neoplastic tissue. Higher eIF6 expression on protein (immunoblot) and mRNA (qRT-PCR) level was confirmed by analyzing fresh frozen GBC patient samples (n = 14). Depletion of eIF6 (using specific siRNA-mediated knockdown) in Mz-ChA-2 and TFK-1 cell lines inhibited cell proliferation and induced apoptosis.

CONCLUSION

Our data indicates that eIF6 overexpression plays a major role in the translational control of GBC, and indicates its potential as a new biomarker and therapeutic target in GBC.

The Four Horsemen in Colon Cancer

Worldwide, neoplasms of the gastrointestinal tract have a very high incidence and mortality. Among these, colorectal cancer, which includes colon and rectum malignancies, representing both highest incidence and mortality. While gallbladder cancer, another neoplasm associated to gastrointestinal tract occurs less frequently. Genetic factors, inflammation and nutrition are important risk factors associated with colorectal cancer development. Likewise, pathogenic microorganisms inducing intestinal dysbiosis have become an important scope to determine the role of bacterial infection on tumorigenesis. Interestingly, in human biopsies of different types of gastrointestinal tract cancer, the presence of different bacterial strains, such as Fusobacterium nucleatum, Escherichia coli, Bacteroides fragilis and Salmonella enterica have been detected, and it has been considered as a high-risk factor to cancer development. Therefore, pathogens infection could contribute to neoplastic development through different mechanisms; including intestinal dysbiosis, inflammation, evasion of tumoral immune response and activation of pro-tumoral signaling pathways, such as β catenin. Here, we have reviewed the suggested bacterial molecular mechanisms and their possible role on development and progression of gastrointestinal neoplasms, focusing mainly on colon neoplasms, where the bacteria Fusobacterium nucleatum, Escherichia coli, Bacteroides fragilis and Salmonella enterica infect.

Molecular pathways and potential biomarkers in gallbladder cancer: A comprehensive review

The most common malignancy of the biliary tract, gallbladder cancer (GBC) often has a dismal prognosis. The aggressive nature of the tumor, delayed diagnosis at advanced stages of the disease, and lack of effective treatment options are some of the factors that contribute to a poor outcome. Early detection and accurate assessment of disease burden is critical to optimize management and improve long-term survival, as well as identify patients for adjuvant therapy and clinical trials. With recent advances in the understanding of the molecular pathogenesis of GBC, several specific diagnostic and biomarkers have been proposed as being of diagnostic and prognostic importance. Indeed, identification of novel diagnostic and prognostic markers has an important role in early diagnosis and development of targeted therapies among patients with GBC. Next-generation sequencing technology and genomewide data analysis have provided novel insight into understanding the molecular pathogenesis of biliary tract cancers, thereby identifying potential biomarkers for clinical use. We herein review available GBC biomarkers and the potential clinical implications in the management of GBC.

Upregulation of eukaryotic translation initiation factor 4E associates with a poor prognosis in gallbladder cancer and promotes cell proliferation in vitro and in vivo

Eukaryotic translation initiation factor 4 (eIF4E) has been demonstrated to promote tumorigenesis in different types of cancer; however, whether eIF4E is involved in the development of GBC is unclear. The present study aimed to explore the biological function of eIF4E in gallbladder cancer (GBC) and identified that the expression level of eIF4E was significantly increased in GBC tissues compared with that in normal gallbladder tissues. The overall survival (OS) was also shorter in the group of patients with GBC with increased eIF4E expression. Increased eIF4E was correlated with advanced stage and higher histologic grade. Knockdown of eIF4E significantly inhibited cell proliferation, colony formation and cell cycle-associated protein expression levels in 2 GBC cell lines. The weight of the tumors in the eIF4E knockdown group was remarkably decreased compared with the control group. It also was revealed that knockdown of eIF4E is associated with upregulating cyclin-dependent kinase inhibitor 1B and down-regulating the expression levels of cyclin E1 and cyclin D1 in vitro and in vivo. These data demonstrated that eIF4E is a novel prognostic marker in GBC and may serve a critical role in the regulation of cell proliferation.

Gallbladder cancer: 7-Year experience from Qatar

BACKGROUND

Gallbladder cancer (GC) is a relatively rare disease. To date, there are no studies describing the epidemiology of this disease in Qatar.

OBJECTIVE

To study the epidemiology of Gallbladder Cancer in Qatar.

METHODS

A retrospective analysis of the cases of GC in Hamad General Hospital in Qatar from 2009 to 2016.

RESULTS

Thirty-five patients presented with GC during the study period, 10 females (28.6%) and 25 males (71.4%). Fourteen patients (40%) were diagnosed incidentally after laparoscopic cholecystectomy, 16 (48.6%) were diagnosed pathologically, and 4 (11.4%) were diagnosed radiologically. The median age at diagnosis was 54 years (31-78). 74.3% of the disease occurred in patients less than 60 years old. Metastatic disease was discovered in 25 patients (71.4%) versus no metastasis in 10 patients (28.6%). The most common sites for metastasis were the liver (42.9%), peritoneum (25.7%), and lymph nodes (25.7%). Curative central hepatic resection was done in 8 patients (22.9%). Pathology showed adenocarcinoma in 27 patients (77.1%), neuroendocrine tumor in 3 patients (8.6%) and high-grade dysplasia in 1 patient (2.9%). No histopathology was available for 4 patients (11.4%). Twenty-eight patients (80.0%) had regular follow up, with 22 (62.9%) still alive. Six patients (17.1%) died during follow up with survival after diagnosis ranging from 42 days to 6.8 years.

CONCLUSIONS

In Qatar, due to the unique demographics, GC is more common in males and younger age groups. Most of the patients present late with metastasis, but curative resection is associated with long-term survival.

Biliary tract cancer prognostic and predictive genomics

Biliary tract cancer (BTC) is comprised of intrahepatic cholangiocarcinoma (ICC), extrahepatic cholangiocarcinoma (EHC) and gallbladder cancer (GBC). These tumors arise in the biliary epithelium, share histological characteristics and are associated with grim prognosis even when diagnosed at early stages. Moreover, its relatively low incidence in developed countries has precluded the development of clinical trials addressing specific differences among BTC subgroups in terms of their biology, treatment response and clinical outcomes. In this scenario, the development of effective treatment strategies for patients has been rather modest. To date, the combination of cisplatin plus gemcitabine remains as the standard first line therapy in advanced disease and after progression to this regimen there are limited treatment options. Next generation sequencing (NGS) studies have assessed the distribution of driver genes and potentially actionable genomic alterations among ICC, EHC and GBC. Here, we outline genomic differences among these subsets and describe key milestones in order to develop novel targeted drugs against BTCs. Although the early results of several studies are promising, international collaboration is critical to conduct adequately-powered trials, enrolling patients from high-incidence countries.

Favorable gallbladder cancer mortality-to-incidence ratios of countries with good ranking of world's health system and high expenditures on health

Background

The mortality-to-incidence ratio (MIR) is a marker that reflects the clinical outcome of cancer treatment. MIR as a prognostic marker is more accessible when compared with long-term follow-up survival surveys. Theoretically, countries with good health care systems would have favorable outcomes for cancer; however, no report has yet demonstrated an association between gallbladder cancer MIR and the World’s Health System ranking.

Methods

We used linear regression to analyze the correlation of MIRs with the World Health Organization (WHO) rankings and total expenditures on health/gross domestic product (e/GDP) in 57 countries selected according to the data quality.

Results

The results showed high crude rates of incidence/mortality but low MIR in more developed regions. Among continents, Europe had the highest crude rates of incidence/mortality, whereas the highest age-standardized rates (ASR) of incidence/mortality were in Asia. The MIR was lowest in North America and highest in Africa (0.40 and 1.00, respectively). Furthermore, favorable MIRs were correlated with good WHO rankings and high e/GDP (p = 0.01 and p = 0.030, respectively).

Conclusions

The MIR variation for gallbladder cancer is therefore associated with the ranking of the health system and the expenditure on health.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-7160-z) contains supplementary material, which is available to authorized users.

Prospective multi-center study of surgeon's assessment of the gallbladder compared to histopathological examination to detect incidental malignancy

PURPOSE

Routine histopathological examination after cholecystectomy for gallstones is performed despite the low rates of incidental findings of malignancy. The aim of this study was to assess predictive values of macroscopic examination of cholecystectomy specimens by surgeons in gallstone disease.

METHODS

A prospective multi-center diagnostic study was carried out between December 2015 and March 2017 at four different centers. All patients undergoing cholecystectomy for gallstone disease were consecutively screened for eligibility. Patients whose ages are 18 to 80 years, and preoperative imaging findings without any pathology except cholelithiasis were included. The gallbladder was first evaluated macroscopically ex situ by two operating surgeons and rated as macroscopically benign (group S1), suspicious for a benign diagnosis (group S2), and suspicious for malignancy (group S3). Thereafter, a pathologist made a final histopathological examination whose results are grouped as chronic cholecystitis (group P1), benign or precancerous lesions in which only cholecystectomy is the adequate treatment modality (group P2), and carcinoma (group P3). Diagnostic accuracy of the surgeon's assessment to the histopathological examination was evaluated using sensitivity, specificity, positive and negative predictive values, and accuracy, and correlated by a kappa agreement coefficient.

RESULTS

A total of 1112 patients were included in this trial. The specificity rates were 96.5%, 100%, and 98.7% for group S1-group S2, group S1-group S3, and group S2-group S3, respectively. Accuracy rates to detect malignancy were 100% and 95. 2% for group S1 and group S2, respectively. Kappa coefficient values were 1.0 and 0.64 for group S1-group S3 and group S2-group S3, respectively (p < 0.001 for both).

CONCLUSION

Assessment of the gallbladder specimen and selective histopathological examination may be adequate after cholecystectomy for gallstone diseases. Such a procedure would have the potential to reduce costs and prevent unnecessary loss of labor productivity without affecting patients' safety. However, higher number of patients in more centers is needed to confirm this hypothesis.

Significance of Metabolic Tumor Volume and Total Lesion Glycolysis Measured Using ¹⁸F-FDG PET/CT in Locally Advanced and Metastatic Gallbladder Carcinoma

PURPOSE

This study aimed to determine the prognostic value of new quantitative parameters of ¹⁸F-fluorodeoxyglucose positron emission tomography/computed tomography (¹⁸F-FDG PET/CT), including metabolic tumor volume (MTV), in patients with locally advanced and metastatic gallbladder cancer (GBC).

MATERIALS AND METHODS

In total, 83 patients initially diagnosed with locally advanced and metastatic GBC and who underwent ¹⁸F-FDG PET/CT at the time of initial diagnosis were retrospectively reviewed. The metabolic volume-based PET parameters of primary tumors and metastatic lesions were measured, including maximum and average standardized uptake values (SUV), MTV, and total lesion glycolysis. An overall survival (OS) analysis was performed using the Kaplan-Meier method with PET and clinical parameters. A Cox proportional hazards regression analysis was performed to determine independent prognostic factors.

RESULTS

In univariate analysis, pathologic differentiation (p<0.001), performance status (PS; p=0.003), C-reactive protein (CRP) level (p=0.009), and PET-related SUV_{mt max} (the highest SUV among the metastatic lesions) (p=0.040) and MTV_total (the sum of the MTVs of both the primary and metastatic lesions) (p=0.031), were significant for OS. In multivariate analysis, MTV_total (hazard ratio: 2.07; 95% confidence interval: 1.23-3.48; p=0.006) remained significant for the prediction of OS, as did differentiation (p=0.001), PS (p=0.001), and CRP (p=0.039).

CONCLUSION

In locally advanced and metastatic GBC, volume-based PET/CT parameters of the total tumor burden of malignancy, such as MTV_total, were found to be useful for the identification of patients with poor prognosis.

Mechanisms Underlying the Prevention and Treatment of Cholelithiasis Using Traditional Chinese Medicine

Cholelithiasis is a major public health concern that necessitates highly effective, feasible, and recurrence-preventing therapies. Currently available surgical treatments and medications cannot effectively avoid the recurrence of cholelithiasis. Hence, several Chinese herbal compounds (CHCs) are considered for the treatment of cholelithiasis, considering that they can effectively discharge gallstones and prevent the recurrence of such condition. In the present narrative review, we aim to summarize the underlying mechanisms of currently used CHCs in the treatment of cholelithiasis and to describe the current situation of traditional Chinese medicine (TCM) use for cholelithiasis. Several commonly used CHCs were used to illustrate these issues. We found that the mechanisms underlying the CHC treatments rely on the amelioration of the biliary dynamics factors, maintenance and protection of the liver function, reduction of the cholesterol and bilirubin levels, and regulation of the inflammatory reactions. CHCs as treatments based on TCM can ameliorate the overall bodily function, thereby preventing the recurrence of cholelithiasis. Appropriate application of CHCs would be beneficial for patients and clinicians, although the safety and efficacy of CHCs need further verification.

Epidemiology of gallbladder cancer

According to GLOBOCAN 2018 data, gallbladder cancer (GBC) accounts for 1.2% of all global cancer diagnoses, but 1.7% of all cancer deaths. Only 1 in 5 GBC cases in the United States is diagnosed at an early stage, and median survival for advanced stage cancer is no more than about a year. The incidence of the disease is increasing in the developed world. Gallstones, biliary cysts, carcinogen exposure, typhoid, and Helicobacter pylori infection, and abnormal pancreaticobiliary duct junctions are all risk factors, many of which account for its geographical, ethnic and sex distribution. Genetics also plays a strong role, as about a quarter of GBC cases are considered familial, and certain ethnicities, such as Native Americans, are at far higher risk for the neoplasm. Prevention includes weight loss, vaccination against and treatment of bacterial infections, early detection and elimination of polyps and cysts, and avoidance of oral estrogen replacement therapy.

Estimates of the current and future burden of cancer attributable to excess body weight and abdominal adiposity in Canada

The increasing prevalence of obesity among Canadians has important implications for newly diagnosed cases of cancer given that excess body weight and abdominal adiposity are known to increase the risk of several cancers. The purpose of this analysis was to estimate the current attributable and future avoidable burden of cancer related to excess body weight and abdominal adiposity among Canadian adults. We estimated the population attributable risk (PAR) for all cancers associated with excess body weight and abdominal adiposity using contemporary cancer incidence, relative risk and exposure prevalence data for body mass index (BMI), waist circumference and waist-to-hip-ratio. Using the partial impact fraction (PIF), we also estimated the future avoidable burden of cancer from 2015 to 2042 in Canada, and by province, through various hypothetical intervention scenarios. In 2003, approximately half (50.5%) of the Canadian population was estimated to be overweight (BMI 25.0-29.9) or obese (BMI ≥30.0), 56.5% to have excess abdominal adiposity and 56.8% with a high waist-to-hip ratio. In 2015, the estimated PARs of all incident cancers associated with excess body weight, excess abdominal adiposity and high waist-to-hip ratio were 7.2%, 8.9% and 10.0%, respectively. If the population BMI could revert to its 1994 distribution, 72,157 associated cancer cases could be prevented cumulatively by 2042. A reduction in excess body weight and abdominal adiposity has the potential to decrease the future cancer burden in Canada substantially, and hence efforts to reverse increasing trends in obesity should be prioritized.

Optimal surgical treatment in patients with T1b gallbladder cancer: An international multicenter study

BACKGROUND

There is no consensus on the optimal treatment of T1b gallbladder cancer (GBC) due to the lack of evidence and the difficulty of anatomy and pathological standardization.

METHODS

A total of 272 patients with T1b GBC who underwent surgical resection at 14 centers with specialized hepatobiliary-pancreatic surgeons and pathologists in Korea, Japan, Chile, and the United States were studied. Clinical outcomes including disease-specific survival (DSS) rates according to the types of surgery were analyzed.

RESULTS

After excluding patients, the 237 qualifying patients consisted of 90 men and 147 women. Simple cholecystectomy (SC) was performed in 116 patients (48.9%) and extended cholecystectomy (EC) in 121 patients (51.1%). The overall 5-year DSS was 94.6%, and it was similar between SC and EC patients (93.7% vs. 95.5%, P = 0.496). The 5-year DSS was similar between SC and EC patients in America (82.3% vs. 100.0%, P = 0.249) as well as in Asia (98.6% vs. 95.2%, P = 0.690). The 5-year DSS also did not differ according to lymph node metastasis (P = 0.688) or tumor location (P = 0.474).

CONCLUSIONS

SC showed similar clinical outcomes (including recurrence) and survival outcomes as EC; therefore, EC is not needed for the treatment of T1b GBC.

Profiling of gallbladder carcinoma reveals distinct miRNA profiles and activation of STAT1 by the tumor suppressive miRNA-145-5p

Gallbladder carcinoma (GBC) is a biliary tract cancer with few treatment options and poor prognosis. Radical surgery is the only potentially curative treatment option but most patients diagnosed with GBC are unresectable. Thus, there is a great need for the development of new treatment options including targeted therapy. Here, we aimed at identifying deregulated miRNAs and affected pathways involved in GBC development and progression. We performed global miRNA profiling of 40 GBC and 8 normal gallbladder tissues and identified large differences with 30% of miRNAs being differentially expressed (false discovery rate: FDR < 0.001). We found 24 miRNAs to be differentially regulated in GBC with poor outcome (p < 0.05) of which miR-145-5p was the most downregulated miRNA. Overexpression of miR-145-5p significantly reduced cell proliferation and colony formation. Gene expression analysis of cells expressing miR-145-5p mimics revealed activation of the Signal transducer and activator of transcription 1 (STAT1) signaling pathway which is mainly tumor suppressive. Furthermore, the activation of STAT1 by miR-145-5p was specifically observed in gallbladder carcinoma and cholangiocarcinoma but not in hepatocellular carcinoma cells. The Protein Tyrosine Phosphatase Receptor Type F (PTPRF) is downregulated upon miR-145 expression and may be involved in STAT1 regulation. In addition, we found that the STAT1-regulated protein IRF7 is downregulated in GBC compared to normal gallbladder tissue and low IRF7 expression is associated with significantly lower overall survival of GBC patients. Thus, this study identified GBC patient subgroups and provides new mechanistic insights in the tumor suppressive function of miR-145-5p leading to activation of STAT1 signaling.

Biliary tract cancer incidence and trends in the United States by demographic group, 1999-2013

BACKGROUND

Biliary tract cancers (BTCs) are rare but deadly cancers (gallbladder cancer [GBC], intrahepatic cholangiocarcinoma [ICC], extrahepatic cholangiocarcinoma [ECC], and ampulla of Vater cancer [AVC]). A recent US study reported increasing GBC incidence among people younger than 45 years and blacks; however, it did not examine trends for other biliary tract sites.

METHODS

This study characterized demographic differences in BTC incidence rates and time trends by anatomic site. Population-based North American Association of Central Cancer Registries data were used to calculate age-adjusted incidence rates, incidence rate ratios (IRRs), and estimated annual percent changes (eAPCs) for 1999-2013 by site and demographic group. For sites with significant differences in eAPC by age group, IRRs were compared by age group.

RESULTS

GBC incidence rates declined among women (eAPC, -0.5%/y; P = .01) and all racial/ethnic groups except for non-Hispanic blacks, among whom rates increased (1.8%/y; P < .0001). Although GBC rates increased among 18- to 44-year-olds (eAPC, 1.8%/y; P = .01), they decreased among people 45 years old or older (-0.4%/y; P = .009). Sex (P < .0001) and racial/ethnic differences (P = .003 to .02) in GBC incidence were larger for younger people than older people. During this period, ICC (eAPC, 3.2%/y; P < .0001) and ECC rates (1.8%/y; P = .001) steadily increased across sex and racial/ethnic groups. Although AVC incidence rates increased among younger adults (eAPC, 1.8%/y; P = .03) but not older adults (-0.20%/y; P = .30), sex and racial/ethnic IRRs did not differ by age.

CONCLUSIONS

Differential patterns of BTC rates and temporal trends have been identified by anatomic site and demographic groups. These findings highlight the need for large pooling projects to evaluate BTC risk factors by anatomic site.

Nomogram to predict overall survival after gallbladder cancer resection in China

AIM

To integrate clinically significant variables related to prognosis after curative resection for gallbladder carcinoma (GBC) into a predictive nomogram.

METHODS

One hundred and forty-two GBC patients who underwent curative intent surgical resection at Peking Union Medical College Hospital (PUMCH) were included. This retrospective case study was conducted at PUMCH of the Chinese Academy of Medical Sciences and Peking Union Medical College (CAMS & PUMC) in China from January 1, 2003 to January 1, 2018. The continuous variable carbohydrate antigen 19-9 (CA19-9) was converted into a categorical variable (cCA19-9) based on the normal reference range. Stages 0 to IIIA were merged into one category, while the remaining stages were grouped into another category. Pathological grade X (GX) was treated as a missing value. A multivariate Cox proportional hazards model was used to select variables to construct a nomogram. Discrimination and calibration of the nomogram were performed via the concordance index (C-index) and calibration plots. The performance of the nomogram was estimated using the calibration curve. Receiver operating characteristic (ROC) curve analysis and decision curve analysis (DCA) were performed to evaluate the predictive accuracy and net benefit of the nomogram, respectively.

RESULTS

Of these 142 GBC patients, 55 (38.7%) were male, and the median and mean age were 64 and 63.9 years, respectively. Forty-eight (33.8%) patients in this cohort were censored in the survival analysis. The median survival time was 20 months. A series of methods, including the likelihood ratio test and Akaike information criterion (AIC) as well as stepwise, forward, and backward analyses, were used to select the model, and all yielded identical results. Jaundice [hazard ratio (HR) = 2.9; 95% confidence interval (CI): 1.60-5.27], cCA19-9 (HR = 3.2; 95%CI: 1.91-5.39), stage (HR = 1.89; 95%CI: 1.16-3.09), and resection (R) (HR = 2.82; 95%CI: 1.54-5.16) were selected as significant predictors and combined into a survival time predictive nomogram (C-index = 0.803; 95%CI: 0.766-0.839). High prediction accuracy (adjusted C-index = 0.797) was further verified via bootstrap validation. The calibration plot demonstrated good performance of the nomogram. ROC curve analysis revealed a high sensitivity and specificity. A high net benefit was proven by DCA.

CONCLUSION

A nomogram has been constructed to predict the overall survival of GBC patients who underwent radical surgery from a clinical database of GBC at PUMCH.

A retrospective analysis of patients with gallbladder cancer: surgical treatment and survival according to tumor stage

INTRODUCTION

gallbladder cancer is the most common biliary neoplasm and the sixth most common tumor of the digestive system. The disease has an ominous prognosis, with a 5-year survival rate of approximately 5%. It is usually diagnosed late and surgical resection is the only potential cure.

METHODS

a retrospective study was carried out in 92 patients with a pathological diagnosis of gallbladder cancer from January 2000 to January 2016.

RESULTS

the mean age of cases was 72 ± 11 years; 64 subjects were females and 28 were males. Symptoms at admission included abdominal pain (78%), anorexia (77%), nausea (76%) and jaundice (45%). Surgery was indicated in 92 (100%) patients and 59 (64%) underwent a curative/intent resection. The initial surgical procedures included simple cholecystectomy in 69 (75%) cases and extended cholecystectomy in eleven (11%) subjects. Rescue surgery was performed in 15 patients with tumor tissue in the cholecystectomy specimen; ten individuals underwent an R0 curative resection. Adjuvant therapy was administered in 30 (33%) patients. The median survival in our series was 12.5 months, with survival rates of 57%, 30% and 20% at one, three and five years, respectively.

CONCLUSION

to conclude, surgical treatment with a complete tumor resection should be considered for all patients, provided that their clinical status allows it.

Patterns of Presentation, Treatment, and Survival Rates of Gallbladder Cancer: a Prospective Study at a Tertiary Care Centre

BACKGROUND

India has high incidence of gallbladder carcinoma with regional variation in incidence, the highest in Northern India. This study examines the patterns of presentation, treatment strategies, and survival rate of all patients with gallbladder cancer (GBC) evaluated at our tertiary academic hospital over a period of 2 years.

METHODS

All patients presented to our institute with established tissue diagnosis of carcinoma gallbladder were accrued in our study over a time period of 2 years. Presentation, treatment modalities, and survival rates were analyzed.

RESULTS

One hundred six patients were included: 80 females and 26 males (F: M = 3:1). Median age was 60 years. Eighty patients (75%) had gallstones and 20 patients (21%) had typical history of chronic cholecystitis. The common symptom and sign at presentation were pain in the right upper abdomen (81%) and lump abdomen (49%), respectively. Overall resectability rate was 19.8% (21/106). Eighty-five patients were unresectable or metastatic and treated with palliative intent. Stagewise distribution at diagnosis was stage I (0%), stage II (4%), stage IIIA (10%), stage IIIB (8%), stage IVA (17%), and stage IVB (61%). Estimated 1-year survival for stages II, IIIA, IIIB, IVA, and IVB was 100, 76, 47.4, 26, and 10.6%, respectively. Significant difference in OS was observed among different stages of GBC (p value <0.001).

CONCLUSION

If proper investigations are done, radical surgery including multi-organ resection can be curative with acceptable morbidity and mortality. Stage at presentation and ability to perform curative resection are the most important prognostic factors predicting survival. Palliative chemotherapy should be considered for metastatic GBC.

Frequency, Risk Factors, and Outcome of Gallbladder Polyps in Patients With Primary Sclerosing Cholangitis: A Case-Control Study

The prevalence polyps (GBPs) in the general population has been estimated to be approximately 5%, with up to 10% of these being dysplastic or malignant. Previous studies have suggested that patients with primary sclerosing cholangitis (PSC) have increased frequency of GBPs. However, data on the prevalence, risk factors, and outcome of GBPs in these patients are sparse. This case‐control study investigates the frequency, risk factors, and outcome of GBPs in patients with PSC. In this study, 363 patients with an established diagnosis of PSC based on magnetic resonance cholangiopancreatography (MRCP), endoscopic retrograde cholangiopancreatography (ERCP), or liver biopsy were identified. Patients with at least one abdominal imaging and no history of cholecystectomy before the first available abdominal imaging were included. The presence of GBPs was confirmed by abdominal computed tomography (CT), magnetic resonance imaging (MRI), or ultrasound. Patients with GBPs were compared to those without GBPs. Furthermore, patients with malignant/premalignant polyps were compared to those with benign polyps. The frequency of GBPs in patients with PSC was 10.6%. There was no significant difference in the frequency of inflammatory bowel disease (IBD) between the two groups. Of the 16 with GBPs who underwent cholecystectomy, 10 had malignant/premalignant lesions, of whom 6 had adenocarcinoma, and 4 had high‐grade dysplasia. Of the 6 patients with adenocarcinoma, 4 had lesions >10 mm, 1 had a lesion as small as 4 mm, and 1 had a 7‐mm lesion. Conclusion: GBPs may be frequently seen in patients with PSC. These lesions seem to occur independent of IBD. In patients with PSC, even small GBPs appear to have a risk of malignancy. These findings suggest that patients with PSC and GBPs may benefit from cholecystectomy, regardless of the size of the polyp.

Factors Associated with Premalignant Epithelial Changes in Chronic Calculous Cholecystitis: A Case-Control Study

INTRODUCTION

Gallstones are known to be associated with premalignant changes in the gallbladder epithelium that range from atypical hyperplasia, metaplasia, dysplasia to carcinoma. Recognition of factors associated with these changes in patients with gallstones can potentially be helpful in identifying patients to whom prophylactic cholecystectomy can be offered to reduce the chances of developing carcinoma.

OBJECTIVE

To identify factors associated with premalignant epithelial changes including atypical hyperplasia, metaplasia, and dysplasia in gallbladder mucosa in patients with chronic calculus cholecystitis.

MATERIALS AND METHODS

This was retrospective case-control study conducted over a period of 10 years from 2004 to 2014. Cases were patients with reported histopathological premalignant epithelial changes along with chronic calculus cholecystitis, and controls were patients without premalignant epithelial changes but chronic calculus cholecystitis. Controls were twice the number of the cases.

RESULTS

Over study period, 92 patients were reported to have premalignant epithelial changes on gall bladder histopathology for whom 184 controls were selected. Of cases, 61 (66%) patients had atypical hyperplasia, while metaplasia and dysplasia were present in 26 (28%) and 5 (5%) cases, respectively. Mean age was 47.5 ± 14.5 years, and 74% of the study population were female. Wall thickness of more than 3 mm (OR = 4.14, p value < 0.001) turned out to be statistically significant independent variables associated with premalignant lesions in gallbladder mucosa.

CONCLUSION

Odds of premalignant epithelial change in gall bladder mucosa in patients with gall bladder wall thickness of more than 3 mm is four times the odds of patients with wall thickness less than 3 mm, and the effect is statistically significant. Prophylactic cholecystectomy should be considered for this group of patients.

Epidemiological trends in digestive cancers in Romania, 1955-2012, compared to alcohol consumption. Correlation or coincidence?

BACKGROUND AND AIMS

Cancer has emerged as the leading cause of death in human populations. The contribution of alcohol has been highly suspected. The purpose of this paper was to analyze the time trend of digestive cancers in Romania, in terms of mortality rates (1955-2012), and incidence rates (2008-2012), and the alcohol consumption data (1961-2010), aiming to find out if there is any association.

METHODS

The data on six more common digestive cancers mortality rates (1955-2012) and incidence rates (2008-2012) were obtained from the historical and recent country statistics and publications of International Agency for Research on Cancer (IARC)/World Health Organisation (WHO), as age-standardized rate expressed per 100,000 population (ASRw). Data on alcohol consumption were obtained from the statistics and publications of WHO and United European Gastroenterology (UEG), as liters of pure alcohol/year.

RESULTS

Between 1955-2012, the ASRw of mortality registered an increase of the cancers of the esophagus in M (from 2.03 to 3.90), and of colorectal cancer in both sexes (from 4.65 to 18.20 in M, and from 4.57 to 9.70 in F). Between 1980-2012, an increasing trend of mortality was registered, in both sexes, for the cancers of the pancreas (from 5.50 to 9.30 in M and from 2.92 to 5.10 in F) and liver (from 1.77 to 11.00, in M, and from 0.83 to 4.20 in F). In terms of incidence, between 2008-20012, an increasing trend of ASRw was registered for the cancers of the esophagus in M (from 3.90 to 4.30), gastric cancer in M (from 15.90 to 16.30), colorectal cancer in both sexes (from 27.60 to 34.50 in M and from 19.00 to 20.20 in F), pancreatic cancer in F (form 5.20 to 5.90), and liver cancer in M (from 8.10 to 9.20). Alcohol consumption per capita (liters pure alcohol/year) increased in the same period, from an average of 5 in 1961, to 12.8 in 2003-2005, and to 14.4 in 2008-2010.

CONCLUSIONS

Given the parallel increase of some digestive cancers and alcohol consumption registered in our area, alcohol could represent more than a coincidence.

CD44 is overexpressed and correlated with tumor progression in gallbladder cancer

Background

Gallbladder cancer (GBC) is a highly lethal disease and the most common biliary tract malignant tumor with poor prognosis. Accumulating evidence indicates that cluster of differentiation 44 (CD44) is overexpressed in several malignancies and has a crucial role in the development of cancer. However, its expression and function in GBC are unclear. The aim of this study was to explore CD44 expression and its role in GBC.

Materials and methods

The expression of CD44 was measured by immunohistochemistry. Tissue microarray analysis was used to confirm the relationship between CD44 expression and clinical outcomes of GBC patients. EDU assay, colony formation assay, cell migration and invasion assay were performed to detect the functions of CD44 in GBC-SD and NOZ transfected with si-RNA.

Results

CD44 was overexpressed and associated with poor outcomes in GBC patients. The univariate and multivariate analyses confirmed that elevated CD44 was an independent prognostic factor for the OS of GBC patients. Silencing CD44 could suppress the GBC cell proliferation, migration and invasion in vitro, as well as attenuated cancer stem cell functions.

Conclusion

CD44 markedly correlated with aggressive tumor behaviors and contributed to the progression of GBC, which could represent a novel prognostic marker and potential therapeutic target for GBC patients.

Plasma Helicobacter pylori Antibody Titers and Helicobacter pylori Infection Positivity Rates in Patients with Gallbladder Cancer or Cholelithiasis: a Hospital-Based Case-Control Study

Objective: Gallbladder cancer is the commonest gastrointestinal cancer in northern Indian women. Some studies have examined the association between Helicobacter pylori infection and gallbladder cancer risk, but findings have been inconsistent. We aimed to examine the association between H. pylori infection and gallbladder cancer in Indian people. Materials and Methods: We conducted a hospital-based case-control study including 100 gallbladder cancer patients with gallstones who were 32 to 79 years old (cases; 72 women and 28 men), and 100 cholelithiasis patients aged 14 to 75 years (controls; 65 women and 35 men). All patients had a diagnosis of gallbladder cancer or cholelithiasis at the Sanjay Gandhi Post Graduate Institute of Medical Sciences in Lucknow having a high gallbladder cancer incidence in northern India, from May 2014 through July 2017. Plasma samples were collected from all patients before surgical treatment. Plasma H. pylori antibody titer was measured by the latex agglutination method and an autoanalyzer. H. pylori infection was defined as antibody titer ≥10 U/mL. Plasma antibody titers and H. pylori infection positivity rates were compared between cases and controls. Results: Mean plasma antibody titers (standard deviation, range) were 11.1 U/mL (11.6, 0–78) in cases and 13.6 U/mL (23.0, 1–164) in controls. H. pylori infection positivity rates were 41% and 42% in cases and controls, respectively. No significant differences in antibody titers or H. pylori infection positivity rates were found between cases and controls. Conclusions: We found no evidence of H. pylori infection as an important risk factor for gallbladder cancer in Indian people.

Prognostic validation of the updated 8th edition Tumor-Node-Metastasis classification by the Union for International Cancer Control: Survival analyses of 307 patients with surgically treated gallbladder carcinoma

In December 2016, the Union for International Cancer Control (UICC) published the 8th edition of the Tumor-Node-Metastasis (TNM) classification of malignant tumors, including a number of vital changes in the definitions of the T2 category, the N category and the stages of gallbladder cancer (GBC). The clinical value of this newly updated classification in patients with surgically treated GBC has not been rigorously validated. The present study aimed to analyze the prognosis of patients with GBC in a high-volume surgical unit, and to validate the prognostic value of the new UICC TNM classification, particularly the main changes in the stages of GBC. Data from 307 patients who were surgically treated and histopathologically diagnosed with GBC between January 2011 and July 2016 in The West China Hospital (Chengdu, Sichuan, China) were retrospectively collected and analyzed. The new UICC criteria distributed 32, 60, 99 and 116 eligible patients in stages I, II, III and IV, respectively. The differences in overall survival time between each stage (I–IV) demonstrated statistical significance (P<0.05). As a result of the main change of this classification, the novel definitions of T2a and T2b effectively stratified the prognosis of patients with T2 GBC (P<0.001). Furthermore, patients with stage IIa tumors also obtained significantly improved overall survival time compared with patients with stage IIb tumors (P=0.04), whereas the comparison between patients with stage IIb and IIIa tumors did not present any notable difference (P=0.20). Additionally, the new N category stratified the survival of the patients effectively (P<0.001). Together with curative resection, this latest classification was indicated to be an independent predictor of survival via multivariate analysis (hazard ratio, 6.25; 95% confidence interval, 3.81–10.26; P<0.001). In conclusion, the newly updated UICC TNM classification could effectively reflect the clinical outcome of patients with surgically treated GBC. Furthermore, tumor location could predict the survival of surgically treated T2 GBC. The novel classification of the N category by the number of lymph nodes involved was also demonstrated to be valid.

Impact of the number of examined lymph nodes on outcomes in patients with lymph node-negative gallbladder carcinoma

AIM

To determine whether the number of examined lymph nodes (LNs) is correlated with the overall survival of gallbladder carcinoma (GBC) patients.

METHODS

Patients were collected from the Surveillance Epidemiology and End Results database (2004-2013) and categorized by the number of LNs into six groups: 1 LN, 2 LNs, 3 LNs, 4 LNs, 5 LNs, and ≥ 6 LNs. Survival curves for overall survival were plotted with a Kaplan-Meier analysis. The log-rank test was used for univariate comparisons.

RESULTS

In a cohort of 893 patients, the median number of examined LNs was two for the entire cohort. The survival for the 1 LN group was significantly poorer than those of the stage I and II disease groups and for the entire cohort. By dichotomizing the number of LNs from 1 to 6, we found that the minimum number of LNs that should be examined was four for stage I, four or five for stage II, and six for stage IIIA disease. Therefore, for the entire cohort, the number of examined LNs should be at least six, which is exactly consistent with the American Joint Committee on Cancer criteria.

CONCLUSION

The examination of higher numbers of LNs is associated with improved survival after resection surgery for N0 GBC. The guidelines for GBC surgery, which recommend that six LNs be examined at least, are statistically valid and should be applied in clinical practice widely.

Targeted Gene Sequencing of Gallbladder Carcinoma Identifies High-impact Somatic and Rare Germline Mutations

BACKGROUND

Gallbladder carcinoma (GBC) is a subtype of biliary tract malignancy with poor prognosis and high fatality rate. The present study was designed to uncover somatic and rare germline mutations in GBC to reveal the disease biology and understand the clinical importance of mutation profile in terms of prognostics and actionability.

MATERIALS AND METHODS

We performed ultra-deep sequencing across 409 cancer-related genes in 11 GBC patients of North-Indian descent. NGS data analysis was performed using Ion Reporter and several other publicly available resources and databases.

RESULTS

We identified 184 nonsynonymous somatic and 60 rare germline mutations in bona-fide cancer drivers such as SMAD family member 4 (SMAD4), lysine methyltransferase 2C (KMT2C), and tumor protein p53 (TP53). All the early-onset cases or hypermutated cases harbored mutation(s) in critical DNA-repair genes. Additionally, we detected 9 novel genes with high-impact somatic mutations in GBC.

CONCLUSION

Our results indicated the significance of inherited rare germline mutations in DNA-repair pathway genes in addition to acquired somatic mutations in GB carcinogenesis.

Gallbladder cancer: review of a rare orphan gastrointestinal cancer with a focus on populations of New Mexico

Gallbladder cancer is a rare malignancy of the biliary tract with a poor prognosis, frequently presenting at an advanced stage. While rare in the United States overall, gallbladder cancer has an elevated incidence in geographically distinct locations of the globe including Chile, North India, Korea, Japan and the state of New Mexico in the United States. People with Native American ancestry have a much elevated incidence of gallbladder cancer compared to Hispanic and non-Hispanic white populations of New Mexico. Gallbladder cancer is also one of the few bi-gendered cancers with an elevated female incidence compared to men. Similar to other gastrointestinal cancers, gallbladder cancer etiology is likely multi-factorial involving a combination of genomic, immunological, and environmental factors. Understanding the interplay of these unique epidemiological factors is crucial in improving the prevention, early detection, and treatment of this lethal disease. Previous studies have failed to identify a distinct genomic mutational profile in gallbladder cancers, however, work to identify promising clinically actionable targets is this form of cancer is ongoing. Examples include, interest in the HER2/Neu signaling pathway and the recognition that chronic inflammation plays a crucial role in gallbladder cancer pathogenesis. In this review, we provide a comprehensive overview of gallbladder cancer epidemiology, risk factors, pathogenesis, and treatment with a specific focus on the rural and Native American populations of New Mexico. We conclude this review by discussing future research directions with the goal of improving clinical outcomes for patients of this lethal malignancy.

Prevalence of gallbladder cancer In patients submitted to cholecystectomy: experience of the University Hospital, Faculty of Medical Sciences, State University of Campinas - UNICAMP

Objective:

to evaluate the prevalence of gallbladder carcinoma in patients submitted to cholecystectomy for chronic cholecystitis at the University Hospital of the State University of Campinas.

Methods:

we conducted a retrospective prevalence study through the analysis of histological specimens from January 2010 to May 2015.

Results:

we analyzed 893 patient reports. Emergency cholecystectomies amounted to 144, and elective ones, 749 (16.2% and 83.8%, respectively). Regarding gender, 72.8% were female and 27.2% male. Gallbladder adenocarcinoma occurred in 12 patients (1.3%) and non-Hodgkin's lymphoma in one (0.1%). In patients with cancer, seven (53.8%) were associated with cholelithiasis and two (15.3%) with gallbladder polyps.

Conclusion:

prevalence results of gallbladder adenocarcinoma in this study were similar to those of Western studies and the main risk factor was cholelithiasis, followed by the presence of gallbladder polyps.

[Management of Gallstone]

Gallstones are one of the most common diseases worldwide. Recently, the incidence of gallstones has increased and the pattern of gallstones has changed in Korea. Laparoscopic cholecystectomy is the standard treatment for symptomatic gallstones. Expectant management is considered the most appropriate choice in patients with asymptomatic gallstones. The dissolution of cholesterol gallstones by oral bile acid, such as ursodeoxycholic acid, can be considered in selected patients with gallstones. Although the advent of laparoscopic cholecystectomy has moved interest away from the pharmacologic treatment of gallstones, several promising agents related to various mechanisms are under investigation.

Liquid biopsy of bile for the molecular diagnosis of gallbladder cancer

INTRODUCTION

Tissue sampling of gallbladder cancer (GBCa) is challenging because of the anatomy of the gallbladder. The aim of this study is to investigate the possibility of diagnosing GBCa patients by performing a liquid biopsy of bile in addition to current diagnostic methods.

METHODS

Thirty patients with GBCa were enrolled in this study. Cytological examination was performed in all patients. Using next generation sequencing (NGS), DNA isolated from the bile and tumor tissue was analyzed for mutations in 49 oncogenes. We also compared these mutations with cytology results.

RESULTS

57.1% of DNA samples from tumor tissue were positive for a mutation. In these patients, 87.5% of the bile circulating tumor DNA (ctDNA) samples had the same mutation. The concordance rate between bile ctDNA and tissue DNA samples was 85.7%, and the mutation frequencies detected in ctDNA were approximately half of what was detected in tumor tissue DNA. On the other hand, the sensitivity of the cytological and bile ctDNA analyses was 45.8% and 58.3%, respectively. The concordance rate between cytology and bile ctDNA analyses was 87.5%.

CONCLUSIONS

Mutated tumor DNA could be detected in bile by NGS. Liquid biopsy of bile might help us to diagnose GBCa because of higher sensitivity and positive predict value compared to cytology with ERCP.

The risk of incidental gallbladder cancer is negligible in macroscopically normal cholecystectomy specimens

BACKGROUND

Cholecystectomy is usually carried out for benign indications. Most perform routine histopathologic examination to detect incidental gallbladder cancer (GBC).

METHODS

Cholecystectomies performed at four hospitals in the Helsinki Metropolitan Area during 2010-2012 were analyzed retrospectively. Patients with preoperative suspicion of neoplasia, active malignancy, or in whom cholecystectomy was performed as a secondary procedure were excluded.

RESULTS

A total of 2034 cholecystectomies were included. In ten patients (0.5%), GBC was identified, each with an associated macroscopic finding, including local hardness (n = 1), a thickened wall (n = 5), acute inflammation and necrosis (n = 1), or suspected neoplasia (n = 3). No GBC was found in macroscopically normal gallbladders (n = 1464). Of the ten patients with GBC, five underwent subsequent liver resection, four had metastatic disease, and one had locally advanced inoperable disease. Three of the five patients who underwent liver resection were alive and disease-free at final follow-up (median 48 months). The remaining seven patients with GBC died of the disease, with a median survival of 14 months (range 10-48 months).

CONCLUSIONS

Routine histopathologic examination of a macroscopically normal gallbladder does not improve diagnosis of GBC. A histopathological examination is, however, mandatory when a macroscopic abnormality is present.

Metagenomics of Microbial Communities in Gallbladder Bile from Patients with Gallbladder Cancer or Cholelithiasis

Salmonella typhi and Helicobacter infections have been shown to increase risk of gallbladder cancer (GBC), but findings have been inconsistent. Other bacterial infections may also be associated with GBC. However, information on microbial pathogens in gallbladder bile of GBC patients is scarce. We aimed to investigate the microbial communities in gallbladder bile of patients with GBC and cholelithiasis (CL). Seven GBC patients and 30 CL patients were enrolled in this study. Genomic DNA was extracted from bile and the V3-V4 region of 16S rRNA was amplified. The sequencing results were compared with the 16S database, and the bacteria were identified by homology searches and phylogenetic analysis. DNA was detected in the bile of three GBC (42.9%; Bolivia, 1; Chile, 2) and four CL patients (13.3%; Bolivia, 1; Chile, 3). Of the 37 patients, 30 (81.1%) were negative and unable to analyze. Salmonella typhi and Helicobacter sp. were not detected in bile from any GBC patients. As the predominant species, Fusobacterium nucleatum, Escherichia coli, and Enetrobacter sp. were detected in bile from GBC patients. Those in bile from CL patients were Escherichia coli, Salmonella sp., and Enerococcus gallinarum. Escherichia coli was detected in bile samples from both GBC and CL patients. Whether the bacteria detected in bile from GBC patients would associated with the development of GBC warrant further investigation.

Trends of Gallbladder Cancer in Jordan Over 2 Decades: Where Are We?

Background and Study Aims:

The prevalence of gallbladder cancer (GBC) varies between different parts of the world. This study is a review of literature and an update of a previously published study conducted in our university and aims to reassess the incidence of GBC over the past 2 decades.

Patients and Methods:

We conducted a retrospective study between 2002 and 2016. Data regarding demographics, clinical presentation, risk factors, histopathology, investigations, and treatments were obtained. A diagnosis of GBC established during surgery or primarily detected in the surgical specimen was classified as incidental.

Results:

Of 11 391 cholecystectomies performed, 31 cases (0.27%) of GBC were found. The mean age of patients with GBC was 68 years (43-103 years), 74% were women. The annual incidence of GBC was 0.2/100 000 (men: 0.1/100 000; women: 0.3/100 000). Biliary colic and acute cholecystitis were the main presentations. Diagnosis of GBC was “incidental” in 67% of cases. About 75% of patients with GBC had gallstones, 13% had polyps, and 3% had porcelain gallbladder. Adenocarcinoma was the dominant (87%) histologic type.

Conclusions:

The GBC rate in our region, similar to others parts of the world, is still low and has not changed over the past 2 decades. This study consolidates the previously published recommendations regarding the high index of suspicion of GBC in elderly with cholelithiasis.