Hepatic metastases from carcinoma of the gallbladder

Bi-segmentectomy versus wedge hepatic resection in extended cholecystectomy for T2 and T3 gallbladder cancer: A matched case-control study

Backgrounds/Aims

Extended cholecystectomy (EC) is the mainstay of treatment in most patients with potentially curable gallbladder cancer (GBC). The optimum extent of hepatic resection in EC is debatable.

Methods

This retrospective study was conducted on patients with GBC who received EC from May 2009 to February 2019. Based on the extent of hepatic resection, patients were divided into ECB (EC involving bi-segmentectomy s4b&5) and ECW (EC involving wedge hepatic resection) groups. Patients with T1 GBC, T4 GBC, and benign diseases were excluded. Post-exclusion, both groups were matched for T and N stage. Matched groups were then compared.

Results

Out of a total of 161 patients who received EC, 86 patients had ECB and 75 patients had ECW. After exclusion and matching, both ECB and ECW groups had 35 patients. Their demographic and clinical profiles were comparable. Surgical blood loss (p = 0.005) and postoperative complication rate (p = 0.035) were significantly less in the ECB group. For ECB vs. ECW, mean recurrence-free survival (RFS) was 58.2 months vs. 42.3 months (p = 0.264) and overall survival (OS) was 61.5 months vs. 43.4 months (p = 0.161). On univariate analysis, higher T and N stages were associated with poor prognosis. On multivariate analysis, higher T stage, N stage, and American Society of Anaesthesiologists grade were associated with poor RFS and OS.

Conclusions

The survival after ECB for T2 and T3 GBC was not significantly superior to that after ECW. However, surgical blood loss and postoperative complications were lower following ECB.

Clinical practice guidelines for the management of biliary tract cancers 2019: The 3rd English edition

BACKGROUND

The Japanese Society of Hepato-Biliary-Pancreatic Surgery launched the clinical practice guidelines for the management of biliary tract cancers (cholangiocarcinoma, gallbladder cancer, and ampullary cancer) in 2007, then published the 2nd version in 2014.

METHODS

In this 3rd version, clinical questions (CQs) were proposed on six topics. The recommendation, grade for recommendation, and statement for each CQ were discussed and finalized by an evidence-based approach. Recommendations were graded as Grade 1 (strong) or Grade 2 (weak) according to the concepts of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system.

RESULTS

The 31 CQs covered the six topics: (a) prophylactic treatment, (b) diagnosis, (c) biliary drainage, (d) surgical treatment, (e) chemotherapy, and (f) radiation therapy. In the 31 CQs, 14 recommendations were rated strong and 14 recommendations weak. The remaining three CQs had no recommendation. Each CQ includes a statement of how the recommendations were graded.

CONCLUSIONS

This latest guideline provides recommendations for important clinical aspects based on evidence. Future collaboration with the cancer registry will be key for assessing the guidelines and establishing new evidence.

Validation of the 8th Edition of the American Joint Committee on Cancer Staging System for Gallbladder Cancer and Implications for the Follow-up of Patients without Node Dissection

PURPOSE

The 8th edition of gallbladder cancer staging in the American Joint Committee on Cancer (AJCC) staging system changed the T and N categories.

MATERIALS AND METHODS

In order to validate the new staging system, a total of 348 surgically resected gallbladder cancers were grouped based on the 8th edition of the T and N categories and compared with patients' survival.

RESULTS

Significant differences were noted between T1b-T2a (p=0.003) and T2b-T3 (p < 0.001) tumors, but not between Tis-T1a, T1a-T1b, and T2a-T2b tumors. However, significant survival differences were observed both by the overall and pair-wise (T1-T2, T2-T3) comparisons (all, p < 0.001) without dividing T1/T2 subcategories. When cases with ≥ 6 examined lymph nodes were evaluated, significant survival differences were observed among the entire comparison (p < 0.001) and pair-wise comparisons of N0-N1 (p=0.001) and N1-N2 (p=0.039) lesions. When cases without nodal dissection (NX) were additionally compared, significant survival differences were observed between patients with N0-NX (p=0.001) and NX-N1 (p < 0.001) lesions.

CONCLUSION

The T category in the 8th edition of the AJCC staging system did not completely stratify the prognosis of patients with gallbladder cancer. Modification by eliminating T subcategories can better stratify the prognosis. In contrast, the N category clearly determines patients' survival with ≥ 6 examined lymph nodes. The survival time in patients of gallbladder cancers without nodal dissection is between N0 and N1 cases. Therefore, close postoperative followed up is recommended for those patients.

Incidental versus non-incidental gallbladder cancer: index cholecystectomy before oncologic re-resection negatively impacts survival in T2b tumors

BACKGROUND

Conflicting data exists whether non-oncologic index cholecystectomy (IC) leading to discovery of incidental gallbladder cancer (IGBC) negatively impacts survival. This study aimed to determine whether a subgroup of patients derives a disadvantage from IC.

METHODS

Patients with IGBC and non-IGBC treated at an academic USA and Chilean center during 1999-2016 were compared. Patients with T1, T4 tumor or preoperative jaundice were excluded. T2 disease was classified into T2a (peritoneal-side tumor) and T2b (hepatic-side tumor). Disease-specific survival (DSS) and its predictors were analyzed.

RESULTS

Of the 196 patients included, 151 (77%) had IGBC. One hundred thirty-six (90%) patients of whom 118 (87%) had IGBC had T2 disease. Three-year DSS rates were similar between IGBC and non-IGBC for all patients. However, for T2b patients, 3-year survival rate was worse for IGBC (31% vs 85%; p = 0.019). In multivariate analysis of T2 patients, predictors of poor DSS were hepatic-side tumor hazard ratio [HR], 2.9; 95% CI, 1.6-5.4; p = 0.001) and N1 status (HR, 2.4; 95% CI, 1.6-3.6; p < 0.001).

CONCLUSIONS

Patients with T2b gallbladder cancer specifically benefit from a single operation. These patients should be identified preoperatively and referred to hepatobiliary center.

Clinical strategies for differentiating IgG4-related cholecystitis from gallbladder carcinoma to avoid unnecessary surgical resection

Immunoglobulin G4 (IgG4)-related cholecystitis (IgG4-C) is often difficult to distinguish from gallbladder carcinoma (GBC). This study aimed to determine a practical strategy for differentiating between IgG4-C and GBC to avoid unnecessary surgical resection. The expression of IgG4 in the gallbladder was detected by immunohistochemistry. The clinicopathological and radiological characteristics of IgG4-C patients and GBC patients were analyzed retrospectively. Immunohistochemistry revealed that IgG4 was upregulated in the plasma cells of IgG4-C tissues. The median serum total bilirubin levels were significantly higher in the patients with IgG4-C than in those with GBC (45.8 µmol L^-1 vs. 29.9 µmol L^-1). The serum γ-GGT levels were higher in IgG4-C patients than in GBC patients, whereas the serum levels of CA125 were significantly higher in GBC patients than in IgG4-C patients. The imaging scans were helpful for differentiating IgG4-C from GBC based on the presence of a layered pattern and Rokitansky-Aschoff sinuses in the gallbladder wall. There were no statistically significant differences in age, presence of abdominal pain, level of emaciation between the two groups. Our study demonstrated that the combination of imaging with serum total bilirubin, γ-GGT and CA125 levels can offer added preoperative diagnostic value and reduce the rate of IgG4-C misdiagnosis.

Clinical implication of surgical resection for recurrent biliary tract cancer: Does it work or not?

Although recent advances in imaging diagnosis, surgical techniques, and perioperative management can result in increased resectability and improved surgical outcomes, most resected patients still develop cancer recurrence. If patients develop cancer recurrence, their prognosis is very ominous. However, there have been some recent reports to show promising outcomes by aggressive surgical strategy in selected patients who developed cancer recurrence. Because there are various surgical procedures being selected at initial surgery in patients with biliary tract cancers, recurrent patterns after resection are very variable in each patient. However, surgical procedures might usually be very complicated and difficult if re‐surgical resection is considered in patients with recurrent biliary tract cancer, Therefore, surgical re‐resection could bring about high surgical morbidity and mortality rates in most previously reported series. Although re‐surgical resection might offer a chance of favorable outcome in selected patients with biliary tract cancers, these aggressive surgical approaches should be carried out in strictly selected patients by expert surgeons at high‐volume centers.

Rates and patterns of recurrence after curative intent resection for gallbladder cancer: a multi-institution analysis from the US Extra-hepatic Biliary Malignancy Consortium

BACKGROUND

Gallbladder cancer is a relatively rare malignancy. The current study aimed to define the incidence and patterns of recurrence following gallbladder cancer resection.

METHODS

Using a multi-institutional cohort we identified 217 patient undergoing curative intent surgery for gallbladder cancer. Patterns of recurrence were classified as locoregional and distant recurrence.

RESULTS

At last follow-up, 76 patients (35.0%) had experienced a recurrence (locoregional only, n = 12, 15.8%; distant only, n = 50, 65.8%; locoregional and distant, n = 14, 18.4%). Median time to recurrence was 9.5 months (IQR 4.7-17.6) and was not associated with recurrence site (all p > 0.05). On multivariable analysis, T3 disease (HR = 8.44, p = 0.014), lymphovascular invasion (HR = 4.24, p < 0.001) and residual disease (HR = 2.04, p = 0.042) were associated with an increased risk of recurrence. Patients who recurred demonstrated a worse 1-, 3- and 5-year OS (1-year OS: 91.3% vs. 68.6%, p = 0.001, 3-year OS: 79.3% vs. 28.7%, p < 0.001, and 5-year OS: 75.9% vs. 16.0%, p < 0.001). After adjusting for other risk factors, recurrence was independently associated with a decreased OS (HR = 3.71, p = 0.006). Of note, receipt of adjuvant therapy was associated with improved OS (HR = 0.56, p = 0.027) among those patients who developed a tumor recurrence.

DISCUSSION

Over one-third of patients experienced a recurrence after gallbladder cancer surgery. While chemotherapy did not decrease the rate of recurrence, patients who experienced recurrence after administration of adjuvant treatment faired better than patients who did not receive adjuvant therapy.

Tumor location is a strong predictor of tumor progression and survival in T2 gallbladder cancer: an international multicenter study

OBJECTIVE

To determine the prognostic impact of tumor location in gallbladder cancer.

BACKGROUND

Depth of tumor is a strong predictor of survival after curative resection of gallbladder cancer. However, the gallbladder has a unique anatomical relationship with the liver, and the clinical significance of tumor location remains unclear.

METHODS

For 437 patients with gallbladder cancer who underwent resection at 4 international institutions, clinicopathologic characteristics and their association with survival were analyzed. Tumor location was defined as "hepatic side" or "peritoneal side," and the prognostic significance of tumor location was evaluated.

RESULTS

Among the 252 patients with T2 disease, patients with tumors on the hepatic side (T2h, n = 99) had higher rates of vascular invasion, neural invasion, and nodal metastasis than patients with tumors on the peritoneal side (T2p, n = 153) (51% vs 19%, 33% vs 8%, and 40% vs 17%, respectively; P < 0.01 for all). After a median follow-up of 58.9 months, 3-year and 5-year survival rates were 52.1% and 42.6%, respectively, for T2h tumors and 73.7% and 64.7%, respectively, for T2p tumors (P = 0.0006). No such differences were observed in T1 or T3 tumors. Multivariate analysis confirmed the independent association of hepatic-side location with survival in T2 tumors (hazard ratio, 2.7; 95% confidence interval, 1.7-4.2; P < 0.001). This subclassification of T2 tumors predicted recurrence in the liver (23% vs 3%; P = 0.003) and distant lymph nodes (16% vs 3%; P = 0.019) even after radical resection.

CONCLUSIONS

After curative resection of T2 gallbladder cancer, tumor location predicts the pattern of recurrence and survival.

"Extended" radical cholecystectomy for gallbladder cancer: Long-term outcomes, indications and limitations

AIM: To delineate indications and limitations for "extended" radical cholecystectomy for gallbladder cancer: a procedure which was instituted in our department in 1982.

METHODS: Of 145 patients who underwent a radical resection for gallbladder cancer from 1982 through 2006, 52 (36%) had an extended radical cholecystectomy, which involved en bloc resection of the gallbladder, gallbladder fossa, extrahepatic bile duct, and the regional lymph nodes (first- and second-echelon node groups). A retrospective analysis of the 52 patients was conducted including at least 5 years of follow up. Residual tumor status was judged as no residual tumor (R0) or microscopic/macroscopic residual tumor (R1-2). Pathological findings were documented according to the American Joint Committee on Cancer Cancer Staging Manual (7th edition).

RESULTS: The primary tumor was classified as pathological T1 (pT1) in 3 patients, pT2 in 36, pT3 in 12, and pT4 in 1. Twenty-three patients had lymph node metastases; 11 had a single positive node, 4 had two positive nodes, and 8 had three or more positive nodes. None of the three patients with pT1 tumors had nodal disease, whereas 23 of 49 (47%) with pT2 or more advanced tumors had nodal disease. One patient died during the hospital stay for definitive resection, giving an in-hospital mortality rate of 2%. Overall survival (OS) after extended radical cholecystectomy was 65% at 5 years and 53% at 10 years in all 52 patients. OS differed according to the pT classification (P < 0.001) and the nodal status (P = 0.010). All of 3 patients with pT1 tumors and most (29 of 36) patients with pT2 tumors survived for more than 5 years. Of 12 patients with pT3 tumors, 8 who had an R1-2 resection, distant metastasis, or extensive extrahepatic organ involvement died soon after resection. Of the remaining four pT3 patients who had localized hepatic spread through the gallbladder fossa and underwent an R0 resection, 2 survived for more than 5 years and another survived for 4 years and 2 mo. The only patient with pT4 tumor died of disease soon after resection. Among 23 node-positive patients, 11 survived for more than 5 years, and of these, 10 had a modest degree of nodal disease (one or two positive nodes).

CONCLUSION: Extended radical cholecystectomy is indicated for pT2 tumors and some pT3 tumors with localized hepatic invasion, provided that the regional nodal disease is limited to a modest degree (up to two positive nodes). Extensive pT3 disease, pT4 disease, or marked nodal disease appears to be beyond the scope of this radical procedure.

Extended right hemihepatectomy for gallbladder carcinoma involving the hepatic hilum

BACKGROUND

Major hemihepatectomy for advanced gallbladder carcinoma remains controversial as it is associated with serious postoperative complications and poor prognosis.

METHODS

All those who underwent extended right hemihepatectomy were identified from a database of patients with gallbladder carcinoma who had surgical resection between 1999 and 2009. The clinicopathological data for these patients were analysed retrospectively.

RESULTS

A total of 126 patients underwent surgical resection, 35 of whom had extended right hemihepatectomy. There were no deaths, but 16 patients had complications. The mean(s.d.) duration of operation and blood loss were 564(206) min and 1472(1268) ml respectively. No blood transfusions were needed in 28 patients. Tumour stage (International Union Against Cancer, sixth edition) was IIA in four, IIB in four, III in 15 and IV in 12 patients. The overall 5-year survival rate was 17 per cent with a median survival of 2·2 years. Three patients survived more than 5 years. The presence of hepatic metastases and gallbladder carcinoma originating from the cystic duct were indicators of poor prognosis.

CONCLUSION

Extended right hemihepatectomy for gallbladder cancer is safe and may contribute to long-term survival in selected patients.

Reduced expression of Raf-1 kinase inhibitory protein is a significant prognostic marker in patients with gallbladder carcinoma

Gallbladder carcinoma is one of the most aggressive malignancies. It is usually diagnosed at an advanced stage, and the prognosis remains poor despite advances in imaging techniques and aggressive surgical treatment. Because of the lack of reliable prognostic markers, the aim of this study was to investigate the prognostic significance of Raf-1 kinase inhibitory protein expression in gallbladder carcinomas. Immunostaining for Raf-1 kinase inhibitory protein was performed on chronic cholecystitis, adenoma, carcinoma in situ, and primary and nodal metastatic gallbladder carcinoma. Raf-1 kinase inhibitory protein expression was reduced in 68.8% (11/16) and 42.3% (44/104) of nodal metastatic and primary gallbladder carcinoma cases, respectively, but in no case of carcinoma in situ, adenoma, or chronic cholecystitis. The differences in Raf-1 kinase inhibitory protein expression in gallbladder carcinoma versus nongallbladder carcinoma tissues (P < .001), and in nodal metastatic gallbladder carcinoma versus primary gallbladder carcinoma (P = .009), were statistically significant. Kaplan-Meier curves showed that patients with Raf-1 kinase inhibitory protein-negative or weakly positive gallbladder carcinoma had a significantly shorter overall survival than did patients with Raf-1 kinase inhibitory protein-positive gallbladder carcinoma (median, 14 versus 120 months; P = .011). Multivariate survival analysis showed that reduced Raf-1 kinase inhibitory protein expression was an independent prognostic predictor for overall survival (P = .020). Our results suggest that reduction in Raf-1 kinase inhibitory protein expression in gallbladder carcinoma contributes to invasion and metastasis and is a significant prognostic marker in patients with gallbladder carcinoma.

Mode of hepatic spread from gallbladder carcinoma: an immunohistochemical analysis of 42 hepatectomized specimens

This study aimed to clarify the mode of hepatic spread from gallbladder carcinoma and to elucidate its prognostic value. A retrospective analysis was conducted of 42 consecutive patients who underwent resection for gallbladder carcinoma with hepatic involvement verified histologically. The mode of hepatic spread was classified into 3 patterns: direct invasion through the gallbladder bed, portal tract invasion, and hepatic metastatic nodules. Intrahepatic lymphatic invasion was declared when either single tumor cells or cell clusters were clearly visible within vessels that showed immunoreactivity to the D2-40 monoclonal antibody. Seven, 24, and 11 patients had direct invasion alone, portal tract invasion with (22 patients) or without (2 patients) direct invasion, and hepatic metastatic nodules, respectively. Of the 24 patients with portal tract invasion, 14 had intrahepatic lymphatic invasion, 8 had neither intrahepatic lymphatic nor venous invasion, and 2 had both intrahepatic lymphatic and venous invasion. To date, 4 patients with direct invasion alone and 4 patients with portal tract invasion survived more than 5 years after resection, whereas all the patients with hepatic metastatic nodules died within 11 months after resection, irrespective of the type of hepatectomy. The mode of hepatic spread (P<0.001) was a strong independent prognostic factor. Direct liver invasion and portal tract invasion, which features intrahepatic lymphatic invasion, are the main modes of hepatic spread from resectable gallbladder carcinoma. The mode of hepatic spread independently predicts long-term survival after resection for patients with gallbladder carcinoma. Hepatic metastatic nodules indicate a dismal outcome after resection.

Evaluation of cholecystic venous flow using indocyanine green fluorescence angiography

BACKGROUND/PURPOSE

The cholecystic veins are thought to be an important metastatic route of gallbladder carcinoma to the liver. In the present study we evaluated the cholecystic venous drainage area, utilizing a novel method, indocyanine green (ICG) fluorescence angiography after superselective catheterization of the cholecystic artery, to detect and elucidate cholecystic venous flow.

METHODS

Cannulation of the cholecystic artery was performed under laparotomy in nine patients who required a cholecystectomy. After ICG injection into the cholecystic artery, the cholecystic venous flow images were visualized with a near-infrared camera system and were analyzed according to site, shape, and time of fluorescence.

RESULTS

Fluorescence images of the cholecystic venous flow could be viewed as real-time images in all patients. We demonstrated that the route of the cholecystic venous flow could be classified into two patterns: type 1, in which the cholecystic veins flowed directly into the hepatic parenchyma adjacent to the gallbladder; and type 2, in which the veins flowed into sites separate from the gallbladder. In the type 1 pattern, fluorescence was observed in segment (S; defined according to Couinaud's nomenclature) 4a or S5 adjacent to the gallbladder in all cases. On the other hand, in the type-2 pattern, fluorescence was observed in S4a (6/9), S5 (8/9), S4b (2/9), S3 (2/9), S1 (1/9), S2 (1/9), and S8 (1/9) distant from the gallbladder. Overall, two-thirds of the cases showed fluorescence in segments other than S4a or S5.

CONCLUSIONS

Indocyanine green (ICG) fluorescence angiography is considered to be a useful method to detect and elucidate cholecystic venous flow in real time. This study showed that the cholecystic venous flow spread to the liver through two different pathways, one that flowed directly into the hepatic parenchyma adjacent to the gallbladder, while the other flowed into sites separate from the gallbladder. Taking these findings into consideration, we may therefore need to reconsider the preventive effects of a hepatic resection.

Fascin overexpression correlates with positive thrombospondin-1 and syndecan-1 expressions and a more aggressive clinical course in patients with gallbladder cancer

BACKGROUND/PURPOSE

This study was conducted to evaluate the prognostic role of fascin expression in gallbladder (GB) cancer and to define the relationship of thrombospondin-1 (TSP-1) and syndecan-1 in fascin expression.

METHODS

We performed immunohistochemical detection of fascin, TSP-1, and syndecan-1 in 43 tissue samples from GB cancer patients who underwent macroscopic complete resection.

RESULTS

There were 19 (44%) and 24 (56%) cases having low- and high-grade fascin expression, respectively. The tumors with high-grade fascin expression tended to more frequently show poorer differentiation, deeper invasion depth, lymph node metastasis, a higher American Joint Committee on Cancer stage, and recurrence (each P < 0.05). The patients with high-grade fascin expression had significantly shorter survival periods than those with low-grade fascin expression (P < 0.05). The frequency of positive TSP-1 or syndecan-1 expression in the cases with high-grade fascin expression was significantly higher than that in the cases with low-grade fascin expression (each P < 0.05).

CONCLUSIONS

These results suggest that a subset of advanced GB cancers revealed a marked overexpression of fascin, which was associated with aggressive clinicopathologic findings and poor overall survival. Furthermore, fascin, TSP-1, and syndecan-1 may act in concert to mediate a more aggressive clinical course through enhanced tumor cell motility.

Hepatic resection in 485 R0 pT2 and pT3 cases of advanced carcinoma of the gallbladder: results of a Japanese Society of Biliary Surgery survey--a multicenter study

PURPOSE

We conducted this study to evaluate the optimal hepatic resection for pT2 and pT3 advanced carcinoma of the gallbladder without invasion of the hepatoduodenal ligament.

METHODS

We conducted a questionnaire survey regarding 4,243 cases of carcinoma of the gallbladder treated during the recent 10-year period at 112 institutions belonging to the Japanese Society of Biliary Surgery. The questionnaires included questions on preoperative-diagnosis, complications, treatment, and surgical treatment, procedures of resection, surgical result, path histological findings, mode, and site of recurrence, additional post-operative treatment. They included 293 pT2 and 192 pT3 R0 cases, which were negative for hepatoduodenal ligament invasion, and the cumulative survival rates and sites of postoperative recurrence in the form of liver metastasis, were retrospectively analyzed in these 485 cases.

RESULT

There were no significant differences in survival rate or recurrence rates in the form of liver metastasis between the groups that underwent resection of the gallbladder bed, the group that underwent segmentectomy 4a+5, and the group that underwent hepatectomy in patients with of both pT2 or pT3 gallbladder cancers. Our results also did not show that liver metastasis to segment 4a5 alone was particularly common.

CONCLUSION

For gallbladder cancer, neither with hepatoduodenal ligament invasion nor hepatic invasion, resection of the gallbladder bed is more preferable for surgical hepatic procedure. For gallbladder cancer that invades any hepatic sites, a hepatic surgical procedure that could eliminate surgical margins would be desirable.

Intrahepatic lymphatic invasion independently predicts poor survival and recurrences after hepatectomy in patients with colorectal carcinoma liver metastases

BACKGROUND

D2-40 monoclonal antibody immunoreactivity is specific for lymphatic endothelium and therefore provides a marker of lymphatic invasion. We hypothesized that intrahepatic lymphatic invasion reflects the nodal status of colorectal carcinoma liver metastases and may function as an adverse prognostic factor.

METHODS

A retrospective analysis of 105 consecutive patients who underwent resection for colorectal carcinoma liver metastases was conducted. Intrahepatic lymphatic invasion was declared when either single tumor cells or cell clusters were clearly visible within vessels that showed immunoreactivity for D2-40 monoclonal antibody. The median follow-up time was 124 months.

RESULTS

Of 105 patients, 13 were classified as having intrahepatic lymphatic invasion. All tumor foci of intrahepatic lymphatic invasion were detected within the portal tracts. Intrahepatic lymphatic invasion was significantly associated with hepatic lymph node involvement (P = 0.039). Survival after resection was significantly worse in patients with intrahepatic lymphatic invasion (median survival time of 13 months; cumulative five-year survival rate of 0%) than in patients without (median survival time of 40 months; cumulative five-year survival rate of 41%; P < 0.0001). Patients with intrahepatic lymphatic invasion also showed decreased disease-free survival rates (P < 0.0001). Intrahepatic lymphatic invasion thus independently affected both survival (relative risk, 7.666; 95% confidence interval, 3.732-15.748; P < 0.001) and disease-free survival (relative risk, 4.112; 95% confidence interval, 2.185-7.738; P < 0.001).

CONCLUSIONS

Intrahepatic lymphatic invasion is associated with hepatic lymph node involvement and is an adverse prognostic factor in patients with colorectal carcinoma liver metastases.

Extended hepatic resection for gallbladder cancer

BACKGROUND

Although radical cholecystectomy is the standard of care for gallbladder cancers that invade perimuscular connective tissue or perforate visceral peritoneum, the role of extended right hepatectomy in achieving negative resection margins is not clear.

METHODS

Clinicopathologic, perioperative, and long-term outcome data were reviewed from patients who underwent hepatic resection for gallbladder cancer.

RESULTS

From 1995 to 2005, 22 consecutive patients underwent hepatic resection for gallbladder cancer, and 11 underwent extended hepatectomy. Negative resection margins were achieved in all patients. There were no significant differences in postoperative morbidity, mortality, and long-term survival after extended and minor hepatectomy. T3 tumors negatively predicted overall and recurrence-free survival.

COMMENTS

Extended hepatectomy achieves negative resection margins for patients with gallbladder cancer and is associated with acceptable morbidity and long-term survival.

Radical lymph node dissection for gallbladder cancer: indications and limitations

Radical lymph node dissection provides survival benefit for patients with pT2 or more advanced gallbladder carcinoma tumors only if potentially curative resection is feasible; it must always be considered when planning a resection or re-resection for robust patients with pT2 or more advanced gallbladder carcinoma tumors. The degree of radical lymphadenectomy depends on clinically assessed nodal status: portal lymph node dissection is limited to cN0 disease; extended portal nodal dissection is indicated for cN0 and a modest degree of cN1 disease; peripancreatic lymph node dissection with pancreaticoduodenectomy is indicated for selected cases of evident peripancreatic nodal disease and/or direct organ involvement. Extended resection with extensive lymphadenectomy should be limited to expert surgeons because it may cause serious morbidity and mortality.

Metastasis of primary gallbladder carcinoma in lymph node and liver

AIM: To evaluate the patterns with metastasis of gallbladder carcinoma in lymph nodes and liver.

METHODS: A total of 45 patients who had radical surgery were selected. The patterns with metastasis of primary gallbladder carcinoma in lymph nodes and liver were examined histopathologically and classified as TNM staging of the American Joint Committee on Cancer.

RESULTS: Of the 45 patients, 29 (64.4%) had a lymph node positive disease and 20 (44.4%) had a direct invasion of the liver. The frequency of involvement of lymph nodes was strongly influenced by the depth of the primary tumor (P = 0.0001). The postoperative survival rate of patients with negative lymph node metastasis was significantly higher than that of patients with positive lymph node metastasis (P = 0.004), but the postoperative survival rate of patients with N1 lymph node metastasis was not significantly different from that of patients with N2 lymph node metastasis (P = 0.3874). The postoperative survival rate of patients without hepatic invasion was significantly better than that of patients with hepatic invasion (P = 0.0177).

CONCLUSION: Complete resection of the regional lymph nodes is important in advanced primary gallbladder carcinoma (PGC). The initial sites of liver spread are located mostly in segments IV and V. It is necessary to achieve negative surgical margins 2 cm from the tumor. In patients with hepatic hilum invasion, extended right hepatectomy with or without bile duct resection or portal vein resection is necessary for curative resection.

Outcome of radical surgery for carcinoma of the gallbladder according to the tumor node metastasis and Japanese Society of Biliary Surgery stages

Primary carcinoma of the gallbladder is a progressive, lethal disease. Survival of patients with this neoplasm depends strictly on lymph node involvement and depth of tumor invasion. The aim of the study was to evaluate the results of our surgical series according to the tumor node metastasis and Japanese Society of Biliary Surgery classification systems. A retrospective analysis of our 15-year experience was performed. Of the 79 patients with gallbladder carcinoma observed at our institution between 1984 and 2001, a radical resection was carried out in 20 patients. Patients with stage I-II disease represent a minority of the cases of gallbladder carcinoma; the disease is localized in these patients, and surgical treatment provides the opportunity for good survival. Survival rates for patients with stage III-IV disease demonstrates that radical extended surgery offers the only chance for a relatively prolonged survival.

Microscopic liver metastasis: prognostic factor for patients with pT2 gallbladder carcinoma

Hepatic metastasis is the most frequent mode of recurrence of advanced gallbladder cancer after radical resection. The aims of this study were to clarify the clinical significance of microscopic liver metastasis from pT2 gallbladder cancer and to clarify whether partial hepatectomy can prevent hepatic recurrence in patients with microscopic liver metastasis. The subjects included 20 patients with pT2 tumors who underwent radical surgery and partial hepatectomy with lymph node dissection. Microscopic liver metastasis was defined as a distant metastatic nodule including cancer cell nests in the lumen of the portal vein and discrete nodular lesions in the liver, all less than 5 mm in diameter. Cox's proportional hazard regression was used to analyze factors that contributed to outcomes. Microscopic metastases were detected in the resected livers from 5 of 20 patients. There were more metastatic lesions within 1 cm of the gallbladder bed than were located 1 to 2 cm away from it. Microscopic liver metastases showed a strong correlation with the extent of blood vessel invasion around the primary tumor and were frequently detected in patients with a primary tumor localized on the hepatic side and with more than 3 cm of subserosal invasion. In four of five patients with microscopic liver metastases, recurrence was found in the remnant liver, which led to death within 15 months after the initial operation. Microscopic liver metastasis, operative curability, and lymph node metastasis were assessed as independent prognostic factors. A large proportion of patients with microscopic liver metastasis suffered from hepatic recurrence. Our results suggest that partial hepatectomy alone cannot prevent hepatic recurrence in patients with microscopic liver metastasis.

Appraisal of surgical treatment for pT2 gallbladder carcinomas

This retrospective study was designed to appraise the surgical procedures for pT2 gallbladder (GB) carcinomas. Twenty patients with pT2 GB carcinomas underwent surgical resection. Hepatectomy of segments 4b and 5 was performed in 19 patients, and an extended right hepatic lobectomy was performed in 1. The extrahepatic bile duct was preserved in 8 patients in whom the disease was limited to the GB fundus and/or body. Regional lymphadenectomy was performed in 18 patients. A separate radical second operation was performed in 8 patients after cholecystectomy. Final pathological staging was stage IB in 15 patients, IIB in 4, and IV in 1. Overall 5-year survival rate in those 20 patients was 77% without operative deaths. The 5-year survival rate in 5 patients with nodal metastasis and in 8 patients without extrahepatic biliary resection was 80% and 100%, respectively. A separate radical second operation in 8 patients yielded 75% survival after 5 years. Perineural invasion as a prognostic determinant was closely associated with tumor extending to the neck or the cystic duct. Partial hepatectomy, usually with extrahepatic biliary resection and regional lymphadenectomy, was appropriate as a standard radical operation for pT2 GB carcinoma, but preservation of extrahepatic bile duct is advocated for disease limited to the GB fundus and/or body. Radical second operation enhanced the chance for cure in patients with pT2 GB carcinoma.

Depth of subserosal invasion predicts long-term survival after resection in patients with T2 gallbladder carcinoma

BACKGROUND

This study aimed to identify a subgroup of patients with inapparent T2 gallbladder carcinoma who may be best suited for radical second resection.

METHODS

A retrospective analysis was conducted of 126 patients with pathologic stage T2 (pT2) gallbladder carcinoma (51 with clinically evident tumor and 75 with inapparent tumor). Depth of subserosal invasion was measured histologically in each gallbladder specimen. The median follow-up period was 113 months.

RESULTS

In all 126 patients, depth of subserosal invasion was the strongest independent prognostic factor by univariate (P <.0001) and multivariate (relative risk, 9.27; P <.0001) analyses. Among the 75 patients with inapparent tumor, the outcome after resection was significantly better in patients who had undergone radical second resection than in patients who had undergone cholecystectomy alone (P =.0006). When depth of subserosal invasion was divided into <or=2 vs. >2 mm, the effectiveness of radical second resection remained only in patients with subserosal invasion >2 mm (P =.0004).

CONCLUSIONS

Depth of subserosal invasion best predicts postresectional long-term survival of pT2 gallbladder carcinoma patients. Among patients with inapparent pT2 tumors, those with subserosal invasion >2 mm are good candidates for radical second resection.

Liver metastasis from gallbladder carcinoma: anatomic correlation with cholecystic venous drainage demonstrated by helical computed tomography during injection of contrast medium in the cholecystic artery

BACKGROUND

The current study evaluated whether the sites of liver metastasis from gallbladder carcinoma are correlated with areas of cholecystic venous drainage (CVD) utilizing helical computed tomography (CT) during the injection of contrast medium into the cholecystic artery (cholecystic artery CT).

METHODS

Cholecystic artery CT scans were performed in 26 patients with gallbladder carcinoma. Liver metastases were examined retrospectively in these patients on CT, and the sites of liver metastasis and CVD were compared closely. The patients were divided into concurrent (those who had metastasis at the time of cholecystic artery CT), early postoperative metastasis (those who developed metastasis within 6 months after surgery), and late postoperative metastasis (those who developed metastasis more than 6 months after surgery) groups. The frequency of metastasis related to CVD was compared between the three groups.

RESULTS

A total of 32 metastases were identified in 11 patients, 21 of which were related to CVD. Six patients were included in the concurrent metastasis group; 18 of 20 tumors were found to be related closely to CVD. There were two patients in the early postoperative metastasis group; all three of the tumors detected were found to be closely related to CVD. Three patients were subclassified as being in the late postoperative metastasis group; none of the nine tumors detected appeared to be in areas associated with CVD.

CONCLUSIONS

The sites of liver metastases were found to be well correlated with the areas with CVD, particularly in the concurrent and early postoperative metastasis groups. CVD may be a useful marker of potential areas of liver metastasis from gallbladder carcinoma, particularly in patients with early stage metastasis.

Intrahepatic inflow areas of the drainage vein of the gallbladder: analysis by angio-CT

BACKGROUND

The drainage veins of the gallbladder (cystic veins) are important hepatic metastatic routes of gallbladder cancer. We studied the cystic vein inflow portions of the intrahepatic vessels by computed tomography during angiography (angio-CT).

METHODS

The subjects were 27 unoperated pancreatic-biliary patients. After superselective catheterization of the cystic artery, angio-CT was performed, and cystic veins and sinusoidal filling were visualized. We identified the cystic vein inflow routes and the vessels they fed.

RESULTS

We found 72 cystic veins in 26 patients. All cystic veins flowed into the intrahepatic portal branches or sinusoids. The cystic veins took either of two routes: one into the liver through the hepatic hilum (17 patients, 21 veins), taken mainly by the portal branch for subsegment 4a (P4a), the anterior portal branch, and the umbilical portion of the portal branch; and the other through the hepatic bed (23 patients, 51 veins), taken mainly by S4a sinusoid, S5 sinusoid, P4a, and P5.

CONCLUSIONS

Angio-CT is useful for detecting the cystic vein inflow portions of the intrahepatic vessels. It makes possible identification of areas where there is a possibility for micrometastasis of the gallbladder cancer.

Radical surgery for gallbladder cancer: current options

Gallbladder carcinoma is the most common malignancy of the biliary tract. There are still many controversies regarding the type of curative surgical treatment for each stage of the disease. The staging system used is the TNM classification of the International Union Against Cancer. Different patterns of spread characterize gallbladder cancer but the two main types are direct invasion and lymph node metastases; since only the depth of invasion can be easily recognized by imaging techniques, it becomes the main variable in choosing the appropriate surgical treatment. Most Tis and T1 tumours are incidentally discovered after cholecystectomy for cholelithiasis and no further therapy is requested; for pT1b tumours, relaparotomy with hepatic resection and N1 dissection is associated with a better survival. For T2 tumours, cholecystectomy with hepatic resection and dissection of N1-2 lymph nodes is the standard treatment, with a 5-year survival of 60-80%. The only chance of long-term survival for patients with a T3-T4 tumour is an extended operation combining an hepatic resection with an N1-2 dissection with or without excision of the common bile duct. A subset of patients with peripancreatic positive nodes or invasion of adjacent organs seems to benefit from a synchronous pancreaticoduodenectomy.

Radical surgery for gallbladder cancer: a worthwhile operation?

AIMS

Extended operations are the only chance of a cure for patients with advanced gallbladder carcinoma, but there is no consensus about which subset of patients can benefit. The aim of this retrospective study is to evaluate the results of surgical resection with special reference to the prognostic factors and to long-term survival.

METHODS

A retrospective review of 70 patients with a diagnosis of gallbladder cancer treated from 1985-1998 was performed: 33 patients had a curative resection and were included in this study. For stage I disease, simple cholecystectomy was considered curative; in most of the other cases, cholecystectomy was associated with lymph node dissection and liver resection.

RESULTS

Hospital mortality and morbidity were 6% and 33%, respectively. Curative resection was associated with an actuarial 5-year survival of 27.4%. Survival of pT1-2 patients was significantly better than that of pT3 (P=0.04) or pT4 patients (P=0.002). Patients with lymph node spread had a poorer prognosis (P=0.06) but four were alive and disease-free with a median survival of 22 months.

CONCLUSIONS

Depth of the tumour and lymph node metastases are important prognostic factors. Patients with pT3-4 tumours or regional lymph node spread should be considered for curative resection because long-term survival is possible.

[Hepatic resections for non-colorectal, non-neuroendocrine metastases. Results of 32 hepatectomies in 27 patients]

STUDY AIM

Liver resections for metastases are commonly performed in colorectal primary tumors and poorly documented in non colorectal tumors. The aim of this study was to report a series of 32 liver resections in 27 patients for different types of non colorectal, non neuroendocrine liver metastases.

PATIENTS AND METHOD

From 1986 to 1997, 27 patients (20 women and 7 men, mean age: 56.8 years) were operated on in the same center for liver metastases. Initial cancer was female genital tract (ovarian and fallopian tube) adenocarcinomas (n = 5), gastrointestinal tract adenocarcinomas (n = 8), sarcomas (n = 8), and miscellaneous cancers (n = 6). Liver resections included atypical resections (n = 9), right hepatectomies (n = 11), extended right hepatectomies (n = 2), left hepatectomies (n = 4) and resections of 2 or 3 segments (n = 6).

RESULTS

There was no perioperative death. Postoperative morbidity included 8 complications in seven patients, requiring reintervention in three patients. Follow-up was complete for all patients. Survival rate at one, two and five years was 59, 44 and 29% respectively. The longest median survival time was observed in genital tract adenocarcinomas (27 months), whereas the other types of malignancies had a 13- to 17-month mean survival rate.

CONCLUSION

These results are almost similar to those observed in liver resections for colorectal metastases. Some carefully selected patients may benefit from liver resection for non colorectal, non neuro-endocrine metastases.

Hepatic resection of noncolorectal nonneuroendocrine metastases

Because hepatic resection is generally a safe procedure, the indications for resection of noncolorectal nonneuroendocrine (NCNNE) hepatic metastases have broadened. The prognostic features of NCNNE metastases treated surgically were reviewed to define better the value of resection. A retrospective review of patients undergoing liver resection for NCNNE metastases between 1978 and 1998 was undertaken. Thirty-seven patients were identified. Mean age was 56 years, with a median follow-up of 22 months. Primary tumor sites were grouped into gastrointestinal (GI) adenocarcinoma (small bowel, n = 4; pancreas, n = 2; esophagus, n = 1) and other (renal cell, n = 7; sarcoma, n = 7; melanoma, n = 5; adrenal, n = 3; unknown adenocarcinoma, n = 3; thyroid, n = 2; testicular, n = 1; ovarian, n = 1; breast, n = 1). All patients underwent surgery for cure. Metastases were synchronous in 14 patients. There was no surgical mortality. Overall 5-year survival rate was 45%. Five-year survival rates were better for patients with non-GI-origin metastases (60% v 0%; P =.01). Long-term survival was seen only in patients with non-GI-origin metastases. The extent of resection, presence of synchronous metastases, or disease-free interval from time of original disease to presentation with liver metastases were not predictive of outcome. We conclude that patients with NCNNE hepatic metastases can undergo liver resection with an expectation of prolonged survival. However, patients with liver metastases from GI primary tumors other than the colorectum are unlikely to show extended survival.

Protocol for the examination of specimens from patients with carcinomas of the gallbladder, including those showing focal endocrine differentiation: a basis for checklists. Cancer Committee of the College of American Pathologists

No Abstract Available

Results of surgical resection of liver metastases from non-colorectal primaries

BACKGROUND

Advances in the field of liver surgery have lowered its associated mortality and morbidity rates, and hepatic resection for metastatic disease is increasingly performed. There are few well defined guidelines for the heterogeneous group of non-colorectal metastases. This study analysed the risks and benefits of surgical resection for liver metastases from non-colorectal primaries.

METHODS

A retrospective study was performed of 34 patients who underwent 37 operations over a 10-year period. Compilation of data from 141 patients from eight additional recent series was performed in order to analyse the effect of histological type on survival.

RESULTS

There were no perioperative deaths. Complications occurred after seven of 37 procedures. Actuarial survival rates were 61, 43 and 27 per cent at 1, 2 and 5 years. Survival was significantly improved for curative versus palliative resection (P < 0.05), and for single versus multiple metastases (P < 0.05). A strong correlation was observed between time to presentation with metastasis and length of survival (P< 0.0001). Survival was significantly better for patients with secondaries from neuroendocrine tumours (P < 0.0001), worse for those with intestinal adenocarcinomas (P < 0.0001) and similar for patients with breast carcinoma (P > 0.5) when compared with the whole group.

CONCLUSION

The low mortality and morbidity rates and the satisfactory survival figures reported justify this type of surgery for selected patients, in the absence of therapeutic alternatives.

Long-term results after curative resection for carcinoma of the gallbladder. French University Association for Surgical Research

BACKGROUND

The surgical management of gallbladder carcinoma is controversial, especially as regards the indications for radical resection. The aim of this study was to evaluate the results of surgical treatment for gallbladder carcinoma with special reference to the extent of its histological spread.

METHODS

Eighty-six patients from 25 French centers underwent resection for cure and were included in this study. They comprised 65 women and 21 men (mean age 65 +/- 21 years). Resection included radical resection in 21 patients (partial hepatectomy, regional lymphadenectomy, and common bile duct resection) and simple cholecystectomy in 65.

RESULTS

There were 3 postoperative deaths (3.5%). The mean follow-up period was 25 +/- 24 months. The overall 5-year actuarial survival rate was 26%. The 5-year actuarial survival rate was 27% for patients who had radical resection. Eight patients with nodal metastasis had a 5-year survival rate of 0%, but the rate for 13 patients without such metastasis was 43% (P <0.05). For patients undergoing simple cholecystectomy, the 5-year actuarial survival rate was 44% for stage I disease, 22% for stage II, and 0% for stage III (P <0.05).

CONCLUSIONS

In patients with stage I gallbladder carcinoma, outcome is good after cholecystectomy only. In stages II to IV, radical resection should only be considered in the absence of regional lymph node metastasis.

[Palliative therapy of carcinomas of the biliary system]

CARCINOMA OF THE GALLBLADDER: Only patients suffering from advanced disease have symptoms, that is pain, jaundice, weight loss. Mean 5-year survival rate tends to be lower than 5%. Tumors can be resected with negative margins in 15 to 25% of the patients. Obstructive jaundice can be managed with endoscopic biliary stent in 84% of the patients. After radiotherapy tumor regression is observed in 80% of the patients. Their mean survival time is 10 months.

CHOLANGIOCARCINOMAS

More than 90% of the patients present with jaundice. At the time of presentation, 50% of the patients already have metastases to lymph nodes. Mean total survival time of all patients is 12 months. Surgical resection can successfully be performed in 30 to 40% of the patients suffering from proximal cholangiocarcinomas. Distal unresectable tumors are best palliated with an endoscopically placed stent in 97.5% of the patients. Patients having undergone radiotherapy will have a mean survival time of 9 to 12 months. There is a 12% response rate after chemotherapy with single agents and one of 23% after combined regimens. Intraarterial application of chemotherapy results in 44% response rate.

CONCLUSION

Carcinomas of the biliary tract are often diagnosed at advanced inoperable stages. Patients quality of life can be ameliorated by palliative treatment, i.e. biliary stents, radio-, chemotherapy. Mean survival time does normally not exceed 1 year.

Outcome of radical surgery for carcinoma of the gallbladder according to the TNM stage

BACKGROUND

The role of surgery in the treatment of gallbladder carcinoma (GBC) is controversial. The outcome after prospective radical surgery for GBC is discussed on the basis of the TNM stage of the tumor.

METHODS

One hundred six patients who had undergone radical surgery were selected. The standard radical procedure consisted of a cholecystectomy accompanied by lymph node dissection, wedge resection of the liver, and resection of the extrahepatic bile ducts. The stage was determined by pathologic examination of resected specimens.

RESULTS

Lymph node metastases were identified in no patients with T1 tumors (n = 15), 48% of patients with T2 tumors (n = 46), 72% of patients with T3 tumors (n = 25), and 80% of patients with T4 tumors (n = 20). One patient died within 30 days after radical surgery (mortality rate, 0.9%). There were 35 5-year survivors including 11 patients with nodal involvement, 10 with stage I tumors, 13 with stage II tumors, 10 with stage III tumors, and 2 with stage IV tumors. The cumulative 5-year survival rate in patients with stage I tumors was 91% (n = 15), 85% in patients with stage II tumors (n = 24), 40% in patients with stage III tumors (n = 28), and 19% in patients with stage IV tumors (n = 39). In patients with stage III and IV tumors the 5-year survival rate was 52% after curative resection (n = 35). This was significantly better than the 5% 5-year survival rate after a noncurative resection (n = 32).

CONCLUSIONS

The presence of lymph node metastases is strongly influenced by the depth of invasion of the primary tumor. Accurate determination of the TNM stage is essential in comparing surgical results, predicting patient outcome, and planning additional treatment. Standard radical surgery contributes to patient survival and is recommended in patients with advanced GBC.