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

Radical cholecystectomy without liver resection for peritoneal side early incidental gallbladder cancer

Gallbladder cancer (GBC) is a rare disease with a poor prognosis. Simple cholecystectomy may be an adequate treatment only for very early disease (Tis, T1a), whereas reoperation is recommended for more advanced disease (T1b and T2). Radical cholecystectomy should have two fundamental objectives: To radically resect the liver parenchyma and to achieve adequate clearance of the lymph nodes. However, recent studies have shown that compared with lymph node dissection alone, liver resection does not improve survival outcomes. The oncological roles of lymphadenectomy and liver resection is distinct. Therefore, for patients with incidental GBC without liver invasion, hepatic resection is not always mandatory.

A deep learning model based on contrast-enhanced computed tomography for differential diagnosis of gallbladder carcinoma

BACKGROUND

Gallbladder carcinoma (GBC) is highly malignant, and its early diagnosis remains difficult. This study aimed to develop a deep learning model based on contrast-enhanced computed tomography (CT) images to assist radiologists in identifying GBC.

METHODS

We retrospectively enrolled 278 patients with gallbladder lesions (> 10 mm) who underwent contrast-enhanced CT and cholecystectomy and divided them into the training (n = 194) and validation (n = 84) datasets. The deep learning model was developed based on ResNet50 network. Radiomics and clinical models were built based on support vector machine (SVM) method. We comprehensively compared the performance of deep learning, radiomics, clinical models, and three radiologists.

RESULTS

Three radiomics features including LoG_3.0 gray-level size zone matrix zone variance, HHL first-order kurtosis, and LHL gray-level co-occurrence matrix dependence variance were significantly different between benign gallbladder lesions and GBC, and were selected for developing radiomics model. Multivariate regression analysis revealed that age ≥ 65 years [odds ratios (OR) = 4.4, 95% confidence interval (CI): 2.1-9.1, P < 0.001], lesion size (OR = 2.6, 95% CI: 1.6-4.1, P < 0.001), and CA-19-9 > 37 U/mL (OR = 4.0, 95% CI: 1.6-10.0, P = 0.003) were significant clinical risk factors of GBC. The deep learning model achieved the area under the receiver operating characteristic curve (AUC) values of 0.864 (95% CI: 0.814-0.915) and 0.857 (95% CI: 0.773-0.942) in the training and validation datasets, which were comparable with radiomics, clinical models and three radiologists. The sensitivity of deep learning model was the highest both in the training [90% (95% CI: 82%-96%)] and validation [85% (95% CI: 68%-95%)] datasets.

CONCLUSIONS

The deep learning model may be a useful tool for radiologists to distinguish between GBC and benign gallbladder lesions.

Risk Factors and Prognostic Factors in GBC

Background: Gallbladder cancer (GBC) is a rare entity with a poor prognosis, usually discovered late due to nonspecific symptoms; therefore, over the last years, attention has been focused on identifying the risk factors for developing this malignancy in order to provide an early diagnosis, as well as new prognostic factors in order to modulate the long-term evolution of such cases. The aim of this review is to discuss both major risk factors and prognostic factors in GBC for a better understanding and integration of relevant and currently available information. Methods: A literature search was performed using Cochrane Library, PubMed, Google Scholar, Elsevier, and Web of Science; studies published after the year of 2000, in English, were reviewed. Results: Over time, risk factors associated with the development of GBC have been identified, which outline the profile of patients with this disease. The most important prognostic factors in GBC remain TNM staging, safety margin, and R0 status, along with perineural invasion and lymphovascular invasion. Both the technique and experience of the surgeons and a pathological examination that ensures final staging are particularly important and increase the chances of survival of the patients. Conclusions: improvements in surgical techniques and pathological analyses might provide better and more consistent guidance for medical staff in the management of patients with GBC.

Oncologic safety of robotic extended cholecystectomy for gallbladder cancer

BACKGROUND

Although laparoscopic cholecystectomy is applicable for the treatment of early gallbladder cancer (GBC), minimally invasive surgery is not widely used for advanced GBC. This is because advanced GBCs necessitate complicated surgical techniques, including lymph node dissection and liver resection. Robotic extended cholecystectomy (REC) is thought to overcome the limitations of laparoscopic surgery, but oncological safety studies are lacking. Therefore, in this study, we aimed to evaluate the oncologic outcomes of REC compared with those of open extended cholecystectomy (OEC).

METHODS

A total of 125 patients, who underwent extended cholecystectomy for GBC with tentative T2 or higher stage between 2018 and 2021, were included and stratified by surgical methods. To minimize the confounding factors, 1:1 propensity-score matching was performed between the patients who underwent REC and those who underwent OEC.

RESULTS

Regarding short-term outcomes, the REC group showed significantly lower estimated blood loss (382.7 vs. 717.2 mL, P = 0.020) and shorter hospital stay (6.9 vs. 8.5 days, P = 0.042) than the OEC group. In addition, the REC group had significantly lower subjective pain scores than the OEC group from the day of surgery through the 5th postoperative day (P = 0.006). Regarding long-term outcomes, there were no significant differences in the 3-year [5-year] overall survival (OS) and disease-free survival (DFS) rates between the REC group [OS, 92.3% (92.3%); DFS, 84.6% (72.5%)] and the OEC group [OS, 96.8% (96.8%); DFS, 78.2% (78.2%)] (P = 0.807 for OS and 0.991 for DFS).

CONCLUSIONS

In this study, REC showed superior short-term outcomes to OEC and no difference in long-term survival outcomes. Additionally, REC was superior to OEC in terms of postoperative pain. Therefore, REC may be a feasible option with early recovery compared with OEC for patients with advanced GBC.

Surgical outcomes of gallbladder cancer: the OMEGA retrospective, multicentre, international cohort study

Background

Gallbladder cancer (GBC) is rare but aggressive. The extent of surgical intervention for different GBC stages is non-uniform, ranging from cholecystectomy alone to extended resections including major hepatectomy, resection of adjacent organs and routine extrahepatic bile duct resection (EBDR). Robust evidence here is lacking, however, and survival benefit poorly defined. This study assesses factors associated with recurrence-free survival (RFS), overall survival (OS) and morbidity and mortality following GBC surgery in high income countries (HIC) and low and middle income countries (LMIC).

Methods

The multicentre, retrospective Operative Management of Gallbladder Cancer (OMEGA) cohort study included all patients who underwent GBC resection across 133 centres between 1st January 2010 and 31st December 2020. Regression analyses assessed factors associated with OS, RFS and morbidity.

Findings

On multivariable analysis of all 3676 patients, wedge resection and segment IVb/V resection failed to improve RFS (HR 1.04 [0.84-1.29], p = 0.711 and HR 1.18 [0.95-1.46], p = 0.13 respectively) or OS (HR 0.96 [0.79-1.17], p = 0.67 and HR 1.48 [1.16-1.88], p = 0.49 respectively), while major hepatectomy was associated with worse RFS (HR 1.33 [1.02-1.74], p = 0.037) and OS (HR 1.26 [1.03-1.53], p = 0.022). Furthermore, EBDR (OR 2.86 [2.3-3.52], p < 0.0010), resection of additional organs (OR 2.22 [1.62-3.02], p < 0.0010) and major hepatectomy (OR 3.81 [2.55-5.73], p < 0.0010) were all associated with increased morbidity and mortality. Compared to LMIC, patients in HIC were associated with poorer RFS (HR 1.18 [1.02-1.37], p = 0.031) but not OS (HR 1.05 [0.91-1.22], p = 0.48). Adjuvant and neoadjuvant treatments were infrequently used.

Interpretation

In this large, multicentre analysis of GBC surgical outcomes, liver resection was not conclusively associated with improved survival, and extended resections were associated with greater morbidity and mortality without oncological benefit. Aggressive upfront resections do not benefit higher stage GBC, and international collaborations are needed to develop evidence-based neoadjuvant and adjuvant treatment strategies to minimise surgical morbidity and prioritise prognostic benefit.

Funding

Cambridge Hepatopancreatobiliary Department Research Fund.

Reappraisal of T1b gallbladder cancer (GBC): clinicopathologic analysis of 473 in situ and invasive GBCs and critical review of the literature highlights its rarity, and that it has a very good prognosis

There are highly conflicting data on relative frequency (2-32%), prognosis, and management of pT1b-gallbladder carcinoma (GBC), with 5-year survival ranging from > 90% in East/Chile where cholecystectomy is regarded as curative, versus < 50% in the West, with radical operations post-cholecystectomy being recommended by guidelines. A total of 473 in situ and invasive extensively sampled GBCs from the USA (n = 225) and Chile (n = 248) were re-evaluated histopathologically per Western invasiveness criteria. 349 had invasive carcinoma, and only 24 were pT1. Seven cases previously staged as pT1b were re-classified as pT2. There were 19 cases (5% of all invasive GBCs) qualified as pT1b and most pT1b carcinomas were minute (< 1mm). One patient with extensive pTis at margins (but pT1b focus away from the margins) died of GBC at 27 months, two died of other causes, and the remainder were alive without disease (median follow-up 69.9 months; 5-year disease-specific survival, 92%). In conclusion, careful pathologic analysis of well-sampled cases reveals that only 5% of invasive GBCs are pT1b, with a 5-year disease-specific survival of > 90%, similar to findings in the East. This supports the inclusion of pT1b in the "early GBC" category, as is typically done in high-incidence regions. Pathologic mis-staging of pT2 as pT1 is not uncommon. Cases should not be classified as pT1b unless extensive, preferably total, sampling of the gallbladder to rule out a subtle pT2 is performed. Critical appraisal of the literature reveals that the Western guidelines are based on either SEER or mis-interpretation of stage IB cases as "pT1b." Although the prognosis of pT1b-GBC is very good, additional surgery (radical cholecystectomy) may be indicated, and long-term surveillance of the biliary tract is warranted.

Oncological outcome of proximal and middle extrahepatic bile duct cancer according to surgical extent (Is hilar resection oncologically acceptable in proximal and middle extrahepatic bile duct cancer?)

BACKGROUND

For proximal to middle bile duct cancer, it is controversial whether bile duct resection alone is sufficient, or whether hepatic or pancreatic resection should be accompanied by initial planning. This study aimed to determine the optimal surgical extent based on oncological outcomes in patients with proximal to middle bile duct cancer.

METHODS

Patients who underwent surgery for proximal to middle extrahepatic bile duct cancer, hilar resection, or combined resection of other organs were included. Clinicopathological characteristics and survival analyses were compared according to operation type.

RESULTS

Among 156 patients in total, R0 rate was 56.7% for hilar resection and 82.7% for other organ resection. Although hilar resection was associated with shorter hospital stay and fewer overall complications, operation type did not affect overall survival (p = 0.259) and disease-free-survival (p = 0.774). Overall survival differed according to R status (5YSR 49.8 vs. 27.1%; p = 0.012).

CONCLUSION

In proximal to middle extrahepatic bile duct cancer, surgery should be tailored to achieve R0 resection according to the extent of the disease rather than uniformly resecting extensively with other organ resections. Hilar resection could be selected if R0 resection is feasible, considering the lower morbidity with similar long-term survival.

Progress in gallbladder cancer with lymph node metastasis

Gallbladder cancer (GBC) is a malignant tumor that originates from the mucosal lining of the gallbladder. It is distinctly regional and is common in certain geographic regions of developing countries. GBC has a high degree of insidiousness as well as a high propensity for metastatic spread, resulting in the majority of patients being diagnosed at an advanced stage. Lymph node metastasis (LNM) is fairly common in GBC patients and is an independent risk factor for a poor prognosis. This article is focused on the lymph node pathways and metastatic directions of GBC. Furthermore, it summarizes the different lymph node groupings, disease stages and treatments. In the future, it is of great significance to develop individualized treatment and predict the outcomes of GBC patients with different lymph node conditions.

Simple cholecystectomy is an adequate treatment for grade I T1bN0M0 gallbladder carcinoma: Evidence from 528 patients

BACKGROUND

T1b gallbladder carcinoma (GBC) is defined as a tumor that invades the perimuscular connective tissue without extension beyond the serosa or into the liver. However, controversy still exists over whether patients with T1b GBC should undergo cholecystectomy alone or radical GBC resection.

AIM

To explore the optimal surgical approach in patients with T1b gallbladder cancer of different pathological grades.

METHODS

Patients with T1bN0M0 GBC who underwent surgical treatment between 2000 and 2017 were included in the Surveillance, Epidemiology, and End Results database. The Kaplan-Meier method and log-rank test were used to analyze the overall survival (OS) and disease-specific survival (DSS) of patients with T1b GBC of different pathological grades. Cox regression analysis was used to identify independent predictors of mortality and explore the selection of surgical methods in patients with T1b GBC of different pathological grades and their relationship with prognosis.

RESULTS

Of the 528 patients diagnosed with T1bN0M0 GBC, 346 underwent simple cholecystectomy (SC) (65.5%), 131 underwent SC with lymph node resection (SC + LN) (24.8%), and 51 underwent radical cholecystectomy (RC) (9.7%). Without considering the pathological grade, both the OS (P < 0.001) and DSS (P = 0.003) of T1b GBC patients who underwent SC (10-year OS: 27.8%, 10-year DSS: 55.1%) alone were significantly lower than those of patients who underwent SC + LN (10-year OS: 35.5%, 10-year DSS: 66.3%) or RC (10-year OS: 50.3%, 10-year DSS: 75.9%). Analysis of T1b GBC according to pathological classification revealed no significant difference in OS and DSS between different types of procedures in patients with grade I T1b GBC. In patients with grade II T1b GBC, obvious survival improvement was observed in the OS (P = 0.002) and DSS (P = 0.039) of those who underwent SC + LN (10-year OS: 34.6%, 10-year DSS: 61.3%) or RC (10-year OS: 50.5%, 10-year DSS: 78.8%) compared with those who received SC (10-year OS: 28.1%, 10-year DSS: 58.3%). Among patients with grade III or IV T1b GBC, SC + LN (10-year OS: 48.5%, 10-year DSS: 72.2%), and RC (10-year OS: 80%, 10-year DSS: 80%) benefited OS (P = 0.005) and DSS (P = 0.009) far more than SC (10-year OS: 20.1%, 10-year DSS: 38.1%) alone.

CONCLUSION

Simple cholecystectomy may be an adequate treatment for grade I T1b GBC, whereas more extensive surgery is optimal for grades II-IV T1b GBC.

Preoperative Assessment and Perioperative Management of Resectable Gallbladder Cancer in the Era of Precision Medicine and Novel Technologies: State of the Art and Future Perspectives

Gallbladder carcinoma (GBC) is a rare malignancy, with an estimated 5-year survival rate of less than 5% in the case of advanced disease. Surgery is the only radical treatment for early stages, but its application and effectiveness depend on the depth of tumoral invasion. The extent of resection is usually determined according to the T-stage. Therefore, an early and correct preoperative assessment is important for the prognosis, as well as for the selection of the most appropriate surgical procedure, to avoid unnecessary morbid surgeries and to reach the best outcomes. Several modalities can be used to investigate the depth of invasion, from ultrasounds to CT scans and MRI, but an ideal method still does not exist. Thus, different protocols are proposed according to different recommendations and institutions. In this scenario, the indications for laparoscopic and robotic surgery are still debated, as well as the role of new technologies such as next-generation sequencing and liquid biopsies. The aim of this article is to summarize the state of the art current modalities and future perspectives for assessing the depth of invasion in GBC and to clarify their role in perioperative management accordingly.

A Novel Clinically Prognostic Stratification Based on Prognostic Nutritional Index Status and Histological Grade in Patients With Gallbladder Cancer After Radical Surgery

Purpose

Gallbladder carcinoma (GBC) is the most common malignancy of the biliary tract, with a 5-year survival rate of 5%. The prognostic models to predict the prognosis of patients with GBC remain controversial. Therefore, to construct a prognosis prediction of GBC, a retrospective cohort study was carried out to investigate the prognostic nutritional index and histological grade in the long-term outcome of patients with GBC after radical surgery (RS).

Methods

A retrospective study of a total of 198 patients with GBC who underwent surgical treatment were enrolled. The hematological indicators, imageological data, and perioperative clinical data were acquired for statistical analysis and poor prognosis model construction.

Results

Prognostic nutrition index (PNI) < 45.88, maximum tumor diameter (MTD) > 2.24 cm, and jaundice (JD) were all associated with a poor prognosis in multivariate logistic regression analysis. The prognosis prediction model was based on the three risk factors, which indicated a superior predictive ability in the primary cohort [area under the curve (AUC) = 0.951] and validation cohort (AUC = 0.888). In multivariate Cox regression analysis, poorly differentiation (PD) was associated with poor 3-year survival. In addition, Kaplan-Meier (KM) survival analysis suggested that GBC patients with high-risk scores and PD had a better prognosis after RS (p < 0.05), but there was no significant difference in prognosis for patients with non-poorly differentiation (NPD) or low-risk scores after RS (p > 0.05).

Conclusion

Our prediction model for GBC patients with prognosis evaluation is accurate and effective. For patients with PD and high-risk scores, RS is highly recommended; a simple cholecystectomy can also be considered for acceptance for patients with NPD or low-risk score. The significant findings provide a new therapeutic strategy for the clinical treatment of GBC.

Diagnostic performance and inter-observer variability to differentiate between T1- and T2-stage gallbladder cancers using multi-detector row CT

PURPOSE

To evaluate the diagnostic performance and inter-observer variability of differentiating T1 and T2 gallbladder (GB) cancers using multi-detector row CT (MDCT).

METHODS

This retrospective study included 151 patients with surgically confirmed T1 (n = 49)- or T2 (n = 102)-stage GB cancer who underwent contrast-enhanced MDCT from 2016 to 2020. Five radiologists (two experienced and three less experienced) evaluated the T-stage with a confidence level calculated using a six-point scale. GB cancers were morphologically classified into three types: polypoid, polypoid with wall thickening, and wall thickening. The diagnostic performance of T-staging was assessed using receiver operating characteristic (ROC) curve analysis. Sensitivity, specificity, accuracy, positive predictive value, and negative predictive value were calculated based on a binary scale (T1 = positive). Inter-observer agreement was assessed using Fleiss κ statistics.

RESULTS

The area under the receiver operating characteristic (ROC) curve of each reviewer for T-staging ranged from 0.69 to 0.80 (median 0.77). The overall accuracy of the five radiologists was 78% (95% confidence interval [CI] 71-84%). Sensitivity was higher and specificity was lower in experienced radiologists than in less experienced radiologists (P < 0.001). The overall inter-observer agreement was fair (κ = 0.36; 95% CI 0.31, 0.41). The overall accuracy for T-stage was 63% (95% CI 48-76), 78% (95% CI 63-88), and 87% (95% CI 77-93) for polypoid, polypoid with wall thickening, and wall thickening type, respectively.

CONCLUSION

The accuracy of MDCT for differentiating T1 and T2 GB cancer is limited, and there is considerable inter-observer variability.

Cáncer de vesícula biliar, una visión actual

Introducción. El diagnóstico de cáncer de vesícula biliar se realiza generalmente de forma incidental durante el estudio de las piezas quirúrgicas o cuando la enfermedad está avanzada y se expresa por su diseminación. Muy pocas veces se diagnostica de forma preoperatoria. Corresponde a la neoplasia más común de las vías biliares y su incidencia varía de acuerdo a la región geográfica. La región andina en Latinoamérica presenta una de las mayores incidencias a nivel mundial. Métodos. Se realizó una revisión narrativa de la literatura, para presentar una información actualizada en lo referente a los factores de riesgo (incluyendo las alteraciones genéticas y moleculares), al diagnóstico y al tratamiento de esta patología. Basados en los datos actuales, presentamos algunas recomendaciones dirigidas al diagnóstico temprano, que permita un manejo más adecuado de nuestros pacientes. Resultados. Se han implicado nuevos factores de riesgo relacionados con la etiología del cáncer de vesícula biliar, como la obesidad, factores genéticos y moleculares. A pesar de la disponibilidad de los métodos diagnósticos imagenológicos, no ha ocurrido una importante variación porcentual en cuanto al estadio al momento del diagnóstico. Conclusiones. El manejo quirúrgico del cáncer de vesícula biliar está indicado en los estadios más tempranos de la enfermedad y es importante evaluar las opciones terapéuticas en pacientes con enfermedad avanzada. Se considera de suma importancia el estudio anatomopatológico de la pieza quirúrgica y la revisión del informe por parte del cirujano

Radical Resection Versus Simple Cholecystectomy for Gallbladder Carcinoma: A Systematic Review and Meta-analysis

PURPOSE

The goal of this study was to review relevant randomized controlled trials or case-control studies to determine radical resection compared with simple cholecystectomy for gallbladder carcinoma.

METHODS

Using appropriate keywords, we identified relevant studies using PubMed, the Cochrane Library, and Embase. Key pertinent sources in the literature were also reviewed, and all articles published through September 2019 were considered for inclusion. For each study, we assessed odds ratios, mean difference, and 95% confidence interval (CI) to assess and synthesize outcomes.

RESULTS

We included 19 studies with a total of 1791 patients in the radical resection group and 3014 in the simple cholecystectomy group. Compared with simple cholecystectomy, radical resection significantly improved the 5-year disease-free survival rate [relative risk (RR): 1.36, 95% CI: 1.02-1.81], the 1-year overall survival (OS) rate (RR: 1.27, 95% CI: 1.04-1.54), and the 3-year OS rate (RR: 1.71, 95% CI: 1.02-2.85). However, there was no significant difference in the recurrence rate (RR: 1.04, 95% CI: 0.87-1.23), and in the 5-year OS rate (RR: 1.05, 95% CI: 0.92-1.19) between the 2 groups.

CONCLUSION

Compared with simple cholecystectomy, radical resection has advantages in improving the 5-year disease-free survival rate, and the 1- and 3-year OS rate of gallbladder carcinoma patients.

Incidental Gallbladder Cancer on Cholecystectomy: Strategy for Re-resection of Presumed Benign Diseases from a Retrospective Multicenter Study by the Yokohama Clinical Oncology Group

BACKGROUND/AIM

Current expert consensus recommends re-resection for incidental gallbladder cancer (IGBC) of pT1b-3. This study examined whether this consensus was reasonably applicable to patients with IGBC in one Japanese region.

PATIENTS AND METHODS

This was a multicenter, retrospective analysis of cholecystectomies for presumed benign diseases between January 2000 and December 2009.

RESULTS

IGBC was diagnosed in 70 (1.0%) out of 6,775 patients undergoing cholecystectomy. Five-year disease-specific cumulative survival was 100% in 19 patients with pT1a, 80.0% in five with pT1b, 49.5% in 33 with pT2, and 23.1% in 13 with pT3. Re-resection was not performed for the 24 patients with pT1a/1b disease, whereas 24 out of 46 patients with pT2/3 underwent re-resection. Regardless of re-resection, independent factors associated with a poor prognosis on multivariate analysis were grade 2 or poorer disease and bile spillage at prior cholecystectomy. In the 24 patients with pT2/3 re-resection, 11 patients without either of these two factors had significantly better 5-year disease-specific cumulative survival than the 13 patients with one or two independent factors associated with a poor prognosis (72.7% vs. 30.8%, p=0.009).

CONCLUSION

This Japanese regional study suggests that indication of re-resection for IGBC should not be determined by pT-factor alone and that much more attention should be paid to pathological and intraoperative findings at prior cholecystectomy.

An intact boundary between the tumor and inner hypoechoic layer discriminates T1 lesions among sessile elevated gallbladder cancers

BACKGROUND

The depth of invasion determines the surgical method for treating gallbladder cancer (GBC). However, the preoperative correct diagnosis of invasion depth, especially discrimination of T1 lesions among sessile elevated GBCs, is difficult. We investigated the utility of preoperative endoscopic ultrasound (EUS) findings for diagnosing the invasion depth.

METHODS

We studied a sessile elevated GBC specimen diagnosed as a T1 lesion before developing our study protocol. EUS evidenced an intact boundary between the tumor and the inner hypoechoic layer (the intact boundary sign). To evaluate the potential of using this sign to diagnose T1 GBC as a primary outcome indicator, we retrospectively analyzed patients who underwent surgical resection of sessile elevated GBCs between April 2009 and March 2020.

RESULTS

Of the 26 surgically resected sessile elevated GBC specimens, 20 were included and six were excluded due to difficulty in evaluating the overall tumor or layer structure. The Kappa coefficient for interobserver agreement regarding the intact boundary sign was 0.733. The sensitivity and specificity of the sign for diagnosing T1 lesions were 0.857 and 1.000, respectively.

CONCLUSION

This new EUS finding could guide the accurate diagnosis of T1 lesions in patients with sessile elevated GBC.

Current Status and Future Perspectives of Perioperative Therapy for Resectable Biliary Tract Cancer: A Multidisciplinary Review

Simple Summary

For decades, there has been no globally accepted neoadjuvant or adjuvant therapy in resectable biliary tract cancer. Based on the results of the BILCAP trial, adjuvant capecitabine has been widely regarded as standard adjuvant therapy. Focusing on the management of resectable biliary tract cancer, this article reviews each therapeutic strategy including surgery, chemotherapy and radiotherapy, and summarises published and ongoing clinical trials of neoadjuvant and adjuvant therapy.

Abstract

Biliary tract cancers (BTCs) are a group of aggressive malignancies that arise from the bile duct and gallbladder. BTCs include intrahepatic cholangiocarcinoma (IH-CCA), extrahepatic cholangiocarcinoma (EH-CCA), and gallbladder cancer (GBCA). BTCs are highly heterogeneous cancers in terms of anatomical, clinical, and pathological characteristics. Until recently, the treatment of resectable BTC, including surgery, adjuvant chemotherapy, and radiation therapy, has largely been based on institutional practice guidelines and evidence from small retrospective studies. Recently, several large randomized prospective trials have been published, and there are ongoing randomized trials for resectable BTC. In this article, we review prior and recently updated evidence regarding surgery, adjuvant and neoadjuvant chemotherapy, and adjuvant radiation therapy for patients with resectable BTC.

Prognostic Value of Carcinoembryonic Antigen (CEA) and Carbohydrate Antigen 19-9 (CA 19-9) in Gallbladder Cancer; 65 IU/mL of CA 19-9 Is the New Cut-Off Value for Prognosis

Simple Summary

Gallbladder cancer (GBC) is the fifth most common cancer of the digestive tract, and preoperative tumor markers for GBC have been studied as a less invasive way to detect the presence of the cancer. CEA and CA 19-9 have been most commonly used for detecting GBC clinically, and various cut-off values were suggested to satisfy this purpose, but there has still been a lack of proper values of these tumor markers to predict the prognosis of GBC. We have aimed to suggest appropriate cut-off values that could help to anticipate prognosis in the preoperative period. Data from carefully selected 539 patients were used in our study, the new cut-off value, 65 IU/mL for CA 19-9 was derived through an up-to-date statistical method. By using this cut-off value, clinicians could get the important reference in the establishment of the strategy of treatment, and the researches about this topic could become more vigorous.

Abstract

Due to the lack of appropriate tumor markers with optimal cut-off values to predict the prognosis of gallbladder cancer (GBC), this study aimed to demonstrate the relationship between prognosis and the levels of carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA 19-9), and to determine optimal thresholds. In total, 539 patients diagnosed with GBC were examined. The relationship between tumor marker levels and overall survival (OS) was analyzed. The C-tree method was used to suggest tumor marker thresholds, and multivariate analysis was conducted to identify prognostic factors for overall survival. The mean age of the patients was 65.3 years, and the 5-year overall survival rate in all patients was 68.9%. Following the C-tree method, the optimal cut-off value was set at 5 IU/mL for CEA and at 65 IU/mL for CA 19-9. Multivariate analysis revealed that age, CA 19-9 level, operative method, T stage, and N stage were significant prognostic factors for OS. Consequently, CA 19-9 had a stronger association with prognosis than CEA, and 65 IU/mL for CA 19-9 may be suggestive in evaluating the prognosis of GBC. Moreover, it could be an effective indicator for determining the surgical extent necessary and the need for adjuvant treatment.

Vascular disorders of the gallbladder and bile ducts: Imaging findings

Vascular disorders of the gallbladder and biliary tree are many and varied. In the acute setting, the clinical presentation of vascular conditions such as hemorrhagic cholecystitis and gangrenous cholecystitis are non-specific and rely on imaging for diagnosis and triaging for emergent surgery. These hemorrhagic and ischemic complications of acute cholecystitis are uncommon but potentially fatal. Hemorrhage into the gallbladder and biliary tree, from other causes, may itself result in acute cholecystitis. Knowledge of vascular anatomy of the gallbladder and biliary tree is essential for surgeons to prevent significant operative bleeding complications, particularly in laparoscopic cholecystectomy. The unique venous drainage of the gallbladder and biliary tree, with their connections to the portal venous system, lends itself to less well-recognised vascular phenomena such as gallbladder varices, portal biliopathy, and gallbladder bed perfusion abnormalities.

Prognostic significance of regional lymphadenectomy in T1b gallbladder cancer: Results from 24 hospitals in China

BACKGROUND

Whether regional lymphadenectomy (RL) should be routinely performed in patients with T1b gallbladder cancer (GBC) remains a subject of debate.

AIM

To investigate whether RL can improve the prognosis of patients with T1b GBC.

METHODS

We studied a multicenter cohort of patients with T1b GBC who underwent surgery between 2008 and 2016 at 24 hospitals in 13 provinces in China. The log-rank test and Cox proportional hazards model were used to compare the overall survival (OS) of patients who underwent cholecystectomy (Ch) + RL and those who underwent Ch only. To investigate whether combined hepatectomy (Hep) improved OS in T1b patients, we studied patients who underwent Ch + RL to compare the OS of patients who underwent combined Hep and patients who did not.

RESULTS

Of the 121 patients (aged 61.9 ± 10.1 years), 77 (63.6%) underwent Ch + RL, and 44 (36.4%) underwent Ch only. Seven (9.1%) patients in the Ch + RL group had lymph node metastasis. The 5-year OS rate was significantly higher in the Ch + RL group than in the Ch group (76.3% vs 56.8%, P = 0.036). Multivariate analysis showed that Ch + RL was significantly associated with improved OS (hazard ratio: 0.51; 95% confidence interval: 0.26-0.99). Among the 77 patients who underwent Ch + RL, no survival improvement was found in patients who underwent combined Hep (5-year OS rate: 79.5% for combined Hep and 76.1% for no Hep; P = 0.50).

CONCLUSION

T1b GBC patients who underwent Ch + RL had a better prognosis than those who underwent Ch. Hep + Ch showed no improvement in prognosis in T1b GBC patients. Although recommended by both the National Comprehensive Cancer Network and Chinese Medical Association guidelines, RL was only performed in 63.6% of T1b GBC patients. Routine Ch + RL should be advised in T1b GBC.

Safety and feasibility of pure laparoscopic extended cholecystectomy: comparison with the open technique in a propensity analysis at a single center

BACKGROUND

The aim of this study was to validate the safety and feasibility of pure laparoscopic extended cholecystectomy (LEC) by comparing the outcome with that of open extended cholecystectomy (OEC). Moreover, on the basis of our experience, we also aimed to investigate the learning curve of pure LEC.

METHODS

This single-center study enrolled patients who were diagnosed primary gallbladder cancer with pathologically confirmed and underwent R0 resection with curative intent between January 2016 and December 2019. A total of 31 patients who underwent OEC and 17 patients who underwent LEC were selected. Propensity score matching analysis was performed in a 1:1 ratio using the nearest-neighbor matching method, and clinical information was retrospectively collected from medical records and analyzed.

RESULTS

The postoperative hospital stay was statistically shorter in the LEC group (7 days) than in the OEC group (12 days). The overall surgical complication rate did not differ between the two groups. The 1- and 3-year disease-free survival rates were 82.4% and 82.4% in the OEC group and 94.2% and 71.5% in the LEC group, respectively (P = 0.94). Considering the correlation between the number of cumulative cases and the operation time and between the number of cumulative cases and the number of retrieved lymph nodes in the LEC group, as the cases were accumulated, both the operation time and the number of retrieved lymph nodes had a statistically significant correlation with the number of cases.

CONCLUSIONS

LEC showed a significant advantage in terms of achieving shorter postoperative hospital stay and similar results to OEC with respect to overall complications and pathological outcomes. The present results confirm that laparoscopy can be considered a safe treatment for primary gallbladder cancer in selected patients.

Current and New Biomarkers for Early Detection, Prognostic Stratification, and Management of Gallbladder Cancer Patients

Gallbladder cancer (GBC) is an aggressive disease that shows evident geographic variation and is characterized by a poor prognosis, mainly due to the late diagnosis and ineffective treatment. Genetic variants associated with GBC susceptibility, including polymorphisms within the toll-like receptors TLR2 and TLR4, the cytochrome P450 1A1 (CYP1A1), and the ATP-binding cassette (ABC) transporter ABCG8 genes, represent promising biomarkers for the stratification of patients at higher risk of GBC; thus, showing potential to prioritize cholecystectomy, particularly considering that early diagnosis is difficult due to the absence of specific signs and symptoms. Similarly, our better understanding of the gallbladder carcinogenic processes has led to identify several cellular and molecular events that may influence patient management, including HER2 aberrations, high tumor mutational burden, microsatellite instability, among others. Despite these reports on interesting and promising markers for risk assessment, diagnosis, and prognosis; there is an unmet need for reliable and validated biomarkers that can improve the management of GBC patients and support clinical decision-making. This review article examines the most potentially significant biomarkers of susceptibility, diagnosis, prognosis, and therapy selection for GBC patients, highlighting the need to find and validate existing and new molecular biomarkers to improve patient outcomes.

BRAZILIAN CONSENSUS ON INCIDENTAL GALLBLADDER CARCINOMA

Background:

Incidental gallbladder cancer is defined as a cancer discovered by histological examination after cholecystectomy. It is a potentially curable disease. However, some questions related to their management remain controversial and a defined strategy is associated with better prognosis.

Aim:

To develop the first evidence-based consensus for management of patients with incidental gallbladder cancer in Brazil.

Methods:

Sixteen questions were selected, and 36 Brazilian and International members were included to the answer them. The statements were based on current evident literature. The final report was sent to the members of the panel for agreement assessment.

Results:

Intraoperative evaluation of the specimen, use of retrieval bags and routine histopathology is recommended. Complete preoperative evaluation is necessary and the reoperation should be performed once final staging is available. Evaluation of the cystic duct margin and routine 16b1 lymph node biopsy is recommended. Chemotherapy should be considered and chemoradiation therapy if microscopically positive surgical margins. Port site should be resected exceptionally. Staging laparoscopy before reoperation is recommended, but minimally invasive radical approach only in specialized minimally invasive hepatopancreatobiliary centers. The extent of liver resection is acceptable if R0 resection is achieved. Standard lymph node dissection is required for T2 tumors and above, but common bile duct resection is not recommended routinely.

Conclusions:

It was possible to prepare safe recommendations as guidance for incidental gallbladder carcinoma, addressing the most frequent topics of everyday work of digestive and general surgeons.

A predictive nomogram for lymph node metastasis of incidental gallbladder cancer: a SEER population-based study

BACKGROUND

Existing imaging techniques have a low ability to detect lymph node metastasis (LNM) of gallbladder cancer (GBC). Gallbladder removal by laparoscopic cholecystectomy can provide pathological information regarding the tumor itself for incidental gallbladder cancer (IGBC). The purpose of this study was to identify the risk factors associated with LNM of IGBC and to establish a nomogram to improve the ability to predict the risk of LNM for IGBC.

METHODS

A total of 796 patients diagnosed with stage T1/2 GBC between 2004 and 2015 who underwent surgery and lymph node evaluation were enrolled in this study. We randomly divided the dataset into a training set (70%) and a validation set (30%). A logistic regression model was used to construct the nomogram in the training set and then was verified in the validation set. Nomogram performance was quantified with respect to discrimination and calibration.

RESULTS

The rates of LNM in T1a, T1b and T2 patients were 7, 11.1 and 44.3%, respectively. Tumor diameter, T stage, and tumor differentiation were independent factors affecting LNM. The C-index and AUC of the training set were 0.718 (95% CI, 0.676-0.760) and 0.702 (95% CI, 0.659-0.702), respectively, demonstrating good prediction performance. The calibration curves showed perfect agreement between the nomogram predictions and actual observations. Decision curve analysis showed that the LNM nomogram was clinically useful when the risk was decided at a possibility threshold of 2-63%. The C-index and AUC of the validation set were 0.73 (95% CI: 0.665-0.795) and 0.692 (95% CI: 0.625-0.759), respectively.

CONCLUSION

The nomogram established in this study has good prediction ability. For patients with IGBC requiring re-resection, the model can effectively predict the risk of LNM and make up for the inaccuracy of imaging.

Laparoscopic total biopsy for suspected gallbladder cancer: A case series

BACKGROUND AND AIMS

Imaging diagnosis of gallbladder cancer remains difficult to achieve preoperatively. We developed a novel approach based on laparoscopic whole-layer cholecystectomy (LWLC) and laparoscopic gallbladder bed dissection (LGBD) for total biopsy, for ultimately determining the optimal treatment strategy for suspected gallbladder cancer detected on preoperative imaging. Here, we describe a case series of patients who underwent this procedure at our institution.

METHODS

We retrospectively examined clinicopathological data of consecutive patients with suspected gallbladder carcinoma at Yamaguchi University Graduate School of Medicine from September 2016 to July 2018 on which a laparoscopic approach was used. Preoperative imaging findings suggestive of gallbladder cancer were defined as follows: elevated lesion >10 mm in diameter, increasing tumor size over time compared with the previous imaging, sessile lesion, irregular wall thickness lesion mimicking cancer, elevated lesion with dense enhancement, or positive results on fluorodeoxyglucose positron emission tomography. LWLC was performed for early-stage or suspected malignant lesions without liver invasion, and LGBD was performed for lesions with an unclear border between the gallbladder and the liver. When postoperative pathological examination revealed the presence of gallbladder cancer invading into the subserosal layer, additional gallbladder bed resection and regional lymphadenectomy were considered. Patient characteristics, perioperative findings, pathological findings, and postoperative outcomes of patients who underwent LWLC or LGBD were reviewed retrospectively, and the short-term outcomes of the laparoscopic approach were analyzed.

RESULTS

Fifteen consecutive patients were included in the study. The median age of the patients was 63 years (IQR 42-76 years); 7 patients were males. We performed LWLC in 12 cases and LBGD in 3 cases. Median (IQR) operation time was 159 (140-193) min and median blood loss was 10 (5-30) mL. No bile leakage caused by intraoperative perforation of the gallbladder was seen. Median hospital stay was 7 (5-9) days. Only one patient developed postoperative complications (abdominal abscess). Histologically, gallbladder cancer was diagnosed in five cases (pT1a, n = 2; pT2, n = 3), and two of the pT2 patients underwent additional open surgery.

CONCLUSIONS

Our laparoscopic-based approach for suspected gallbladder cancer might represent a safe strategy and could play an important role in defining the optimal treatment strategy.

Role of tumour location and surgical extent on prognosis in T2 gallbladder cancer: an international multicentre study

BACKGROUND

In gallbladder cancer, stage T2 is subdivided by tumour location into lesions on the peritoneal side (T2a) or hepatic side (T2b). For tumours on the peritoneal side (T2a), it has been suggested that liver resection may be omitted without compromising the prognosis. However, data to validate this argument are lacking. This study aimed to investigate the prognostic value of tumour location in T2 gallbladder cancer, and to clarify the adequate extent of surgical resection.

METHODS

Clinical data from patients who underwent surgery for gallbladder cancer were collected from 14 hospitals in Korea, Japan, Chile and the USA. Survival and risk factor analyses were conducted.

RESULTS

Data from 937 patients were available for evaluation. The overall 5-year disease-free survival rate was 70·6 per cent, 74·5 per cent for those with T2a and 65·5 per cent among those with T2b tumours (P = 0·028). Regarding liver resection, extended cholecystectomy was associated with a better 5-year disease-free survival rate than simple cholecystectomy (73·0 versus 61·5 per cent; P = 0·012). The 5-year disease-free survival rate was marginally better for extended than simple cholecystectomy in both T2a (76·5 versus 66·1 per cent; P = 0·094) and T2b (68·2 versus 56·2 per cent; P = 0·084) disease. Five-year disease-free survival rates were similar for extended cholecystectomies including liver wedge resection versus segment IVb/V segmentectomy (74·1 versus 71·5 per cent; P = 0·720). In multivariable analysis, independent risk factors for recurrence were presence of symptoms (hazard ratio (HR) 1·52; P = 0·002), R1 resection (HR 1·96; P = 0·004) and N1/N2 status (N1: HR 3·40, P < 0·001; N2: HR 9·56, P < 0·001). Among recurrences, 70·8 per cent were metastatic.

CONCLUSION

Tumour location was not an independent prognostic factor in T2 gallbladder cancer. Extended cholecystectomy was marginally superior to simple cholecystectomy. A radical operation should include liver resection and adequate node dissection.

Early outcomes of robotic extended cholecystectomy for the treatment of gallbladder cancer

BACKGROUND

Simple laparoscopic cholecystectomy is sufficient for patients with early gallbladder cancer (GBC). However, because advanced GBCs of T2 or more advanced stages require more complex procedures such as liver resection and lymph node dissection, minimally invasive surgery (MIS) has not been popularized. To evaluate the applicability of MIS for GBC, we report the early outcomes of robotic extended cholecystectomies (RECs).

METHODS

Thirteen patients who radiologically suspected to have T2 or more advanced stages of GBC underwent REC from February 2018 to April 2019. Thirty-nine patients who underwent open extended cholecystectomy were selected by 1:3 propensity score matching, and the differences of clinicopathologic features according to surgical methods were analyzed.

RESULTS

Compared with open method, operation time, estimated blood loss, postoperative complication rate, and number of retrieved lymph nodes were not significantly different. In REC group, duration of hospital stay was shorter (6.6 vs 8.3 days, P = .002) and postoperative pain was significantly lower in the REC group (P = .024).

CONCLUSION

The early outcomes of REC were favorable with regard to early recovery and less pain, with similar number of retrieved lymph nodes. REC is a promising option for treatment of GBC, but further long-term survival studies are needed.

Long-term outcomes of surgical resection for T1b gallbladder cancer: an institutional evaluation

BACKGROUND

There is no comprehensive agreement concerning the overall performance of radical resection for T1b gallbladder cancer (GBC). This research focused on addressing whether T1b GBC may spread loco-regionally and whether radical resection is necessary.

METHODS

A retrospective analysis was conducted of 1032 patients with GBC who underwent surgical resection at our centre and its affiliated institutions between January 1982 and December 2018. A total of 47 patients with T1b GBC, 29 (62%) of whom underwent simple cholecystectomy and 18 (38%) of whom underwent radical resection with regional lymph node dissection, were enrolled in the study.

RESULTS

GBC was diagnosed pre-operatively in 16 patients (34%), whereas 31 patients (66%) had incidental GBC. There was no blood venous or perineural invasion in any patient on histology evaluation, except for lymphatic vessel invasion in a single patient. There were no metastases in any analysed lymph nodes. The open surgical approach was more prevalent among the 18 patients who underwent radical resection (open in all 18 patients) than among the 29 patients who underwent simple cholecystectomy (open in 21; laparoscopic in 8) (P = 0.017). The cumulative 10- and 20-year overall survival rates were 65 and 25%, respectively. The outcome following simple cholecystectomy (10-year overall survival rate of 66%) was akin to that following radical resection (64%, P = 0.618). The cumulative 10- and 20-year disease-specific survival rates were 93 and 93%, respectively. The outcome following simple cholecystectomy (10-year disease-specific survival rate of 100%) was equivalent to that following radical resection (that of 86%, P = 0.151). While age (> 70 years, hazard ratio 5.285, P = 0.003) and gender (female, hazard ratio 0.272, P = 0.007) had a strong effect on patient overall survival, surgical procedure (simple cholecystectomy vs. radical resection) and surgical approach (open vs. laparoscopic) did not.

CONCLUSIONS

Most T1b GBCs represent local disease. As pre-operative diagnosis, including tumour penetration of T1b GBC, is difficult, the decision of radical resection is justified. Additional radical resection is not required following simple cholecystectomy provided that the penetration depth is restricted towards the muscular layer and that surgical margins are uninvolved.

[Surgical treatment of malignant biliary tract diseases]

BACKGROUND

Cancer of the intrahepatic and extrahepatic biliary tracts is characterized by a low incidence and a very heterogeneous appearance.

OBJECTIVE

Summary and evaluation of current surgical strategies in the treatment of malignant biliary tract diseases.

MATERIAL AND METHODS

An analysis of English language publications as well as European and American guidelines and recommendations for the surgical treatment of malignant diseases of the biliary tract was carried out. The results and recommendations were summarized and evaluated on the basis of experiences in this center.

RESULTS

Surgery is considered to be the only curative treatment option; however, prospective randomized studies and existing guidelines are based on limited evidence. Surgical strategies and the extent of resection differ between carcinomas of the intrahepatic and extrahepatic bile ducts depending on localization, size and number of lesions as well as their proximity to surrounding structures.

CONCLUSION

Sufficient experience in the treatment of these rare tumors is of special importance for the implementation of individualized overall concepts and for the sufficient performance of the mostly complex resections.

Minimally Invasive Single-Site Cholecystectomy in Obese Patients: Laparoscopic vs. Robotic

Robotic single-site cholecystectomy (RSSC) has emerged as an alternative procedure to overcome the shortcomings of single-fulcrum laparoscopic cholecystectomy in terms of the ergonomics and reducing the physical and mental stress of the surgeon. It is also necessary to assess the safety of RSSC for obese patients in a world with an increasing population of obese people. RSSC took a longer operation time, but the actual dissection time was similar to that of single-fulcrum laparoscopic cholecystectomy. There was no difference in postoperative pain, except for during the immediate postoperative period, and in the length of the hospital stay. RSSC had the advantage of reducing the incidence of intraoperative iatrogenic gallbladder perforation. It is critical to prevent any intraoperative bile leakage, which is associated as a worse prognostic factor in those patients with gallbladder cancer. Additional studies with a prospective design and larger number of study subjects will be required to confirm the safety and feasibility of RSSC. Moreover, the cost benefit and safety for treating malignant lesions are also issues to be addressed. RSSC is expected to be further expanded as an operative mode in the future.

Essential updates to the surgical treatment of biliary tract cancer

Biliary tract cancer, which includes intrahepatic cholangiocarcinoma, extrahepatic bile duct cancer, gallbladder cancer, and ampullary cancer, is an intractable disease with a dismal prognosis. Prognosis is particularly poor in cases involving vessels or lymph nodes. Hepatobiliary pancreatic surgeons worldwide have consistently focused on improving surgical treatment, perioperative management, and chemotherapy to improve the outcomes of these diseases. There has been significant progress even in the last 2 years (2017 and 2018), such as promising findings reported by studies on the optimal extent of surgical treatment and multi-institutional randomized controlled trials on adjuvant chemotherapy. We overview the current trends and advancements made in surgical treatment in 2017 and 2018.

Simple Cholecystectomy Is Adequate for Patients With T1b Gallbladder Adenocarcinoma < 1 cm in Diameter

Purpose: Consensus-based clinical guidelines recommend that simple cholecystectomy (SC) is adequate for T1a gallbladder adenocarcinoma (GBA), but extended cholecystectomy (EC), SC plus lymphatic dissection, should be considered for T1b and more advanced GBA. Whether lymphatic dissection is necessary for the treatment of T1b GBA remains controversial. This study attempts to better define the current criteria for local treatment of T1b GBA, by examining the relationship between lymph node (LN) metastasis and tumor size in such patients.

Patients and methods: Clinical data from patients with T1b GBA receiving curative surgical treatment between 2004 and 2015 were collected from the Surveillance, Epidemiology, and End Results (SEER) database. Baseline characteristics for the entire cohort were described, and overall survival (OS) and cancer-specific survival (CSS) were analyzed with the Kaplan–Meier method.

Results: In total, 277 patients were enrolled for further analysis; 127 underwent lymphadenectomy. Among them, 23 patients had tumors <1 cm in diameter, none of which had LN metastasis; 104 patients had tumors ≥1 cm, 15 of which had positive LNs. In the group with tumor size <1 cm, there was no significant survival difference between treatment with SC or EC (P = 0.694). A clinical benefit was observed in T1b GBA patients with a tumor size ≥1 cm receiving EC vs. those receiving SC (P = 0.012).

Conclusion: SC was adequate for treatment of T1b GBA < 1 cm in diameter. This evidence may be included as part of current guidelines.