Laparoscopic cholecystectomy for treatment of unexpected early-stage gallbladder cancer

Effect of anesthetic technique on antitumor immunity in patients undergoing surgery for gall bladder cancer: A prospective randomized comparative study

There is a paucity of literature regarding the effect of anesthetic techniques on antitumor immunity, especially in gall bladder malignancies. We designed a study to compare the effect of propofol-based total intravenous anesthesia and sevoflurane-based general anesthesia-on antitumor immunity, including tumor growth factor-β (TGF-β), T-helper cell profile, and inflammatory markers. A pilot prospective randomized trial was conducted in 64 patients undergoing surgery for gall bladder malignancy under general anesthesia in a tertiary specialty cancer hospital. Adult cancer patients of ASA physical status I-III fulfilling the inclusion criteria were randomized to either group S (sevoflurane-based general anesthesia) or group T (propofol-based total intravenous anesthesia). Preoperative (morning of surgery) and postoperative (24 h and 1 month after surgery) blood samples were obtained. Demographic profile and preoperative parameters were comparable between both groups. There was a statistically significant difference in the postoperative value of TGF-β (higher in group T). There was a statistically significant difference in postoperative interleukin-17A value (indicative of TH17 cells), and it was found to be higher in group S. Propofol-based TIVA increases serum TGF-β levels. At the same time, Sevoflurane modulates T-helper cells-based immunity to increase TH17 cells in patients with gall bladder cancer. Multiple larger studies will be required to validate the results and provide useful recommendations.

Cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy and intraoperative radiation therapy in the management of gallbladder cancer: a case report

Gallbladder cancer (GBC) is a rare and highly aggressive malignancy, often characterized by nonspecific clinical presentations and late diagnosis, which contribute to its poor prognosis. It is commonly detected at advanced stages, leading to low survival rates. Surgical resection is the primary treatment, with the extent of surgery depending on the T stage of the cancer. In advanced cases, surgery is only considered if it can potentially be curative. Despite various treatment approaches for advanced GBC, survival outcomes remain poor. In our case series, we introduce a novel treatment approach combining cytoreductive surgery, intraoperative radiation therapy, and hyperthermic intraperitoneal chemotherapy. Remarkably, we observed a 100% one-year survival rate, with one patient achieving eight years of disease-free survival without recurrence or metastasis. This aggressive treatment strategy did not lead to increased morbidity or mortality, suggesting its safety and feasibility. However, larger-scale studies are required to draw definitive conclusions.

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.

Value of contrast-enhanced ultrasound in diagnosis and differential diagnosis of polypoid lesions of gallbladder ≥ 1 cm

OBJECTIVES

To evaluate the usefulness of Contrast-enhanced ultrasound (CEUS) in the diagnosis and differential diagnosis of Polypoid lesions of gallbladder (PLGs) ≥ 1 cm.

METHODS

A prospective analysis was performed on 180 patients with PLGs ≥ 1 cm. 175 cases were confirmed by pathological diagnosis and the remaining were confirmed by other imaging findings. The characteristics of lesions on conventional Ultrasonography (US) and CEUS were recorded.

RESULTS

Significant differences were observed in enhancement patterns between benign and malignant PLGs during both arterial (P < 0.001) and venous phases (P < 0.001). The malignant lesions typically yielded a "fast-in and fast-out" enhancement pattern. There was no significant difference in Arrival time (AT) between malignant and benign PLGs. If we consider wash-out time ≤ 40 s as a diagnostic standard for malignant lesions, the sensitivity, specificity, and accuracy were 88.24%, 85.62%, and 86.11%, respectively. Destruction of the Gallbladder (GB) wall was a particularly important indication of malignant PLGs, and the sensitivity, specificity, and accuracy were 93.33%, 92.12%, and 92.22%, respectively. The accuracy of CEUS in the diagnosis of PLGs, as well as malignant and benign lesions, was 92.22%, 92.47%, and 91.17%, respectively.

CONCLUSIONS

The "fast-in and fast-out" enhancement pattern, hyper-enhancement in comparison to the GB wall in the arterial phase, wash-out time ≤ 40 s, GB wall destruction, and hepatic parenchymal infiltration are the characteristic findings of malignant PLGs. Besides, CEUS provides a valuable reference to classify some of the benign lesions.

Aggressive Surgical Management of Gallbladder Cancer: Long-Term Results From a Retrospective Study of 315 Chinese Patients

Objective

To investigate the best surgical treatment for the gallbladder cancer patient.

Summary of Background Data

Until now, aggressive surgery for advanced gallbladder cancer has been controversial. In this study, we analyzed gallbladder cancer patients' data retrospectively to find out which is the best surgical treatment for the patient.

Methods

From 2009 to 2013, 315 cases of gallbladder carcinoma were identified. Data were analyzed retrospectively. The review included analysis of survival rate, postoperative complications, operative mortality rate, and correlation between local extent of the primary tumor and frequency of nodal metastases.

Results

Postoperative complications occurred in 15 patients (6.2%). A total of 3% of patients who underwent a radical surgery procedure had complications, but in the extended radical surgery group, it was 9.8%. Operative mortality rate was 4.94%. No lymph node metastases were found in patients with T1 tumors. Nodal involvement in patients with T3 (55.22%) and T4 (82.50%) tumors was significantly higher than that in patients with T2 tumors (44.12%). In patients with stages I and II cancers, the radical resection group had a better survival rate than the simple cholecystectomy group. In patients with stage III cancer, the extended radical surgery group and radical surgery group showed better survival rates than others. In patients with stage IV cancer, the extended radical surgery group showed a 4% survival rate at 2 years, but others group had a 0% survival rate.

Conclusions

Simple cholecystectomy may decrease the long survival rates in patients with stages I and II cancer. In more advanced stages, extended radical resection should be performed if R0 resections can be achieved.

Early Gallbladder Carcinoma: A Single-Center Experience

Aims and background

Controversy continues regarding the best surgical treatment for early gallbladder carcinoma defined as a tumor confined to the mucosa (pT1a) or to the muscularis propria (pT1 b) according to the TNM classification. This study evaluates the effectiveness of different surgical approaches in patients with early gallbladder carcinoma in terms of long-term survival.

Materials and methods

From 1980 to 2001, 175 patients with gallbladder carcinoma were admitted to our department. Fifteen of them underwent resections for early gallbladder carcinoma: 4 patients for pT1a tumors and 11 patients for pT1b tumors. All patients with pT1a tumors and 8 patients with pT1b tumors underwent simple cholecystectomy. The remaining 3 patients with pT1 b tumors underwent extended cholecystectomy.

Results

The 5-10 year cumulative survival rate was 100% for patients with pT1a tumors, 37.5% for patients with pT1b tumors who underwent simple cholecystectomy, and 100% for patients with pT1b tumors who underwent extended cholecystectomy.

Conclusions

Simple cholecystectomy is the appropriate treatment for patients with pT1a tumors, whereas patients with pT1b tumors require an extended cholecystectomy.

Preneoplastic and neoplastic gallbladder lesions detected after cholecystectomy

Introduction

Gallbladder cancer (GBC) is diagnosed often incidentally after cholecystectomies, with a rate of 0.1–3%.

Aim

To review the clinical and morphological aspects of GBC and pre-neoplastic lesions in patients who underwent cholecystectomy.

Material and methods

A total of 5026 patients who underwent cholecystectomy between January 1, 2012 and December 31, 2017 were included in the study. Histological changes (acute cholecystitis, adenomyomatosis, xanthogranulomatous cholecystitis (XGC), polyps, antral metaplasia, intestinal metaplasia (IM), dysplasia, cancer, and others) in gallbladders (GB) from 5029 patients who underwent cholecystectomy for cholelithiasis were analysed.

Results

Gallbladder cancer was more common in women than in men (14/4 = 3.5). A significant relation was found between cholelithiasis and GBC (p = 0.031). Of the patients with GBC, six had stage 1a (T1a + T1b), five had stage 1b (T2N0), two had stage 2 (T3N0), three had stage 2b (T1-3 N1), one had stage 3 (T4 N0), and one had stage 4 (T3N1M1). The IM was more common in females than in males (K/E = 3.3). A significant relationship was found between cholecystitis and IM (p < 0.001). A significant association was observed between IM and adenomyomatosis hyperplasia (p = 0.016).

Conclusions

In this study, it was observed that adenomyomatous hyperplasia and adenomatous polyp were associated with metaplastic changes in the GB pathologies, including XGC and follicular cholecystitis. It is thought that metaplasia-dysplasia may be associated with GBC. However, further studies on GB carcinogenesis are needed.

National Failure of Surgical Staging for T1b Gallbladder Cancer

BACKGROUND

Current guidelines recommend radical cholecystectomy with regional lymphadenectomy (RC-RL) for patients with T1b gallbladder cancer (GBC). However, the extent to which these guidelines are followed is unclear. This study aimed to evaluate current surgical practices for T1b GBC and their implications for overall management strategies and associated outcomes.

METHODS

This retrospective cohort study investigated patients identified from the National Cancer Data Base (2004-2012) with non-metastatic T1b GBC. The patients were categorized according to type of surgical treatment received: simple cholecystectomy (SC) or RC-RL. Among the patients who had lymph nodes pathologically examined, nodal status was classified as pN- or pN+. Use of any adjuvant therapy was ascertained. Overall survival (OS) was compared based on type of surgical treatment and nodal status.

RESULTS

The cohort comprised 464 patients (247 SC and 217 RC-RL cases). The positive margin status did not differ between the two groups (6.1% for SC vs 2.3% for RC-RL; p = 0.128). For RC-RL, the pN+ rate was 15%. Adjuvant therapies were used more frequently in pN+ (53.1% vs 9.4% for pN-). By comparison, 10.9% of the SC patients received adjuvant therapy. The OS for RC-RL-pN- (5-years OS, 64.4%) was significantly better than for RC-RL-pN+ (5-years OS, 15.7%) or SC (5-years OS, 48.3%) (p < 0.001).

CONCLUSION

Less than 50% of the patients with a T1b GBC primary tumor undergo the recommended surgical treatment. Given that 15% of these patients have nodal metastasis and in light of the previously described benefits of adjuvant therapy for node positive GBC, failure to perform RC-RL risks incomplete staging and thus undertreatment for patients with T1b GBC.

Current Role of Minimally Invasive Radical Cholecystectomy for Gallbladder Cancer

Background. For Tis and T1a gallbladder cancer (GbC), laparoscopic cholecystectomy can provide similar survival outcomes compared to open cholecystectomy. However, for patients affected by resectable T1b or more advanced GbC, open approach radical cholecystectomy (RC), consisting in gallbladder liver bed resection or segment 4b-5 bisegmentectomy, with locoregional lymphadenectomy, is considered the gold standard while minimally invasive RC (MiRC) is skeptically considered. Aim. To analyze current literature on perioperative and oncologic outcomes of MiRC for patients affected by GbC. Methods. A Medline review of published articles until June 2016 concerning MiRC for GbC was performed. Results. Data relevant for this review were presented in 13 articles, including 152 patients undergoing an attempt of MiRC for GbC. No randomized clinical trial was found. The approach was laparoscopic in 147 patients and robotic in five. Conversion was required in 15 (10%) patients. Postoperative complications rate was 10% with no mortality. Long-term survival outcomes were reported by 11 studies, two of them showing similar oncologic results when comparing MiRC with matched open RC. Conclusions. Although randomized clinical trials are still lacking and only descriptive studies reporting on limited number of patients are available, current literature seems suggesting that when performed at highly specialized centers, MiRC for GbC is safe and feasible and has oncologic outcomes comparable to open RC.

Trends in port-site metastasis after laparoscopic resection of incidental gallbladder cancer: A systematic review

BACKGROUND

The risk of port-site metastasis after laparoscopic removal of incidental gallbladder cancer was previously estimated to be 14-30%. The present study was designed to determine the incidence of port-site metastasis in incidental gallbladder cancer in the modern era (2000-2014) versus the historic era (1991-1999). We also investigated the site of port-site metastasis.

METHODS

Using PRISMA, a systematic review was conducted to identify papers that addressed the development of port-site metastasis after laparoscopic resection of incidental gallbladder cancer. Studies that described cancer-specific outcomes in ≥5 patients were included. A validated quality appraisal tool was used, and a weighted estimate of the incidence of port-site metastasis was calculated.

RESULTS

Based on data extracted from 27 papers that met inclusion criteria, the incidence of port-site metastasis in incidental gallbladder cancer has decreased from 18.6% prior to 2000 (95% confidence interval 15.3-21.9%, n = 7) to 10.3% since then (95% confidence interval 7.9-12.7%, n = 20) (P < .001). The extraction site is at significantly higher risk than nonextraction sites.

CONCLUSION

The incidence of port-site metastasis in incidental gallbladder cancer has decreased but remains high relative to other primary tumors. Any preoperative finding that raises the suspicion of gallbladder cancer should prompt further investigation and referral to a hepato-pancreato-biliary specialist.

Surgical procedure determination based on tumor-node-metastasis staging of gallbladder cancer

AIM: To investigate the impact of surgical procedures on prognosis of gallbladder cancer patients classified with the latest tumor-node-metastasis (TNM) staging system.

METHODS: A retrospective study was performed by reviewing 152 patients with primary gallbladder carcinoma treated at Peking Union Medical College Hospital from January 2003 to June 2013. Postsurgical follow-up was performed by telephone and outpatient visits. Clinical records were reviewed and patients were grouped based on the new edition of TNM staging system (AJCC, seventh edition, 2010). Prognoses were analyzed and compared based on surgical operations including simple cholecystectomy, radical cholecystectomy (or extended radical cholecystectomy), and palliative surgery. Simple cholecystectomy is, by definition, resection of the gallbladder fossa. Radical cholecystectomy involves a wedge resection of the gallbladder fossa with 2 cm non-neoplastic liver tissue; resection of a suprapancreatic segment of the extrahepatic bile duct and extended portal lymph node dissection may also be considered based on the patient’s circumstance. Palliative surgery refers to cholecystectomy with biliary drainage. Data analysis was performed with SPSS 19.0 software. Kaplan-Meier survival analysis and Logrank test were used for survival rate comparison. P < 0.05 was considered statistically significant.

RESULTS: Patients were grouped based on the new 7^th edition of TNM staging system, including 8 cases of stage 0, 10 cases of stage I, 25 cases of stage II, 21 cases of stage IIIA, 21 cases of stage IIIB, 24 cases of stage IVA, 43 cases of stage IVB. Simple cholecystectomy was performed on 28 cases, radical cholecystectomy or expanded gallbladder radical resection on 57 cases, and palliative resection on 28 cases. Thirty-nine cases were not operated. Patients with stages 0 and I disease demonstrated no statistical significant difference in survival time between those receiving radical cholecystectomy and simple cholecystectomy (P = 0.826). The prognosis of stage II patients with radical cholecystectomy was better than that of simple cholecystectomy. For stage III patients, radical cholecystectomy was significantly superior to other surgical options (P < 0.05). For stage IVA patients, radical cholecystectomy was not better than palliative resection and non-surgical treatment. For stage IVB, patients who underwent palliative resection significantly outlived those with non-surgical treatment (P < 0.01)

CONCLUSION: For stages 0 and I patients, simple cholecystectomy is the optimal surgical procedure, while radical cholecystectomy should be actively operated for stages II and III patients.

Impact of routine histopathological examination of gall bladder specimens on early detection of malignancy - a study of 4,115 cholecystectomy specimens

Gall bladder carcinoma is the most common cancer of biliary tree, characterized by rapid progression and a very high mortality rate. Detection at an early stage, however, is indicative of a very good prognosis and prolonged survival. The practice of histopathological examination of gall bladder specimens removed for clinically benign conditions and its usefulness has been a subject of controversy. The present prospective study was carried out over a period of four years in order to find out the incidence of unsuspected gallbladder carcinoma in cholecystectomy specimens received in our histopathology laboratory and to analyze their clinico-pathological features. A total of 4,115 cases were examined. Incidentally detected cases comprised 0.44%, which accounted for 72% of all gall bladder carcinomas detected. The majority were in an early, surgically resectable stage. From the results of this study we recommend that in India and other countries with relatively high incidences of gall bladder carcinoma, all cholecystectomy specimens should be submitted to histopathology laboratory, as this is the only means by which malignancies can be detected at an early, potentially curable stage.

Laparoscopic radical cholecystectomy with lymph node dissection for gallbladder carcinoma

BACKGROUND

Laparoscopic surgery has been widely employed in the field of digestive surgery, since the minimally invasive procedure provides a significant benefit to patients. However, laparoscopic curative surgery for gallbladder cancer has been rarely described. The aim of this study was to evaluate the effectiveness and validity of laparoscopic radical cholecystectomy with lymph node dissection (Lap-RC) to treat with T1b/T2 gallbladder carcinoma.

METHODS

A total of 11 patients underwent Lap-RC for gallbladder carcinoma from November 2001 until June 2013. While 4 patients were preoperatively diagnosed with T1b/T2 gallbladder carcinoma, 7 patients were diagnosed with incidental T1b/T2 gallbladder carcinoma by postoperative pathological examination after laparoscopic cholecystectomy. Common bile duct resection and biliary tract reconstruction were performed in 2 cases. End points in this clinical study were tumor recurrence and survival of patients.

RESULTS

Mean operative time was 196 min, and average hospital stay after surgery was 6.4 days, excluding 2 cases with biliary tract reconstruction. One patient died of recurrence of cancer 89 months after surgery, and another patient died of other reason with local recurrence 39 months after the operation. The other 9 patients were all alive without recurrence at this writing. The 5-year survival rate was 100 % for T1b patients and 83.3 % for T2. These results indicate that almost equivalent outcomes compared with open surgery in terms of curability were achieved.

CONCLUSIONS

We conclude that pure laparoscopic radical cholecystectomy with lymph node dissection is safe and beneficial for the patients with T1b/T2 gallbladder carcinoma.

Surgical strategy for T1 gallbladder cancer: a nationwide multicenter survey in South Korea

BACKGROUND

The aim of this study was to investigate the clinical features and clinical outcomes of T1 gallbladder (GB) cancer and to determine an appropriate surgical strategy for T1 GB cancer.

METHODS

A nationwide multicenter study, in which 16 University Hospitals in Korea participated, was performed from 1995 to 2004. A total of 258 patients, 117 patients with T1a and 141 patients with T1b disease were enrolled. Clinicopathologic findings and long-term follow-up results were analyzed after a consensus meeting of the Korean Pancreas Surgery Club was held.

RESULTS

Simple cholecystectomy was performed in 95 patients (81.2 %) with T1a tumor and in 89 patients (63.1 %) with T1b tumor (p < 0.01). Lymph node metastasis was observed in 2.9 % of T1a patients and in 9.9 % of T1b patients (p = 0.391). A significant difference in 5-year disease-specific survival (DSS) rates was observed between T1a and T1b patients (96.4 vs 84.8 %, respectively, p = 0.03). However, no significant 5-year DSS rate difference was observed between those who underwent simple cholecystectomy or extended cholecystectomy, regardless of whether lymph node dissection was performed or whether lymph node metastasis was present. There was no significant difference in recurrence-free survival between simple cholecystectomy and extended cholecystectomy.

CONCLUSIONS

There was no superiority of extended cholecystectomy over simple cholecystectomy in the aspect of survival and recurrence especially in T1b gallbladder cancer. Furthermore, the effectiveness of regional lymphadenectomy for treatment purpose remains questionable. Therefore, simple cholecystectomy could be recommended as a surgical strategy of T1 gallbladder cancer.

A different perspective on macroscopic sampling of cholecystectomy specimens

Background

Because there may be interdepartmental differences in macroscopic sampling of cholecystectomy specimens, we aimed to investigate differences between the longitudinal sampling technique and our classical sampling technique in cholecystectomy specimens in which there was no obvious malignancy.

Methods

Six hundred eight cholecystectomy specimens that were collected between 2011 and 2012 were included in this study. The first group included 273 specimens for which one sample was taken from each of the fundus, body, and neck regions (our classical technique). The second group included 335 specimens for which samples taken from the neck region and lengthwise from the fundus toward the neck were placed together in one cassette (longitudinal sampling). The Pearson chi-square, Fisher exact, and ANOVA tests were used and differences were considered significant at p<.05.

Results

In the statistical analysis, although gallbladders in the first group were bigger, the average length of the samples taken in the second group was greater. Inflammatory cells, pyloric metaplasia, intestinal metaplasia, low grade dysplasia, and invasive carcinoma were seen more often in the second group.

Conclusions

In our study, the use of a longitudinal sampling technique enabled us to examine a longer mucosa and to detect more mucosal lesions than did our classical technique. Thus, longitudinal sampling can be an effective technique in detecting preinvasive lesions.

Prognosis of incidental gallbladder carcinoma is not influenced by the primary access technique: analysis of 837 incidental gallbladder carcinomas in the German Registry

BACKGROUND

The use of the laparoscopic approach (LC) for gallbladder carcinoma and incidental gallbladder carcinomas (IGBC) remains controversial. However, recent studies suggest that LC has no adverse effects relative to the open approach. A definitive conclusion regarding the safety of LC that is based on data from a large patient cohort is needed.

METHODS

To draw a definite conclusion about the safety of LC in IGBC, data from the 837 patients with IGBC [registered in the German Registry (GR)] were analyzed.

RESULTS

Of the 837 patients, 492 underwent LC, 200 underwent open surgery (OC), and 142 initially underwent LC, but the approach was converted to OC. The 5-year survival rates of the three groups indicated that LC was associated with significantly better survival. LC was not associated with a poorer prognosis in patients with T1, T2, or T3 stage disease or in patients who underwent immediate radical re-resection (IRR; n = 330). LC was associated with a significant survival benefit in the 490 patients who did not undergo IRR. LC was comparable with OC in terms of overall recurrence rates and the rate of accidental intraoperative perforation.

CONCLUSIONS

The GR data, which relate to a large homogenous patient cohort, showed that when other potential influencing factors, e.g., IRR were eliminated, the primary access technique had no effect on prognosis. Stage-adjusted therapy should always be performed irrespective of the primary access technique.

A 21-year analysis of stage I gallbladder carcinoma: is cholecystectomy alone adequate?

OBJECTIVES

Gallbladder carcinoma (GBC) is a rare disease that is often diagnosed incidentally in its early stages. Simple cholecystectomy is considered the standard treatment for stage I GBC. This study was conducted in a large cohort of patients with stage I GBC to test the hypothesis that the extent of surgery affects survival.

METHODS

The National Cancer Institute's Surveillance, Epidemiology and End Results (SEER) database was queried to identify patients in whom microscopically confirmed, localized (stage I) GBC was diagnosed between 1988 and 2008. Surgical treatment was categorized as cholecystectomy alone, cholecystectomy with lymph node dissection (C + LN) or radical cholecystectomy (RC). Age, gender, race, ethnicity, T1 sub-stage [T1a, T1b, T1NOS (T1 not otherwise specified)], radiation treatment, extent of surgery, cause of death and survival were assessed by log-rank and Cox's regression analyses.

RESULTS

Of 2788 patients with localized GBC, 1115 (40.0%) had pathologically confirmed T1a, T1b or T1NOS cancer. At a median follow-up of 22 months, 288 (25.8%) had died of GBC. Five-year survival rates associated with cholecystectomy, C + LN and RC were 50%, 70% and 79%, respectively (P < 0.001). Multivariate analysis showed that surgical treatment and younger age were predictive of improved disease-specific survival (P < 0.001), whereas radiation therapy portended worse survival (P = 0.013).

CONCLUSIONS

In the largest series of patients with stage I GBC to be reported, survival was significantly impacted by the extent of surgery (LN dissection and RC). Cholecystectomy alone is inadequate in stage I GBC and its use as standard treatment should be reconsidered.

T-category reflects the histopathologic characteristics of gallbladder cancer

AIMS

Gallbladder (GB) cancer is a relatively uncommon gastrointestinal malignancy and is known to often result in unfavorable outcomes. Recent advances in aggressive surgical resection have improved the overall survival rate of patients with GB cancer. We aimed to evaluate the outcomes and prognostic factors of GB cancer following a surgical resection with curative intent.

METHODS

Between March 2001 and March 2009, 89 patients with GB cancer underwent surgical resection with curative intent at the National Cancer Center of Korea. We then conducted a retrospective analysis of clinicopathologic data.

RESULTS

Nineteen patients underwent simple cholecystectomy and 70 patients underwent extended cholecystectomy. Tumor-free resection margins were obtained in 84 cases. The 1-, 3- and 5-year disease-specific survival rates in the 89 patients were 85.8%, 68.0% and 64.1%, respectively. By multivariate analysis, only the T-category was significant (p < 0.001). The T-category showed a close correlation with all of the other histopathologic factors which were significant in univariate analysis.

CONCLUSION

The T-category of GB cancer represents not only the depth of the primary tumor but also the aggressiveness of its histopathologic nature.

High-grade dysplasia of the cystic duct margin in the absence of malignancy after cholecystectomy

BACKGROUND

A total of 750,000 cholecystectomies are performed annually in the USA. No data exist on patients with microscopic high-grade dysplasia at the cystic duct margin and the associated incidence of cholangiocarcinoma.

METHODS

Pathology reports for 1992-2010 were reviewed for patients with high-grade dysplasia of the cystic duct margin in the absence of invasive gallbladder cancer. Clinical data were obtained from chart review.

RESULTS

Five patients with high-grade dysplasia at the cystic duct margin without evidence of malignancy were identified. Radiologic imaging was abnormal in two patients. The cystic duct stump was abnormally dilated in both patients and one patient had an enlarged portacaval lymph node. All five patients underwent exploration and resection of either the cystic duct stump or the bile duct. Specimens in four of the patients showed no evidence of malignancy or dysplasia. One patient was found to have a node-positive adenocarcinoma of the cystic duct.

CONCLUSIONS

High-grade dysplasia at the cystic duct margin without evidence of invasive gallbladder cancer is rare. Patients with this finding should undergo cross-sectional imaging and a diagnosis of an underlying cholangiocarcinoma should be considered, especially if imaging reveals any abnormalities.

Adjuvant radio-chemotherapy after extended or simple cholecystectomy in gallbladder cancer

PURPOSE

To analyse results of combined treatment of adjuvant radio-chemotherapy (RT-CT) in patients diagnosed with gallbladder cancer (GBC) after complete resection.

METHODS AND MATERIAL

From June 1993 until July 2006, 67 patients with a diagnosis of GBC who underwent R0 surgical resection and were staged as T1b-2-3N0-1M0 received adjuvant RT-CT. Radiotherapy consisted of whole abdominal irradiation (20 Gy at 100 cGy daily) plus a boost to the tumour bed for a total of 45-59.4 Gy. Concomitant chemotherapy (fluoropyrimidines) was given. Overall survival (OS) and median survival were analysed in relation to different prognostic factors.

RESULTS

With a median follow-up of 90 months, 5-year OS was 41%, in the group who underwent extended cholecystectomy it reached 57% and it was only 27% in those who underwent simple cholecystectomy (p = 0.005). Median survival was 42 months for the whole population, not yet reached for the extended cholecystectomy subgroup and 23 months for the simple cholecystectomy subgroup. When analysing for histological grade, median survival was 23 months for those graded as high grade (III or IV) and 57 months for those of low-unknown grade (p = 0.029). In multivariate analysis, a statistically significant OS benefit was found for those who underwent extended cholecystectomy (p = 0.003).

CONCLUSIONS

In the absence of randomised studies, these data support the use of extended cholecystectomy followed by adjuvant RT-CT in patients diagnosed as stages T1b-2- 3N0-1M0 GBC after R0 resection.

Systematic review on the surgical treatment for T1 gallbladder cancer

AIM: To evaluate the efficacy of simple and extended cholecystectomy for mucosa (T1a) or muscularis (T1b) gallbladder (GB) cancer.

METHODS: Original studies on simple and extended cholecystectomy for T1a or T1b GB cancer were searched from MEDLINE (PubMed), Cochrane Library, EMBase, and CancerLit using the search terms of GB, cancer/carcinoma/tumor/neoplasm.

RESULTS: Twenty-nine out of the 2312 potentially relevant publications met the eligibility criteria. Of the 1266 patients with GB cancer included in the publications, 706 (55.8%) and 560 (44.2%) had T1a and T1b GB cancer, respectively. Simple cholecystectomy for T1a and T1b GB cancer was performed in 590 (83.6%) and 375 (67.0%) patients, respectively (P < 0.01). In most series, the treatment of choice was simple cholecystectomy for T1a GB cancer patients with a 5-year survival rate of 100%. Lymph node metastasis was detected in 10.9% of the T1b GB cancer patients and in 1.8% of the T1a GB cancer patients, respectively (P < 0.01). Eight patients (1.1%) with T1a GB cancer and 52 patients (9.3%) with T1b GB cancer died of recurrent GB cancer (P < 0.01).

CONCLUSION: Simple cholecystectomy represents the adequate treatment of T1a GB cancer. There is no definite evidence that extended cholecystectomy is advantageous over simple cholecystectomy for T1b GB cancer.

Incidental gallbladder carcinoma diagnosed during or after laparoscopic cholecystectomy

BACKGROUND

Gallbladder carcinoma (GC) is a highly lethal neoplasm. With the increase of cholecystectomies since the wide acceptance of laparoscopic cholecystectomy (LC), the incidental diagnosis of gallbladder carcinoma is more frequent. The aim of the present study was to report our experience with GC diagnosed during or after the performance of LC.

METHODS

A total of 10,466 LCs were carried out from January 1999 to December 2007 in our hospital. Records of patients with incidental carcinoma were collected and analyzed retrospectively.

RESULTS

Of all the patients, 20 (0.19%) were histopathologically diagnosed as having a GC. There were 4 men and 16 women; the median age in this group was 65.7 years (range: 37-81 years).The depth of cancer invasion was: pTis (4 cases), pT1a (2 cases), pT1b (2 cases), pT2 (6 cases), pT3 (4 cases), and pT4 (2 cases). The sensitivity and specificity of intraoperatively frozen section examination were 83.3 and 100%, respectively. Patients with in situ, pT1a and pT1b tumors underwent LC only, and there were no recurrences. The survival rate between patients with GC diagnosed during or after LC showed no difference; it was dependent on the depth of cancer invasion.

CONCLUSIONS

The survival with incidental GC is related to stage, and it validates that a carefully performed LC is adequate treatment for carcinoma in situ, and stage 1a and b cancer. A frozen section examination was helpful but did not provide a definitive diagnosis. Meticulous techniques during LC, including retrieval of the gallbladder in a retrieval bag, may prevent port-site recurrence and intraperitoneal dissemination.

Current management of gallbladder carcinoma

Gallbladder cancer (GBC) represents the most common and aggressive type among the biliary tree cancers (BTCs). Complete surgical resection offers the only chance for cure; however, only 10% of patients with GBC present with early-stage disease and are considered surgical candidates. Among those patients who do undergo "curative" resection, recurrence rates are high. There are no established adjuvant treatments in this setting. Patients with unresectable or metastatic GBC have a poor prognosis. There has been a paucity of randomized phase III data in this field. A recent report demonstrated longer overall survival with gemcitabine in combination with cisplatin than with gemcitabine alone in patients with advanced or metastatic BTCs. Molecularly targeted agents are under development. In this review, we attempt to discuss the current status and key issues involved in the management of GBC.

Are histological alterations observed in the gallbladder precancerous lesions?

INTRODUCTION

Gallbladder cancer, which is characterized by rapid progression and a poor prognosis, is a complex disease to treat. Unfortunately, little is known currently about its etiology or pathogenesis. A better understanding of its carcinogenesis and determining risk factors that lead to its development could help improve the available treatment options.

METHOD

Based on this better understanding, the histological alterations (such as acute cholecystitis, adenomyomatosis, xanthogranulomatous cholecystitis, polyps, pyloric metaplasia, intestinal metaplasia, dysplasia, cancer and others) in gallbladders from 1,689 patients who underwent laparoscopic cholecystectomy for cholecystolithiasis were analyzed. The association of these gallbladder histological alterations with clinical data was studied.

RESULTS

Gender analysis revealed a greater incidence of inflammatory changes in males, while dysplasia and cancer were only found in women. The incidence of cholesterolosis was greater in the patients 60 years of age and under, and the incidence of adenomyomatosis and gangrene was greater in the elderly patients. A progressive increase in the average age was observed as alterations progressed through pyloric metaplasia, intestinal metaplasia, dysplasia and then cancer, suggesting that the metaplasia-dysplasia-carcinoma sequence may occur in gallbladder cancer. Gallbladder histological alterations were also observed in asymptomatic patients.

CONCLUSION

The results of this study suggest that there could be an association between some histological alterations of gallbladder and cancer, and they also suggest that the metaplasia-dysplasia-carcinoma sequence could in fact be true in the case of gallbladder cancer. Nevertheless, further studies directed towards a perfect understanding of gallbladder carcinogenesis are required.

Radical resection for T1b gallbladder cancer: a decision analysis

BACKGROUND

Gallbladder cancer is the most common malignancy of the biliary tract. Radical surgery (including liver resection and regional lymphadenectomy) is applied for some gallbladder cancers, but the benefits of these procedures are unproven. For patients with T1b cancers discovered incidentally on cholecystectomy specimens, the utility of radical surgery remains debated.

METHODS

A decision analytic Markov model was created to estimate and compare life expectancy associated with management strategies for a simulated cohort of patients with incidentally discovered T1b gallbladder cancer after routine cholecystectomy. In one strategy, patients were treated with no additional surgery; in another, patients were treated with radical resection. The primary (base-case) analysis was calculated based on a cohort of 71-year-old females and incorporated best available input estimates of survival and surgical mortality from the literature. Sensitivity analysis was performed to assess the effects of model uncertainty on outcomes.

RESULTS

In the base-case analysis, radical resection was favoured over no further surgical resection, providing a survival benefit of 3.43 years for patients undergoing radical resection vs. simple cholecystectomy alone. Sensitivity analysis on the age at diagnosis demonstrated that the greatest benefit in gained life-years was achieved for the youngest ages having radical resection, with this benefit gradually decreasing with increasing age of the patient. High peri-operative mortality rates (>/=36%) led to a change in the preferred strategy to simple cholecystectomy alone.

CONCLUSIONS

Decision analysis demonstrates that radical resection is associated with increased survival for most patients with T1b gallbladder cancer.

[Gallbladder cancer in a regional hospital]

OBJECTIVES

To assess the management of gallbladder cancer (GBC) in our region.

MATERIAL AND METHODS

Data on 372 patients who underwent cholecystectomy were identified from our database (January 2003 to February 2008) and 6 patients were found to have GBC.

RESULTS

Four patients had incidental carcinoma, one case was preoperatively suspected, and one patient presented with jaundice and locally advanced neoplasia. The incidence was 2 per 100,000 inhabitants per year; incidental carcinoma in 1.1% of cholecystecomies. The ultrasonography showed multilithiasis in 2 patients, sludge and neoplasia in 1, gallstones more than 3cm in 2, and tumor mass only in 1 case. T stage: 1 case of T0 (in situ), 1 of T1, 2 of T2 and one T4. Incidental carcinomas were reoperated on when a T2 was established: 2 underwent lymphadenectomy and cystic stump resection, 1 segmentectomy IVb-V and lymphadenectomy. In the preoperative suspected neoplasia a cholecystectomy, lymphadenectomy, and partial hepatic gallbladder bed resection was initially performed.

CONCLUSIONS

GBC has a low incidence but it will be found in 1% of cholecystectomies. There is no adjuvant treatment and T-based surgical treatment is the is the only opportunity to reach cure in those patients. A national GBC database would be helpful in the publication of national guidelines for this disease.

Consideration of anatomical structures relevant to the surgical strategy for managing gallbladder carcinoma

AIMS

Gallbladder carcinoma usually presents late with advanced disease. It develops in an anatomically complex area. Consideration is given to resection of relevant local structures with respect to outcome.

METHODS

A comprehensive literature review was performed, searching Medline for articles published since 2000, using the MeSH heading of 'gallbladder cancer' and 'surgery'. Abstracts were reviewed and articles retrieved if the main focus of the article centred on the surgical management of gallbladder carcinoma.

OBSERVATIONS

Hepatic resection is advocated and tailored to pathological T stage. Lymph node dissection and bile duct resection, as well as en bloc resection of other viscera, remain areas of controversy.

CONCLUSIONS

Eastern and Western practice standards of care differ, but hepatic resection with some lymph node dissection is present in both approaches. Philosophy regarding aggression with respect to en bloc resection of adjacent organs and actual extent of lymphatic resection remains disparate.

A review of the surgical strategies for the management of gallbladder carcinoma based on T stage and growth type of the tumour

AIMS

Surgery for gallbladder carcinoma is a technically challenging exercise. The extent of resection varies based on a number of factors, and controversy exists regarding what constitutes an acceptable resection. A review of current recommendations and practice was undertaken.

METHODS

A comprehensive literature review was performed, searching Medline for articles published since 2000, using the MeSH heading of 'gallbladder cancer' and 'surgery'. Abstracts were reviewed and articles retrieved if the main focus of the article centred on the surgical management of gallbladder carcinoma.

OBSERVATIONS

The extent of hepatic resection and lymph node dissection required varies in particular with T stage. Growth pattern and anatomical location of the tumour within the gallbladder also influence surgical management.

CONCLUSIONS

Discrepancy exists between the Eastern and Western literature in terms of what constitutes an acceptable limit of resection, and these issues are discussed.

Gallbladder cancer--a comprehensive review

AIM

Gallbladder cancer is the fifth most common cancer involving the gastrointestinal tract, but it is the most common malignant tumour of the biliary tract worldwide. The percentage of patients diagnosed to have gallbladder cancer after simple cholecystectomy for presumed gallbladder stone disease is 0.5-1.5%. This tumour is traditionally regarded as a highly lethal disease with an overall 5-year survival of less than 5%. The marked improvement in the outcome of patients with gallbladder cancer in the last decade is because of the aggressive radical surgical approach that has been adopted, and improvements in surgical techniques and peri-operative care. This article aims to review the current approach to the management of gallbladder cancer.

METHODS

A Medline, PubMed database search was performed to identify articles published from 1990 to 2007 using the keywords 'carcinoma of gallbladder', 'gallbladder cancer', 'gallbladder neoplasm' and 'cholecystectomy'.

RESULTS AND CONCLUSIONS

The overall 5-year survival for patients with gallbladder cancer who underwent Ro curative resection was reported to range from 21% to 69%. Laparoscopic cholecystectomy is absolutely contraindicated when gallbladder cancer is known or suspected pre-operatively. Patients with a pre-operative suspicion of gallbladder cancer should undergo open exploration and cholecystectomy after proper pre-operative assessment. For patients whose cancer is an incidental finding on pathological review, a second radical resection is indicated except for Tis and T1a disease. There is still controversy for the optimal management of T1b disease. Although the role of surgery for advanced disease remains controversial, patients with advanced gallbladder cancer can benefit from radical resection, provided a potentially curative Ro resection is possible. There is still no effective adjuvant therapy for gallbladder cancer.

Recurrence of cholangiogenous carcinoma in port-sites two years after laparoscopic removal of noncancerous gallbladder

We present a unique case of carcinoma diagnosed in port-site, two years after uncomplicated laparoscopic cholecystectomy for benign cholecystitis. Analysis of morphology and cytokeratin profile (CK19+ and CK20+/-) of resected port-site tumor allows us to establish the diagnosis of tubular carcinoma with probable cholangiogenic origin. The primary carcinoma was not diagnosed in archival gallbladder tissue, despite repeated histological examination. No other primary tumor was identified during follow-up. Patient history and histological/immunohistochemical picture of the recurrent tumor suggested that primary carcinoma was probably located in the gallbladder, but was not detected during initial and repeated histological examinations of postoperative specimen. The patient is still alive, 12 months after the first port-site recurrence and 36 months after initial laparoscopy.

Management of T2 gallbladder cancer: are practice patterns consistent with national recommendations?

BACKGROUND

The national recommendation for the management of localized T2 gallbladder cancer (GBCA) is radical cholecystectomy. Although reported survival for localized T2 disease has been poor, groups have documented improvement with radical resection. We hypothesized that a discrepancy exists between national recommendations and current practice patterns.

METHODS

Patients diagnosed with localized T2 GBCA between 1988 and 2002 were identified from the Surveillance, Epidemiology, and End Results registry. Age, sex, race, ethnicity, extent of surgery, and overall survival were assessed. Surgical procedure was categorized as cholecystectomy alone (CS), cholecystectomy plus lymph node dissection (CS+LN), radical cholecystectomy (RCS), or other. Survival calculations were made using the Kaplan-Meier method and compared with the log-rank test.

RESULTS

Of 382 patients with pathologically confirmed T2 GBCA, 280 were women. The median patient age was 75 years. A total of 238 patients underwent CS, 76 underwent CS+LN, and 14 underwent RCS. The remaining 54 patients underwent a lesser or no procedure and were excluded from comparative analysis. The median survival was 14 months for all patients and 14, 14, and 8 months for subgroups treated with CS, CS+LN, and RCS, respectively. Rates of 5-year survival were 23%, 24%, and 36% for CS, CS+LN, and RCS subgroups, respectively. There was no significant difference in survival rates between RCS and CS+LN, or between RCS and CS.

CONCLUSIONS

The majority of patients with T2 GBCA in the United States are not managed according to current national recommendations.

[Incidentalomas of the liver and gallbladder. Evaluation and therapeutic procedure]

The expanding use of ultrasound in general practice is leading to an ever increasing rate of detection of true hepatic incidentaloma. The correct diagnosis of hepatic incidentaloma may be made in over 90% with non-invasive means. The questionable diagnosis of "symptomatic" incidentaloma should undergo close scrutiny prior to a decision in favour of surgery. With regard to more recent literature, the former "absolute" requirement for surgical resection in all cases of liver cell adenoma may have to be reappraised. Final inability to rule out malignancy represents an unquestionable indication for surgery in the light of low rates of morbidity and lack of mortality in this otherwise healthy patient group. Percutaneous biopsies should not be performed due to oncological hazards, indeterminate results and potential for acute complications.The stage-oriented radical re-resection following diagnosis of an incidentally detected gallbladder cancer may lead to significantly improved long-term survival, especially in the early tumour stages T1b and T2, which represents the most common stage of gallbladder cancer in incidentaloma. Patients at elevated risk for incidental gallbladder cancer should undergo thorough instruction with regard to the potential hazards of laparoscopic cholecystectomy. Multimodal therapeutic strategies directed at advanced stages of incidentally detected gallbladder cancer should be evaluated in prospective multicentre studies.

Laparoscopic cholecystectomy only could be an appropriate treatment for selected clinical R0 gallbladder carcinoma

BACKGROUND

Laparoscopic cholecystectomy (LC) for gallbladder carcinoma still is controversial except for the early stages of gallbladder carcinoma (Tis). This study was designed to evaluate and revisit the role of LC in treating gallbladder carcinoma.

METHODS

Available medical records of patients with surgeries for gallbladder carcinoma were retrospectively investigated from August 1992 to February 2005.

RESULTS

Among 219 patients treated for gallbladder carcinoma, 57 (26%) underwent LC. A total of 16 patients (28.1%) underwent subsequent radical cholecystectomy (LC-RC), and 41 (71.9%) were only followed up without radical surgery (LC). Tis was found in 11 patients (19.3%), T1a in 3 patients (5.3%), T1b in 8 patients (14%), T2 in 19 patients (33.3%), and T3 in 16 patients (28.1%). The findings showed R0 in 14 cases of the radical cholecystectomy group, and clinical R0 was noted in 30 cases of the LC-only group. No survival differences were noted between LC and LC-RC (p = 0.2575), especially in the case of T2 lesions (p = 0.6274), nor between the R0 and clinical R0 (p = 0.5839). However, significant survival differences were noted between the R2 and R0 groups, and between R2 and clinical R0, respectively (p < 0.001).

CONCLUSIONS

The findings show that LC could be appropriate treatment for gallbladder carcinoma only in selected cases of clinical R0 lesions.