The significance of anatomic tumor location in gallbladder cancer

New trends in diagnosis and management of gallbladder carcinoma

Gallbladder (GB) carcinoma, although relatively rare, is the most common biliary tree cholangiocarcinoma with aggressiveness and poor prognosis. It is closely associated with cholelithiasis and long-standing large (> 3 cm) gallstones in up to 90% of cases. The other main predisposing factors for GB carcinoma include molecular factors such as mutated genes, GB wall calcification (porcelain) or mainly mucosal microcalcifications, and GB polyps ≥ 1 cm in size. Diagnosis is made by ultrasound, computed tomography (CT), and, more precisely, magnetic resonance imaging (MRI). Preoperative staging is of great importance in decision-making regarding therapeutic management. Preoperative staging is based on MRI findings, the leading technique for liver metastasis imaging, enhanced three-phase CT angiography, or magnetic resonance angiography for major vessel assessment. It is also necessary to use positron emission tomography (PET)-CT or 18F-FDG PET-MRI to more accurately detect metastases and any other occult deposits with active metabolic uptake. Staging laparoscopy may detect dissemination not otherwise found in 20%-28.6% of cases. Multimodality treatment is needed, including surgical resection, targeted therapy by biological agents according to molecular testing gene mapping, chemotherapy, radiation therapy, and immunotherapy. It is of great importance to understand the updated guidelines and current treatment options. The extent of surgical intervention depends on the disease stage, ranging from simple cholecystectomy (T1a) to extended resections and including extended cholecystectomy (T1b), with wide lymph node resection in every case or IV-V segmentectomy (T2), hepatic trisegmentectomy or major hepatectomy accompanied by hepaticojejunostomy Roux-Y, and adjacent organ resection if necessary (T3). Laparoscopic or robotic surgery shows fewer postoperative complications and equivalent oncological outcomes when compared to open surgery, but much attention must be paid to avoiding injuries. In addition to surgery, novel targeted treatment along with immunotherapy and recent improvements in radiotherapy and chemotherapy (neoadjuvant-adjuvant capecitabine, cisplatin, gemcitabine) have yielded promising results even in inoperable cases calling for palliation (T4). Thus, individualized treatment must be applied.

Effects of Cystic Duct Margin Involvement on the Survival Rates of Patients With Gallbladder Cancer: A Propensity Score-Matched Case-Control Study

Background In gallbladder cancer (GBC), extrahepatic bile duct (EHBD) resection is selectively performed if gross direct extension or microscopic involvement of the cystic duct margin (CDM) is detected. Although CDM is usually sent for frozen biopsy intraoperatively in most centers, there are no studies regarding the routine use of CDM frozen biopsy irrespective of the tumor location and paucity of literature regarding the impact of CDM status on recurrence-free and overall survival in GBC. The presence of obstructive jaundice in GBC usually indicates the involvement of EHBD or cystic duct-bile duct junction. The present study aimed to analyze the necessity of routine CDM frozen biopsy in patients with resectable GBC without jaundice, regardless of the tumor location. The impact of positive CDM on survival was also evaluated. Methods This retrospective observational case-control study was conducted from May 2009 to March 2021 and included 105 patients with resectable GBC without macroscopic EHBD infiltration and jaundice. Patients were divided into CDM-negative (n=91) and CDM-positive (n=14) groups. Propensity score matching was performed for variables such as performance status, tumor size, tumor-node-metastasis (TNM) stage, and adjuvant chemotherapy. After propensity score matching, 27 patients (CDM-negative=13, CDM-positive=14) were included. The primary outcome was to analyze the role of routine CDM frozen biopsy regardless of tumor location, and secondary outcomes were to study the impact of positive CDM status on survival and evaluate predictive factors for CDM positivity. A subgroup analysis was conducted to assess clinicopathologic characteristics and outcomes of the anatomical location of the tumor. Results Of 105 patients, 91 had negative CDM, and 14 had positive CDM. Among 14 patients with positive CDM, only one patient had a tumor in the fundus/body, and the remaining had a tumor involving the neck. All CDM-positive patients underwent bile duct excision with hepaticojejunostomy. Common bile duct (CBD) involvement was present in 50% of patients with positive CDM in the final histopathological examination. In the matched population, patients with positive CDM had a significantly higher rate of neck tumors (p=0.001). Recurrence-free survival (24 vs. 12 months, p=0.30) and overall survival (24.5 vs. 20 months, p=0.417) were comparable between CDM-negative and CDM-positive groups, respectively. On multivariate analysis, preoperative and intraoperative tumor location were independent predictive factors for CDM positivity. On subgroup analysis, 30 patients had tumor involving the neck of the gallbladder, and the remaining 75 had at the fundus and body of the gallbladder. Neck tumors had inferior recurrence-free survival (17 vs. 30 months, p=0.012) and overall survival (24 vs. 36 months, p=0.048) compared to non-neck tumors. Conclusions Routine use of CDM frozen analysis in patients with resectable GBC without jaundice, regardless of tumor location, can be avoided. It can be selectively preferred in patients with GBC involving the neck since tumor location is found to be an independent predictive factor for CDM positivity. Positive CDM has comparable survival outcomes to negative CDM, providing a similar R0 resection rate and tumor stage. However, neck tumors have a worse prognosis than non-neck tumors.

The Significance of Tumor Locations in Patients with Gallbladder Carcinoma After Curative-Intent Resection

OBJECTIVE

To evaluate the significance of tumor locations in patients with resected gallbladder carcinoma (GBC) and to supply the indication of extra-hepatic bile duct resection (EHBDR) according to tumor locations.

METHODS

Patients with resected GBC from 2010 to 2020 in our hospital were retrospectively analyzed. Comparative analyses and a meta-analysis were performed according to different tumor locations (body/fundus/neck/cystic duct).

RESULTS

Article: A total of 259 patients were identified (neck: 71; cystic: 29; body: 51; fundus: 108). Patients with proximal tumors (neck/cystic duct) were often in a more advanced stage and had more aggressive tumor biological features as well as a worse prognosis compared with those with distal tumors (fundus/body). Moreover, the observation was even more obvious between cystic duct and non-cystic duct tumors. Cystic duct tumor was an independent prognostic factor for overall survival (P = 0.01). EHBDR provided no survival advantage even in those with cystic duct tumor.

META-ANALYSIS

With our own cohort incorporated, five studies with 204 patients with proximal tumors and 5167 patients with distal tumors were identified. Pooled results revealed that proximal tumors indicated worse tumor biological features and prognosis versus distal tumors.

CONCLUSION

Proximal GBC had more aggressive tumor biological features, and a worse prognosis versus distal GBC and cystic duct tumor can be regarded as an independent prognostic factor. EHBDR had no obvious survival advantage even in those with cystic duct tumor and was even harmful in those with distal tumors. Upcoming more powerful well-designed studies are required for further validation.

Competing-risk nomogram for predicting survival in patients with advanced (stage III/IV) gallbladder cancer: A SEER population-based study

OBJECTIVE

The primary aim of this study was to assess the cumulative incidence of cause-specific mortality (CSM) and other cause-specific mortality (OCSM) for patients with advanced gallbladder cancer (GBC), and then to develop a nomogram based on competing-risk analysis to forecast CSM.

METHODS

We identified the patients with GBC with specific screening criteria and from the Surveillance Epidemiology and End Results (SEER) database. We calculated the cumulative incidence function for CSM and OCSM, and constructed a competing-risk nomogram based on the Fine and Gray's proportional subdistribution hazard regression model to forecast the probability of CSM of these patients. In addition, the concordance index and calibration plot were performed to validate the novel established model.

RESULTS

A total of 1411 patients were included in this study. The 1-, 2-, and 3-year overall cumulative mortalities were 46.2, 62.2, and 69.6% for CSM, respectively, while they were 6.2, 8.7, and 10.4% for OCSM. Additionally, the 1-, 2-, and 3-year estimates of overall survival were 47.6, 29.1, and 19.9% for above these patients, respectively. We also developed a competing-risk nomogram to estimate the CSM. The concordance index was 0.775 (95% confidence interval (CI): 0.750-0.800) in the training set and that was 0.765 (95% CI: 0.730-0.800) in the internal validation set, which suggests the robustness of the novel established model. Furthermore, the calibration curves and concordance index demonstrated that the nomogram was well-calibrated and demonstrated good discriminative ability.

CONCLUSIONS

The ample sample allowed us to develop a reliable model which demonstrated better calibration and discrimination for predicting the probability of CSM of patients with advanced GBC.