Carcinoma of the gallbladder

Gallbladder cancer: past, present and an uncertain future

Although gallbladder cancer (GBC) is the most common malignancy of the biliary tract, its relatively low incidence and confounding symptomatology result in advanced disease at the time presentation, contributing to the poor prognosis and decreased survival associated with this disease. It is therefore increasingly important to understand its pathogenesis and risk factors to allow for the earliest possible diagnosis. To date, gallbladder cancer is poorly understood compared to other malignancies, and is still most commonly discovered incidentally after cholecystectomy. Moreover, while much is known about biliary neoplasms as a whole, understanding the clinical and molecular nuances of GBC as a separate disease process will prove a cornerstone in the development of early intervention, potential screening and overall more effective treatment strategies. The present work reviews the most current understanding of the pathogenesis, diagnosis, staging and natural history of GBC, with additional focus on surgical treatment. Further, review of current adjuvant therapies for unresectable and advanced disease as well as prognostic factors provide fertile ground for the development of future studies which will hopefully improve treatment outcomes and affect overall survival for this highly morbid, poorly understood malignancy.

Cytologic diagnosis of gallbladder lesions - A study of 150 cases

AIMS AND OBJECTIVES

Gallbladder (GB) carcinoma is among the five most common forms of gastrointestinal cancers and the diagnosis is usually made when the carcinoma is already in an advanced stage. The aim of this study was to assess the application of ultrasound (US) guided fine needle aspiration (FNA) in diagnosing GB carcinoma.

MATERIAL AND METHODS

The present study was carried out on 150 patients suspected to have GB carcinoma on ultrasonography. US-guided FNA from GB was done in these patients and FNA of the other organs was simultaneously done in 20 patients. Histopathology of the GB was available in 14 cases.

RESULTS

Ultrasonography in these patients revealed mass/thickening of the wall of GB in 140 (93.3%) cases and nonspecific US findings in 10 (6.7%). Out of the 140 cases malignancy was cytologically diagnosed in 105 (75%) cases while 12 (8.5%) cases were inflammatory and 23 (16.5%) were inconclusive. Adenocarcinoma was the most common morphologic type. Metastatic tumor deposits were noted in FNA from space occupying lesions of the liver in 12 cases, abdominal lymph nodes in 5 cases, and 1 case each of supraclavicular lymph node, stomach and bilateral ovaries. Of the 10 cases with non-specific US findings, 3 had carcinoma and 7 were inconclusive on cytologic examination.

CONCLUSION

US guided FNA provides a rapid and reliable diagnosis in cases of GB carcinoma.

Adequate extent in radical re-resection of incidental gallbladder carcinoma: analysis of the German Registry

BACKGROUND

Complete surgical resection is the only potentially curative treatment of gallbladder cancer. Gallbladder carcinoma is suspected preoperatively in 30% of patients, and 70% are incidentally discovered by the pathologist (incidental gallbladder carcinoma, IGBC). If IGBC is detected postoperatively, a re-resection, including liver resection and lymph node dissection, in T2 tumor cases and more advanced stages is recommended. It remains unclear whether the prognosis of wedge resection (2-3-cm margin) of the gallbladder bed is the same as that of resection of segments IVb/V.

METHODS

The German Registry, founded in 1997, aims to prospectively record all IGBC cases in Germany. In this study patients with a radical re-resection were treated according to the S3 Guidelines in Germany. The aim of this study was to clarify whether different techniques of liver re-resection show comparable results or if they differ depending on the tumor stage in IGBC patients (n = 624).

RESULTS

A significant survival advantage in patients who have an early re-resection was observed. There was a trend of better survival in T1 tumor stage patients who undergo the less radical re-resection, especially the wedge-resection technique of 3 cm in the gallbladder bed. In T2 tumor stage patients there is a tendency for better survival with the IVb/V-resection technique compared to the 3-cm wedge resection in the gallbladder bed, and a significant survival benefit for these two techniques compared to less radical resection was evident. T3 tumor cases showed better survival with the more radical resection techniques.

CONCLUSIONS

The wedge-resection technique combined with lymph node dissection may be the surgical strategy of choice in T1 tumor cases. For T2 tumors, IVb/V resection combined with lymph node dissection of the hepatoduodenal ligament appears to be the minimum volume of resection required. More radical procedures are needed for tumors infiltrating the serosa or beyond.

Gallbladder cancer

BACKGROUND

Gallbladder cancer (GC) is a relatively rare but highly lethal neoplasm. We review the epidemiology, etiology, pathology, symptoms, diagnosis, staging, treatment, and prognosis of GC.

METHOD

A Pubmed database search between 1971 and February 2007 was performed. All abstracts were reviewed and articles with GC obtained; further references were extracted by hand-searching the bibliography. The database search was done in the English language.

RESULTS

The accurate etiology of GC remains unclear, while the symptoms associated with primary GC are not specific. Treatment with radical cholecystectomy is curative but possible in only 10% to 30% of patients. For patients whose cancer is an incidental finding on pathologic review, re-resection is indicated, where feasible, for all disease except T1a. Patients with advanced disease should receive palliative treatment. Laparoscopic cholecystectomy is contraindicated in the presence of GC.

CONCLUSION

Prognosis generally is extremely poor. Improvements in the outcome of surgical resection have caused this approach to be re-evaluated, while the role of chemotherapy and radiotherapy remains controversial.

Gallbladder cancer: the role of laparoscopy and radical resection

OBJECTIVES

We assess how laparoscopy has altered the presentation of patients with gallbladder cancer and determine whether radical resection in patients with gallbladder cancer is beneficial.

SUMMARY BACKGROUND DATA

The widespread adoption of laparoscopic cholecystectomy has led to an increased frequency of incidentally discovered gallbladder carcinoma. Little data exist to guide surgeons in the optimum management of patients with gallbladder cancer, particularly with respect to the potential advantages of radical resection.

METHODS

Records of 107 patients with gallbladder cancer admitted to a tertiary academic medical center between 1995 and 2004 were reviewed. Gallbladder cancer was found incidentally in 53 patients (50%). Fifty-two of these patients underwent a routine laparoscopic cholecystectomy and were found to have gallbladder cancer intraoperatively or following the operation by subsequent pathologic evaluation of the specimen. Gallbladder cancer had been diagnosed preoperatively by radiology in the other 54 patients (50%). These patients did not undergo laparoscopic cholecystectomy and were explored electively.

RESULTS

The median age at presentation was 67 years and 66% were female. Patients who were found to have gallbladder carcinoma incidentally at laparoscopic cholecystectomy had a significant increase in survival when compared with those who were admitted electively with a known diagnosis (P < 0.001). All patients who presented with a known diagnosis had stage II or greater disease, and 36% of these were stage IV carcinomas. However, 82% of those patients who were found incidentally were stage I or II. The overall 5-year survival for all patients was 15%; those discovered incidentally at laparoscopic cholecystectomy had a 5-year survival of 33%. This difference was significant among patients with stage II carcinomas. In the laparoscopic group, there was no difference in survival between the patients who were immediately converted to an open resection when identified to have gallbladder cancer intraoperatively (n = 6) and those who had a completed laparoscopic cholecystectomy and were re-explored at a later point when found to have gallbladder cancer by subsequent pathology (n = 33). There was a significant improvement in survival in 50 patients (47%) who underwent some form of radical resection (P < 0.001). Stage for stage comparison showed that this was significant in stage II disease. Patients who underwent hepatic resection along with lymphadenectomy and extra hepatic biliary resection had similar survival compared with those who had hepatic resection and lymphadenectomy alone.

CONCLUSIONS

Laparoscopic cholecystectomy appears to have resulted in the earlier discovery of gallbladder cancer in some patients, resulting in increased probability of survival. Patients discovered with gallbladder carcinoma during a laparoscopic cholecystectomy do not have to be converted immediately to an open resection and should be referred to a tertiary care center for further exploration. Adjunctive radical surgical resection, either at the time of cholecystectomy or subsequently, increases survival significantly in early stage disease.

Biliary obstruction in gall bladder cancer is not sine qua non of inoperability

BACKGROUND

The presence of biliary obstruction in patients with gallbladder cancer (GBC) is generally viewed as an indicator of advanced disease, inoperability and poor prognosis.

METHODS

Data was collected from patients with GBC with obstructive jaundice who underwent resection during the period January 2001 to October 2003. Systematic analysis of prospective data was undertaken; patients were analyzed for resectability, post-operative morbidity, mortality and disease-free survival.

RESULTS

During this period 14 patients with GBC with biliary obstruction underwent resection with curative intent. In these jaundiced patients, the resectability rate was 27.45% (14 of 51). In the jaundiced group the mortality was 7.14% the morbidity rate 50%, the mean disease free survival was 23.46 months (median 26 months and range of 2 to 62 months). Seven patients (50%) survived more than two years.

CONCLUSION

Biliary obstruction in gall bladder cancer is not sine qua non of inoperability and resection results in meaningful prolongation of survival.

Gallbladder cancer: surgical results after cholecystectomy in 25 patients with lamina propria invasion and 26 patients with muscular layer invasion

BACKGROUND/PURPOSE

It has been stated that simple cholecystectomy is sufficient treatment for all patients with pT1 gallbladder cancer. However, other authors note the necessity of carrying out extended surgery when there is muscular-layer involvement.

METHODS

A consecutive series of gallbladder carcinomas with lamina propria or muscular layer invasion were analyzed. Between July 1982 and December 2000, 51 patients with pT1 gallbladder carcinomas were treated with simple cholecystectomy (group A, 25 patients with lamina propria-invasion; group B, 26 patients with muscular-layer invasion). Patients with intraepithelial carcinomas were excluded from the study.

RESULTS

There were no differences between the groups in average age, sex ratios, association with other tumors, histologic type, malignancy grade, cholecystitis type, macroscopic aspects, lymph node status, or treatment applied. After an average of 6 years' follow-up, no patients in group A and nine patients (34.6%) in group B died due to gallbladder carcinoma. Cystic lymph nodes could be studied in five of these nine patients who relapsed, and the results were negative for metastasis. Lymphatic or venous invasion was observed in five of these nine patients.

CONCLUSIONS

According to these results, cholecystectomy is not sufficient treatment for gallbladder carcinoma with muscular-layer invasion.

Preliminary study of p53 and c-erbB-2 expression in gallbladder cancer in Indian patients manuscript id: 8962091628764582

BACKGROUND

The inactivation of the tumour suppressor gene and activation of the proto-oncogene are the key steps in the development of the human cancer. The p53 and c-erbB-2 are the best examples of it. In the present study, our aim was to determine the role of these genes in the carcinogenesis of gallbladder by immunohistochemistry.

METHODS

In all 78 consecutive patients of gall bladder diseases were studied for p53 and c-erbB-2 expression immunohistochemically and their expression was correlated with the age, grades and stages of the disease and presence of stone. An informed consent was obtained in each case. Chi square and z test were applied to see the association of p53 and c-erbB-2 over expression with other clinicopathological factors.

RESULTS

Eight (20%) patients of gall bladder cancer were positive for p53 expression and 10 (25%) patients for c-erbB-2. The p53 positivity increased with increasing grade while cerbB-2 positivity decreased with increasing grade of gall bladder cancer. Mean age in cerbB-2 positive cases were lesser as compared to negative cases while p53 did not show such association with age.

CONCLUSION

Only one case of gall bladder cancer co-expressed the p53 and c-erbB-2, thereby suggesting that p53 and c-erbB-2 may have independent role in carcinogenesis of gall bladder cancer. c-erbB-2 over expression in adenoma and younger age group indicates its role as an early event in carcinogenesis of gallbladder. However study of larger sample is required to further validate the results.

The surgical management of incidental gallbladder carcinoma

AIMS

To report the surgical management of carcinoma of the gallbladder.

METHODS

A retrospective study in 65 patients who underwent simple (SC) or extended (EC) cholecystectomy for gallbladder carcinoma.

RESULTS

28 patients underwent extended cholecystectomy (EC) and 37 had simple cholecystectomy (SC). The multivariate analysis showed that lymph-node status (positive vs negative, p=0.001, Hazard Ratio [HR]:14.2, 95% Confidence Interval [CI]:3.1-62.8) and type of surgery (SC vs EC, p=0.01, HR:10.2, 95% CI:1.7-62.8) were the most important prognostic factors related to death. This analysis indicated that EC in those with pT(2) or pT(3) was associated with a reduce hazard of death by 90% in the follow-up period.

CONCLUSIONS

In gallbladder cancer patients who diagnose after simple cholecystectomy, those with pT(1) with clear margins need no further surgery. In patients with pT(2) or pT(3) incidental carcinoma, the completion radical re-operation is the only chance for long-term survival.

Gallbladder cancer in India: a dismal picture

BACKGROUND

Gallbladder cancer (GBC) is one of the most common gastrointestinal malignancies. The data regarding GBC are, however, limited.

METHODS

Records of 634 patients with GBC over a 10-year period were examined with regard to the clinical presentation, investigative findings, treatment, operative findings and outcome.

RESULTS

The mean age of patients was 51 +/- 11 years and men : women ratio was 0.36:1.00. Pain, jaundice and hepatomegaly were seen in 81.0%, 76.0% and 61.5% patients, respectively. On imaging, a mass replacing the gallbladder was seen in 73% patients. Gallstones were present in 54% patients. Surgery was carried out in 291 (46%) patients and endoscopic treatment in 72 (19%) patients but no intervention was carried out in the remaining patients because of disseminated disease. Among the patients who were operated on, 2.0% had stage I GBC, 3.4% stage II, 17.5% stage III, 47.0% stage IVa and 29.8% stage IVb. Radical resection was possible in 133 (46%) patients. The 30-day mortality was 10% with most (90%) deaths in patients with stage IV disease. The median survival after simple cholecystectomy and radical surgery was 33.5 and 12.0 months, respectively. However, among those who underwent debulking, palliative bypass or exploratory laparotomy alone, the survival ranged between 1 and 3 months. Logistic regression analysis showed that only radical resection improved the long-term survival (P < 0.05).

CONCLUSIONS

The majority of patients with GBC in India have advanced unresectable disease. Detection of GBC at an early stage is incidental and rare but is associated with long-term survival. Radical surgery, when feasible, is the only option for achieving long-term survival.

Current perspectives in gallbladder carcinoma

Carcinoma gallbladder (CaGB) is not a common malignancy in a large number of countries in the world, except Chile, Japan, some parts of India, and a few other regions. Lacunae exist even today in terms of understanding of its epidemiology, aetiopathogenesis, and in the early pick up of malignanacy, as well as in choosing the most appropriate treatment option for a given case. While Japanese surgeons have advocated radical resections for CaGB and have shown good outcome resulting in long- term survival, others have not felt convinced about the desirability of undertaking such morbid surgical procedures in all patients. Also, radical resections have not always resulted in a tumor-free state and a cure in a large percentage of cases. Under the circumstances, the clinician's mind is often confused as to the most beneficial option for that patient once curative resection is not possible. Palliation of the jaundice and/or gastric outlet obstruction relieves the symptoms but does not prolong survival. The role of adjuvant chemotherapy with or without cytoreductive surgery has not been fully explored in CaGB. The present review quotes experience that seems to support the above contention. However, a number of well-designed multicentric trials are required to confirm the above philosophy of treatment for the benefit of patients suffering from CaGB.

Gallbladder carcinoma: radiologic-pathologic correlation

Primary carcinoma of the gallbladder is an uncommon, aggressive malignancy that affects women more frequently than men. Older age groups are most often affected, and coexisting gallstones are present in the vast majority of cases. The symptoms at presentation are vague and are most often related to adjacent organ invasion. Therefore, despite advances in cross-sectional imaging, early-stage tumors are not often encountered. Imaging studies may reveal a mass replacing the normal gallbladder, diffuse or focal thickening of the gallbladder wall, or a polypoid mass within the gallbladder lumen. Adjacent organ invasion, most commonly involving the liver, is typically present at diagnosis, as is biliary obstruction. Periportal and peripancreatic lymphadenopathy, hematogenous metastases, and peritoneal metastases may also be seen. The vast majority of gallbladder carcinomas are adenocarcinomas. Because most patients present with advanced disease, the prognosis is poor, with a reported 5-year survival rate of less than 5% in most large series. The radiologic differential diagnosis includes the more frequently encountered inflammatory conditions of the gallbladder, xanthogranulomatous cholecystitis, adenomyomatosis, other hepatobiliary malignancies, and metastatic disease.

Risk factors for biliary tract cancers

OBJECTIVE

Little is known regarding risk factors for biliary tract cancer, i.e., gallbladder carcinoma and extrahepatic bile duct carcinoma. This is the first case-control study conducted in the U.S. regarding risk factors for these cancers.

METHODS

In this hospital-based case-control study, we reviewed the medical records of 69 patients with primary biliary tract cancer who were admitted to Columbia-Presbyterian Medical Center for surgery between January 1, 1980, and April 4, 1994, and of 138 controls, consisting of patients admitted for surgery for benign conditions.

RESULTS

We found a significant association between cholelithiasis and biliary tract cancers (odds ratio, 19.5; 95% confidence interval, 6.4-59.4). Risk factors associated with gallbladder cancer included female gender, age, cigarette smoking, and postmenopausal status in women. Risk factors associated with extrahepatic bile duct cancer included history of cholecystectomy and hysterectomy in women.

CONCLUSION

The risk factors for biliary tract cancers that have been identified in our study delineate a high-risk population, which in the future may be targeted for preventive measures.

Carcinoma of the gallbladder presenting as scalp tumour

Carcinoma of the gallbladder is characterized by rapid tumour growth associated with lymphatic and local tumour invasion. The peritoneum, GIT and lungs are common sites of seeding. Distant metastasis to bone rarely occurs. Here we document a case of silent gallbladder carcinoma presenting as scalp tumour with improved survival.

Cholecystosonographic evaluation of the prevalence of gallbladder diseases. A university hospital experience

Ninety-five healthy volunteers and 515 patients with problems other than those of the biliary tract were examined using real-time, gray-scale, B-mode ultrasonography. Eighty-two patients (13.44%) were found to have asymptomatic gallbladder disease: 68 (11.14%) had cholelithiasis, 5 (0.81%) had acalculus cholecystitis, and 2 (0.32%) had polyps. Three cases of carcinoma of the gallbladder were also detected, suggesting that ultrasound examination of the high-risk population in an endemic area should not be confined to the disease concerned but that the gallbladder of such patients should also be screened to pick up asymptomatic gallbladder disease. Hence ultrasound can be used as a screening modality for the early detection of carcinoma of the gallbladder.

Hepatic metastases from carcinoma of the gallbladder

BACKGROUND

The optimal hepatic resection margin for gallbladder cancer (GBC) is still debated. To explore this issue, the authors analyzed the mode of hepatic spread of GBC.

METHODS

Of 85 patients undergoing radical cholecystectomy, 20 had hepatic metastases. The pattern of hepatic metastasis was examined grossly and histologically in specimens.

RESULTS

Twelve patients had evidence of microscopic angiolymphatic portal tract invasion, with or without direct liver invasion. Four had direct invasion alone, and three had distant hepatic metastatic nodules. The distance (y axis) between the farthest angiolymphatic lesion and primary tumor (mm) correlated significantly with the gross depth (x axis) of direct invasion (mm): y = 1.3 + 0.33x (r = 0.88, P < 0.01). Three patients with metastatic nodules died of blood-borne disease within a year. Eight of the others obtained either long-term palliation or cure after potentially curative resection. Lymph node metastases were detected in 90% of patients.

CONCLUSIONS

The extent of microscopic angiolymphatic portal tract invasion correlates well with the gross depth of direct invasion of the liver. This correlation may be useful for estimating adequate hepatectomy margins. A hepatectomy with an adequate margin combined with a radical lymphadenectomy provides benefit for selected patients with hepatic metastases.