Treatment of carcinoma of the gallbladder in Japan

[Clinical, epidemiological and therapeutic features of biliary tract cancers: about 20 cases]

Biliary tract cancers mainly occur in two sites: gallbladder cancer which are adenocarcinomas and intra- and extrahepatic cholangiocarcinomas. We conducted a retrospective study of 20 cases with biliary tract cancer in the Department of Surgery at the General Hospital in Grand-Yoff between January 2006 and October 2014. 40% of patients had gallbladder cancer, 60% of patients had common bile duct cancer. Sex ratio was 1. The average age of patients was 58.1 years. The average time to diagnosis was 3.77 months. Symptomatology was dominated by icteric syndrome and right hypochondrium pain. All patients had biological manifestation of cholestatic syndrome. Abdominal ultrasound was performed in 65% of patients, while abdominal CT scan in 85% of cases and MRI in 35% of cases. Advanced cancers were predominant in our case series (n=19). The majority of patients underwent palliative surgery. The most practiced treatment was biliary diversion (50% of patients). There was a predominance of cholangiocarcinomas. The overall operative morbidity rate was 43.75%. The overall mortality rate in our patients with biliary tract cancers of any site was 31.25%. Median survival was 4 months and a half. Biliary tract cancers have multifaceted features and can be differentiated essentially among intrahepatic cholangiocarcinoma, extrahepatic cholangiocarcinoma, gallbladder adenocarcinoma whose evolution is globally different but the prognosis is spontaneously poor.

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.

Radical lymph node dissection for gallbladder cancer: indications and limitations

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

Incidental carcinoma of the gallbladder

Incidental gallbladder carcinoma (GBC) is a difficult management issue as there are no established guidelines. Laparoscopic cholecystectomy is associated with increased dissemination of the tumour cells (both in the peritoneal cavity and port sites). Depth of tumour invasion (T stage) and positive surgical margins are the most important prognostic factors, although tumour differentiation, lymphatic, perineural and vascular invasion may also affect the outcome. Simple cholecystectomy is adequate for mucosal (T1a) lesions only. For T1b tumours port site/wound excision with second radical operation (probably extended cholecystectomy -- wedge liver excision with regional lymphadenectomy) should be advised. T2 tumours should be treated with second radical operation (extended cholecystectomy or excision of medial liver segments 4b and 5 or 4, 5 and 8 with regional lymphadenectomy with or without excision of the extra-hepatic bile duct). Few T3 tumours can be cured and in some survival time may be prolonged by a second radical operation. More extensive liver resection (segments 4b and 5 or segments 4, 5 and 8) with regional lymphadenectomy with excision of the extra-hepatic bile duct should be advised. A second radical operation may palliate some T4 tumours. In the absence of extensive nodal disease, this operation may prolong the survival time. Excision of the extra-hepatic bile duct should be undertaken whenever the tumour involves the cystic duct margin or the extra-hepatic biliary tree. Epidemiology, risk factors, aetiopathogenesis and the modes of spread of GBC are discussed in relation to appropriateness of the second radical operation. Indications, types and role of the second radical operation are discussed.

Gastrointestinal malignancies

Gastrointestinal cancers are collectively the most common malignancies in the world. In the United States, colorectal cancer accounts for most of these malignancies. This is unfortunate, because colorectal cancer is highly preventable. Moreover, screening for colorectal cancer is cost effective and becomes increasingly important in an aging population. Individuals who are more at risk require earlier screening and intervention. For all gastrointestinal cancer, surgery remains the most important curative option. For patients who cannot be cured, quality of life is the yardstick by which palliative options should be evaluated.

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.

Biliary tract cancer accompanied by anomalous junction of pancreaticobiliary ductal system in adults

BACKGROUND

Anomalous junction of the pancreaticobiliary ductal system (AJPBDS) is a congenital anomaly in which the junction is located outside the duodenal wall. Recently, attention has been focused on the high incidence of malignancy in this anomaly. The purpose of this study was to clarify the clinicopathological features of this anomaly and to determine the appropriate surgical approach for biliary tract cancer associated with AJPBDS.

METHODS

The data for 38 patients with AJPBDS, including 14 who had been treated for biliary tract cancer (2 with bile duct cancer and 12 with gallbladder cancer), were retrospectively reviewed. We assessed the clinical features, characteristics of the tumor, operative procedure, and outcome for each patient.

RESULTS

The incidence of malignancy in AJPBDS was 17.8% (2 patients with bile duct cancer and 3 with gallbladder cancer) in the bile duct dilatation group (n = 28) and 90% (9 patients with gallbladder cancer) in the no-dilatation group (n = 10) . The mean length of the common channel was 24.7 mm (range 20 to 35 mm) . Resection with lymphadenectomy was performed in 9 (64.3%) of 14 patients, and curative resection in 5 of these 9 patients. Ten (71%) of the 14 patients had lymph node involvement noted either at the time of initial diagnosis or at surgery. The incidence of lymph node metastasis was closely related to the depth of tumor involvement. Ten patients died of recurrence or primary cancer, from 3 to 30 months after operation. Four patients are still alive without recurrent disease from 2.5 to 13 years after operation.

CONCLUSION

For patients with AJPBDS without bile duct dilatation, prophylactic cholecystectomy is recommended even if no malignant lesion is found in the gallbladder because of the high incidence of gallbladder cancer and the poor prognosis. Both early detection and curative resection of the tumor are essential for successful treatment of biliary tract cancer.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Surgical treatment of 724 carcinomas of the gallbladder. Results of the French Surgical Association Survey

OBJECTIVE

The objective of this study was to evaluate the benefit of an aggressive approach to gallbladder carcinoma on long-term survival.

SUMMARY BACKGROUND DATA

Recent studies have shown that an aggressive surgical treatment of bile duct carcinoma can be associated with a surprising long-term survival. However, recent data on gallbladder carcinoma are not available.

METHODS

Data were obtained from a questionnaire sent to 73 institutions in France, Europe, and overseas, and they were analyzed retrospectively. The review included an analysis of patient sex and age, associated hepatobiliary diseases, symptoms and signs, diagnostic tests, operative management, pathology reports, and survival.

RESULTS

Seventy-eight per cent of the patients were women, and 22% were men (p < 0.001). Gallstones were present in 86% of the cases. Four per cent of the patients had Tis stage lesions, 11% had T1 to T2 stage lesions, and 85% had T3 to T4 stage lesions (p < 0.001). Pain was the most frequent symptom (77%). Twenty-three per cent of the patients underwent curative operations, and 77% had a palliative treatment (25% of the patients underwent exploratory laparotomy). Exploratory laparotomy was followed by the highest mortality rate (66%), and older patients (> 70 years) had a higher operative risk (p < 0.04). The overall median survival was 3 months, and long-term survival correlated with the cancer stage (Tis, > 60 months; T1 to T2, > 22 months, and T3 to T4, 2 to 8 months). No differences were observed among the different surgical procedures adopted.

CONCLUSIONS

No progress has been made in the last 10 years in the treatment of gallbladder malignancies.

Surgical treatment of 724 carcinomas of the gallbladder. Results of the French Surgical Association Survey

OBJECTIVE

The objective of this study was to evaluate the benefit of an aggressive approach to gallbladder carcinoma on long-term survival.

SUMMARY BACKGROUND DATA

Recent studies have shown that an aggressive surgical treatment of bile duct carcinoma can be associated with a surprising long-term survival. However, recent data on gallbladder carcinoma are not available.

METHODS

Data were obtained from a questionnaire sent to 73 institutions in France, Europe, and overseas, and they were analyzed retrospectively. The review included an analysis of patient sex and age, associated hepatobiliary diseases, symptoms and signs, diagnostic tests, operative management, pathology reports, and survival.

RESULTS

Seventy-eight per cent of the patients were women, and 22% were men (p < 0.001). Gallstones were present in 86% of the cases. Four per cent of the patients had Tis stage lesions, 11% had T1 to T2 stage lesions, and 85% had T3 to T4 stage lesions (p < 0.001). Pain was the most frequent symptom (77%). Twenty-three per cent of the patients underwent curative operations, and 77% had a palliative treatment (25% of the patients underwent exploratory laparotomy). Exploratory laparotomy was followed by the highest mortality rate (66%), and older patients (> 70 years) had a higher operative risk (p < 0.04). The overall median survival was 3 months, and long-term survival correlated with the cancer stage (Tis, > 60 months; T1 to T2, > 22 months, and T3 to T4, 2 to 8 months). No differences were observed among the different surgical procedures adopted.

CONCLUSIONS

No progress has been made in the last 10 years in the treatment of gallbladder malignancies.

Cancer of the gallbladder associated with anomalous junction of the pancreatobiliary duct system without bile duct dilatation

The aim of this study was to delineate clinical features and prognosis of cancer of the gallbladder associated with anomalous junction of the pancreatobiliary duct system without bile duct dilatation, and to determine methods for managing the disease. A retrospective study of seven patients is presented. A further 27 cases from the Japanese literature were reviewed retrospectively with regard to method of treatment and prognosis. In 11 of 18 patients in whom staging was known the tumour was stage V, representing advanced disease. In seven of 34 cases curative operation was performed; only two patients survived for > 3 years. This poor outcome was due largely to delayed diagnosis of cancer of the gallbladder. Prophylactic cholecystectomy is recommended in patients with this anomalous junction without bile duct dilatation or a malignant lesion in the gallbladder, because of the high incidence of cancer of the biliary tract.

Experimental chemotherapy for xenograft cell lines of human bile duct and gall bladder cancers in nude mice

Most biliary tract cancers are advanced and inoperable when first diagnosed. Even if surgery can be performed, the postsurgical prognosis of these diseases is poor. In the present study, we investigated effective chemotherapies for a human bile duct cancer xenograft cell line (undifferentiated carcinoma, BDC-SN) and a gall bladder cancer xenograft cell line (well-differentiated adenocarcinoma, GBC-GN), which were transplanted into nude mice. Eight anticancer agents (CDDP, 5-FU, VDS, MMC, ADR, EPIR, CQ, and VP-16) and their various combinations were evaluated at 2-4 times the clinical dose. When used singly, CDDP, 5-FU, and VDS were effective against BDC-SN, and only CDDP was effective against GBC-GN. Among the various 2-agent combinations, CDDP + 5-FU was the most effective against both BDC-SN and GBC-GN. However, 3-agent combinations consisting of CDDP + 5-FU + another agent were less effective than the CDDP + 5-FU double regimen and caused significant loss of weight as well as high mortality. These results suggest that CDDP + 5-FU may be the most useful regimen against biliary tract cancers in clinical application.

Carcinoma in situ of the gallbladder with superficial extension into the Rokitansky-Aschoff sinuses and mucous glands

Twenty-four cases of carcinoma in situ of the gallbladder encountered over the past 29 years were evaluated histopathologically. Macroscopic classification disclosed 12 protruding types and 12 superficial types (7 elevated types and 5 flat types). Histologically, 18 cases had papillary growth and 6 had tubular patterns. Epithelial dysplasia of varying degrees was observed around the carcinoma in situ in all except one case and was seen more extensively in superficial type cases, although it was often hard to distinguish dysplasia from carcinoma in situ in some cases. Metaplasia of the mucous glands was observed in 20/24 cases (83.3%). Superficial extension of carcinoma in situ into the Rokitansky-Aschoff sinuses (located below the muscle layer) was observed in 11 cases (45.8%), and extension into the mucous glands was seen in 8 cases (33.3%). These results indicate that it is very important to be able to differentiate invasive carcinoma from cases with superficial extension of dysplasia and/or carcinoma in situ deep into the mucous glands or Rokitansky-Aschoff sinuses. Histological assessment should also be conducted carefully while considering these factors.

Surgical treatment of primary carcinoma of the gallbladder based on the histologic analysis of 48 surgical specimens

During the past 5 years, extended cholecystectomy and/or more radical procedures, including pancreatoduodenectomy and extended hepatic lobectomy, were performed on 48 patients with carcinoma of the gallbladder in an attempt to cure the disease. It was retrospectively proven from microscopic analysis of the surgical specimens taken from the 48 patients that 28 patients had received curative resections. The 28 consisted of all 4 patients with stage I carcinoma, all 9 with stage II, 6 of 8 with stage III, and 9 of 27 with stage IV. We reached the following conclusions: (1) extended cholecystectomy with resection of the bile duct in the hepatoduodenal ligament is the optimum procedure for patients with stage I and stage II carcinomas, and (2) for patients with stage III carcinoma, more radical procedures, including pancreatoduodenectomy and/or wider resection of the liver, might result in curative resection of the disease. For some patients with stage IV tumors, such as duodenal invasion or direct invasion of the liver, curative resection may be achieved by pancreatoduodenectomy or extended hepatic lobectomy.

Resection combined with intraoperative radiation therapy (IORT) for stage IV (TNM) gallbladder carcinoma

From October 1976 to May, 1990, a total of 86 patients with stage IV (TNM) gallbladder cancer were treated at Tsukuba University Hospital. Twenty-seven of the 86 patients underwent tumor resection; 43 patients received palliative surgery. The remaining 16 were too advanced to have surgery. Of 27 patients who had tumor resection, 9 had resection alone, 17 had intraoperative radiation therapy (IORT) +/- postoperative external radiotherapy (ERT), and 1 had postoperative ERT. The procedures used were: extended right hepatic lobectomy plus hepaticobiliary resection (HBR) (n = 2), hepatic segmentectomy (SIVb, SV) plus HBR (n = 9), hepatic segmentectomy (SIV, V, VI) with HBR (n = 1), hepatic segmentectomy (SIV, V) plus HBR with pancreaticoduodenectomy (PD) (n = 3), PD plus HBR (n = 1), cholecystectomy with wedge resection of the gallbladder fossa plus HBR (n = 3), and cholecystectomy plus HBR (n = 3), and cholecystectomy (n = 4). Regional lymph node dissections were performed in every patient and 17 of 27 patients underwent additional resections of adjacent organs such as the stomach, duodenum, colon, and abdominal wall. A single dose of 20-30 Gy was delivered intraoperatively for 17 patients. A mean total dose of 36.4 Gy (1.8/fraction) was added to IORT for 10 patients. The three-year cumulative survival rate was 10.1% for resection plus IORT but 0% for resection alone. The longest survivor is alive and well at 3 years and 3 patients are alive 16, 13, and 4 months after tumor resection followed by IORT plus ERT.

Intraoperative radiation therapy for carcinoma of the gallbladder

The recognition of a high incidence of local failure following surgical management of adenocarcinoma of the gallbladder has led to the use of adjuvant radiation therapy. In order to deliver higher doses to the gallbladder bed, intraoperative radiation therapy (IORT) has been used both with and without external beam radiation. The experience to date is reviewed. Ten patients have been treated, all of whom had either gross residual or unresected disease. The median survival for the group was approximately 1 year. There were no long-term survivors. The IORT did not contribute to the overall morbidity. Because of the limited number of patients and the advanced nature of the disease, the role of IORT in the management of gallbladder carcinoma has yet to be determined. The utility of this modality will most likely reside in the treatment of minimal residual disease at the time of cholecystectomy rather than in the palliative treatment of unresectable tumors.

Carcinoma of the gallbladder. The Roswell Park experience

The median survival, from diagnosis, of patients with cancer of the gallbladder is 6 months. Our purpose in reviewing our experience was to identify factors, either in patient characteristics or treatment, that influence this statistic. In 22 years 71 cases of gallbladder carcinoma were referred to Roswell Park Memorial Institute in Buffalo, New York. Most had a cholecystectomy that revealed an unsuspected neoplasm, before referral. Mean age was 62 years and 75% were female. Symptoms, signs, and laboratory and imaging studies were uniformly unhelpful in determining the diagnosis. Early diagnosis at a stage amenable to surgical excision remains the sole salvation. Patients who receive chemotherapy did better than those who did not, but this is probably a reflection of patient selection. Newer treatment modalities are urgently needed.

Gallstones in gallbladder diseases

The correlation between gallbladder stones (gallstones) and various gallbladder diseases was examined. The incidence of gallstones was 47.1% in cases of non-neoplastic epithelial polyp, 48.0% in adenoma, and 59.1% in adenocarcinoma. There was no relation between the incidence of gallstones and sex. The incidence of gallstones in cancer cases showed no difference among histological gradings. Non-neoplastic epithelial polyps, adenomas and carcinomas were divided into metaplastic type and non-metaplastic type based on the presence or absence of metaplastic changes. Comparison of the incidence of gallstones showed that cases of metaplastic-type polyp and adenoma had a higher incidence of gallstones than non-metaplastic-type polyp and adenoma. In the cases of cancer, no differences were observed in the incidence of gallstones between metaplastic-type and non-metaplastic-type carcinomas. However, comparison among early carcinomas showed that metaplastic-type carcinoma had a significantly higher incidence of gallstones than the non-metaplastic-type. These results suggest that gallstones may play an important role in the histogenesis of gallbladder diseases of the metaplastic type.

The surgical treatment for carcinoma of the gallbladder--rationale of the second-look operation for inapparent carcinoma

Eighty-seven patients with carcinoma of the gallbladder treated in our hospital over a 15-year period were reviewed. Macroscopic curative resection was performed in 30 cases, 6 of which received second-look operations, and their cumulative five-year survival rate was 42.6 per cent. Histological and clinical analysis of our cases initially diagnosed by postoperative histologic examination revealed that the depth of carcinomatous invasion was the most important criterion for the indication of second-look operation, and that the second-look operation is mandatory for the inapparent carcinoma limited to the muscularis or subserosa. The surgical procedures of the second-look operation were: resection of the anterior inferior and medial inferior areas of the liver and dissection of the regional lymph-nodes. The presence of invasion of carcinoma to the cut end of the cystic duct or severe carcinomatous invasion to the lymphatic vessels were also important histopathologic findings for a second-look operation. Cases in which lymphatic invasions are remarkably observed, should receive an en bloc hepato-cholecystectomy plus a resection of the extrahepatic bile duct with neural tissues and soft fatty tissues in the hepatoduodenal ligament in a two-stage operation.