Preoperative CT findings for prediction of resectability in patients with gallbladder cancer

A contemporary view on vascular resections and reconstruction during hepatectomies

Oncological hepatic surgery carries the possibility to perform vascular reconstructions for advanced tumours with vessel invasion since surgery often represents the only potentially curative approach for these tumours. An extended review was conducted in an attempt to understand and clarify the latest trends in hepatectomies with vascular resections. We searched bibliographic databases including PubMed, Scopus, references from bibliographies and Cochrane Library. Information and outcomes from worldwide clinical trials were collected from qualified institutions performing hepatectomies with vascular resection and reconstruction. Careful patient selection and thorough preoperative imaging remain crucial for correct and safe surgical planning. A literature analysis shows that vascular resections carry different indications in different diseases. Despite significant advances made in imaging techniques and technical skills, reports of hepatectomies with vascular resections are still associated with high postoperative morbidity and mortality. The trend of complex liver resection with vascular resection is constantly on the increase, but more profound knowledge as well as further trials are required. Recent technological developments in multiple fields could surely provide novel approaches and enhance a new era of digital imaging and intelligent hepatic surgery.

Should we suspect gallbladder cancer if which CT finding is observed in patients with localized gallbladder wall thickening?

PURPOSE

To identify high-risk computed tomography (CT) features for predicting gallbladder (GB) cancer in patients presenting with localized GB wall thickening.

METHODS

This retrospective analysis included 120 patients (mean age: 63.9 ± 10.0 years; 51 men) exhibiting localized GB wall thickening on CT scans obtained between January 2008 and May 2017. Two radiologists independently evaluated CT imaging features for predicting GB cancer. The diagnostic performance of significant imaging features and their combinations was evaluated. High-risk CT features ranked by accuracy were delineated for predicting GB cancer.

RESULTS

This study included 55 patients with GB cancer and 65 with benign GB conditions. The top-four most accurate CT imaging features for predicting GB cancer were identified: heterogeneously enhancing single layer or strongly enhancing thick inner layer; GB wall thickness > 6.5 mm; hyperenhancement on arterial phase; and absence of intramural small cystic lesions (accuracies of 90.0 %, 88.3 %, 85.0 %, and 85.0 %, respectively). The combination of any three high-risk features exhibited the highest accuracy (94.2 %). The presence of any high-risk feature yielded a sensitivity of 100 %, whereas that of all high-risk features indicated a specificity of 100 %.

CONCLUSION

CT imaging features, whether alone or in combination, could effectively and accurately predict GB cancer among patients with localized GB wall thickening. This finding holds significance in guiding decisions regarding further diagnostic tests and treatment planning.

Outcomes of Self-expandable Metal Stents in Patients With Unresectable Gallbladder Cancer Undergoing Percutaneous Biliary Drainage

Background

Biliary obstruction in gallbladder cancer (GBC) is associated with worse prognosis and needs drainage. In patients with biliary confluence involvement, percutaneous biliary drainage (PBD) is preferred over endoscopic drainage. However, PBD catheters are associated with higher complications compared to endoscopic drainage. PBD with self-expandable metal stents (SEMS) is desirable for palliation. However, the data in patients with unresectable GBC is lacking.

Materials and methods

This retrospective study comprised consecutive patients with proven GBC who underwent PBD-SEMS insertion between January 2021 and December 2022. Technical success, post-procedural complications, clinical success, duration of stent patency, and biliary reinterventions were recorded. Clinical follow-up data was analysed at 30 days and 180 days of SEMS insertion and mortality was recorded.

Results

Of the 416 patients with unresectable GBC, who underwent PBD, 28 (median age, 50 years; 16 females) with PBD-SEMS insertion were included. All SEMS placement procedures were technically successful. There were no immediate/early post-procedural complications/deaths. The procedures were clinically successful in 63.6% of the patients with hyperbilirubinemia (n = 11). Biliary re-interventions were done in 6 (21.4%). The survival rate was 89.3 % (25/28) at 30 days and 50% at 180 days. The median follow-up duration was 80 days (range, 8-438 days).

Conclusion

PBD-SEMS has moderate clinical success and 6-months patency in almost half of the patients with metastatic GBC and must be considered for palliation.

Evaluation of three-dimensional dual-energy CT cholangiopancreatography image quality in patients with pancreatobiliary dilatation: Comparison with conventional single-energy CT

Objective

This study aimed to evaluate three-dimensional (3D) negative-contrast CT cholangiopancreatography (nCTCP) image quality using dual-energy CT (DECT) with iterative reconstruction (IR) technique in patients with pancreatobiliary dilatation compared with single-energy CT (SECT).

Methods

Of the patients, 67 and 56 underwent conventional SECT (SECT set) and DECT with IR technique (DECT set), respectively. All patients were retrospectively analyzed during the portal phase to compare objective image quality and other data including patient demographics, hepatic and pancreatic parenchymal enhancement, noise, and attenuation difference (AD) between dilated ducts and enhanced hepatic parenchyma, signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR), and CT volume dose index (CTDIvol). Two radiologists used the five-point Likert scale to evaluate the subjective image quality of 3D nCTCP regarding image noise, sharpness of dilated ducts, and overall image quality. Statistical analyses used the Mann-Whitney U test.

Results

No significant difference in patient demographics in either CT set was showed during objective evaluation (p > 0.05). However, higher hepatic and pancreatic parenchymal enhancement, AD, SNR, and CNR and lower hepatic and pancreatic noise (p < 0.005) as well as CTDIvol (p = 0.005) on DECT than on SECT were observed. Higher mean grades on DECT than on SECT were showed for image noise (4.65 vs 3.92), sharpness of dilated ducts (4.52 vs 3.94), and overall image quality (4.45 vs 3.91; p < 0.001), respectively during subjective evaluation.

Conclusion

A higher overall image quality and lower radiation dose on 3D nCTCP can be obtained by DECT with IR technique than with conventional SECT in patients with pancreatobiliary dilatation.

Three-dimensional visualization and evaluation of hilar cholangiocarcinoma resectability and proposal of a new classification

BACKGROUND

As digital medicine has exerted profound influences upon diagnosis and treatment of hepatobiliary diseases, our study aims to investigate the accuracy of three-dimensional visualization and evaluation (3DVE) system in assessing the resectability of hilar cholangiocarcinoma (hCCA), and explores its potential clinical value.

MATERIALS AND METHODS

The discovery cohort, containing 111 patients from April 2013 to December 2019, was retrospectively included to determine resectability according to revised criteria for unresectability of hCCA. 3D visualization models were reconstructed to evaluate resectability parameters including biliary infiltration, vascular involvement, hepatic atrophy and metastasis. Evaluation accuracy were compared between contrast-enhanced CT and 3DVE. Logistic analysis was performed to identify independent risk factors of R0 resection. A new comprehensive 3DVE classification of hCCA based on factors influencing resectability was proposed to investigate its role in predicting R0 resection and prognosis. The main outcomes were also analyzed in cohort validation, including 34 patients from January 2020 to August 2022.

RESULTS

3DVE showed an accuracy rate of 91% (95%CI 83.6-95.4%) in preoperatively evaluating hCCA resectability, significantly higher than 81% (95%CI 72.8-87.7%) of that of CT (p = 0.03). By multivariable analysis, hepatic artery involvement in 3DVE was identified an independent risk factor for R1 or R2 resection (OR = 3.5, 95%CI 1.4,8.8, P < 0.01). New 3DVE hCCA classification was valuable in predicting patients' R0 resection rate (p < 0.001) and prognosis (p < 0.0001). The main outcomes were internally validated.

CONCLUSIONS

3DVE exhibited a better efficacy in evaluating hCCA resectability, compared with contrast-enhanced CT. Preoperative 3DVE demonstrated hepatic artery involvement was an independent risk factor for the absence of R0 margin. 3DVE classification of hCCA was valuable in clinical practice.

Rapid detection of serological biomarkers in gallbladder carcinoma using fourier transform infrared spectroscopy combined with machine learning

Gallbladder cancer (GBC) is the most common malignant tumour of the biliary tract. GBC is difficult to diagnose and treat at an early stage because of the lack of effective serum markers and typical symptoms, resulting in low survival rates. This study aimed to investigate the applicability of dried serum Fourier-transform infrared (FTIR) spectroscopy combined with machine learning algorithms to correctly differentiate patients with GBC from patients with gallbladder disease (GBD), cholangiocarcinoma (CCA), hepatocellular carcinoma (HCC) and healthy individuals. The differentiation between healthy individuals and GBC serum was better using principal component analysis (PCA) and linear discriminant analysis (LDA) for six spectral regions, especially in the protein (1710-1475 cm^-1) and combined (1710-1475 + 1354-980 cm^-1) region. However, the PCA-LDA model poorly differentiated GBC from GBD, CCA, and HCC in serum spectra. We evaluated the PCA- LDA, PCA-support vector machine (SVM), and radial basis kernel function support vector machine (RBF-SVM) models for GBC diagnosis and found that the RBF-SVM model performed the best, with 88.24-95% accuracy, 95.83% sensitivity, and 78.38-94.44% specificity in the 1710-1475 + 1354-980 cm^-1 region. This study demonstrated that serum FTIR spectroscopy combined with the RBF-SVM algorithm has great clinical potential for GBC screening.

CT features of divisional bile ducts in healthy Labrador Retrievers

Computed tomography (CT) is increasingly being used for the study of gallbladder and bile duct diseases. The first step in interpreting CT findings is understanding the cross-sectional anatomy of the structures involved, but there are no published studies describing the CT features of the divisional bile ducts. In dogs, anatomic studies report two common patterns including three or four divisional bile ducts. The aim of this retrospective, descriptive, anatomical study was to describe the size and pattern of the visible divisional bile ducts, based on their location and extension, using contrast-enhanced CT in a group of Labrador Retrievers without evidence of hepatobiliary diseases. The correlation between the biliary duct number and dimensions, and the visceral fat area percentage (VFA%) was also evaluated. The right lateral divisional duct (RLD) was visualized in four of 40 dogs, the left lateral divisional duct (LLD) in nine of 40 dogs, and in 17 of 40 dogs, both were simultaneously visualized. In 10 of 40 dogs, the RLD and LLD were not highlighted. When visible, the RLD has a median diameter of 0.23 cm and a median length of 0.82 cm. The LLD has a median diameter of 0.23 cm and a median length of 2.72 cm. The median diameter of the common bile duct before and after the insertion of divisional bile ducts was 0.23 and 0.25 cm, respectively. No correlation with the VFA% was found. At least one of the divisional bile ducts could be visualized using contrast-enhanced CT in the majority of sampled dogs (75%) .

The diagnostic value of staging laparoscopy in gallbladder cancer: a nationwide cohort study

BACKGROUND

Disseminated disease (DD) is often found at (re-)exploration in gallbladder cancer (GBC) patients. We aimed to assess the yield of staging laparoscopy (SL) and identify predictors for DD.

METHODS

This retrospective study included patients from all Dutch academic centres with primary GBC (pGBC) and incidentally diagnosed GBC (iGBC) planned for (re-)resection. The yield of SL was determined. In iGBC, predictive factors for DD were assessed.

RESULTS

In total, 290 patients were included. Of 183 included pGBC patients, 143 underwent laparotomy without SL, and 42 (29%) showed DD perioperatively. SL, conducted in 40 patients, identified DD in eight. DD was found in nine of 32 patients who underwent laparotomy after SL. Of 107 included iGBC patients, 100 underwent laparotomy without SL, and 19 showed DD perioperatively. SL, conducted in seven patients, identified DD in one. Cholecystitis (OR = 4.25; 95% CI 1.51-11.91) and primary R1/R2 resection (OR = 3.94; 95% CI 1.39-11.19) were independent predictive factors for DD.

CONCLUSIONS

In pGBC patients, SL may identify DD in up to 20% of patients and should be part of standard management. In iGBC patients, SL is indicated after primary resection for cholecystitis and after initial R1/R2 resection due to the association of these factors with DD.

Prediction model based on preoperative CT findings for carotid artery invasion in patients with head and neck masses

Objectives

To investigate the performance of a model in predicting carotid artery (CA) invasion in patients with head and neck masses using computed tomography (CT).

Methods

This retrospective study included patients with head and neck masses who underwent CT and surgery between January 2013 and July 2021. Patient characteristics and ten CT features were assessed by two radiologists. The patients were randomly allocated to a training cohort (n=106) and a validation cohort (n=109). Independent risk factors for CA invasion were assessed by univariate and multivariate logistic regression analyses. The predictive model was established as a nomogram using the training cohort. In addition, the calibration, discrimination, reclassification, and clinical application of the model were assessed in the validation cohort.

Results

A total of 215 patients were evaluated, including 54 patients with CA invasion. Vascular wall deformation (odds ratio [OR], 7.17; p=0.02) and the extent of encasement to the CA (OR, 1.02; p&lt;0.001) were independent predictors of CA invasion in the multivariable analysis in the training cohort. The performance of the model was similar between the training and validation cohort, with an area under the receiver operating characteristic curve of 0.93 (95% confidence intervals [CI], 0.88-0.98) and 0.88 (95% CI, 0.80-0.96) (p=0.07), respectively. The calibration curve showed a good agreement between the predicted and actual probabilities.

Conclusion

A predictive model for carotid artery invasion can be defined based on features that come from patient characteristics and CT data to help in improve surgical planning and invasion evaluation.

Successful conversion surgery for locally advanced gallbladder cancer after gemcitabine and nab-paclitaxel chemotherapy

Objective

Gallbladder cancer (GBC) is highly malignant and is often diagnosed at the advanced stage. Lack of opportunity to surgery results in an unsatisfactory outcome. This pilot study employed gemcitabine combined with nab-paclitaxel (AG) as a conversion therapeutic measure for locally advanced GBC and successfully achieved conversion surgery in three initially unresectable GBC patients. We will introduce our experience on improving the outcome of this dismal disease.

Methods

Radiology and nuclear medicine imaging were performed in each patient, and resectability was evaluated by joint consultation of our multi-disciplinary team (MDT). Patients evaluated as unresectable were treated with the AG regimen and re-evaluated for treatment response. When complete or partial response is achieved, MDT opinion would be required to assess the possibility of performing conversion surgery with R0 resection.

Results

Three GBC patients who were initially evaluated as unresectable successfully underwent R0 resection after conversion therapy with the AG regimen. The first case was a recurrent GBC patient evaluated as locally advanced and eventually achieved pathological complete response. The second case was a GBC patient who underwent R1 resection with residual lesions in the gallbladder bed and isolated No. 16 lymph node metastasis and who had a pathologically complete response after treatment. The third case had multiple but resectable liver metastases; both objective response and partial pathologic response were achieved. None of the patients experienced serious treatment-related adverse events. All cases revealed no evidence of recurrence or metastasis after a median follow-up of 12 months.

Conclusions

Conversion therapy shows a favorable efficacy in those unresectable GBC patients. Gemcitabine plus nab-paclitaxel has the potential to be used as a preoperative treatment option for GBC patients at the advanced stage. To further explore the efficacy of AG on conversion therapy for GBC patients, a prospective clinical trial has been registered (ChiCTR2200055698).

Predictive model for the intraoperative unresectability of hilar cholangiocarcinoma: Reducing futile surgical exploration

Introduction

Surgical exploration is widely performed in hilar cholangiocarcinoma (HCCA), but the intraoperative resectability rate is only 60%-80%. Exploration substantially increases pain and mental stress, and the costs and length of hospital stay are considerably increased. Identifying preoperative risk factors associated with unresectability could decrease unnecessary exploration.

Materials and methods

In total, 440 HCCA patients from multiple centers were enrolled. Those receiving surgical exploration were divided into the resected and unresected groups. Morphological variables including Bismuth classification, lymph node metastasis and vessel invasion were obtained from radiological exams. Logistic regression for the training cohort was used to identify risk factors for unresectability, and a nomogram was constructed to calculate the unresectability rate. A calibration curve assessed the power of the nomogram.

Results

Among 311 patients receiving surgical exploration, 45 (14.7%) were unresectable by intraoperative judgment. Compared with the resected group, unresected patients had similar costs (p = 0.359) and lengths of hospital stay (p = 0.439). Multivariable logistic regression of the training cohort (235 patients) revealed that CA125, Bismuth-Corlette type IV, lymph node metastasis and hepatic artery invasion were risk factors for unresectability. Liver atrophy (p = 0.374) and portal vein invasion (p = 0.114) were not risk factors. The nomogram was constructed based on the risk factors. The concordance index (C-index) values of the calibration curve for predicting the unresectability rate of the training and validation (76 patients) cohorts were 0.900 (95% CI, 0.835–0.966) and 0.829 (95% CI, 0.546–0.902), respectively.

Conclusion

Analysis of preoperative factors could reveal intraoperative unresectability and reduce futile surgical explorations, ultimately benefiting HCCA patients.

Prognostic Value of the Albumin-to-γ-glutamyltransferase Ratio for Gallbladder Cancer Patients and Establishing a Nomogram for Overall Survival

Purpose: The albumin-to-γ-glutamyltransferase ratio (AGR), a novel inflammation-related index, has been reported to have prognostic importance in several malignancies but not yet in gallbladder cancer (GBC). This study intended to assess the prognostic value of AGR in GBC and to develop a nomogram based on AGR for predicting overall survival (OS) in GBC patients after surgery.

Methods: Medical records of 140 qualified GBC patients between July 2003 and June 2017 were retrospectively analyzed. The function “surv_cutpoint” in the R package “survminer” was implemented to discover the optimal cut-off value of AGR. A nomogram on the fundamental of Cox model was established in the training cohort and was internally validated using calibration curves, Harrell's concordance index, time-dependent AUC plots and decisive curve analyses.

Results: The optimal AGR cut-off value concerning overall survival was 2.050. Univariate and multivariate analyses demonstrated that AGR (HR=0.354, P=0.004), T stage (HR=3.114, P=0.004), R0 resection (HR=0.448, P=0.003), BMI (HR=0.470, P=0.002) and CA19-9 (HR=1.704, P=0.048) were independent predictors for OS. The nomogram combining these prognostic factors showed considerable prognostic performance in term of consistency, discrimination and net benefit.

Conclusion: AGR has independent prognostic value for OS in GBC patients receiving surgery. A nomogram incorporating AGR, T stage, R0 resection, CA19-9 and BMI achieved enhanced prognostic ability.

Biliary tract cancer

Biliary tract cancers, including intrahepatic, perihilar, and distal cholangiocarcinoma as well as gallbladder cancer, are low-incidence malignancies in most high-income countries, but represent a major health problem in endemic areas; moreover, the incidence of intrahepatic cholangiocarcinoma is rising globally. Surgery is the cornerstone of cure; the optimal approach depends on the anatomical site of the primary tumour and the best outcomes are achieved through management by specialist multidisciplinary teams. Unfortunately, most patients present with locally advanced or metastatic disease. Most studies in advanced disease have pooled the various subtypes of biliary tract cancer by necessity to achieve adequate sample sizes; however, differences in epidemiology, clinical presentation, natural history, surgical therapy, response to treatment, and prognosis have long been recognised. Additionally, the identification of distinct patient subgroups harbouring unique molecular alterations with corresponding targeted therapies (such as isocitrate dehydrogenase-1 mutations and fibroblast growth factor receptor-2 fusions in intrahepatic cholangiocarcinoma, among others) is changing the treatment paradigm. In this Seminar we present an update of the causes, diagnosis, molecular classification, and treatment of biliary tract cancer.

CT-based nomogram for predicting survival after R0 resection in patients with gallbladder cancer: a retrospective multicenter analysis

OBJECTIVES

To establish a prognostic nomogram for patients undergoing R0 resection for gallbladder cancer based on preoperative CT.

METHODS

A total of 151 patients (64 males, 87 females; mean age, 73.26 years) with gallbladder cancer who underwent CT and surgery with margin-negative resection were retrospectively collected at two tertiary institutions. The demographic and radiologic parameters were analyzed using univariate and multivariate Cox regression analyses to identify independent prognostic factors. The final CT-based nomogram was constructed to predict prognosis after curative resection of gallbladder cancer. Calibration curves for the survival probabilities were obtained for internal validation.

RESULTS

Mass-forming type (hazard ratio [HR], 28.80), bile duct invasion (HR, 4.76), duodenal invasion (HR, 6.32), colon invasion (HR, 4.37), gallstones (HR, 0.09), and cholecystitis (HR, 2.56) were significant independent predictors for recurrence-free survival (p < .05). Mass-forming type (HR, 8.16, p < .001), bile duct invasion (HR, 2.92, p = .013), duodenal invasion (HR, 3.72, p = .012), and regional lymph node metastasis (HR, 2.07, p = .043) were independent predictors of poor cancer-specific survival (CSS) and were used to construct the nomogram. The nomogram showed a good predictive ability for the probabilities of survival on the calibration curves, and the concordance index of the model in predicting CSS was .768.

CONCLUSION

Preoperative CT findings could predict the prognosis of gallbladder cancer, and the CT-based nomogram accurately predicted CSS in patients with gallbladder cancer after attempted curative resection.

KEY POINTS

• Among the preoperative imaging features, mass-forming type, bile duct invasion, duodenal invasion, and regional lymph node metastasis were independent predictors of poor cancer-specific survival. • The nomogram constructed using preoperative CT findings showed a good predictive ability for the survival on calibration curves, and the concordance index of the model in predicting cancer-specific survival was 0.768.

γ-glutamyl transferase-to-platelet ratio based nomogram predicting overall survival of gallbladder carcinoma

BACKGROUND

Gallbladder carcinoma (GBC) carries a poor prognosis and requires a prediction method. Gamma-glutamyl transferase–to–platelet ratio (GPR) is a recently reported cancer prognostic factor. Although the mechanism for the relationship between GPR and poor cancer prognosis remains unclear, studies have demonstrated the clinical effect of both gamma-glutamyl transferase and platelet count on GBC and related gallbladder diseases.

AIM

To assess the prognostic value of GPR and to design a prognostic nomogram for GBC.

METHODS

The analysis involved 130 GBC patients who underwent surgery at Peking Union Medical College Hospital from December 2003 to April 2017. The patients were stratified into a high- or low-GPR group. The predictive ability of GPR was evaluated by Kaplan–Meier analysis and a Cox regression model. We developed a nomogram based on GPR, which we verified using calibration curves. The nomogram and other prognosis prediction models were compared using time-dependent receiver operating characteristic curves and the concordance index.

RESULTS

Patients in the high-GPR group had a higher risk of jaundice, were older, and had higher carbohydrate antigen 19-9 levels and worse postoperative outcomes. Univariate analysis revealed that GPR, age, body mass index, tumor–node–metastasis (TNM) stage, jaundice, cancer cell differentiation degree, and carcinoembryonic antigen and carbohydrate antigen 19-9 levels were related to overall survival (OS). Multivariate analysis confirmed that GPR, body mass index, age, and TNM stage were independent predictors of poor OS. Calibration curves were highly consistent with actual observations. Comparisons of time-dependent receiver operating characteristic curves and the concordance index showed advantages for the nomogram over TNM staging.

CONCLUSION

GPR is an independent predictor of GBC prognosis, and nomogram-integrated GPR is a promising predictive model for OS in GBC.