Retrospective analysis of outcome in 63 gallbladder carcinoma patients after radical resection

Early Recurrence in Resected Gallbladder Carcinoma: Clinical Impact and Its Preoperative Predictive Score

BACKGROUND

Surgical resection is the only potentially curative therapy for gallbladder carcinoma (GBC). However, the postoperative recurrence rate is high (approximately 50%), and recurrence occasionally develops early after surgery.

PATIENTS AND METHODS

A total of 139 patients who underwent macroscopically curative resection for GBC between 2002 and 2018 were retrospectively reviewed. Early recurrence (ER) was defined as recurrence within 6 months after surgery. Univariate and multivariate logistic regression analysis was performed using preoperative factors that may influence early recurrence, namely patient background factors, tumor markers, imaging findings, and body composition parameters obtained preoperatively, to create a predictive score for ER.

RESULTS

The median follow-up period was 21.9 months (range, 6.2-195.7 months). Postoperative recurrence was observed in 55 (39.6%) patients, of whom 14 (25.5%) developed ER. The median overall survival after surgery was 104.7 months for the non-ER group and 15.7 months for the ER group. On multivariate analysis, high carbohydrate antigen 19-9, low muscle attenuation, high visceral fat attenuation, liver invasion, and other organ invasion on preoperative computed tomography were identified as independent risk factors for ER. A preoperatively predictive scoring system for ER was constructed by weighting the above five factors. The nomogram showed an area under the curve of 0.881, indicating good predictive potential for ER.

CONCLUSIONS

ER in resected GBC indicates a very poor prognosis. The present preoperative scoring system can sufficiently predict ER and may be helpful in determining the optimal treatment strategies.

To Resect or Not to Resect Extrahepatic Bile Duct in Gallbladder Cancer?

The indications for and limitations of extrahepatic bile duct resection (EHBDR) in the context of gallbladder (GB) cancer are unclear. The purpose of this review was to examine the current literature to determine the impact of EHBDR on loco-regional recurrence and survival in GB cancer. The EMBASE and Medline databases were searched up to February 2016 using the terms: extrahepatic bile duct resection and gallbladder cancer. Studies published in the last 20 years were eligible for inclusion. Given the heterogeneity of the population and the study methodologies employed, qualitative data synthesis in the form of meta-analysis was deemed implausible. Twenty-four studies fulfilled the inclusion criteria. The selected studies include 6,722 (55%) EHBDRs in a total of 12,251 GB cancer operations. The 25 studies were categorized into seven groups: 1) cancer survival all stages; 2) hepatoduodenal ligament invasion; 3) outcome in EHBDR and EHBDNR; 4) pT1b tumors; 5) pT2 tumors; 6) pT3/T4 tumors; and 7) incidental GB cancer. Radical cholecystectomy with EHBDR should be used as a standard operation for tumors involving the neck or the cystic duct of the GB (either macroscopically or microscopically). In all other cases, operative strategy should be individualized to the patient.

Unexpected gallbladder cancer: Surgical strategies and prognostic factors

Gallbladder cancer is the most common tumor of the biliary tract and it is associated with a poor prognosis. Unexpected gallbladder cancer is a cancer incidentally discovered, as a surprise, at the histological examination after cholecystectomy for gallstones or other indications. It is a potentially curable disease, with an intermediate or good prognosis in most cases. An adequate surgical strategy is mandatory to improve the prognosis and an adjunctive radical resection may be required depending on the depth of invasion. If the cancer discovered after cholecystectomy is a pTis or a pT1a, a second surgical procedure is not mandatory. In the other cases (pT1b, pT2 and pT3 cancer) a re-resection (4b + 5 liver segmentectomy, lymphadenectomy and port-sites excision in some cases) is required to obtain a radical excision of the tumor and an accurate disease staging. The operative specimens of re-resection should be examined by the pathologist to find any “residual” tumor. The “residual disease” is the most important prognostic factor, significantly reducing median disease-free survival and disease-specific survival. The other factors include depth of parietal invasion, metastatic nodal disease, surgical margin status, cholecystectomy for acute cholecystitis, histological differentiation, lymphatic, vascular and peri-neural invasion and overall TNM-stage.

Extra-Hepatic Bile Duct Resection: an Insight in the Management of Gallbladder Cancer

BACKGROUND

Involvement of extrahepatic bile duct in gallbladder cancer (GBC) is considered a sign of advanced disease; resection of extrahepatic bile duct in GBC has been a contentious issue considering the poor prognosis of the disease.

METHODS

This retrospective study was done in two tertiary teaching hospitals of North India. The case records of all the GBC patients who underwent radical cholecystectomy with extra-hepatic bile duct resection were reviewed. Details concerning the clinical presentation, preoperative therapy, operative procedure, indication of bile duct resection, postoperative complications and outcome were retrieved from the case records. Kaplan-Meier analysis was done to estimate median disease-free survival and overall survival.

RESULTS

There were 17 GBC patients who underwent radical cholecystectomy with resection of extrahepatic bile duct. Median age of the patients was 51 years (range 35-62); male to female ratio was 5:12. Six patients were diagnosed after histopathological examination of resected gallbladder specimen following cholecystectomy (incidental gallbladder cancer). All the patients had R'0' resection. The indication for extra-hepatic bile duct resection was direct infiltration of hepatoduodenal ligament in nine, positive cystic duct margin in two, densely adherent pericholedochal lymphnodes in one and associated ampullary growth in one patient. Kaplan-Meier analysis predicted median disease-free survival of 20 months and median overall survival of 26 months.

CONCLUSION

Extrahepatic bile duct resection to achieve R'0' resection in the management of advanced gallbladder cancer is safe with acceptable postoperative morbidity and has potential to improve survival.

The surgical management of gallbladder cancer

Among biliary tract cancers, gallbladder cancer (GBC) is a potentially lethal malignancy with abysmal long-term survival. Surgery is central to the management of GBC, and presently, provides the only ray of hope for long-term survival. Radical cholecystectomy, which includes cholecystectomy with a limited hepatic resection, regional lymphadenectomy and adjacent organ resection if required is used to encompass the tumor with negative margins - R'0' resection is the standard surgical treatment for the management of GBC. Absence of randomized controlled trials to address various surgical controversies due to rarity of disease in western world, advanced disease at presentation, high frequency of unresectability/inoperability at surgery, deficient neoadjuvant/adjuvant strategies and nihilistic views of oncologists due to aggressive disease biology has resulted in marked heterogeneity in surgical strategies employed to manage GBC across the surgical centers globally.

Managing the incidentally detected gallbladder cancer: algorithms and controversies

INTRODUCTION

Gallbladder cancer (GBC) is the fifth most common neoplasm of the gastrointestinal tract and the most common cancer of the biliary tract. GBC is suspected preoperatively in only 30-40% of patients. The other 60-70% are discovered incidentally (IGBC) by the pathologist on a gallbladder specimen following cholecystectomy for benign diseases such as polyps, gallstones, and cholecystitis.

MATERIALS AND METHODS

Between 1995 and 2011, 30 cases of GBC, who underwent resection with curative intent in our institutions, were retrospectively reviewed. They were analyzed for demographic data, and type of operation, surgical morbidity and mortality, histopathological classification, and survival. Incidental GBC was compared with suspected or preoperatively diagnosed GBC. Overall survival, disease-free survival (DFS) and the difference in DFS between patients previously treated with laparoscopic cholecystectomy and those who had oncological resection as first intervention were analyzed. The authors also present a systematic review to evaluate the role of extended surgery in the treatment of the incidental GBC.

RESULTS

GBC was diagnosed in 30 patients, 16 women and 14 men. The M/F ratio was 1:1.14 and the mean age was 69.4 years (range 45-83 years). A preoperative diagnosis was possible only in 14 cases; fourteen of the incidental cases were diagnosed postoperatively after the pathological examination; two were suspected intraoperatively at the opening of the surgical specimen and then confirmed by frozen sections. The ratio between incidental and nonincidental cases was 1, 14/1, with twelve cases discovered after laparoscopic cholecystectomy. Eighty-one per cent of the incidental cases were discovered at an early stage (≤II). The preoperative diagnosis of the 30 patients with GBC was: GBC with liver invasion diagnosed by preoperative CT (nine cases); gallbladder abscess perforated into hepatic parenchyma and involving the transversal mesocolon and hepatic hilum (one case); porcelain gallbladder (three cases); gallbladder adenoma (four cases); and chronic cholecystolithiasis (thirteen cases). Every case, except one, with a T1b or more advanced invasion underwent IVb + V wedge liver resection and pericholedochic/hepatoduodenal lymphoadenectomy. One patient refused further surgery. Cases with Tis and T1a involvement were treated with cholecystectomy alone. Nine of the sixteen patients with incidental diagnosis reached 5-year DFS (56.25%) and eight of them are recurrence free. Surprisingly, one patient reached 38 mo survival despite a port-site recurrence (the only one in our experience) 2 years after the original surgery requiring further resection. Cases with non incidental diagnosis were more locally advanced and only two patients experienced 5 years DFS (Tables 2 and 3).

CONCLUSION

Laparoscopic cholecystectomy does not affect survival if implemented properly. Reoperation should have two objectives: R0 resection and clearance of the lymph nodes.

Surgical approaches to advanced gallbladder cancer : a 40-year single-institution study of prognostic factors and resectability

PURPOSE

The aim was to evaluate prognostic factors and factors associated with the resectability of advanced gallbladder cancer (GBC).

METHODS

This was a single-institution retrospective review of 274 consecutive surgically-treated cases of advanced GBC (excluding incidental GBC and early GBC). Univariate and multivariate analysis were performed to assess prognostic variables. R0 resection and survival rates were investigated for each local extension factor.

RESULTS

Long-term survival was uncommon among patients with multiple liver metastases (H2-3: n = 22; 2-year survival, 0 %), dissemination (P1-3: n = 16; 3-year survival, 0 %), invasion through the hepatoduodenal ligament (Binf3: n = 45; 5-year survival, 4.6 %), or group 3 lymph node (LN) metastasis including of the para-aortic LN (N3: n = 52; 13.7 %). Long-term survival rates did not differ significantly between patients who did and did not undergo bile duct resection or pancreaticoduodenectomy. Survival did not differ significantly according to the type of hepatectomy performed.

CONCLUSION

Surgery may not be indicated for patients with multiple liver metastasis, dissemination, Binf3, or visible para-aortic LN metastasis. Furthermore, it is important to achieve R0 surgery in cases of GBC.

Surgical strategy for T2 and T3 gallbladder cancer: is extrahepatic bile duct resection always necessary?

PURPOSE

Resection of the extrahepatic bile duct is not performed uniformly in gallbladder cancer. The study investigated the clinical significance of resection of extrahepatic bile duct (EHBD) in T2 and T3 gallbladder cancer.

METHODS

Between 2000 and 2010, 71 T2 or T3 gallbladder cancer patients who underwent R0 resection at Korea University Medical Center were included. Clinicopathological data were reviewed retrospectively. Survival analysis and comparison between EHBD resection and non-resection groups were performed.

RESULTS

The 32 men and 39 women had 49 T2 tumors and 22 T3 tumors. The overall survival rate was 67.8 % at 3 years and 47.2 % at 5 years. In multivariate analysis for overall survival, lymphovascular invasion and lymph node metastasis were significant independent predictors. Comparing the patients according to EHBD resection, the EHBD resection group demonstrated significantly longer hospital stay, longer operative time, more transfusion requirement, more extensive liver resection, and less treatment of neoadjuvant therapy. Significantly higher proportions of perineural invasion and lymph node metastasis were noted in the EHBD resection group. There were no statistically significant differences in survival between the EHBD resection and non-resection groups.

CONCLUSIONS

Resection of extrahepatic bile duct was not always necessary in T2 and T3 cancers. However, the patients who undergo resection of extrahepatic bile duct tended to have more aggressive tumor characteristics and undergo more aggressive surgical approach. To enhance overall survival for the patients with T2 and T3 gallbladder cancers, surgeons should try to perform R0 resection including EHBD resection.

Radical lymph node dissection and assessment: Impact on gallbladder cancer prognosis

AIM: To investigate the lymph node metastasis patterns of gallbladder cancer (GBC) and evaluate the optimal categorization of nodal status as a critical prognostic factor.

METHODS: From May 1995 to December 2010, a total of 78 consecutive patients with GBC underwent a radical resection at Liaocheng People’s Hospital. A radical resection was defined as removing both the primary tumor and the regional lymph nodes of the gallbladder. Demographic, operative and pathologic data were recorded. The lymph nodes retrieved were examined histologically for metastases routinely from each node. The positive lymph node count (PLNC) as well as the total lymph node count (TLNC) was recorded for each patient. Then the metastatic to examined lymph nodes ratio (LNR) was calculated. Disease-specific survival (DSS) and predictors of outcome were analyzed.

RESULTS: With a median follow-up time of 26.50 mo (range, 2-132 mo), median DSS was 29.00 ± 3.92 mo (5-year survival rate, 20.51%). Nodal disease was found in 37 patients (47.44%). DSS of node-negative patients was significantly better than that of node-positive patients (median DSS, 40 mo vs 17 mo, χ² = 14.814, P < 0.001), while there was no significant difference between N1 patients and N2 patients (median DSS, 18 mo vs 13 mo, χ² = 0.741, P = 0.389). Optimal TLNC was determined to be four. When node-negative patients were divided according to TLNC, there was no difference in DSS between TLNC < 4 subgroup and TLNC ≥ 4 subgroup (median DSS, 37 mo vs 54 mo, χ² = 0.715, P = 0.398). For node-positive patients, DSS of TLNC < 4 subgroup was worse than that of TLNC ≥ 4 subgroup (median DSS, 13 mo vs 21 mo, χ² = 11.035, P < 0.001). Moreover, for node-positive patients, a new cut-off value of six nodes was identified for the number of TLNC that clearly stratified them into 2 separate survival groups (< 6 or ≥ 6, respectively; median DSS, 15 mo vs 33 mo, χ² = 11.820, P < 0.001). DSS progressively worsened with increasing PLNC and LNR, but no definite cut-off value could be identified. Multivariate analysis revealed histological grade, tumor node metastasis staging, TNLC and LNR to be independent predictors of DSS. Neither location of positive lymph nodes nor PNLC were identified as an independent variable by multivariate analysis.

CONCLUSION: Both TLNC and LNR are strong predictors of outcome after curative resection for GBC. The retrieval and examination of at least 6 nodes can influence staging quality and DSS, especially in node-positive patients.

Evaluation of a prospective surgical strategy of extended resection to achieve R0 status in gall bladder cancer

INTRODUCTION

Radical resection to achieve R0 status remains the only potential curative option in patients with gall bladder cancer (GBC). This study was aimed to evaluate the efficacy of an extended criterion of radical resection to achieve R0 status in GBC.

METHODS

A triple-phase CT with 3D reconstruction was done in all patients. A standard resectability criterion was followed in all patients. A minimum of liver segment 4B + 5 resection and radical lymphadenectomy including the para-aortic areas were undertaken in all patients. Adjacent organectomy was added as required.

RESULTS

Between November 2008 and April 2011, 59 patients with GBC underwent operation and 40 (resectability, 68 %) underwent resection. The resectional procedures performed were segmentectomy 4B + 5 in 31 (78 %), median sectorectomy in 2 (5 %), extended right hepatectomy in 3 (8 %), and hepatopancreaticoduodenectomy in 4 (10 %) patients. Postoperative complications occurred in 24 (60 %) patients. Two patients died postoperatively. A total of 829 lymph nodes were harvested and the median lymph node count was 18 (4-77). Twenty-three (58 %) patients had lymph node metastases. Twenty-eight of 40 (70 %) had disease limited till N1 nodes. Metastases up to N2 lymph nodes were seen in 12 (30 %). American Joint Committee on Cancer seventh edition stages were I-2 (5 %) patients, II-5 (13 %), III-19 (48 %), and IV-14 (35 %). R0 resection was achieved in 33 (83 %) patients. Four patients had recurrence and one died of recurrence. All other patients are alive till the last follow-up.

CONCLUSIONS

Assessment with triple-phase CT with 3D reconstruction can produce high resectability rate in GBC. Extended criterion of radical resection results in R0 status in more than 80 % of patients with GBC.

Analysis of the relationships between clinicopathologic factors and survival in gallbladder cancer following surgical resection with curative intent

Background

This study elucidated the relationships between various clinicopathologic factors and the outcome of patients with gallbladder cancer (GBC) treated by surgical resection with curative intent.

Methods

Between January 2003 and January 2011, 76 patients with GBC underwent surgical resection with curative intent at our department. We then conducted a retrospective analysis of clinicopathologic data. Fourteen clinicopathological variables were selected for univariate and multivariate analysis to evaluate their influence on the outcome.

Results

The actuarial 1-, 3-, and 5-year survival rates in the 76 resected cases were 56.6%, 32.7%, and 23.8%, respectively. The univariate analysis revealed that curative resection (P<0.001), lymph node metastasis (P<0.001), AJCC stage (P = 0.030), tumor location (P = 0.008), histologic differentiation (P = 0.028), intraoperative blood loss (P = 0.011), and preoperative jaundice (P = 0.012) were significant risk factors for survival. Multivariate analysis revealed that noncurative resection and tumor location on gallbladder neck were significant risk factors for poor outcome. Among jaundiced patients, we discovered that gallbladder carcinoma with tumor thrombus in common bile duct (CBD) was very rare but with relatively special clinical manifestation and characteristic radiography manifestation. The prognosis of gallbladder carcinoma with tumor thrombus in CBD after surgical procedure was apparently better than gallbladder carcinoma with invasion of hilar tissues.

Conclusions

Curative surgical resection remains the only effective approach to the treatment of GBC. This series confirm that jaundice is a poor prognostic factor. However, the presence of jaundice does not preclude resection, especially in highly selected patients (when R0 resection is achievable). Gallbladder carcinoma with tumor thrombus in CBD has special clinical characteristics, which need to be awared by radiologists and clinicians.

Incidental gallbladder cancer during laparoscopic cholecystectomy: Managing an unexpected finding

AIM: To evaluate the impact of incidental gallbladder cancer on surgical experience.

METHODS: Between 1998 and 2008 all cases of cholecystectomy at two divisions of general surgery, one university based and one at a public hospital, were retrospectively reviewed. Gallbladder pathology was diagnosed by history, physical examination, and laboratory and imaging studies [ultrasonography and computed tomography (CT)]. Patients with gallbladder cancer (GBC) were further analyzed for demographic data, and type of operation, surgical morbidity and mortality, histopathological classification, and survival. Incidental GBC was compared with suspected or preoperatively diagnosed GBC. The primary endpoint was disease-free survival (DFS). The secondary endpoint was the difference in DFS between patients previously treated with laparoscopic cholecystectomy and those who had oncological resection as first intervention.

RESULTS: Nineteen patients (11 women and eight men) were found to have GBC. The male to female ratio was 1:1.4 and the mean age was 68 years (range: 45-82 years). Preoperative diagnosis was made in 10 cases, and eight were diagnosed postoperatively. One was suspected intraoperatively and confirmed by frozen sections. The ratio between incidental and nonincidental cases was 9/19. The tumor node metastasis stage was: pTis (1), pT1a (2), pT1b (4), pT2 (6), pT3 (4), pT4 (2); five cases with stage Ia (T1 a-b); two with stage Ib (T2 N0); one with stage IIa (T3 N0); six with stage IIb (T1-T3 N1); two with stage III (T4 Nx Nx); and one with stage IV (Tx Nx Mx). Eighty-eight percent of the incidental cases were discovered at an early stage (≤ II). Preoperative diagnosis of the 19 patients with GBC was: GBC with liver invasion diagnosed by preoperative CT (nine cases), gallbladder abscess perforated into hepatic parenchyma and involving the transversal mesocolon and hepatic hilum (one case), porcelain gallbladder (one case), gallbladder adenoma (one case), and chronic cholelithiasis (eight cases). Every case, except one, with a T1b or more advanced invasion underwent IVb + V wedge liver resection and pericholedochic/hepatoduodenal lymphadenectomy. One patient with stage T1b GBC refused further surgery. Cases with Tis and T1a involvement were treated with cholecystectomy alone. One incidental case was diagnosed by intraoperative frozen section and treated with cholecystectomy alone. Six of the nine patients with incidental diagnosis reached 5-year DFS. One patient reached 38 mo survival despite a port-site recurrence 2 years after original surgery. Cases with non incidental diagnosis were more locally advanced and only two patients experienced 5-year DFS.

CONCLUSION: Laparoscopic cholecystectomy does not affect survival if implemented properly. Reoperation should have two objectives: R0 resection and clearance of the lymph nodes.

Gallbladder cancer involving the extrahepatic bile duct is worthy of resection

OBJECTIVE

To clarify the value of resection of gallbladder cancer involving the extrahepatic bile duct.

BACKGROUND

: Several recent studies have proven that jaundice and extrahepatic biliary involvement are independent predictors of a poor outcome. Only a few authors recommend resection of such advanced disease.

METHODS

One hundred patients with pT3/4, pN0/1, M0 disease were the subjects of this study. Mortality and long-term outcome were analyzed using a prospectively collected database.

RESULTS

The only factor associated with mortality in univariate and multivariate analyses was intraoperative blood loss. The 5-year survival rate and median survival time were 23% and 1.5 years for patients with pathologic extrahepatic biliary invasion (pEBI), and 54% and 15.4 years for patients without pEBI. Twelve patients with pEBI survived beyond 5 years. Multivariate analysis revealed that R1/2 resection and combined resection of adjacent organs other than the liver and extrahepatic bile duct (CRAO) were independent predictors of poor outcome. Five-year survival rate and median survival time after R0 resection without CRAO were 36% and 3.8 years even in patients with pEBI. In contrast, after R0 resection with CRAO 5-year survival and median survival time were 16% and 0.8 years, respectively.

CONCLUSIONS

Patients with advanced gallbladder cancer with pEBI are candidates for resection when distant metastases are absent and R0 resection is achievable. When CRAO is unnecessary, surgical resection should be aggressively planned.

Is adjuvant radiotherapy needed after curative resection of extrahepatic biliary tract cancers? A systematic review with a meta-analysis of observational studies

BACKGROUND

The role for adjuvant radiotherapy (ART) after curative resection in extrahepatic cholangiocarcinoma remains unclear. Due to the lack of randomized trials, available data comes from single center experiences or data-based population studies with inconclusive results.

OBJECTIVE

To assess the impact of radiotherapy (with or without concurrent chemotherapy) on toxicity and survival of radically resected patients with extrahepatic bile duct cancer (extrahepatic cholangiocarcinoma, gallbladder cancer and pure ampullary cancer).

DATA SOURCES AND STUDY SELECTION

Eligible studies with data on survival, recurrence and toxicity were retrieved from the MEDLINE, ISI web of science, EMBASE and Cochrane databases from January 1995 to December 2008, to ensure that all ART treatments were performed with conventional 3D techniques. In the absence of randomized controlled-studies, all observational cohort studies (longitudinal and historical) were initially considered. Ten retrospective cohort studies (where the use of concurrent CT was reported only in 2), met all inclusion criteria and were enrolled for final meta-analysis. Hazard ratio (HR) had to be extracted from survival curves using the Tierney et al. methods. MIX 1.7 statistical software was used for meta-analysis.

RESULTS

All studies on ART used conventional 3D-techniques. Patients in the ART cohorts were more likely to have involved surgical margins and positive lymph nodes. For extrahepatic cholangiocarcinoma location, ART significantly improved overall survival (HR 0.62; 95% CI 0.48 to 0.78, p<0.001). Meta-analysis was not feasible for gallbladder cancer and ampullary cancer locations. Late radiation-induced toxicity was low (2-9% late obstruction or GI bleeding).

CONCLUSION

In the absence of randomized controlled studies, we found in the present systematic review and meta-analysis of observational studies that, patients with extrahepatic cholangiocarcinoma treated with adjuvant RT have a significant lower risk of dying compared to patients treated with surgery alone.

Prognostic factors of patients with advanced gallbladder carcinoma following aggressive surgical resection

BACKGROUND

The prognosis for patients with advanced gallbladder carcinoma is dismal despite aggressive surgical resection. The aim of this study is to determine useful prognostic factors for patients with gallbladder carcinoma following aggressive surgical resection.

METHODS

Medical records of 62 patients with gallbladder carcinoma who underwent surgical resection were retrospectively reviewed. Univariate and multivariate models were used to analyze the effect of clinicopathological factors on long-term survival.

RESULTS

According to the UICC staging system, ten (16%), 11 (18%), eight (13%), 16 (25%), nine (15%), and eight patients (13%) were diagnosed with stages I, II, IIIA, IIIB, IVA, and IVB disease, respectively. Partial hepatectomy and pancreatoduodenectomy were performed for 43 (69%) and 11 (18%) patients, respectively. Overall survival rates of all 62 and 41 patients with UICC stages III and IV disease were 71% and 56% at 1 year, 48% and 23% at 3 years, and 48% and 23% at 5 years, respectively (median survival time, 15.8 and 12.7 months, respectively). Multivariate analysis revealed that independent prognostic factors included tumor differentiation (p = 0.006), hepatic invasion (p = 0.002), lymph node metastasis (p = 0.009), and surgical margin status (p = 0.002) for all patients, and adjuvant chemotherapy (p = 0.005), tumor differentiation (p = 0.008), hepatic invasion (p = 0.001), and surgical margin status (p = 0.022) for patients with UICC stages III and IV disease.

CONCLUSIONS

R0 resection and adjuvant chemotherapy are significant prognostic factors in advanced gallbladder carcinoma and should be performed to improve survival.

Incidentally-discovered gallbladder cancer: When, why and which reoperation?

Cancer of the gallbladder, a rare entity with a poor prognosis, is often discovered incidentally during or after cholecystectomy. It tends to disseminate early via lymphatic, peritoneal, endobiliary, and hematogenous pathways. Diagnosis is made intra-operatively in only a quarter of cases, by examination of the opened cholecystectomy specimen in the operating room by the surgeon; this procedure should be routine. For incidentally-discovered cancers, survival was 28% at five years. Prognostic factors include age, TNM stage, gallbladder perforation during cholecystectomy and less-than-optimal resection at re-operation. Whether the laparoscopic route for the initial cholecystectomy has an impact on survival remains a subject of debate. R0 surgery is the only potentially curative treatment: simple cholecystectomy with clear margins is adequate resection for stage T1a tumors; extended cholecystectomy with lymphadenectomy and possibly resection of the bile duct is required for more advanced stages. After curative resection, neo-adjuvant or adjuvant chemotherapy and radiotherapy have not, so far, proven effective. Improvement of surgical practices (systematic review of cholecystectomy specimens in the OR, prevention of gallbladder perforation with bile spillage during surgery, early re-intervention for optimal resection) could improve the prognosis of these cancers.

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 cancer diagnosed following laparoscopic cholecystectomy

BACKGROUND

Laparoscopic cholecystectomy (LC) is the treatment of choice for benign gallbladder disease. Gallbladder cancers have been found following LC. The aim of the present study was to evaluate the survival outcome and prognosis of incidental gallbladder cancer diagnosed after LC.

METHODS

From January 2002 to December 2007, 3,145 patients underwent LC at the Department of Surgery, Korea University Medical Center. Of these, 33 patients (1.05%) were diagnosed with gallbladder cancer after LC. Clinicopathological characteristics were retrospectively reviewed in this study.

RESULTS

Of the 33 patients studied, 9 were men and 24 were women. Laparoscopic cholecystectomy alone was performed in 26 patients, and additional radical surgery was performed in 7 others. Regarding tumor staging, there were 2 Tis, 6 T1a, 4 T1b, 17 T2, and 4 T3 tumors. Male patients had a significantly higher incidence of moderately and poorly differentiated tumors (P < 0.001), T2 and T3 tumors (P = 0.02), additional second operations (P = 0.046), and recurrence (P = 0.016). The cumulative 1-, 3-, and 5-year survival rates were 87.2, 73.1, and 47.0%, respectively. Univariate analysis revealed that significant prognostic factors for poorer survival were male gender (P = 0.026), age older than 65 years (P = 0.013), the presence of inflammation (P = 0.009), moderately or poorly differentiated tumor (P < 0.001), nonpolypoid gross type (P = 0.003), and pT stage (P < 0.001). Tumor differentiation was a significantly independent predictor of poor prognosis.

CONCLUSIONS

Male patients exhibited aggressive tumor characteristics. Laparoscopic cholecystectomy is an adequate treatment for pT1 tumors. For pT2 and pT3 patients, additional radical surgery might be needed to achieve a tumor-free surgical margin, along with lymph node dissection.

Surgical outcomes and prognostic factors for T2 gallbladder cancer following surgical resection

BACKGROUND

Depth of tumor invasion is an important prognostic factor for gallbladder cancer. The aim of this study was to investigate the clinicopathological prognostic factors of T2 gallbladder cancer.

METHODS

We retrospectively reviewed the clinicopathological data and survival for 83 patients with T2 gallbladder cancers who underwent surgical resection between January 1995 and December 2007.

RESULTS

The overall survival rates were 48.9% at 3 years and 29.3% at 5 years. Univariate analysis revealed that R0 resection (P < 0.001), extended surgery (P = 0.028), lymph node dissection (P = 0.024), non-infiltrative tumors (P = 0.001), well differentiation (P = 0.001), absence of lymphatic (P = 0.025), perineural (P = 0.001), and vascular (P = 0.025) invasion, absence of lymph node metastasis (P = 0.001), negative resection margin (P = 0.016), and stage (P = 0.002) were significantly better predictors for survival. A significant difference in survival between Rx and R1 was not found. R0 resection, lymph node dissection, well differentiation, and absence of perineural and vascular invasion were significantly independent prognostic factors for overall survival. Recurrence occurred in 48 patients (57.8%). Age older than 65 years, R0 resection, non-infiltrative tumors, and good differentiation were significant independent predictors of disease-free survival by multivariate analysis.

CONCLUSIONS

For T2 tumors, radical surgery including lymph node dissection should be performed to achieve R0 resection. Tumors with infiltrative types and suspicious lymph node metastasis in the intraoperative findings were candidates for aggressive surgical management to improve patient survival.

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.

Total laparoscopic resection of the gallbladder together with the gallbladder bed

Patients with carcinoma of the gallbladder that is preoperatively diagnosed by radiology do not undergo laparoscopic resection, because such surgery is thought to worsen the prognosis of gallbladder carcinoma. However, the prognosis for patients with incidental T2 gallbladder carcinoma who are treated laparoscopically is reportedly no worse than that for patients undergoing conventional surgery. We successfully performed total laparoscopic resection of the gallbladder together with the gallbladder bed without any complications. We believe that this procedure represents a valid therapeutic option for carefully selected patients with T2 carcinoma of the gallbladder.

Analysis of the extent of resection for adenocarcinoma of the gallbladder

Gallbladder cancer has historically been considered an incurable malignancy; although, extended resection has been associated with cure in selected patients. However, the optimal extent of resection is unknown. The objective of this study was to analyze the impact of the extent of resection for gallbladder adenocarcinoma on disease-specific survival (DSS) and perioperative morbidity. Analysis of a prospective hepatobiliary surgery database identified patients undergoing surgical resection for gallbladder adenocarcinoma from 1990 to 2002. Clinicopathologic factors including extent of resection were analyzed for their association with DSS and perioperative morbidity. Long-term outcome was evaluable in 104 patients. With median follow-up of 58 months for survivors, the actuarial 5-year DSS was 42%. Thirty-six patients (35%) underwent major hepatectomy, but in 15 this was not mandatory to clear all disease. Sixty-eight patients (65%) underwent common bile duct (CBD) excision, but 32 were performed empirically. Twenty-one patients (20%) underwent en bloc resection of adjacent organs other than the liver. The performance of a major hepatectomy or a CBD excision was not associated with other clinicopathologic variables or long-term survival. Resection of adjacent organs were associated with advanced T stage but not with survival. T stage, N stage, histologic differentiation, and CBD involvement were independently associated with survival. Major hepatectomy and CBD excision were significantly associated with perioperative morbidity. We conclude that tumor biology and stage, rather than extent of resection, predict outcome after resection for gallbladder cancer. Major hepatic resections, including major hepatectomy and CBD excision, are appropriate when necessary to clear disease but are not mandatory in all cases.

Renal cell carcinoma with unusual metastasis to the gallbladder

Gallbladder involvement in patients with renal cell carcinoma (RCC) is extremely rare. We present a report of a 61-year-old man with a synchronous RCC metastasis to the gallbladder presenting as an intraluminal polypoid mass simulating primary gallbladder carcinoma. Enhanced abdominal computed tomography demonstrated a well-enhanced polypoid lesion in the gallbladder. Intraoperative rapid pathological examination of the gallbladder tumor showed clear cell-type cancerous cells. Microscopically, tumor cells of both the resected kidney and gallbladder had round uniform nuclei, clear cytoplasm, and well-defined cytoplasmic borders, forming alveolar patterns. Immunohistochemically, the tumor cells were negative for cytokeratin 7 (CK7) and carcinoembryonic antigen (CEA), which is usually positive in primary clear cell carcinoma of the gallbladder. Therefore, the final diagnosis was RCC with a synchronous gallbladder metastasis.