Surgical management of gallbladder cancer

Survival analysis and prognostic factors of the carcinoma of gallbladder

BACKGROUND

The present study aims to evaluate the survival status of patients with gallbladder cancer (GBC) and explore the prognostic factors for the improvement and preventions.

METHODS

The study consists of 176 patients with clinically diagnosed gallbladder cancer; the study was conducted between 2019 and 2021 registered at Kamala Nehru Memorial Cancer Hospital, Prayagraj, India. The survival rates were analyzed by the Kaplan-Meier method; survival rate difference was analyzed by log-rank test, prognosis factors; and hazard ratio for mortality outcomes was estimated using Cox regression method.

RESULTS

The overall median survival time of patients was 5 months with the 1-year, 2-year, and 3-year survival rates of 24.4%, 8.5%, and 4.5%, respectively. The 3-year survival for patients with jaundice was 2.9%, liver infiltration (4.2%), gallstones (0.8%), and with advanced tumor grade (1.4%). Elderly GBC patients had lower survival rates (3.8%), while the 3-year overall survival for patients residing in urban areas dropped to zero. No patients in the tumor stage (T3/T4) and with distance metastasis stage survived in 3 years, while only 1.1% of patients with advanced nodal stage survived. On receiving surgery and radiation therapy, the 3-year survival rate increased to 19.5% and 35%, respectively. The results of multivariate analysis showed that urban region (HR = 1.568, p = 0.040), gallstone or not (1.571, p = 0.049), N stage (HR = 1.468, p = 0.029), and M stage (HR = 2.289, p < 0.0001) were independent risk factors for prognosis, while surgery or not (HR = 0.573, p = 0.030) was the protective factor for the prognosis of GBC.

CONCLUSION

The overall survival of GBC in the Gangetic belt is poor. The geographical region of patients, gallstones, and N and M stage was the risk factors for prognosis, while surgery or not was the protective factor for the prognosis of GBC.

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 Rationality of Resectional Surgery and Palliative Interventions in the Management of Patients with Gallbladder Cancer

The aim of the present study was to evaluate in a retrospective manner, the survival period and survival rate according to stages and groups after R0, R1, R2 resections and palliative interventions. Between 2003 and 2012, 67 patients diagnosed with gallbladder carcinoma were retrospectively analyzed. Patient demographics, the survival period, and survival rate according to stages and groups after R0, R1, R2 resections and palliative interventions were retrospectively analyzed. Sixty-seven patients were diagnosed with gallbladder carcinoma. Thirty-eight patients (56.7%) were female and 29 patients (43.3%) were male. The median survival period was significantly longer in stage II and III diseases than in stage IV disease ( P < 0.001). The R0, R1, and R2 resection rates in patients who underwent surgery with curative intent were 67.7, 19.4, and 12.9 per cent, respectively. The R0 resection rate according to the tumor stages was 100 per cent for stage I, 87.5 per cent for stage II, 66.7 per cent for stage III, and 42.8 per cent for stage IV disease. The median follow-up period was six months (eight days to 36 months). During this follow-up period, 53 patients (79.1%) died. In conclusion, R0 resection rate decreases when tumor stage increases. The highest survival rates after R0 resection are achieved in patients with stage I, II, and III diseases. Radical surgery has no benefit over palliative surgery for stage IV disease in terms of 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.