Outcome of radical surgery for carcinoma of the gallbladder according to the tumor node metastasis and Japanese Society of Biliary Surgery stages

Macroscopic Inflammation Status of Resected Gallbladder Predicts Therapeutic Outcome After Radical Resection for Gallbladder Carcinoma

Objective

Gallbladder carcinoma (GBC) is one of the digestive cancers with poor prognosis, for which surgical resection is the only potentially curative therapy. Prognostic value of macroscopic inflammatory status of the resected gallbladder in patient with GBC has not been fully investigated. We retrospectively investigated the relation between macroscopic inflammatory status and disease-free as well as overall survival after radical resection for GBC.

Method

The subjects were 44 patients who underwent radical resection for GBC between January 2004 and April 2011 at Jikei University Hospital. We retrospectively investigated the relationship between clinicopathologic variables, including macroscopic inflammatory status and disease-free as well as overall survival.

Results

In univariate analysis, disease-free survival was poor in patients with Tumor-Nodes-Metastasis (TNM) stage ≥III (P < 0.0001) and positive vascular invasion (P = 0.0001). Patients with macroscopic chronic inflammation tended to have poor disease-free survival than those with normal type (P = 0.0930). Overall survival was poor in patients with TNM stage ≥III (P < 0.0001), presence of intraoperative blood transfusion (P = 0.0125), positive vascular invasion (P = 0.0055), and macroscopic chronic inflammation (P = 0.0281). In multivariate analysis, TNM stage ≥III (P < 0.0114) and macroscopic chronic inflammation (P = 0.0350) were independent predictors of disease-free survival. For overall survival, TNM stage ≥III (P = 0.0054) and macroscopic chronic inflammation (P = 0.0124) were the independent predictors. Moreover, macroscopic chronic inflammation correlated with the presence of gallstones.

Conclusion

The macroscopic Inflammation status of resected gallbladder cancer correlates with oncologic outcome in patients with GBC treated by radical resection.

"Extended" radical cholecystectomy for gallbladder cancer: Long-term outcomes, indications and limitations

AIM: To delineate indications and limitations for "extended" radical cholecystectomy for gallbladder cancer: a procedure which was instituted in our department in 1982.

METHODS: Of 145 patients who underwent a radical resection for gallbladder cancer from 1982 through 2006, 52 (36%) had an extended radical cholecystectomy, which involved en bloc resection of the gallbladder, gallbladder fossa, extrahepatic bile duct, and the regional lymph nodes (first- and second-echelon node groups). A retrospective analysis of the 52 patients was conducted including at least 5 years of follow up. Residual tumor status was judged as no residual tumor (R0) or microscopic/macroscopic residual tumor (R1-2). Pathological findings were documented according to the American Joint Committee on Cancer Cancer Staging Manual (7th edition).

RESULTS: The primary tumor was classified as pathological T1 (pT1) in 3 patients, pT2 in 36, pT3 in 12, and pT4 in 1. Twenty-three patients had lymph node metastases; 11 had a single positive node, 4 had two positive nodes, and 8 had three or more positive nodes. None of the three patients with pT1 tumors had nodal disease, whereas 23 of 49 (47%) with pT2 or more advanced tumors had nodal disease. One patient died during the hospital stay for definitive resection, giving an in-hospital mortality rate of 2%. Overall survival (OS) after extended radical cholecystectomy was 65% at 5 years and 53% at 10 years in all 52 patients. OS differed according to the pT classification (P < 0.001) and the nodal status (P = 0.010). All of 3 patients with pT1 tumors and most (29 of 36) patients with pT2 tumors survived for more than 5 years. Of 12 patients with pT3 tumors, 8 who had an R1-2 resection, distant metastasis, or extensive extrahepatic organ involvement died soon after resection. Of the remaining four pT3 patients who had localized hepatic spread through the gallbladder fossa and underwent an R0 resection, 2 survived for more than 5 years and another survived for 4 years and 2 mo. The only patient with pT4 tumor died of disease soon after resection. Among 23 node-positive patients, 11 survived for more than 5 years, and of these, 10 had a modest degree of nodal disease (one or two positive nodes).

CONCLUSION: Extended radical cholecystectomy is indicated for pT2 tumors and some pT3 tumors with localized hepatic invasion, provided that the regional nodal disease is limited to a modest degree (up to two positive nodes). Extensive pT3 disease, pT4 disease, or marked nodal disease appears to be beyond the scope of this radical procedure.

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.

Current management of gallbladder carcinoma

Gallbladder cancer (GBC) represents the most common and aggressive type among the biliary tree cancers (BTCs). Complete surgical resection offers the only chance for cure; however, only 10% of patients with GBC present with early-stage disease and are considered surgical candidates. Among those patients who do undergo "curative" resection, recurrence rates are high. There are no established adjuvant treatments in this setting. Patients with unresectable or metastatic GBC have a poor prognosis. There has been a paucity of randomized phase III data in this field. A recent report demonstrated longer overall survival with gemcitabine in combination with cisplatin than with gemcitabine alone in patients with advanced or metastatic BTCs. Molecularly targeted agents are under development. In this review, we attempt to discuss the current status and key issues involved in the management of GBC.

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.

Gallbladder cancer--a comprehensive review

AIM

Gallbladder cancer is the fifth most common cancer involving the gastrointestinal tract, but it is the most common malignant tumour of the biliary tract worldwide. The percentage of patients diagnosed to have gallbladder cancer after simple cholecystectomy for presumed gallbladder stone disease is 0.5-1.5%. This tumour is traditionally regarded as a highly lethal disease with an overall 5-year survival of less than 5%. The marked improvement in the outcome of patients with gallbladder cancer in the last decade is because of the aggressive radical surgical approach that has been adopted, and improvements in surgical techniques and peri-operative care. This article aims to review the current approach to the management of gallbladder cancer.

METHODS

A Medline, PubMed database search was performed to identify articles published from 1990 to 2007 using the keywords 'carcinoma of gallbladder', 'gallbladder cancer', 'gallbladder neoplasm' and 'cholecystectomy'.

RESULTS AND CONCLUSIONS

The overall 5-year survival for patients with gallbladder cancer who underwent Ro curative resection was reported to range from 21% to 69%. Laparoscopic cholecystectomy is absolutely contraindicated when gallbladder cancer is known or suspected pre-operatively. Patients with a pre-operative suspicion of gallbladder cancer should undergo open exploration and cholecystectomy after proper pre-operative assessment. For patients whose cancer is an incidental finding on pathological review, a second radical resection is indicated except for Tis and T1a disease. There is still controversy for the optimal management of T1b disease. Although the role of surgery for advanced disease remains controversial, patients with advanced gallbladder cancer can benefit from radical resection, provided a potentially curative Ro resection is possible. There is still no effective adjuvant therapy for gallbladder cancer.

Gallbladder cancer

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSION

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

A curative resection improves the postoperative survival rate even in patients with advanced gallbladder carcinoma

The aim of this study was to evaluate the results of our series of 90 operations for gallbladder carcinoma according to the Japanese Society of Biliary Surgery (JSBS) classification system and to clarify the appropriate surgical strategy for advanced gallbladder carcinoma based on the depth of primary tumor invasion and lymph node metastasis. Generally, only a surgical resection can achieve a prognostic improvement of the advanced gallbladder carcinoma. The survival of patients with this neoplasm depends strictly on the depth of histological primary tumor invasion and lymph node metastasis. A retrospective analysis was conducted on 90 patients from 1990 to 2004 who underwent a surgical resection of gallbladder carcinoma. The factors influencing survival were examined. Thirty-nine patients with palliative treatment (not resected cases), which was diagnosed as T3 or T4 by preoperative imagings, were also included in this study. The significance of the variables for survival was examined by the Kaplan-Meier method and the log-rank test followed by multivariate analyses using Cox's proportional hazard model. Portal invasion, lymph node metastasis, the surgical margin (+ vs. -) and the final curability (fCurA, B vs. C) were all found to be independent prognostic factors in the multivariate analysis. In pT2 gallbladder carcinoma, a better survival was achieved in an aggressive surgical approach, in order of a S4a+S5 hepatic resection, an extended cholecystectomy and a cholecystectomy. In pT3 and pT4, although radical extended surgery did not provide the opportunity for good survival even after lobectomy of the liver, the survival of patients with curative surgery was statistically better than in those without curative surgery. In addition, the nodal involvement of pN1 to pN2 was better than that with pN3. A S4a+S5 hepatectomy, therefore, appears to be adequate for the treatment of pT2 gallbladder carcinoma. Even in patients with pT3 and pT4 gallbladder carcinoma, long-term survival can be expected by an operation with a tumor-free surgical margin. The role of radical surgery, however, is considered to be limited in patients with pN3 lymph node metastasis.

Gallbladder cancer: Defining the indications for primary radical resection and radical re-resection

BACKGROUND

The role of radical resection for gallbladder cancer is an ongoing area of debate. In this review, we present our experience managing gallbladder cancer at a tertiary center by using an aggressive surgical approach for T2 or greater disease, reserving simple cholecystectomy only for T1 lesions.

METHODS

Seventy-six patients with histologically confirmed gallbladder cancer were identified from our cancer registry. Estimated survival distributions were calculated by the Kaplan-Meier method, and comparisons were made by using the log-rank test. The Cox proportional hazards model was used to determine the effect on survival of T stage, nodal status, age, and margins.

RESULTS

Sixty-four patients were assessable for this study. Simple cholecystectomy was the only procedure performed in 10 T2 and 15 T3 cases. Radical cholecystectomy was performed as the primary procedure in two T2, two T3, and six T4 cases. Radical re-resection was accomplished in seven T2 and two T3 cases. Excluding the T4 group, there was a significant survival advantage (P = .007) for the radical resection group (n = 13; median survival not yet reached) compared with the simple cholecystectomy group (n = 25; median survival, 17 months; 95% confidence interval, 7-27 months). Analysis of the 13 T2 and T3 patients who underwent radical resections revealed that the radical re-resection group (n = 9) had an overall survival similar to that of the primarily resected group (n = 4). All T2N(+) and T3N(-) patients are still alive and disease free after 5 years of follow-up, whereas none of the T3N(+) or T4 patients survived beyond 24 months. Increasing T stage and age (>65 years) were independent predictors of a poor prognosis.

CONCLUSIONS

Radical resection for T2 and T3 disease resulted in a significant survival advantage compared with simple cholecystectomy. Patients who undergo radical re-resection after an incidentally discovered gallbladder cancer experience the same survival benefit as primarily resected patients. Radical resection for T2N(-), T2N(+), and T3N0 cases can achieve long-term survival. Conversely, the prognosis for T3N(+) and T4 patients is poor, and improved outcome for this group will likely depend on the development of multi-institutional neoadjuvant clinical trials that can identify effective systemic regimens.

Evidence-based gallbladder cancer staging: changing cancer staging by analysis of data from the National Cancer Database

BACKGROUND

A recent revision of the American Joint Committee on Cancer (AJCC) staging for gallbladder cancer (6th Edition) involved some major changes. Most notably, T2N0M0 tumors were moved from stage II to stage IB; T3N1M0 disease was moved from stage III to stage IIB; and T4NxM0 (x = any) tumors were moved from stage IVA to stage III.

METHODS

In order to determine if these changes were justified by data, an analysis of the 10,705 cases of gallbladder cancer collected between 1989 and 1996 in the NCDB was performed. All patients had >5 year follow-up.

RESULTS

The staging according to the 6th Edition provided no discrimination between stage III and IV. Five-year survivals for stage IIA, IIB, III, and IV (6th Edition) were 7%, 9%, 3%, 2% respectively. The data from the National Cancer Database (NCDB) were used to derive a proposed new staging system that builds upon Edition 5 and had improved discrimination of stage groups over previous editions.

CONCLUSIONS

Changes in staging systems should be justified by data. Multicenter databases, including the NCDB, represent important resources for verification of evidence-based staging systems.