Validation of American Joint Committee on Cancer eighth staging system for gallbladder cancer and its lymphadenectomy guidelines

A Systemic Review and Meta-analysis of Laparoscopic Surgery Versus Open Surgery for Gallbladder Cancer

Introduction

Laparoscopy in gallbladder cancer (GBC) has a possible role in staging, radical cure, and palliation in gallbladder cancer. However, a few studies have advocated the use of laparoscopic approach and concluded the safety of this approach. This present study was undertaken to determine the safety and feasibility between open and laparoscopic cholecystectomy in patients with the non-metastatic GBC.

Materials and Methods

A systematic database search was performed in MEDLINE, Embase, and Google Scholar for relevant articles. As a result, a list of such studies, clinical trials, published in English up to May 2021, was obtained,14 studies were included and statistical analysis was conducted using RevMan software 5.3 (The Nordic Cochrane Centre).

Results

The 5-year survival rate was reported in 13 out of 14 studies (1388 patients), and all compared laparoscopic and open approach. There was no significant heterogeneity in between the studies (chi-square, 10.66; df, 12; I2, 0%). There was significant higher overall survival in open group (389/850 vs 194/538 or 1.45, 95% CI (1.12-1.88), P value, 0.005). There was no significant difference in recurrence rate, operative time, blood loss, lymph node yield, and postoperative complication in between open and laparoscopic groups.

Conclusions

Our present study demonstrates that overall survival is significantly increased with open approach when compared with laparoscopic approach. There is no difference in recurrence rate, operative time, blood loss, lymph node yield, and postoperative complications between the open and laparoscopic cholecystectomy groups.

DNMT3A Cooperates with YAP/TAZ to Drive Gallbladder Cancer Metastasis

Gallbladder cancer (GBC) is an extremely lethal malignancy with aggressive behaviors, including liver or distant metastasis; however, the underlying mechanisms driving the metastasis of GBC remain poorly understood. In this study, it is found that DNA methyltransferase DNMT3A is highly expressed in GBC tumor tissues compared to matched adjacent normal tissues. Clinicopathological analysis shows that DNMT3A is positively correlated with liver metastasis and poor overall survival outcomes in patients with GBC. Functional analysis confirms that DNMT3A promotes the metastasis of GBC cells in a manner dependent on its DNA methyltransferase activity. Mechanistically, DNMT3A interacts with and is recruited by YAP/TAZ to recognize and access the CpG island within the CDH1 promoter and generates hypermethylation of the CDH1 promoter, which leads to transcriptional silencing of CDH1 and accelerated epithelial-to-mesenchymal transition. Using tissue microarrays, the association between the expression of DNMT3A, YAP/TAZ, and CDH1 is confirmed, which affects the metastatic ability of GBC. These results reveal a novel mechanism through which DNMT3A recruitment by YAP/TAZ guides DNA methylation to drive GBC metastasis and provide insights into the treatment of GBC metastasis by targeting the functional connection between DNMT3A and YAP/TAZ.

Rapidly growing double cancer of the gallbladder: A case report

INTRODUCTION

Gallbladder cancer is a rare malignancy and double cancer of the gallbladder is extremely rare. Biliary tree malignancies including cholangiocarcinoma and gallbladder cancer are aggressive cancers and have a poor prognosis. This reports a rare case of double adenocarcinoma of the gallbladder.

PRESENTATION OF CASE

A 77-year old woman with a cholelithiasis and decreased body weight was diagnosed with rapidly growing gallbladder tumor by abdominal computed tomography scan. A combined resection of the gallbladder, extrahepatic bile duct, segments 4a and 5 of the liver and regional lymph node dissection were performed. Pathologic examination revealed double poorly differentiated adenocarcinoma of the gallbladder. The patient had no evidence of recurrence for 40 months after resection.

DISCUSSION

This patient had double cancer of the gallbladder. Gallbladder cancer is an aggressive cancer and has a poor prognosis. The only curative therapy is radical resection. In this patient, radical laparotomy and adjuvant chemotherapy were performed. The pathological diagnosis of the resected specimen was double cancer of the gallbladder.

CONCLUSION

This is a report of rapidly growing double cancer of the gallbladder. Patients with gallbladder cancer may benefit from aggressive surgical resection and adjuvant chemotherapy.

Development and External Validation of a Model to Predict Overall Survival in Patients With Resected Gallbladder Cancer

OBJECTIVE

The aim of this study was to develop and validate a clinical prediction model to predict overall survival in patients with nonmetastatic, resected gallbladder cancer (GBC).

BACKGROUND

Although several tools are available, no optimal method has been identified to assess survival in patients with resected GBC.

METHODS

Data from a Dutch, nation-wide cohort of patients with resected GBC was used to develop a prediction model for overall survival. The model was internally validated and a cohort of Australian GBC patients who underwent resection was used for external validation. The performance of the American Joint Committee on Cancer (AJCC) staging system and the present model were compared.

RESULTS

In total, 446 patients were included; 380 patients in the development cohort and 66 patients in the validation cohort. In the development cohort median survival was 22 months (median follow-up 75 months). Age, T/N classification, resection margin, differentiation grade, and vascular invasion were independent predictors of survival. The externally validated C-index was 0.75 (95%CI: 0.69-0.80), implying good discriminatory capacity. The discriminative ability of the present model after internal validation was superior to the ability of the AJCC staging system (Harrell C-index 0.71, [95%CI: 0.69-0.72) vs. 0.59 (95% CI: 0.57-0.60)].

CONCLUSION

The proposed model for the prediction of overall survival in patients with resected GBC demonstrates good discriminatory capacity, reasonable calibration and outperforms the authoritative AJCC staging system. This model can be a useful tool for physicians and patients to obtain information about survival after resection and is available from https:// gallbladderresearch.shinyapps.io/Predict_GBC_survival/.

Development and validation of a nomogram to predict overall survival in patients with incidental gallbladder cancer: A retrospective cohort study

Objective

The aim of this study was to develop and validate a nomogram to predict the overall survival of incidental gallbladder cancer.

Methods

A total of 383 eligible patients with incidental gallbladder cancer diagnosed in Shanghai Eastern Hepatobiliary Surgery Hospital from 2011 to 2021 were retrospectively included. They were randomly divided into a training cohort (70%) and a validation cohort (30%). Univariate and multivariate analyses and the Akaike information criterion were used to identify variables independently associated with overall survival. A Cox proportional hazards model was used to construct the nomogram. The C-index, area under time-dependent receiver operating characteristic curves and calibration curves were used to evaluate the discrimination and calibration of the nomogram.

Results

T stage, N metastasis, peritoneal metastasis, reresection and histology were independent prognostic factors for overall survival. Based on these predictors, a nomogram was successfully established. The C-index of the nomogram in the training cohort and validation cohort was 0.76 and 0.814, respectively. The AUCs of the nomogram in the training cohort were 0.8, 0.819 and 0.815 for predicting OS at 1, 3 and 5 years, respectively, while the AUCs of the nomogram in the validation cohort were 0.846, 0.845 and 0.902 for predicting OS at 1, 3 and 5 years, respectively. Compared with the 8th AJCC staging system, the AUCs of the nomogram in the present study showed a better discriminative ability. Calibration curves for the training and validation cohorts showed excellent agreement between the predicted and observed outcomes at 1, 3 and 5 years.

Conclusions

The nomogram in this study showed excellent discrimination and calibration in predicting overall survival in patients with incidental gallbladder cancer. It is useful for physicians to obtain accurate long-term survival information and to help them make optimal treatment and follow-up decisions.

Clockwise Anterior-to-Posterior-Double Isolation (CAP-DI) Approach for Portal Lymphadenectomy in Biliary Tract Cancer: Technique, Yield, and Outcomes

Background: Portal lymphadenectomy (PLND) is the current standard for oncologic resection of biliary tract cancers (BTCs). However, published data show it is performed infrequently and often yields less than the recommended 6 lymph nodes. We sought to identify yield and outcomes using a Clockwise Anterior-to-Posterior technique with Double Isolation of critical structures (CAP-DI) for PLND. Methods: Consecutive patients undergoing complete PLND for BTCs using CAP-DI technique were identified (2015−2021). Lymph node (LN) yield and predictors of LN count were examined. Secondary outcomes included intraoperative and postoperative outcomes, which were compared to patients having hepatectomy without PLND. Results: In total, 534 patients were included; 71 with complete PLND (36 gallbladder cancers, 24 intrahepatic cholangiocarcinomas, 11 perihilar cholangiocarcinomas) and 463 in the control group. The median PLND yield was 5 (IQR 3−8; range 0−17) and 46% had at least 6 nodes retrieved. Older age was associated with lower likelihood of ≥6 node PLND yield (p = 0.032), which remained significant in bivariate analyses with other covariates (p < 0.05). After adjustment for operative factors, performance of complete PLND was independently associated with longer operative time (+46.4 min, p = 0.001), but no differences were observed in intraoperative or postoperative outcomes compared to the control group (p > 0.05). Conclusions: Yield following PLND frequently falls below the recommended minimum threshold of 6 nodes despite a standardized stepwise approach to complete clearance. Older age may be weakly associated with lower PLND yield. While all efforts should be made for complete node retrieval, failure to obtain 6 nodes may be an unrealistic metric of surgical quality.

Novel immune scoring dynamic nomograms based on B7-H3, B7-H4, and HHLA2: Potential prediction in survival and immunotherapeutic efficacy for gallbladder cancer

Background

Gallbladder cancer (GBC) is a mortal malignancy with limited therapeutic strategies. We aimed to develop novel immune scoring systems focusing on B7-H3, B7-H4, and HHLA2. We further investigated their potential clinical effects in predicting survival and immunotherapeutic efficacy for GBC.

Methods

This was a retrospective cohort study in a single center that explored the expression characteristics of B7-H3, B7-H4, and HHLA2. The immune scoring nomograms for prognostic were developed via logistic regression analyses. Their performance was evaluated using the Harrell concordance index (C-index) and decision curves analysis (DCA), and validated with calibration curves.

Results

B7-H3, B7-H4, and HHLA2 manifested with a relatively high rate of co-expression patterns in GBC tissues. They were associated with worse clinicopathological stage, suppression of immune microenvironment, and unfavorable prognosis in postoperative survival. B7 stratification established based on B7-H3, B7-H4, and HHLA2 was an independent prognostic predictor (p&lt;0.05 in both groups). Moreover, immune stratification was also successfully constructed based on B7 stratification and the density of CD8+ TILs (all p&lt;0.001). The prediction models were developed based on B7-/or immune stratification combined with the TNM/or Nevin staging system. These novel models have excellent discrimination ability in predicting survival and immunotherapeutic efficacy for GBC patients by DCA and clinical impact plots. Finally, dynamic nomograms were developed for the most promising clinical prediction models (B7-TNM model and Immune-TNM model) to facilitate prediction.

Conclusions

Immune scoring systems focusing on B7-H3, B7-H4, and HHLA2 may effectively stratify the prognosis of GBC. Prognostic nomograms based on novel immune scoring systems may potentially predict survival and immunotherapeutic efficacy in GBC. Further valid verification is necessary.

Long-Term Oncologic Outcomes for T2 Gallbladder Cancer According to the Type of Surgery Performed and the Optimal Timing for Sequential Extended Cholecystectomy

BACKGROUND

Sequential extended cholecystectomy (SEC) is currently recommended for T2 and higher gallbladder cancer (GBC) diagnosed after simple cholecystectomy (SC), but the value and timing of re-resection has not been fully studied. We evaluated the long-term oncologic outcomes of T2 GBC according to the type of surgery performed and investigated the optimal timing for SEC.

METHODS

Patients diagnosed with T2 GBC who underwent SC, extended cholecystectomy (EC), or SEC between 2002 and 2017 were retrospectively reviewed. Those who underwent other surgical procedures or those with incomplete medical records were excluded. Overall survival (OS) and disease-free survival (DFS) according to the types of surgeries and prognostic factors for OS and DFS were analyzed. Survival analysis was done between groups that were divided according to the optimal cutoff time interval between SC and SEC based on DFS data.

RESULTS

Of the 226 T2 GBC patients, 53, 173, and 44 underwent SC, EC, and SEC, respectively. The 5-year OS rate was 50.1%, 73.2%, and 78.7%, and the DFS rate was 46.8%, 66.3%, and 65.2% in the SC, EC, and SEC groups, respectively. EC (p = 0.001 and p = 0.001) and SEC (p = 0.007 and p = 0.065) groups had better 5-year OS and DFS rates than the SC group. Preoperative CA 19-9 level > 37 U/mL (HR 1.56; 95% CI 1.87-2.79; p < 0.001) and N1 stage (HR 2.88; 95% CI 1.76-4.71; p < 0.001) were associated with poorer prognosis. The optimal cutoff interval between SC and SEC was 28 days. Patients who underwent SEC ≤ 28 days after the initial cholecystectomy had better 5-year DFS rates than patients who underwent SEC after > 28 days (75.0% vs. 52.8%, p = 0.023).

CONCLUSIONS

SEC is recommended for T2 GBC diagnosed after SC, because SEC provides better survival outcomes than SC alone. A time interval of less than 28 days to SEC is associated with an improved DFS.

Examination of the characteristics of long-term survivors among patients with gallbladder cancer with liver metastasis who underwent surgical treatment: a retrospective multicenter study (ACRoS1406)

Background

Gallbladder cancer (GBC) with liver metastasis is considered unresectable. However, there have been infrequent reports of long-term survival in patients with GBC and liver metastases. Therefore, we examined the characteristics of long-term survivors of gallbladder cancer with liver metastasis.

Methods

A retrospective multicenter study of 462 patients with GBC (mean age, 71 years; female, 51%) was performed. Although patients with pre-operatively diagnosed GBC and liver metastasis were generally excluded from resection, some cases identified during surgery were resected.

Result

In patients with resected stage III/IV GBC (n = 193), the period 2007–2013 (vs. 2000–2006, hazard ratio 0.63), pre-operative jaundice (hazard ratio 1.70), ≥ 2 liver metastases (vs. no liver metastasis, hazard ratio 2.11), and metastasis to the peritoneum (vs. no peritoneal metastasis, hazard ratio 2.08) were independent prognostic factors for overall survival, whereas one liver metastasis (vs. no liver metastasis) was not. When examining the 5-year overall survival and median survival times by liver metastasis in patients without peritoneal metastasis or pre-operative jaundice, those with one liver metastasis (63.5%, not reached) were comparable to those without liver metastasis (40.4%, 33.0 months), and was better than those with ≥ 2 liver metastases although there was no statistical difference (16.7%, 9.0 months). According to the univariate analysis of resected patients with GBC and liver metastases (n = 26), minor hepatectomy, less blood loss, less surgery time, papillary adenocarcinoma, and T2 were significantly associated with longer survival. Morbidity of Clavien–Dindo classification ≤ 2 and received adjuvant chemotherapy were marginally not significant. Long-term survivors (n = 5) had a high frequency of T2 tumors (4/5), had small liver metastases near the gallbladder during or after surgery, underwent minor hepatectomy without postoperative complications, and received postoperative adjuvant chemotherapy.

Conclusions

Although there is no surgical indication for GBC with liver metastasis diagnosed pre-operatively, minor hepatectomy and postoperative chemotherapy may be an option for selected patients with T2 GBC and liver metastasis identified during or after surgery who do not have other poor prognostic factors.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12876-022-02234-9.

Clinical and metabolic parameters for predicting disease progression of gallbladder adenocarcinoma

OBJECTIVE

This study aimed to identify reliable predictors of disease progression in patients with gallbladder (GB) adenocarcinoma.

PATIENTS AND METHODS

A total of 54 patients with GB adenocarcinoma underwent preoperative F-18 fluorodeoxyglucose (FDG) PET/CT. Age, sex, clinical stage, and pathologic differentiation were collected. Tumor size and PET parameters such as SUVmax, SUVmean, SUVpeak, metabolic tumor volume (MTV), and total lesion glycolysis were measured. Univariate and multivariate logistic regression analyses were performed to determine the utility of clinical values and PET parameters. Pearson bivariate correlation was used to evaluate the association between progression-free survival (PFS) and various parameters.

RESULTS

No recurrence was found in 15 of 54 patients, while six showed recurrence and another 33 manifested disease progression. There were significant differences in size, stage, pathologic differentiation, and PET parameters between the groups with and without recurrence/progression. However, there was no difference in those parameters between the groups with recurrence and progression. The average PFS of the groups with no recurrence, recurrence, and progression groups was 33.1, 17.1, and 5.0 months, respectively. In univariate analysis, age, sex, clinical stage, pathologic differentiation, size, and PET parameters were correlated with PFS. In multivariate analysis, only clinical stage and MTV were statistically significant and MTV showed the highest odds ratio. Pearson correlation coefficients showed moderate negative correlations between PFS and clinical stage or MTV.

CONCLUSION

In GB adenocarcinoma, clinical stage and MTV are the most powerful parameters for predicting recurrence and disease progression. Based on clinical stage, MTV will represent a strong prognostic predictor.

Lymphadenectomy in gallbladder adenocarcinoma: Are we doing enough?

BACKGROUND

Current AJCC guidelines recommend evaluating ≥6 lymph nodes during gallbladder cancer resection but real world data suggest this is rarely achieved. We evaluated the extent of lymphadenectomy and survival among patients with gallbladder adenocarcinoma.

METHODS

Patients with resected pT1b-T3 gallbladder adenocarcinoma were identified from the NCDB (2004-2017). Propensity scores were created for the odds of sufficient lymphadenectomy (≥6 nodes), patients were matched 1:1 and survival was analyzed using the Kaplan-Meier method.

RESULTS

Overall, 4760 patients were identified: 16.7% underwent sufficient lymphadenectomy, which was predictive of nodal disease (OR 1.77, 95%CI 1.51-2.08) and demonstrated a survival benefit in N0 (median OS 140.8 versus 44.4 months; p < 0.0001) and N1-2 disease (median OS 27.7 versus 17.7 months; p < 0.0001) after matching.

CONCLUSIONS

The majority of patients with gallbladder adenocarcinoma do not undergo the recommended nodal dissection, resulting in a survival disadvantage, likely due to understaging, decisions regarding adjuvant therapy and local tumor recurrence.

Effect of lymphadenectomy on the prognosis for N0 gallbladder carcinoma patients: A study based on SEER database

Background

It remains unclear whether lymph node dissection is necessary for patients with N0 gallbladder carcinoma (GBC). The objective of this study was to evaluate the effect of lymphadenectomy on the prognosis for N0 GBC patients. The secondary objective was to establish a prognostic model of survival for N0 GBC patients being founded on the large samples.

Methods

Patient data were obtained from the database named SEER (Surveillance, Epidemiology, and End Results database) between 2010 and 2014. Analyses of Kaplan–Meier survival and multivariate Cox regression were performed in subgroups based on regional lymph nodes removal (LNR) to calculate the excess risk of cause‐specific death. A prognosis nomogram was constructed build on the results of a multivariate analysis to predict the specific survival time (CSS) rates of N0 GBC patients.

Result

A total of 1406 N0 GBC patients were included in this research. The majority of N0 GBC patients undergoing cancer‐directed surgery did not undergo LNR (64.5%). The results showed that LNR can improve the survival of N0 GBC patients, including those at the T1a and T1b stages, and a wider range of lymph node dissection (LNR2) compared to LNR1 was more conducive to the prognosis. Furthermore, multivariate regression analysis showed that LNR was an independent favorable prognostic factor of N0 GBC. Finally, a nomogram was constructed to accurately predict the prognosis of N0 gallbladder cancer patients.

Conclusion

This study demonstrated a significant survival benefit for extended lymph nodes removed in N0 GBC patients. These results recommend that an extended lymph node dissection strategy is needed for N0 GBC patients.

Regional lymph node sampling in hepatoma resection: insight into prognosis

BACKGROUND

The importance of regional lymph node sampling (LNS) during resection of hepatocellular carcinoma (HCC) is poorly understood. This study sought to ameliorate this knowledge gap through a nationwide population-based analysis.

METHODS

Patients who underwent liver resection (LR) for HCC were identified from Surveillance, Epidemiology and End Results (SEER-18) database (2003-2015). Cohort-based clinicopathologic comparisons were made based on completion of regional LNS. Propensity-score matching reduced bias. Overall and disease-specific survival (OS/DSS) were analyzed.

RESULTS

Among 5395 patients, 835 (15.4%) underwent regional LNS. Patients undergoing LNS had larger tumors (7.0vs4.8 cm) and higher T-stage (30.9 vs. 17.6% T3+, both p < 0.001). Node-positive rate was 12.0%. Median OS (50 months for both) and DSS (28 vs. 29 months) were similar between cohorts, but node-positive patients had decreased OS/DSS (20/16 months, p < 0.01). Matched patients undergoing LNS had equivalent OS (46 vs. 43 months, p = 0.869) and DSS (27 vs. 29 months, p = 0.306) to non-LNS patients. The prognostic impact of node positivity persisted after matching (OS/DSS 24/19 months, p < 0.01). Overall disease-specific mortality were both independently elevated (overall HR 1.71-unmatched, 1.56-matched, p < 0.01; disease-specific HR 1.40-unmatched, p < 0.01, 1.25-matched, p = 0.09).

CONCLUSION

Regional LNS is seldom performed during resection for HCC, but it provides useful prognostic information. As the era of adjuvant therapy for HCC begins, surgeons should increasingly consider performing regional LNS to facilitate optimal multidisciplinary management.

Role of Mean Platelet Volume in the Prognosis of Gallbladder Carcinoma: A Tertiary Centre Experience

Mean platelet volume (MPV) is an inflammatory marker indicative of platelet activation. There are several studies that suggest an association between the neoplastic process and cancer metastasis. We performed a retrospective analysis to investigate the role of MPV as a prognostic informative marker in gallbladder cancer. This study included 73 patients who underwent treatment for gallbladder cancer with curative or palliative intent. MPV was obtained and statistically analysed to investigate the association between the nodal status (N), the overall stage as per the American Joint Committee on Cancer (AJCC) staging system, perineural invasion, and differentiation of the tumor. The statistical analysis was done using SPSS Statistics, version 23 (IBM Corp., Armonk, NY). We found that the MPV values were significantly high in node-positive cases (OR = 3.623, 95% CI = 7.778-1.687, p value = -0.0001), cases in the advanced stage (OR = 3.623, 95% CI = 7.778-1.687, p value = 0.0001), cases with perineural invasion (OR = 3.396, 95% CI = 8.319-1.387, p value = -0.0001), and poor differentiation (OR = 2.327, 95% CI = 4.651-1.164, p value = -0.002 ). MPV is an inexpensive and convenient inflammatory marker that correlates with nodal positivity in the staging and prognostication of gallbladder cancer. This marker can be used to ascertain the risk status of gallbladder cancer.

The 8th Edition American Joint Committee on Cancer Staging for Hepato-pancreato-biliary Cancer: A Review and Update

CONTEXT.—

Cancer staging provides critical information for patients and treating physicians to battle against cancer, predict prognosis, and guide treatment decisions. The American Joint Committee on Cancer (AJCC) staging system uses a tumor, node, metastasis (TNM) scoring algorithm and is the foremost classification system for adult cancers. This system is updated every 6 to 8 years to allow sufficient time for implementation of changes and for relevant examination and discussion of data validating those changes in staging.

OBJECTIVE.—

To review the updates in the 8th edition American Joint Committee on Cancer staging system on hepato-pancreato-biliary cancer.

DATA SOURCES.—

Literature review.

CONCLUSIONS.—

The 8th edition, published in 2016 and implemented on January 1, 2018, has been in use for approximately 3 years. Compared with the 7th edition, some of the changes are quite radical. This review aims to provide a summary of the changes/updates of the 8th edition with focus on hepato-pancreato-biliary cancers, and evaluate its performance through literature review.

A comparison of outcomes in patients with intracholecystic papillary neoplasms or conventional adenocarcinomas of the gallbladder

BACKGROUND

Intracholecystic papillary neoplasm (ICPN) of the gallbladder (GB) is an exophytic intraepithelial neoplasm. This study aimed to investigate clinicopathologic findings, prognosis and recurrence patterns of patients with ICPN as compared to those patients with conventional adenocarcinoma of the gallbladder (GBC).

METHODS

Patients who underwent surgical resection for suspected GB cancer between 2000 and 2018 were included. ICPN was defined as an exophytic papillary mass within the GB lumen with a size ≥1.0 cm.

RESULTS

Of 607 patients, 241 patients (40%) were pathologically diagnosed with ICPN. Of the 241 patients with ICPNs, 110 (46%) were T1 or less. Following T stage-matched analysis, the rate of lymph node metastases were comparable (50 [52%] vs. 37 [49%], P = 0.581). The five-year survival rate was higher in ICPN, but after T stage-matching, they were comparable (69.1 vs. 63.2%, P = 0.171). Overall recurrence rates were also comparable, with the exception of lower peritoneal seeding in patients with ICPN.

CONCLUSION

Patients with ICPN who underwent resection were more likely to have an earlier T stage. There was no significant difference in prognosis and recurrence between ICPN and conventional GBC after stage matching. Therefore, the treatment strategy for ICPN should follow the same protocols used for conventional GBC.

External validation study of the 8th edition of the American Joint Committee on Cancer staging system for perihilar cholangiocarcinoma: a single-center experience in China and proposal for simplification

Background

Several changes have been made to the primary tumor (T) and lymph node (N) categories in the new 8^th edition of the American Joint Committee on Cancer (AJCC) staging system for perihilar cholangiocarcinoma (pCCA). This study was conducted to validate the 8^th edition of the AJCC staging system for pCCA in China.

Methods

A total of 335 patients who underwent curative-intent resection for pCCA between January 2010 and December 2018 were retrospectively enrolled. The overall survival (OS) of groups of patients was calculated using the Kaplan-Meier method. The log-rank test was used to compare OS between groups. The concordance index (C-index), Akaike information criteria (AIC), and time-dependent area under receiver operating characteristic (ROC) curve (AUC) were computed to evaluate the discriminatory power of the 8^th and 7^th editions of the AJCC staging system.

Results

The T category changed in 25 (7.5%) patients, the N category changed in 39 (11.6%) patients, and the tumor-node-metastasis (TNM) stage changed in 157 (46.9%) patients when the 8^th and 7^th editions were compared. No statistically significant difference in survival was observed between T2aN0M0 and T2bN0M0. The C-index of the 8^th edition was 0.609 [95% confidence interval (CI): 0.568-0.650], which was slightly higher than that of the 7^th edition (C-index, 0.599, 95% CI: 0.558-0.640). The time-dependent AUC value also corroborated that the 8^th edition had a better performance than the 7^th edition.

Conclusions

The 8^th edition of the AJCC staging system for pCCA showed a better ability than the 7^th edition to discriminate patient survival. However, further simplification of the 8^th edition is still needed.

Prognostic Nomograms to Predict Survival of Patients with Resectable Gallbladder Cancer: A Surveillance, Epidemiology, and End Results (SEER)-Based Analysis

Background

Gallbladder adenocarcinoma (GBAC) is globally acknowledged as one of the most common malignancies among all gastrointestinal cancers. Despite prognosis of GBAC patients remains poor, patients with early-stage disease can be observed with long-term survival.

Material/Methods

In this study, 2556 patients with pathological GBAC between 2010 and 2015 were derived from the Surveillance, Epidemiology, and End Results (SEER) database. The prognostic nomograms containing all independent prognostic factors for predicting overall survival (OS) and cancer-specific survival (CSS) were constructed to achieve superior prognostic discriminatory ability.

Results

Based on the AJCC 7^th TNM staging system, we found the TNM substaging was not accurate enough to predict the survival and stratify the risk. Based on the results of univariate and multivariate analyses, a more precise prognostic nomogram was constructed containing all significant independent prognostic factors (age, grade, TNM stage, bone metastasis, and chemotherapy) for OS, while age, grade, TNM stage, bone metastasis and radiotherapy significant independent prognostic factors for CSS. The C-index of the constructed nomogram for predicting OS and CSS was 0.740 and 0.737 higher than that of TNM staging alone (0.667 for OS and 0.689 for CSS), respectively. In addition, the calibration curves and decision curve analysis further showed its robust power in survival prediction.

Conclusions

The constructed nomograms showed better discrimination abilities to predict OS and CSS rates at 1, 3, and 5 years. In the future, these constructed models for this disease will assist in risk stratification to guide GBAC treatment.

Rates, Predictors, and Outcomes of Portal Lymphadenectomy for Resectable Gallbladder Cancer

INTRODUCTION

Lymphadenectomy (LND) is recommended following surgical resection of ≥ T1b gallbladder cancer (GBC). However, frequency and stage-specific survival benefits of LND remain unclear.

PATIENTS AND METHODS

The National Cancer Database (NCDB; 2006-15) was queried for resected pathologic stage I-III GBC. LND performance, predictors of receiving LND, and LND association with overall survival (OS) were assessed.

RESULTS

Of 2302 total patients, 1343 (58.3%) underwent LND. Patients who underwent LND were younger and more frequently had private health insurance, a negative surgical margin, higher pathologic T stage, and received adjuvant chemotherapy (all p < 0.001). LND rates were highest at academic centers (70.1%) relative to all other facility types (p < 0.001). LND was independently associated with improved OS [hazard ratio (HR) 0.52, 95% confidence interval (CI) 0.44-0.61]. LND was associated with improved OS for pT1b, pT2, and pT3 patients (all p < 0.05) on univariate analysis. LND was independently associated with improved OS in pT2 (HR 0.44, CI 0.35-0.56) and pT3 (HR 0.54, CI 0.43-0.69) patients.

CONCLUSIONS

LND is associated with a 48% reduction in risk of death in patients with resectable non-metastatic GBC, with greatest impact in pT2-3 patients. Patients without LND have similar OS to patients with node-positive disease, highlighting the importance of LND. Underutilization of LND likely results in undertreatment of patients with undiagnosed nodal disease, which may contribute to unfavorable oncologic outcomes.

Validation of the 8th Edition American Joint Commission on Cancer (AJCC) Gallbladder Cancer Staging System: Prognostic Discrimination and Identification of Key Predictive Factors

The scope of our study was to compare the predictive ability of American Joint Committee on Cancer (AJCC) 7th and 8th edition in gallbladder carcinoma (GBC) patients, investigate the effect of AJCC 8th nodal status on the survival, and identify risk factors associated with the survival after N reclassification using the National Cancer Database (NCDB) in the period 2005-2015. The cohort consisted of 7743 patients diagnosed with GBC; 202 patients met the criteria for reclassification and were denoted as stage ≥III by AJCC 7th and 8th edition criteria. Overall survival concordance indices were similar for patients when classified by AJCC 8th (OS c-index: 0.665) versus AJCC 7th edition (OS c-index: 0.663). Relative mortality was higher within strata of T1, T2, and T3 patients with N2 compared with N1 stage (T1 HR: 2.258, p < 0.001; T2 HR: 1.607, p < 0.001; Τ3 HR: 1.306, p < 0.001). The risk of death was higher in T1-T3 patients with Nx compared with N1 stage (T1 HR: 1.281, p = 0.043, T2 HR: 2.221, p < 0.001, T3 HR: 2.194, p < 0.001). In patients with AJCC 8th edition stage ≥IIIB GBC and an available grade, univariate analysis showed that higher stage, Charlson-Deyo score ≥ 2, higher tumor grade, and unknown nodal status were associated with an increased risk of death, while year of diagnosis after 2013, academic center, chemotherapy. and radiation therapy were associated with decreased risk of death. Chemotherapy and radiation therapy were associated with decreased risk of death in patients with T3-T4 and T2-T4 GBC, respectively. In conclusion, the updated AJCC 8th GBC staging system was comparable to the 7th edition, with the recently implemented changes in N classification assessment failing to improve the prognostic performance of the staging system. Further prospective studies are needed to validate the T2 stage subclassification as well as to clarify the association, if any is actually present, between advanced N staging and increased risk of death in patients of the same T stage.

Site-specific metastases of gallbladder adenocarcinoma and their prognostic value for survival: a SEER-based study

Background

Gallbladder cancer is a rare but highly malignant cancer, which often progresses to a metastatic stage when diagnosed because of its asymptomatic manifestation. In this study, we intended to analyze the prognostic value of metastatic gallbladder adenocarcinoma (GBA) with site-specific metastases.

Methods

Using the Surveillance, Epidemiology, and End Results (SEER) database, GBA patients diagnosed with metastases between 2010 and 2016 were selected to identify the prognosis according to the isolated metastatic sites, including liver, lung, bone, brain and distant lymph nodes (DL). Kaplan–Meier methods were used for survival comparisons and multivariable Cox regression models were constructed to find out independent factors that associated with survival.

Results

Data from 1526 eligible patients were extracted from the SEER database. Among the patients, 788 (51.6%) had isolated liver metastases, 80 (5.2%) had isolated distant nodal involvement, 45 (2.9%) had isolated lung metastases, 21 (1.4%) had isolated bone metastases, 2 (0.1%) had isolated brain metastases and 590 (38.7%) had multiple metastases. No significant survival difference was shown between patients with single or multisite metastases (P > 0.05). Patients with isolated lung or DL metastases had significant better survival outcomes than those with isolated bone metastases (P < 0.05). Multivariate analysis showed that performing surgery at primary site, receiving chemotherapy were associated with better OS and CSS for patients with isolated liver or DL metastases.

Conclusions

The study showed that different metastatic sites affect survival outcomes in metastatic GBA patients. Highly selected subset of patients with liver or DL metastases might benefit from surgery at primary site.

Gallbladder cancer revisited: the evolving role of a radiologist

Gallbladder cancer is the most common malignancy of the biliary tract. It is also the most aggressive biliary tumor with the shortest median survival duration. Complete surgical resection, the only potentially curative treatment, can be accomplished only in those patients who are diagnosed at an early stage of the disease. Majority (90%) of the patients present at an advanced stage and the management involves a multidisciplinary approach. The role of imaging in gallbladder cancer cannot be overemphasized. Imaging is crucial not only in detecting, staging, and planning management but also in guiding radiological interventions. This article discusses the role of a radiologist in the diagnosis and management of gallbladder cancer.

Prognostic impact of tumor location in resected gallbladder cancer: A national cohort analysis

BACKGROUND AND OBJECTIVES

Tumor location (peritoneal vs hepatic) has been incorporated in the 8th edition of the American Joint Committee on Cancer Staging system for gallbladder cancer. However, larger studies are needed to confirm the prognostic impact of tumor location.

METHODS

Patients with pathologically-confirmed gallbladder cancer with information on primary tumor location were included from the National Cancer Database (2009-2012). We compared patients with hepatic-side tumors to those on the peritoneal side. Survival data were plotted using the Kaplan-Meier method. Prognostic factors were modeled with a multivariate Cox Proportional Hazards Model. Primary outcome was overall survival (OS).

RESULTS

A total of 1251 patients were included. In comparison to patients with peritoneal-sided tumors, patients with hepatic-sided tumors were more likely to: be of higher pT stage (pT3: 49% vs 24%; P < .001); node positive (31% vs 24%; P = .016); undergo liver resection (53% vs 25%; P < .001); or have positive margins (29% vs 16%; P < .001). However, on multivariate analysis, there was no difference in OS between the groups (HR, 0.97; 95% CI, 0.79-1.18; P = .753). Liver resection was associated with improved survival regardless of tumor location in pT2 tumors (peritoneal: HR, 0.57; P = .034; hepatic: HR, 0.67; P < .001).

CONCLUSIONS

This study failed to demonstrate the independent prognostic value of primary tumor location in patients with gallbladder cancer.

Comparison of overall survival in gallbladder carcinoma at academic versus community cancer centers: An analysis of the National Cancer Data Base

BACKGROUND AND OBJECTIVES

Gallbladder carcinoma (GBC) has a poor prognosis. Studies demonstrated that teaching facilities may provide a lower risk of mortality in patients undergoing pancreatic and colon resection vs nonteaching facilities. We hypothesized that survival rates are higher in academic cancer centers (ACCs) vs community cancer centers (CCCs).

METHODS

Patients with all stages of GBC were identified from the National Cancer Database (2007-2012). Propensity score matching adjusted for selection bias. Descriptive statistics were calculated for all variables. Overall survival (OS) was compared by facility type (ACC vs CCC) and case volume (low vs high) via multivariable Cox proportional hazards regression.

RESULTS

A total of 7967 patients met the inclusion criteria. Following propensity matching, 2801 patients were analyzed from each facility type. Median OS following surgery was higher for ACC (20.99 months, 95% confidence interval [CI], 19.61-22.64, P = .002) than CCC (17.68 months, 95% CI, 16.46-19.25). Following Cox modeling, GBC treatment at ACCs was a protective factor for OS (adjusted hazard ratio 0.876, 95% CI, 0.801-0.958, P = .004).

DISCUSSION

GBC treatment at ACCs is an independent predictor of OS. High volume ACCs are associated with improved OS compared with low volume ACCs. The site of care and case volume in ACCs may contribute to improved survival outcomes.

Modified staging classification of gallbladder carcinoma on the basis of the 8th edition of the American Joint Commission on Cancer (AJCC) staging system

PURPOSE

The 8th edition of the American Joint Commission on Cancer (AJCC) Staging System for gallbladder cancer (GBC) has been used in clinical practice, but we have found some deficiencies in this edition.

METHODS

Survival analyses were performed to evaluate the application of various editions of the AJCC staging systems using the Surveillance, Epidemiology, and End Results (SEER) database (N = 9616 patients) and Fudan University Zhongshan Hospital (FUZH) database (N = 327 patients). A modified staging system was proposed based on the 8th edition of the AJCC Staging System.

RESULTS

Although all N2 diseases were grouped into stage IVB as M1 in the 8th edition, some patients with N2 diseases could undergo R0 resection, and had longer survival than patients with M1 diseases had in both cohorts (p < 0.001 in SEER, p = 0.041 in FUZH). Furthermore, in the SEER database, stage IIIA patients aberrantly had poorer survival than stage IIIB patients had (p < 0.001). Therefore, we proposed a modified staging system by rearranging the substages. N2 disease was subdivided and reappraised according to T stage, and the aberrant survival reversal of stage IIIA and stage IIIB disease was also corrected. Through our modification, the C-index of the 8th AJCC Staging System was elevated from 0.596 [95% confidence interval (CI): 0.585-0.607] to 0.623 (95% CI: 0.612-0.634) for local disease in the SEER cohort. Similar findings were also observed in the FUZH cohort.

CONCLUSION

Our modified 8th AJCC Staging System is more suitable for GBC and could be adopted for clinical practice.

Validation of the prognostic performance in various nodal staging systems for gallbladder cancer: results of a multicenter study

BACKGROUND

Although the current nodal staging system for gallbladder cancer (GBC) was changed based on the number of positive lymph nodes (PLN), it needs to be evaluated in various situations.

METHODS

We reviewed the clinical data for 398 patients with resected GBC and compared nodal staging systems based on the number of PLNs, the positive/retrieved LN ratio (LNR), and the log odds of positive LN (LODDS). Prognostic performance was evaluated using the C-index.

RESULTS

Subgroups were formed on the basis of an restricted cubic spline plot as follows: PLN 3 (PLN = 0, 1-2, ≥ 3); PLN 4 (PLN = 0, 1-3, ≥ 4); LNR (LNR = 0, 0-0.269, ≥ 0.27); and LODDS (LODDS < - 0.8, - 0.8-0, ≥ 0). The oncological outcome differed significantly between subgroups in each system. In all patients with GBC, PLN 4 (C-index 0.730) and PLN 3 (C-index 0.734) were the best prognostic discriminators of survival and recurrence, respectively. However, for retrieved LN (RLN) ≥ 6, LODDS was the best discriminator for survival (C-index 0.852).

CONCLUSION

The nodal staging system based on PLN was the optimal prognostic discriminator in patients with RLN < 6, whereas the LODDS system is adequate for RLN ≥ 6. The following nodal staging system considers applying different systems according to the RLN.

Gallbladder Cancer: Diagnosis, Surgical Management, and Adjuvant Therapies

Gallbladder cancer (GBC) is an often lethal disease, but surgical resection is potentially curative. Symptoms may be misdiagnosed as biliary colic; over half of new diagnoses are made after laparoscopic cholecystectomy for presumed benign disease. Gallbladder polyps >1 cm should prompt additional imaging and cholecystectomy. For GBC diagnosed after cholecystectomy, tumors T1b and greater necessitate radical cholecystectomy. Radical cholecystectomy includes staging laparoscopy, hepatic resection, and locoregional lymph node clearance to achieve R0 resection. Patients with locally advanced disease (T3 or T4), hepatic-sided T2 tumors, node positivity, or R1 resection may benefit from adjuvant chemotherapy. Chemotherapy increases survival in unresectable disease.