Surgical indications and extent of resection in gallbladder cancer

Incidence and management of gallbladder cancer in cholecystectomy specimens: a 5-year tertiary centre experience

BACKGROUND

Gallbladder cancer (GBC) is an uncommon, but highly aggressive cancer. Half of these cases are diagnosed pre-operatively, and the remaining cases are discovered incidentally on post-cholecystectomy specimens. There is a significant geographical variability in GBC incidence, with increasing age, female sex, and prolonged duration of cholelithiasis being risk factors for GBC. The primary aim was to define the overall local incidence of GBC incidental GBC and management of these cases. The secondary aim was to determine any pertinent risk factors in our case population.

METHODS

A retrospective observational study was performed on all the cholecystectomy specimens at the Gold Coast Hospital and Health Service from 1 January 2016 to 2 December 2021. Data was collected via the electronic medical record. The incidence and management of gallbladder cancers was calculated, and association with body mass index (BMI), smoking status, diabetes, inflammatory bowel disease (IBD) was identified.

RESULTS

3904 cholecystectomy specimens were reviewed. GBC was identified in 0.46% of cholecystectomies. 50% of these cases were found incidentally. Abdominal pain was the most common presenting complaint (94.4%). GBC was associated with increased age and BMI and female sex. There was no association between smoking status, diabetes or IBD with an increased incidence of cancer. Tumour staging guided surgical and/or adjuvant chemotherapy.

CONCLUSION

GBC is rare. Patients with symptoms are associated with a poor prognosis. Incidental cancers are common, and negative margin resection based on the T stage of the cancer is the most reliable curative option.

Survival benefits of simple versus extended cholecystectomy and lymphadenectomy for patients with T1b gallbladder cancer: An analysis of the surveillance, epidemiology, and end results database (2004 to 2013)

Although guidelines recommend extended surgical resection, radical resection and lymphadenectomy for patients with tumor stage (T)1b gallbladder cancer, these procedures are substantially underutilized. This population‐based, retrospective cohort study aimed to evaluate treatment patterns and outcomes of 401 patients using the US Surveillance, Epidemiology, and End Results (SEER) database from 2004 to 2013. Results showed that median overall survival (OS) was 69 months for lymphadenectomy patients and 37 months for those without lymphadenectomy. Lymphadenectomy also tended to prolong cancer‐specific survival (CSS), although the differences were not statistically significant. OS and CSS were similar for patients who received simple cholecystectomy and extended surgical resection. Cox proportional hazards regression models revealed survival advantages in patients with stage T1bN0 gallbladder cancer compared to those with stage T1bN1, and patients who received simple cholecystectomy plus lymphadenectomy compared to those who did not receive lymph node dissection. In further analyses, patients undergoing simple cholecystectomy who had five or more lymph nodes excised had better OS and CSS than those without lymph node dissection. In conclusion, survival advantages are shown for patients with T1b gallbladder cancer undergoing surgeries with lymphadenectomy. Future studies with longer follow‐up and control of potential confounders are highly warranted.

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.

Resection of Isolated Port Site Metastasis in Gall Bladder Cancers-Careful Selection and Perioperative Systemic Therapy May Improve Outcomes

Excision of port site (PSE) for patients having undergone laparoscopic cholecystectomy (LC) is not a standard recommendation. We retrospectively evaluated a cohort of patients with isolated PSM without any prior cancer-directed therapy who were assessed for resection between March 2012 and July 2016 at Tata Memorial Hospital, Mumbai. Eleven of a total 13 patients underwent wide excision for PSM in the given time period. Upfront resection was undertaken in six patients while seven patients received neoadjuvant chemotherapy (NACT) and two received neoadjuvant chemo radiotherapy (NACTRT) prior to attempted resection. With the median follow-up of 22 months, post PSM disease-free survival (DFS) was 20 months (95% CI 15-24 months) and overall survival (OS) was 37 months (95% CI 22-51 months). Careful selection along with an aggressive management strategy may be a step forward in the treatment of patients with isolated PSM.

Technical Aspects of Gallbladder Cancer Surgery

In this review, the authors present an updated description of gallbladder cancer in 2 sections based on presentation: disease that presents incidentally following laparoscopic cholecystectomy and malignancy that is suspected preoperatively. Elements pertaining to technical aspects of surgical resection provide the critical focus of this review and are discussed in the context of evidence-based literature on gallbladder cancer today.

Gall Bladder Cancer

Gallbladder carcinoma (GBC) is the most common biliary epithelial malignancy, with an estimated 10,910 new cases and 3700 deaths per year (Siegel et al. in CA Cancer J Clin 65:5–29, 2015 [1]). This disease’s insidious nature and typically late presentation place it among the most lethal of invasive neoplasms. Gallbladder cancer spreads early by lymphatic or hematogenous metastasis and by direct invasion into the liver. While surgery may well be curative at early stages, both surgical and nonsurgical treatments remain largely unsuccessful in patients with more advanced disease.

Gallbladder polyps: Factors affecting surgical decision

AIM: To determine the factors affecting the decision to perform surgery, and the efficiency of ultrasonography (USG) in detecting gallbladder polyps (GP).

METHODS: Data for 138 patients who underwent cholecystectomy between 1996 and 2012 in our clinic with a diagnosis of GP were retrospectively analyzed. Demographic data, clinical presentation, principal symptoms, ultrasonographic and histopathological findings were evaluated. Patients were evaluated in individual groups according to the age of the patients (older or younger than 50 years old) and polyp size (bigger or smaller than 10 mm) and characteristics of the polyps (pseudopolyp or real polyps). χ² tests were used for the statistical evaluation of the data.

RESULTS: The median age was 50 (26-85) years and 91 of patients were female. Of 138 patients who underwent cholecystectomy with GP diagnosis, only 99 had a histopathologically defined polyp; 77 of them had pseudopolyps and 22 had true polyps. Twenty-one patients had adenocarcinoma. Of these 21 patients, 11 were male, their median age was 61 (40-85) years and all malignant polyps had diameters > 10 mm (P < 0.0001). Of 138 patients in whom surgery were performed, 112 had ultrasonographic polyps with diameters < 10 mm. Of the other 26 patients who also had polyps with diameters > 10 mm, 22 had true polyps. The sensitivity of USG was 84.6% for polyps with diameters > 10 mm (P < 0.0001); however it was only 66% in polyps with diameters < 10 mm.

CONCLUSION: The risk of malignancy was high in the patients over 50 years old who had single polyps with diameters > 10 mm.

The improvement of surgical treatment for patients with gallbladder cancer: analysis of 208 consecutive cases over the past decade

OBJECTIVES

The aim of this study was to determine if there has been improvement in survival for patients with gallbladder cancer treated with surgical procedures.

METHODS

A retrospective review of all patients with gallbladder cancer admitted during the past 11 years was conducted. The patients were categorized into two periods: period 1, from 1 January 2000 to 31 December 2005 (group 1, n = 77); and period 2, from 1 January 2006 to 31 December 2010 (group 2, n = 131).

RESULTS

The two groups have similar age, sex distribution, and symptoms. There were more patients with advanced stage in group 2 (P = 0.001). And patients in group 2 were treated with more aggressive surgical procedures compared with group 1. Patients of group 2 had a better surgical outcomes and longer 5-year overall survival (9 % vs. 19 %, P = 0.040) and disease-free survival (P = 0.017). Median survival in group 1 was 14.7 months, while in group 2 it was 22.3 months. Patients underwent R0 resection in group 2 had better survival than that in group 1 (P = 0.009), while they had similar survival for those who underwent non-R0 resection in both periods (P = 0.108).

CONCLUSIONS

A significant improvement of disease-free survival and long-term survival results was observed in the past decade.

The role of laparoscopic staging in patients with incidental gallbladder cancer

BACKGROUND

The role of staging laparoscopy (SL) in patients with incidental gallbladder cancer (IGBC) is ill defined. This study evaluates the utility of SL with the aim of identifying variables associated with disseminated disease (DD).

METHODS

Consecutive patients with IGBC who underwent re-exploration between 1998 and 2009 were identified from a prospective database. The yield and accuracy of SL were calculated. Demographics, tumour- and treatment-related variables were correlated with findings of DD.

RESULTS

Of the 136 patients submitted to re-exploration for possible definitive resection, 19 (14.0%) had DD. Staging laparoscopy was carried out in 46 (33.8%) patients, of whom 10 (21.8%) had DD (peritoneal disease [n = 6], liver metastases [n = 3], retroperitoneal disease [n = 1]). Disseminated disease was identified by SL in two patients (yield = 4.3%), whereas eight were diagnosed after conversion to laparotomy (accuracy = 20.0%). The likelihood of DD correlated closely with T-stage (T1b, n = 0; T2, n = 5 [7.0%], T3, n = 14 [26.0%]; P = 0.004). A positive margin at initial cholecystectomy (odds ratio [OR] 5.44, 95% confidence interval [CI] 1.51-24.37; P = 0.004) and tumour differentiation (OR 7.64, 95% CI 1.1-NA; P= 0.006) were independent predictors of DD on multivariate analysis.

DISCUSSION

Disseminated disease is relatively uncommon in patients with IGBC and SL provides a very low yield. However, patients with poorly differentiated, T3 or positive-margin gallbladder tumours are at high risk for DD and targeting these patients may increase the yield of SL.

Revision surgery for incidentally detected early gallbladder cancer in laparoscopic era

BACKGROUND

Incidentally detected early gallbladder cancer (IDEGB) is an early carcinoma first diagnosed on microscopic examination after a cholecystectomy for symptomatic benign gallbladder disease. After diagnosis of IDEGB it is often necessary a completion of treatment by a second tailored revision procedure. Despite early reports contraindicating laparoscopic approach because of high risk of neoplastic seeding, recent data seem to demonstrate that this approach per se does not influence clinical outcomes. We refer our experience in revision surgery by a totally laparoscopic approach that includes hepatic resection, lymphadenectomy, and port-sites excision.

METHODS

From January 2006 to March 2008, four patients with IDEGB were carried out to revision procedure by a totally laparoscopic approach. The mean operative time of procedure has been 162 minutes, whereas blood loss has been <100 mL (mean 85.1±23.3 mL). The postoperative course has been uneventful in all patients and perioperative mortality (within 40 days from intervention) 0. Hospital stay has been, respectively, 4, 5, 5, and 6 days (mean 5 days). During follow-up, at the last fluorine-18-labeled fluordesoxyglucose-positron emission tomography (FDG-PET) scan examination, respectively, 4, 3, and--for 2 patients--2 years after revision laparoscopic procedure, pathologic FDG accumulation was not reported.

CONCLUSIONS

Totally laparoscopic revision surgery for IDEGC seems to be a legitimate procedure, and, in our experience, reports satisfactory clinical outcomes in terms of perioperative and middle term oncological results. Larger and prospective studies are needed to support definitively oncological safety of this approach.

Comparative analysis between clinical outcomes of primary radical resection and second completion radical resection for T2 gallbladder cancer: single-center experience

BACKGROUND

Gallbladder (GB) cancer may be discovered incidentally by histopathologic examination following simple cholecystectomy. Incidental GB cancer > or =T2 or > or =N1 needs a second radical resection. It is a matter of concern whether the prognosis may be worse in patients with T2GB cancer who undergo a second radical resection than in those who undergo primary radical resection.

METHODS

Between March 2001 and March 2009, 21 patients underwent a one-step operation (OSO group), and 17 patients underwent a two-step operation (TSO group) for T2GB cancer. We compared clinicopathologic factors and survival between patients in the OSO group (n = 9) and those in the TSO group (n = 9) with T2N0M0 GB cancer and between patients in the OSO group (n = 12) and those in the TSO group (n = 8) with T2N1M0 GB cancer.

RESULTS

Except for patient age, clinicopathologic factors as well as disease-free survival were not significantly different between the OSO group and the TSO group in the aforementioned cancer stages. Patient age was significantly higher in the OSO group than in the TSO group.

CONCLUSIONS

Second completion radical resection following initial simple cholecystectomy (TSO) provided a survival benefit similar to that of primary radical surgery (OSO) for patients with both T2N0M0 and T2N1M0 GB cancers in our study.

Early gallbladder carcinoma: a clinicopathologic study of 13 cases of intramucosal carcinoma

We report the clinicopathologic features of 13 cases of intramucosal carcinoma (IMC) of the gallbladder. All IMCs were incidental findings in cholecystectomy specimens for cholelithiasis. However, one of the patients had a carcinoma of the pancreas, and the gallbladder incidentally removed during the Whipple procedure showed an IMC. Another patient had a small cell carcinoma of the gallbladder, and one of the sections showed an IMC. Of the IMCs, 10 were well-differentiated adenocarcinomas, 1 was a moderately differentiated adenocarcinoma, 1 was an undifferentiated carcinoma, and 1 was a squamous cell carcinoma. Of the patients, 8 were disease-free from 3 to 11 years, and 2 patients died, one as a result of the pancreatic ductal carcinoma and the other with disseminated metastases of the small cell carcinoma. The follow-up of another patient was too short to be significant. Two patients were lost to follow-up. Our findings suggest that a simple cholecystectomy is a curative procedure for IMCs of the gallbladder.

Rational therapeutic strategy for T2 gallbladder carcinoma based on tumor spread

AIM: To evaluate the adequacy of surgical treatment of T2 gallbladder carcinoma (GBCa) according to tumor spread in the subserosal layer.

METHODS: A series of 84 patients with GBCa were treated at Saga University Hospital, Japan between April 1989 and October 2008. The tumor stage was graded according to the TNM staging for GBCa from the American Joint Committee on Cancer Manual 6th edition. Tumor staging revealed 30 patients with T2 tumors. T2 GBCa was divided into three groups histologically by the extent of tumor spread in the subserosal layer, using a score of ss minimum (ss min), ss medium (ss med) or ss massive (ss mas).

RESULTS: For ss min GBCa, there was no positive pathological factor and patient survival was satisfactory with simple cholecystectomy, with or without extra-hepatic bile duct resection. For ss med GBCa, some pathological factors, h-inf (hepatic infiltration), ly (lymphatic invasion) and n (lymph node metastasis), were positive. For ss mas GBCa, there was a high incidence of positive pathological factors. The patient group with extra-hepatic bile duct resection with D2 lymph node dissection (BDR with D2) and those with S4a5 hepatectomy had significantly better survival rates.

CONCLUSION: We suggest that radical surgery is not necessary for ss min GBCa, and partial hepatectomy and BDR are necessary for both ss med and ss mas GBCa.

Systematic review: should routine resection of the extra-hepatic bile duct be performed in gallbladder cancer?

BACKGROUND/AIM

Complete surgical resection is associated with improved outcomes in gallbladder cancer. Whether the extra-hepatic bile duct (EHBD) should be routinely excised for gallbladder cancer is unclear.

OBJECTIVE

To analyze literature concerning EHBD excision to determine if it is associated with survival advantage and hence can be routinely recommended.

MATERIALS AND METHODS

A systematic search using Medline, Embase, and Cochrane Central Register of Controlled Trials for the years 1988-2008.

RESULTS

EHBD excision was reported to be performed routinely for T1-4 in some studies, while others reported resection to facilitate lymph node clearance or if the EHBD was grossly involved by disease that remained otherwise resectable. While one study demonstrated 100% survival in T1 disease, other reports do not demonstrate any survival benefit of EHBD excision in T1 disease. Four studies (level IV-V) demonstrated 60% to 90% five-year survival for routine excision in T2 disease, while three other studies demonstrated no survival advantage but increased morbidity due to the procedure. In T3/4 disease, one study (level IV-V) demonstrated a benefit in T4 disease only, and another study (level IV-V) reported a survival advantage in patients in whom the bile duct was not involved; five other studies showed no impact of routine EHBD excision on survival but reported morbidity following anastomotic leaks.

CONCLUSIONS

Available evidence does not support routine resection of EHBD in gallbladder cancer. EHBD excision should be performed in the presence of specific indications, viz., to achieve an R0 resection of the primary tumor and/ or to aid complete lymph node dissection that would compromise the EHBD by devascularization.

Management of gallbladder cancer

Resection is a means of improving survival in patients with gallbladder cancer. A more aggressive surgical approach, including resection of the gallbladder, liver, and regional lymph nodes, is advisable for patients with T1b to T4 tumors. Aggressive resection is necessary because a patient's gallbladder cancer stage determines the outcome, not the surgery itself. Therefore, major resections should be offered to appropriately selected patients. Patients with advanced tumors or metastatic disease are not candidates for radical resection and thus should be directed to more suitable palliation.

Evolving treatment strategies for gallbladder cancer

Gallbladder cancer is an uncommon cancer that has traditionally been associated with a poor prognosis. In the era of laparoscopic cholecystectomy, incidental gallbladder cancer has dramatically increased and now constitutes the major way patients present with gallbladder cancer. While patients with incidental gallbladder cancer have a better survival than patients with nonincidental gallbladder cancer, incidental gallbladder cancer can be associated with a varied prognosis. Imaging with computed tomography (CT), magnetic resonance imaging (MRI), and [18]F-fluorodeoxyglucose (FDG) positron emission tomography (PET), as well as diagnostic laparoscopy, all have varying roles in the workup of patients with incidental gallbladder cancer. For patients with T1b, T2, and T3 incidental gallbladder cancer re-resection is generally recommended. At re-exploration, many patients with incidental gallbladder cancer will have residual disease. Definitive oncologic management requires re-resection of the liver, portal lymphadenectomy, and attention to the common bile duct. The extent of the hepatic resection should be dictated by the ability to achieve a microscopically negative (R0) margin. Routine resection of the common bile duct is unnecessary but should be undertaken in the setting of a positive cystic duct margin. If an incidental gallbladder cancer is discovered at the time of surgery, whether the surgeon should directly proceed with a more definitive oncologic operation should depend on the surgeon's skill-set and experience. Gallbladder cancer has a propensity to recur. Although data for adjuvant therapy following resection are limited, some data do suggest a survival benefit for adjuvant chemoradiation therapy. Management of patients with gallbladder cancer requires a multidisciplinary approach with input from a surgeon skilled in hepatobiliary surgery.

Consideration of anatomical structures relevant to the surgical strategy for managing gallbladder carcinoma

AIMS

Gallbladder carcinoma usually presents late with advanced disease. It develops in an anatomically complex area. Consideration is given to resection of relevant local structures with respect to outcome.

METHODS

A comprehensive literature review was performed, searching Medline for articles published since 2000, using the MeSH heading of 'gallbladder cancer' and 'surgery'. Abstracts were reviewed and articles retrieved if the main focus of the article centred on the surgical management of gallbladder carcinoma.

OBSERVATIONS

Hepatic resection is advocated and tailored to pathological T stage. Lymph node dissection and bile duct resection, as well as en bloc resection of other viscera, remain areas of controversy.

CONCLUSIONS

Eastern and Western practice standards of care differ, but hepatic resection with some lymph node dissection is present in both approaches. Philosophy regarding aggression with respect to en bloc resection of adjacent organs and actual extent of lymphatic resection remains disparate.

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.

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.

Hepatectomy of segment 4a and 5 combined with extra-hepatic bile duct resection for T2 and T3 gallbladder carcinoma

BACKGROUND

The prognosis of advanced gallbladder carcinoma (GBCa) remains unfortunate. However, the prognostic factors and the efficacy of extended resection remain unclear. The adequacy for extended resection for T2 and T3 GB Ca, according to the characteristics of either the clinicopathological factors or the prognostic factors, was evaluated.

METHODS

A series of 73 patients with GBCa were treated after 1989. Tumor staging from the AJCC revealed 23 patients with T2 tumors, and 29 patients with T3 tumors, respectively.

RESULTS

For T2 GB Ca, the patient group of extra-hepatic bile duct resection (BDR) and the patient group of S4a + 5 hepatectomy S4a + 5 had significantly better survival rates. For T3 GB Ca, the patient group of BDR and S4a + 5 tend to have better survival rates. For both T2 and T3 GB Ca, either pancreatoduodenectomy (PD) or pylorus-preserving pancreatoduodenectomy (PpPD) showed no significant difference in survival.

CONCLUSION

S4a + 5 combined with BDR and D2 lymph node dissection is a highly recommended operation for the treatment of T2 and T3 GB Ca. Further extension of the operation, such as the addition of PD (PpPD) or an extended hepatectomy, should be carefully modified for each individual according to the cancer spread mode.

Management of T2 gallbladder cancer: are practice patterns consistent with national recommendations?

BACKGROUND

The national recommendation for the management of localized T2 gallbladder cancer (GBCA) is radical cholecystectomy. Although reported survival for localized T2 disease has been poor, groups have documented improvement with radical resection. We hypothesized that a discrepancy exists between national recommendations and current practice patterns.

METHODS

Patients diagnosed with localized T2 GBCA between 1988 and 2002 were identified from the Surveillance, Epidemiology, and End Results registry. Age, sex, race, ethnicity, extent of surgery, and overall survival were assessed. Surgical procedure was categorized as cholecystectomy alone (CS), cholecystectomy plus lymph node dissection (CS+LN), radical cholecystectomy (RCS), or other. Survival calculations were made using the Kaplan-Meier method and compared with the log-rank test.

RESULTS

Of 382 patients with pathologically confirmed T2 GBCA, 280 were women. The median patient age was 75 years. A total of 238 patients underwent CS, 76 underwent CS+LN, and 14 underwent RCS. The remaining 54 patients underwent a lesser or no procedure and were excluded from comparative analysis. The median survival was 14 months for all patients and 14, 14, and 8 months for subgroups treated with CS, CS+LN, and RCS, respectively. Rates of 5-year survival were 23%, 24%, and 36% for CS, CS+LN, and RCS subgroups, respectively. There was no significant difference in survival rates between RCS and CS+LN, or between RCS and CS.

CONCLUSIONS

The majority of patients with T2 GBCA in the United States are not managed according to current national recommendations.

Gallbladder carcinoma

Although it is the most common cancer of the biliary tree, gallbladder carcinoma remains an uncommon disease. As a result, many clinicians rarely encounter it and there is uncertainty regarding proper management. Resection is the most effective and only potentially curative treatment. Early stage tumors are often curable with a proper resection; however, many patients present late in the course of the disease when surgical intervention is no longer effective. While other treatment modalities are used in patients with advanced disease, there is limited data on efficacy. In many cases, the diagnosis is made after a cholecystectomy has been performed and an incidental tumor is identified in the specimen. In such cases, reoperation and definitive resection is appropriate and effective for patients with invasive lesions.

Gallbladder cancer: surgical results after cholecystectomy in 25 patients with lamina propria invasion and 26 patients with muscular layer invasion

BACKGROUND/PURPOSE

It has been stated that simple cholecystectomy is sufficient treatment for all patients with pT1 gallbladder cancer. However, other authors note the necessity of carrying out extended surgery when there is muscular-layer involvement.

METHODS

A consecutive series of gallbladder carcinomas with lamina propria or muscular layer invasion were analyzed. Between July 1982 and December 2000, 51 patients with pT1 gallbladder carcinomas were treated with simple cholecystectomy (group A, 25 patients with lamina propria-invasion; group B, 26 patients with muscular-layer invasion). Patients with intraepithelial carcinomas were excluded from the study.

RESULTS

There were no differences between the groups in average age, sex ratios, association with other tumors, histologic type, malignancy grade, cholecystitis type, macroscopic aspects, lymph node status, or treatment applied. After an average of 6 years' follow-up, no patients in group A and nine patients (34.6%) in group B died due to gallbladder carcinoma. Cystic lymph nodes could be studied in five of these nine patients who relapsed, and the results were negative for metastasis. Lymphatic or venous invasion was observed in five of these nine patients.

CONCLUSIONS

According to these results, cholecystectomy is not sufficient treatment for gallbladder carcinoma with muscular-layer invasion.

Operative approach to gallbladder cancer

In most Western countries gallbladder cancer is a rare tumor with a poor prognosis. The majority of patients present with advanced-stage tumors (stage IV) that are not amenable to surgical resection. At the other end of the spectrum a small percentage of patients present with stage I disease that may be cured by cholecystectomy. The role for surgery in patients with stage II and III disease remains controversial, but most hepatobiliary surgeons believe that an aggressive surgical approach improves survival for these patients. However, the extent of hepatic and lymph node resection, the need for resection of the extrahepatic ducts in nonjaundiced patients, the role of vascular resection, and the advisability of hepatopancreatoduodenectomy remain a matter of debate. Although no data from prospective, randomized studies are available, resection of the gallbladder and adjacent liver with or without the extrahepatic bile ducts and with a regional lymph node dissection is the operative approach recommended for selected patients with gallbladder cancer.

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.

Clinical significance of extrahepatic bile duct resection for advanced gallbladder cancer

BACKGROUND AND OBJECTIVES

The aim of this study was to determine the clinical significance of extrahepatic bile duct (EHBD) resection during surgery for advanced gallbladder cancer.

METHODS

Among 110 patients with pT2 or higher grade gallbladder cancer, 58 patients without microscopic invasion to the EHBD were reviewed. Prognostic factors of the 58 patients were evaluated by multivariate analysis. The impact of EHBD resection on survival was assessed in relation to two prognostic determinants: (i) lymph node metastasis: positive (n = 23) and negative (n = 35); (ii) perineural invasion: positive (n = 25) and negative (n = 33).

RESULTS

Hepatic metastasis and perineural invasion were found to be independently significant prognostic factors. (i) No survival benefit of additional EHBD resection could be confirmed in each group of patients with or without nodal metastasis. (ii) In 25 patients with perineural invasion, 14 patients who underwent EHBD resection showed better survival as compared to the 11 patients who did not undergo EHBD resection (5-year survival rate, 46% vs. 0%, P = 0.009). In the remaining 33 patients without perineural invasion, the additional EHBD resection did not yield significant improvement of survival (P = 0.28).

CONCLUSIONS

Resection of EHBD may offer prognostic advantage when perineural invasion exists, even in the absence of biliary infiltration.

Laparoscopic cholecystectomy and gallbladder cancer

Heightened awareness of the possible presence of gallbladder cancer (GBC) and the knowledge of appropriate management are important for surgeons practising laparoscopic cholecystectomy (LC). Long-term effects of initial LC versus open cholecystectomy (OC) on the prognosis of patients with GBC remain undefined. Patients who are suspected to have GBC should not undergo LC, since it is advantageous to perform the en-bloc radical surgery at the initial operation. Since preoperative diagnosis of early GBC is difficult, preventive measures, such as preventing bile spillage and bagging the gallbladder should be applied for every LC. Many port-site recurrences (PSR) have been reported after LC, but the incidence of wound recurrence is not higher than after OC. No radical procedure is required after postoperative diagnosis of incidental pT1a GBC. It is unclear if patients with pT1b GBC require extended cholecystectomy. In pT2 GBC, patients should have radical surgery (atypical or segmental liver resection and lymphadenectomy). In advanced GBC (pT3 and pT4), radical surgery can cure only a small subset of patients, if any. Additional port-site excision is recommended, but the effectiveness of such measure is debated.

Adjuvant external-beam radiotherapy with concurrent chemotherapy after resection of primary gallbladder carcinoma: A 23-year experience

PURPOSE

Primary adenocarcinoma of the gallbladder is a rare malignancy. To better define the role of adjuvant radiation therapy and chemotherapy, a retrospective analysis of the outcome of patients undergoing surgery and adjuvant therapy was undertaken.

METHODS AND MATERIALS

Twenty-two patients with primary and nonmetastatic gallbladder cancer were treated with radiation therapy after surgical resection. Median radiation dose was 45 Gy. Eighteen patients received concurrent 5-fluorouracil (5-FU) chemotherapy. Median follow-up was 1.7 years in all patients and 3.9 years in survivors.

RESULTS

The 5-year actuarial overall survival, disease-free survival, metastases-free survival, and local-regional control of all 22 patients were 37%, 33%, 36%, and 59%, respectively. Median survival for all patients was 1.9 years.

CONCLUSION

Our series suggests that an approach of radical resection followed by external-beam radiation therapy with radiosensitizing 5-FU in patients with locally advanced, nonmetastatic carcinoma of the gallbladder may improve survival. This regimen should be considered in patients with resectable gallbladder carcinoma.

Outcome of gall bladder polypoidal lesions detected by transabdominal ultrasound scanning: A nine year experience

AIM: To determine the outcome of polypoidal lesions within the gall bladder (PLG) diagnosed by trans-abdominal scanning.

METHODS: A nine-year (1993-2002) retrospective case-note review of all patients who underwent ultrasound scanning after referral to a single Upper GI Surgeon at a District General Hospital was conducted. Patients who were diagnosed with a PLG were included in our study. A database was constructed and patient details, investigations including ultrasound scan (USS) findings, treatment and histology and final diagnosis were recorded.

RESULTS: Twenty-three (out of 651) patients were diagnosed pre-operatively by USS to have a polyp-like gall bladder lesion (PLG). Post cholecystectomy histological examination revealed 12 gallstones, 7 cholesterol polyps, 3 adenocarcinomas within polyps and 1 normal gall bladder. The specificity of USS in the diagnosis of PLG was 92.3%. All the true polyps were malignant. Overall USS had 66.66% sensitivity and 100% specificity in the pre-operative suspicion of malignancy. Using size greater than 10 mm as measured on USS as a cut-off, we find 100% sensitivity and 86.95% specificity with a positive predictive value of 50% in the diagnosis of malignancy in PLG.

CONCLUSION: A large number of PLG are in fact calculi within diseased gall bladder. In cases of gall bladder polyps more then 10 mm in size on USS further imaging (cross-sectional and/or EUS) is indicated prior to surgery. This will help in the optimal management of patients and avoid histological surprises.

An aggressive surgical approach leads to improved survival in patients with gallbladder cancer: a 12-year study at a North American Center

OBJECTIVE

To determine if an aggressive surgical approach, with an increase in R0 resections, has resulted in improved survival for patients with gallbladder cancer.

SUMMARY BACKGROUND DATA

Many physicians express a relatively nihilistic approach to the treatment of gallbladder cancer; consensus among surgeons regarding the indications for a radical surgical approach has not been reached.

METHODS

A retrospective review of all patients with gallbladder cancer admitted during the past 12 years was conducted. Ninety-nine patients were identified. Cases treated during the 12-year period 1990 to 2002 were divided into 2 time-period (TP) cohorts, those treated in the first 6 years (TP1, N = 35) and those treated in the last 6 years (TP2, N = 64).

RESULTS

Disease stratification by stage and other demographic features were similar in the 2 time periods. An operation with curative intent was performed on 38 patients. Nine (26%) R0 resections were performed in TP1 and 24 (38%) in TP2. The number of liver resections, as well as the frequency of extrahepatic biliary resections, was greater in TP2 (P < 0.04). In both time periods, an R0 resection was associated with improved survival (P < 0.02 TP1, P < 0.0001 TP2). Overall survival of all patients in TP2 was significantly greater than in TP1 (P < 0.03), with a median survival of 9 months in TP1 and 17 months in TP2. The median 5-year survival in TP1 was 7%, and 35% in TP2. The surgical mortality rate for the entire cohort was 2%, with a 49% morbidity rate.

CONCLUSIONS

A margin-negative, R0 resection leads to improved survival in patients with gallbladder cancer.

The surgical management of incidental gallbladder carcinoma

AIMS

To report the surgical management of carcinoma of the gallbladder.

METHODS

A retrospective study in 65 patients who underwent simple (SC) or extended (EC) cholecystectomy for gallbladder carcinoma.

RESULTS

28 patients underwent extended cholecystectomy (EC) and 37 had simple cholecystectomy (SC). The multivariate analysis showed that lymph-node status (positive vs negative, p=0.001, Hazard Ratio [HR]:14.2, 95% Confidence Interval [CI]:3.1-62.8) and type of surgery (SC vs EC, p=0.01, HR:10.2, 95% CI:1.7-62.8) were the most important prognostic factors related to death. This analysis indicated that EC in those with pT(2) or pT(3) was associated with a reduce hazard of death by 90% in the follow-up period.

CONCLUSIONS

In gallbladder cancer patients who diagnose after simple cholecystectomy, those with pT(1) with clear margins need no further surgery. In patients with pT(2) or pT(3) incidental carcinoma, the completion radical re-operation is the only chance for long-term survival.