Current perspectives in gallbladder carcinoma

Importance of accurate diagnosis of congenital agenesis of the gallbladder from atypical gallbladder stone presentations: A case report

BACKGROUND

Congenital agenesis of the gallbladder (CAGB) is a rare condition often misdiagnosed as cholecystolithiasis, leading to unnecessary surgeries. Accurate diagnosis and surgical exploration are crucial in patients with suspected CAGB or atypical gallbladder stone symptoms. Preoperative imaging, such as magnetic resonance cholangiopancreatography (MRCP), plays a vital role in confirming the diagnosis. Careful intraoperative dissection is necessary to avoid iatrogenic injuries and misdiagnosis. Multidisciplinary consultations and collaboration, along with the use of various diagnostic methods, can minimize associated risks.

CASE SUMMARY

We present the case of a 34-year-old female with suspected gallbladder stones, ultimately diagnosed with CAGB through surgical exploration. The patient underwent laparoscopic examination followed by open exploratory surgery, which confirmed absence of the gallbladder. Subsequent imaging studies supported the diagnosis. The patient received appropriate postoperative care and experienced a successful recovery.

CONCLUSION

This case highlights the rarity of CAGB and the importance of considering this condition in the differential diagnosis of patients with gallbladder stone symptoms. Accurate diagnosis using preoperative imaging, such as MRCP, is crucial to prevent unnecessary surgeries. Surgeons should exercise caution and conduct meticulous dissection during surgery to avoid iatrogenic injuries and ensure accurate diagnosis. Multidisciplinary collaboration and utilization of various diagnostic methods are essential to minimize the risk of misdiagnosis. Selection of the optimal treatment strategy should prioritize minimizing trauma and maintaining open communication with the patient and their family members.

Concurrent Cholecystectomy Is Associated with a Lower Risk of Recurrence after Curative Resection in Early-Stage Hepatocellular Carcinoma: A 10 Year Observational Single-Center Study

Background: Cholecystectomy has been reported to be associated with increased risk of developing hepatocellular carcinoma (HCC). However, there is little information about the impact of cholecystectomy on the outcome of HCC. Aims: To evaluate the long-term effect of concurrent cholecystectomy on recurrence and overall survival in HCC after curative hepatectomy. Patients and Methods: We retrospectively enrolled 857 patients with BCLC stage 0 or A HCC who underwent primary resection from January 2001 to June 2016. The impact of concurrent cholecystectomy on overall survival (OS) and recurrence-free survival (RFS) were analyzed by Cox’s proportional hazards models after one-to-one propensity score matching (PSM). Results: Of the 857 patients, 539 (62.9%) received concurrent cholecystectomy (cholecystectomy group) and 318 (37.1%) did not (non-cholecystectomy group). During the mean follow-up period of 75.0 months, 471 (55.0%) patients experienced recurrence, and 321 (37.5%) died. RFS and OS were not significantly different between the groups. After PSM, a total of 298 patients were enrolled in each group. RFS was significantly higher in the cholecystectomy than non-cholecystectomy group (p = 0.044). In multivariate analysis, age (p = 0.022), serum AFP (p = 0.008), liver cirrhosis (p < 0.001), diabetes (p = 0.004), tumor number (p = 0.005), tumor size (p = 0.002), histological grade (p = 0.001), microvascular invasion (p < 0.001) and cholecystectomy (p = 0.021) were independent risk factors for HCC recurrence. However, there were no significant differences in OS between the cholecystectomy and non-cholecystectomy groups. Conclusions: Concurrent cholecystectomy may reduce recurrence in early-stage HCC after curative resection. Further studies are needed to validate our results.

Locally advanced gallbladder cancer: a review of the criteria and role of imaging

Gallbladder carcinoma (GBC) is among one of the gastrointestinal malignancies with extremely dismal prognosis. This is due to the advanced stage at presentation. Majority of the patients with GBC are not considered candidates for surgery because of the locally advanced disease or metastases. However, with the accumulating evidence regarding the role of neoadjuvant chemotherapy, there is a need to correctly identify a subset of patients with locally advanced GBC who will benefit maximally from neoadjuvant chemotherapy and will be successfully downstaged to receive curative (R0) surgery. In this context, there is a lack of consensus and different groups have resorted to criteria for locally advanced disease eligible for neoadjuvant chemotherapy based on personal or institutional experiences. Imaging plays a critical role in the evaluation of patients with GBC as it helps stratify patients into resectable and unresectable. Imaging also has the potential to identify patients with locally advanced GBC and hence facilitate neoadjuvant chemotherapy and improve outcomes. In this review, we evaluate the various criteria for locally advanced GBC and the role of imaging in this scenario.

Gallbladder cancer - no improvement in survival over time in a Swedish population

BACKGROUND

Gallbladder cancer (GBC) has an extremely poor outcome. The aim of this study was to examine trends in GBC incidence, treatment and overall survival in a complete population of affected persons in a well-defined region in Sweden in 2000-2014.

MATERIAL AND METHODS

Altogether 546 individuals with GBC were identified at Sweden's Regional Cancer Centre West. Subjects were grouped into three 5-year periods (Period A: 2000-2004, Period B: 2005-2009 and Period C: 2010-2014) and the survival, diagnosis, staging, grading and treatment for each period were investigated. Patients dead at date of diagnosis (n = 39) and patients with not invasive cancer (n = 25) were not included in the analysis.

RESULTS

The incidence was unchanged over the study period. The survival curves for the time periods were not significantly separated. Median survival was 4.7 months in Period A, 4.8 months in Period B and 6.1 months in Period C. Stage migration to more M1 in Periods B and C occurred and survival was improved for these cohorts. More individuals were diagnosed using only diagnostic imaging (p = .02). There were 177 curatively aiming operative procedures carried out on 482 persons (37%). The survival after surgery for the three periods improved over time (p = .02). Individuals who underwent a liver bed resection after a cholecystectomy had better survival than individuals who had cholecystectomy combined with liver resection. More persons were treated with chemotherapy, but no significant impact was found on survival in the total GBC population.

CONCLUSIONS

Although there were signs of improved diagnosis of GBC, the survival rate did not improve over time. There was a significant stage migration to more M1 in Periods B and C. Therapeutics able to downsize a cancer and increase the effectiveness of surgery with curative intent are warranted.

Validation of the EORTC QLQ-BIL21 questionnaire for measuring quality of life in patients with cholangiocarcinoma and cancer of the gallbladder

Background:

There is no specific quality of life (QoL) measurement tool to quantify QoL in patients with biliary tract cancer. Quality of life measurement is an increasingly crucial trial end point and is now being incorporated into clinical practice.

Methods:

This International Multicentre Phase IV Validation Study assessed the QLQ-BIL21 module in 172 patients with cholangiocarcinoma and 91 patients with cancer of the gallbladder. Patients completed the questionnaire at baseline pretherapy and subsequently at 2 months. Following this, the psychometric properties of reliability, validity, scale structure and responsiveness to change were analysed.

Results:

Analysis of the QLQ-BIL21 scales showed appropriate reliability with Cronbach's α-coefficients >0.70 for all scales overall. Intraclass correlations exceeded 0.80 for all scales. Convergent validity >0.40 was demonstrated for all items within scales, and discriminant validity was confirmed with values <0.70 for all scales compared with each other. Scale scores changed in accordance with Karnofsky performance status and in response to clinical change.

Conclusions:

The QLQ-BIL21 is a valid tool for the assessment of QoL in patients with cholangiocarcinoma and cancer of the gallbladder.

Rescued expression of WIF-1 in gallbladder cancer inhibits tumor growth and induces tumor cell apoptosis with altered expression of proteins

As a highly conserved metabolic pathway, the Wnt signaling pathway is involved in cell differentiation, proliferation and several other processes. In normal cells, this pathway is suppressed, and abnormal activation is often associated with tumor occurrence and development. In certain types of tumor, Wnt inhibitory factor 1 (WIF-1), an inhibitor of the Wnt pathway, inhibits tumor growth. However, the effect of the expression of WIF-1 on gallbladder cancer remains to be fully elucidated. In the current study, reverse transcription-quantitative polymerase chain reaction and western blotting were conducted. The present study demonstrated that, in gallbladder cancer, WIF-1 generally exhibited low levels of expression as a result of gene promoter methylation. Treatment with the drug, 5-aza-2-deoxycytidine, increased the expression of WIF-1 in the GBC-SD gallbladder cell line. In addition, a WIF-1-expression plasmid was transfected into GBC-SD cells, and it was found that cell proliferation, invasion and metastasis declined significantly, whereas the apoptotic rate increased. A nude mouse tumor transplantation experiment showed that the oncogenicity of the GBC-SD cells expressing WIF-1 was substantially lower, compared with that of the untransfected GBC-SD cells and of GBD-SD cells expressing the control plasmid. A fluorescent protein chip experiment showed that the restored expression of WIF-1 affected the expression of several cellular proteins. These alterations may explain the different biological behavior of the tumor cells expressing WIF-1. As an effective inhibitory factor of the Wnt signaling pathway, WIF-1 modulated the expression of proteins controlling the proliferation, apoptosis and metastasis of gallbladder tumor cells, thus suppressing the tumor. Therefore, WIF-1 may be an effective treatment target for gallbladder cancer.

Expression of cluster of differentiation 74 in gallbladder carcinoma and the correlation with epithelial growth factor receptor levels

Cluster of differentiation 74 (CD74), a transmembrane glycoprotein, has been previously reported to be important in the pathogenesis of several cancers, including hematological malignancies and solid tumors. The present study analyzed the significance of CD74 in gallbladder carcinomas (GBCs) and indicated the correlation of CD74 expression with epithelial growth factor receptor levels. Immunohistochemistry (IHC) was used to examine the expression of CD74 in GBC and normal gallbladder tissues, and western blotting was used to investigate whether CD74 expression varied in well-, moderately- and poorly-differentiated tumors. The correlation between the expression of CD74 and epithelial growth factor receptor levels was studied using the Spearman's rank correlation coefficient. The results of the IHC analysis revealed that CD74 was not expressed in the normal gallbladder tissues, and the mean integrated optical density value of CD74 in the poorly-differentiated tissues was increased compared with that in the well- and moderately-differentiated tissues. The results of the western blotting were consistent with the results of the IHC. The expression of CD74 was positively correlated with epithelial growth factor receptor levels (r=0.607; P<0.05). These results indicate that CD74 may be important in the progression of GBC.

Gallbladder Cancer in the 21st Century

Gallbladder cancer (GBC) is an uncommon disease in the majority of the world despite being the most common and aggressive malignancy of the biliary tree. Early diagnosis is essential for improved prognosis; however, indolent and nonspecific clinical presentations with a paucity of pathognomonic/predictive radiological features often preclude accurate identification of GBC at an early stage. As such, GBC remains a highly lethal disease, with only 10% of all patients presenting at a stage amenable to surgical resection. Among this select population, continued improvements in survival during the 21st century are attributable to aggressive radical surgery with improved surgical techniques. This paper reviews the current available literature of the 21st century on PubMed and Medline to provide a detailed summary of the epidemiology and risk factors, pathogenesis, clinical presentation, radiology, pathology, management, and prognosis of GBC.

Adeno-associated virus mediated gene transfer of Shepherdin inhibits gallbladder carcinoma growth in vitro and in vivo

Gene therapy, a significantly crucial strategy for treatment of malignancies, has been gradually accepted in recent years. However, this therapeutic approach has being facing great challenges concerning problems which include complicated development of cancer with multiple gene control, effective target shortage, low efficiency of gene transferring and safety of the vector delivery system. Shepherdin, a novel peptidomimetic molecule designed from Lys-79 to Leu-87 of survivin, has been identified as a tumor suppressor with the function that can not only competitively interfere with the interaction between survivin and Hsp90 (heat shock protein-90) leading to the degradation of survivin to anti-tumor, but also competitively target the ATP-dependent binding pocket of Hsp90 resulting in the dysfunction of Hsp90 chaperone to cell apoptosis via a mitochondrial dependent or independent pathway. In the present study, we designed and constructed a recombinant Adeno-associated virus (rAAV) loading fusion gene NT4-TAT-6His-Shepherdin. The expression of Shepherdin in gallbladder carcinoma (GBC) cells was detected and its strong inhibitory effects against GBC growth were evaluated after AAV mediated gene transfer of Shepherdin into GBC cells and xenograft tumors. MTT assay and flow cytometric analysis demonstrated that rAAV containing Shepherdin gene could significantly inhibit the growth of GBC and this effect was closely associated with apoptosis. These results indicated that rAAV-NT4-TAT-6His-Shepherdin may be considered a novel therapeutic strategy in the gene therapy for gallbladder carcinoma.

Resection after neoadjuvant chemotherapy in advanced carcinoma of the gallbladder: a retrospective study

Although rare over most of the world, Gallbladder cancer is very common in northern india. A delayed presentation, aggressive nature,lack of randomised trials and a poor prognosis have all contributed to the nihilistic halo encircling gallbladder cancer. None of the advances in oncology have been exploited enough to shatter the nihilistic halo. In this background we sought to analyze if the addition of neoadjuvant chemotherapy had any impact on the resectability, overall and disease free survival in patients with advanced carcinoma of the gallbladder. We reviewed the records of all patients who underwent surgery for carcinoma of the gall bladder from 2004 to 2010 at our institute retrospectively. Twenty-one patients received neoadjuvant chemotherapy and subsequently taken up for surgery. Outcome analysis of these 21 patients were done by Kaplan meier method and graphs plotted. Out of the 21 patients who were taken up for surgery after neoadjuvant chemotherapy, fourteen patients underwent R0 resection (Group 1). Seven patients had been rendered inoperable on exploration (Group 2). Thus about 66.67 % of patients deemed resectable after neoadjuvant chemotherapy on imaging underwent R0 resection. The mean overall survival of the group 1 was 42.8 months versus 6.6 months of group 2(Hazard Ratio: 3.42). Neoadjuvant chemotherapy improves resectability in some patients with unresectable gall bladder cancer. Resection after neoadjuvant chemotherapy is feasible and may improve survival in a select group of patients. However randomized studies are required to establish its definitive role.

Multiple primary malignancies of the liver and the colon: a complex diagnostic and decisional process with a final unanswered question

We herein present the case of a 78-year-old man with an incidental finding of a solid hepatic mass without symptoms and only a laparotomic cholecystectomy for acute cholecystitis in the past surgical history. A colonoscopy, a magnetic resonance imaging scan, a positron emission tomography scan, and a computed tomography scan completed the preoperative workup: a neoplastic lesion 4.3 × 3 cm in size was diagnosed at segments IV and V, associated with a neoplastic involvement of the splenic flexure without signs of colonic occlusion. After colonic resection, a frozen section on a granulomatous-like tissue at gastric border suggested a diagnosis of an adenocarcinoma of bilio-pancreatic type, changing the surgical strategy to include gastric resection and hepatic pedicle node dissection. The discussion turns around the idea that a final diagnosis of colon cancer with regional nodal involvement (pT3N1) and metastatic gallbladder cancer with multiple peritoneal seedings cannot be excluded.

Gallbladder cancer: past, present and an uncertain future

Although gallbladder cancer (GBC) is the most common malignancy of the biliary tract, its relatively low incidence and confounding symptomatology result in advanced disease at the time presentation, contributing to the poor prognosis and decreased survival associated with this disease. It is therefore increasingly important to understand its pathogenesis and risk factors to allow for the earliest possible diagnosis. To date, gallbladder cancer is poorly understood compared to other malignancies, and is still most commonly discovered incidentally after cholecystectomy. Moreover, while much is known about biliary neoplasms as a whole, understanding the clinical and molecular nuances of GBC as a separate disease process will prove a cornerstone in the development of early intervention, potential screening and overall more effective treatment strategies. The present work reviews the most current understanding of the pathogenesis, diagnosis, staging and natural history of GBC, with additional focus on surgical treatment. Further, review of current adjuvant therapies for unresectable and advanced disease as well as prognostic factors provide fertile ground for the development of future studies which will hopefully improve treatment outcomes and affect overall survival for this highly morbid, poorly understood malignancy.

All cholecystectomy specimens must be sent for histopathology to detect inapparent gallbladder cancer

OBJECTIVES

Traditionally, a gallbladder removed for presumed benign disease has been sent for histopathological examination (HPE), but this practice has been the subject of controversy. This study was undertaken to compare patients in whom gallbladder cancer (GBC) was diagnosed after cholecystectomy on HPE with GBC patients in whom the gallbladder was not sent for HPE and who therefore presented late with symptoms.

METHODS

A retrospective analysis of prospectively collected data for 170 GBC patients diagnosed after cholecystectomy was conducted. All patients presented to one centre during 2000-2011. These patients were divided into two groups based on the availability of histopathology reports: Group A included patients who presented early with HPE reports (n = 93), and Group B comprised patients who presented late with symptoms and without HPE reports (n = 77).

RESULTS

The median time to presentation in Group A was significantly lower than in Group B (29 days vs. 152 days; P < 0.001). Signs or symptoms suggestive of recurrence (pain, jaundice or gastric outlet obstruction) were present in four (4.3%) patients in Group A and all (100%) patients in Group B (P < 0.001). Patients deemed operable on preoperative evaluation included all (100%) patients in Group A and 38 (49.4%) patients in Group B (P < 0.0001). The overall resectability rate (69.9% vs. 7.8%) and median survival (54 months vs. 10 months) were significantly higher in Group A compared with Group B (P < 0.0001).

CONCLUSIONS

Patients in whom a cholecystectomy specimen was sent for HPE presented early, had a better R0 resection rate and longer overall survival. Hence, routine HPE of all cholecystectomy specimens should be performed.

Clinical usefulness of endoscopic ultrasonography in the differential diagnosis of gallbladder wall thickening

BACKGROUND AND AIMS

The differential diagnosis of gallbladder (GB) cancer from inflammatory diseases in patients with a thickened GB wall is difficult, whereas the pre-operative diagnosis of GB cancer is critical for selecting the appropriate surgical modality. We evaluated the clinical usefulness of endoscopic ultrasonography (EUS) for the differential diagnosis of GB wall thickening.

METHODS

The medical records, post-operative pathology reports, and images of EUS for 134 patients with GB wall thickening (>3 mm) who underwent laparoscopic or open cholecystectomies at our institution between December 2006 and February 2010 were retrospectively reviewed.

RESULTS

Thirteen patients (9.7%) had neoplastic GB wall thickening (11 with adenocarcinomas and two with adenosquamous carcinomas) and the remaining 121 patients (90.3%) had non-neoplastic GB wall thickening (117 with inflammatory GB wall thickening and four with adenomyomatosis). The mean (± standard deviation [SD], mm) GB wall thickness was 6.5 ± 3.3 and 19.4 ± 7.7 for non-neoplastic and neoplastic GB wall thickening, respectively (P < 0.01). The EUS variables which had a statistically significant association with neoplastic GB wall thickening were GB wall thickening >10 mm, disruption of the normal two layers of the GB wall, hypoechoic internal echogenecity, and the absence of gallstones. Based on the multivariate analyses, GB wall thickening >10 mm and hypoechoic internal echogenecity were independent predictive factors for neoplastic GB wall thickening.

CONCLUSIONS

The diagnostic power of EUS for differentiating neoplastic and non-neoplastic GB wall thickening could be improved by the appropriate application of some EUS variables.

Development of a questionnaire (EORTC module) to measure quality of life in patients with cholangiocarcinoma and gallbladder cancer, the EORTC QLQ-BIL21

Background:

Quality of life measurement in cholangiocarcinoma and gallbladder cancer involves the assessment of patient-reported issues related to the symptoms, disease and treatment of these tumours. This study describes the development of the disease-specific quality of life (QoL) questionnaire for patients with cholangiocarcinoma and gallbladder cancer to supplement the European Organization for Research and Treatment of Cancer (EORTC)-QLQ C30 core cancer questionnaire.

Methods:

Phases 1–3 of the guidelines for module development published by the EORTC were followed, with adaptations for incorporation of questions from existing modules.

Results:

A total of 47 QoL issues (questions) were identified; 44 questions from the two related validated questionnaires, the EORTC QLQ-PAN26 (pancreatic module) and the EORTC QLQ-LMC21 (liver metastases module), two from the Functional Assessment of Cancer Therapy hepatobiliary module questionnaire in the literature search and one from healthcare professional interviews. Following phase 1 and 2 interviews with patients (n=101) and health care professionals (n=6), a 23-question provisional questionnaire was formulated. There were five questions from PAN26, 15 from LMC21 and three extra questions. In phase 3, the provisional item list was pre-tested in 52 patients in four languages and this resulted in a 21-item module.

Conclusion:

This is the only disease-specific QoL questionnaire for patients with cholangiocarcinoma and gallbladder cancer, and initial assessments show it to be accurate and acceptable to patients in reflecting QoL in these diseases.

Ala499Val (C>T) and Lys939Gln (A>C) polymorphisms of the XPC gene: their correlation with the risk of primary gallbladder adenocarcinoma--a case-control study in China

Genetic variations in the gene XPC may be associated with increased risk for gallbladder cancer (GBC). In this study, we detected two non-synonymous polymorphisms in XPC (Ala499Val and Lys939Gln) in 334 cases of GBC and 329 subjects of hospital-based age- and sex frequency-matched controls in China using a polymerase chain reaction-restriction fragment length polymorphism assay. Allelic association analysis for the two single-nucleotide polymorphisms (SNPs) showed that the risk allele T of Ala499Val was significantly associated with GBC [odds ratio (OR)=1.40, 95% confidence interval (CI): 1.11-1.76, P=0.005), with a population attributive risk of 5.3%. Logistic regression analysis revealed that Ala499Val CT heterozygote (OR=1.56, 95% CI: 1.13-2.14, P=0.002) and TT homozygote (OR=1.93, 95% CI: 1.04-3.55, P=0.048) had a significantly increased risk compared with CC homozygotes. Genetic analysis suggested that either the SNPs directly exert an effect or the linked functional gene impact of the disease trait likely follows an additive or dominant model. Gene interaction analysis demonstrated that the effects of XPC diplotypes (defined as the number of risk genotypes at the two SNP loci) were highly dependent on gallstone. The data from this case-control study indicated that XPC exonic variants contributed to the risk of GBC in this Chinese population.

Genetic variants involved in gallstone formation and capsaicin metabolism, and the risk of gallbladder cancer in Chilean women

AIM: To determine the effects of genetic variants associated with gallstone formation and capsaicin (a pungent component of chili pepper) metabolism on the risk of gallbladder cancer (GBC).

METHODS: A total of 57 patients with GBC, 119 patients with gallstones, and 70 controls were enrolled in this study. DNA was extracted from their blood or paraffin block sample using standard commercial kits. The statuses of the genetic variants were assayed using Taqman^® SNP Genotyping Assays or Custom Taqman^® SNP Genotyping Assays.

RESULTS: The non-ancestral T/T genotype of apolipoprotein B rs693 polymorphism was associated with a decreased risk of GBC (OR: 0.14, 95% CI: 0.03-0.63). The T/T genotype of cholesteryl ester transfer protein (CETP) rs708272 polymorphism was associated with an increased risk of GBC (OR: 5.04, 95% CI: 1.43-17.8).

CONCLUSION: Genetic variants involved in gallstone formation such as the apolipoprotein B rs693 and CETP rs708272 polymorphisms may be related to the risk of developing GBC in Chilean women.

Is there a role for cholecystectomy in gallbladder carcinoma discovered to be unresectable for cure at laparotomy?

BACKGROUND

Palliative operative resection in patients with locally advanced cancer of the gallbladder (GBC) found not to be amenable to radical resection for cure at exploration has received little attention. This article evaluates the benefits, if any, of cholecystectomy with biliary drainage in such patients.

METHODS

Available records of locally advanced but nonmetastatic GBC patients treated in the Department of Surgical Oncology, B.H.U., Varanasi, India, during the last 8 years were retrospectively reviewed. Of these, 30 patients (group I) with GBC (T(3-4),N(0-1),M(0)) treated with cholecystectomy +/- biliary bypass were selected and compared with equal number of controls matched for age (+/-5 years), sex, histopathology, stage, residence, and postoperative chemotherapy who underwent biopsy +/- biliary bypass only (group II) followed by chemotherapy during the same period. Survival rates were calculated by using Kaplan-Meier curves. Follow-up ranged from 1-15 months.

RESULTS

The median survival was 7 and 2 months for groups I and II (P < 0.0001), respectively. The 30-day postoperative mortality and morbidity was 3% vs. 12% and 13% vs. 16% in groups I and II, respectively.

CONCLUSIONS

Results suggest that a better median survival can be achieved after cholecystectomy in locally advanced unresectable GBC compared with only bypass and biopsy procedures. These findings may justify a palliative cholecystectomy in selected patients with locally advanced GBC.

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.

Therapeutic effect of rapamycin on gallbladder cancer in a transgenic mouse model

The macrolide fungicide rapamycin has shown significant antiproliferative action toward a variety of tumor types. In this study, we used BK5.erbB2 transgenic mice as an animal model to examine the therapeutic effect of rapamycin as a potential treatment for gallbladder cancer. Homozygous BK5.erbB2 mice overexpressing the wild-type rat erbB2 gene in basal epithelial cells of the gallbladder have an approximately 70% incidence of gallbladder adenocarcinoma by 2 to 3 months of age. Groups of mice ( approximately 2-3 months of age) were treated with rapamycin by i.p. injection (once daily for 14 days) and then sacrificed 24 h after the last treatment. Rapamycin significantly reduced the incidence and severity of gallbladder carcinoma in BK5.erbB2 mice in a dose-dependent manner. Tumors responsive to treatment exhibited a higher number of apoptotic cells. Furthermore, rapamycin treatment led to decreased levels of phosphorylated p70 S6 kinase (Thr(389)) in gallbladder tissue as assessed by both Western blot and immunofluorescence analyses. Finally, immunofluorescence staining revealed elevated phosphorylated Akt (Ser(473)) and phosphorylated mammalian target of rapamycin (mTOR; Ser(2448)) in human gallbladder cancer compared with normal gallbladder tissue. Based on our results using a novel genetically engineered mouse model and the fact that the Akt/mTOR pathway is activated in human gallbladder cancer, rapamycin and related drugs may be effective therapeutic agents for the treatment of human gallbladder cancer.

Contribution of silent gallstones in gallbladder cancer

Silent (asymptomatic) gallstones are detected frequently with the widespread use of abdominal ultrasonography. The presence of gallstones is found strongly associated with gallbladder carcinoma. Studies on the natural history and most decision analysis studies do not favor prophylactic cholecystectomy for patients with silent gallstones. Gallbladder carcinoma is known to be highly aggressive and lethal disease with a poor outcome. It is rarely diagnosed early and only 10-30% patients are offered radical surgery on presentation. This has lead to a dilemma leading most surgeons to opt for an expectant management of silent gallstones. It thus raises the important question of the implications of leaving asymptomatic gallstones untouched. In this paper the author has reviewed the current understanding on silent gallstones and gallbladder carcinoma.

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

Primary carcinoma of the gallbladder is a progressive, lethal disease. Survival of patients with this neoplasm depends strictly on lymph node involvement and depth of tumor invasion. The aim of the study was to evaluate the results of our surgical series according to the tumor node metastasis and Japanese Society of Biliary Surgery classification systems. A retrospective analysis of our 15-year experience was performed. Of the 79 patients with gallbladder carcinoma observed at our institution between 1984 and 2001, a radical resection was carried out in 20 patients. Patients with stage I-II disease represent a minority of the cases of gallbladder carcinoma; the disease is localized in these patients, and surgical treatment provides the opportunity for good survival. Survival rates for patients with stage III-IV disease demonstrates that radical extended surgery offers the only chance for a relatively prolonged survival.

Preoperative diagnosis and staging of gallbladder carcinoma by EUS

BACKGROUND

EUS has recently been shown to be efficacious for the preoperative assessment of depth of invasion of gallbladder carcinoma. This study assessed the value of EUS for determining T stage (International Union Against Cancer).

METHODS

Preoperative EUS findings in 41 patients with gallbladder carcinoma were analyzed retrospectively. EUS images were classified according to the shape of the tumor and the adjacent gallbladder wall structure as follows: type A, pedunculated mass with preserved adjacent wall structures; type B, sessile and/or broad-based mass with a preserved outer hyperechoic layer of the gallbladder wall; type C, sessile and/or broad-based mass with a narrowed outer hyperechoic layer; type D, sessile and/or broad-based mass with a disrupted outer hyperechoic layer. EUS and histopathologic findings were compared, including the depth of invasion of the tumor in the resection specimen.

RESULTS

The 4 categories of EUS images of gallbladder carcinoma correlated with the histologic depth of invasion and T stage. Accuracies for the EUS classification as type A corresponding to pTis, type B to pT1, type C to pT2, and type D to pT3-4 were, respectively, 100%, 75.6%, 85.3%, and 92.7%.

CONCLUSIONS

Preoperative EUS imaging accurately depicts T stage of gallbladder carcinoma and allows for effective therapeutic decision making.

Gallbladder cancer in northern Jordan

BACKGROUND AND AIM

To highlight the epidemiological, clinical, and pathological features of gallbladder cancer in Jordan as a model for the Middle East. Only scattered reports are available from this region.

METHODS

The histopathological reports and the hospital records for all cholecystectomies performed at Princess Basma Teaching Hospital between 1994-2000 were retrospectively reviewed to identify all patients with gallbladder carcinoma. All the histological slides for the cancer group were reviewed and reclassified by a single pathologist.

RESULTS

Of 4502 cholecystectomies performed, 33 cases (0.73%) of gallbladder carcinoma were found. The mean age was 61.4 years (range 39-80 years). The male : female ratio was 1 : 3.7. Biliary colic and/or acute cholecystitis were the main presentations. Gallstones were present in 88% (29/33) of the patients. The spectrum of histological subtypes was similar to other series. Only three cases were diagnosed preoperatively, making the incidence of incidental gallbladder cancer 0.66% (30/4502). Simple cholecystectomy was performed for 13 patients. The remaining 20 patients underwent cholecystectomy and portal lymphadenectomy with (five cases) or without (15 cases) extrahepatic resection of the bile ducts. The mean follow up was 22 months (SD +/- 18.95 months; range 1-96 months). The 2-year survival rates for stages I, II, III, and IV were 100%, 42.9%, 10.8%, and 0%, respectively (P = 0.0013).

CONCLUSIONS

The importance of a high index of suspicion when dealing with cholelithiasis in elderly patients, particularly with large sized stones, cannot be over-emphasized. Proper gross inspection in the theater should be a routine procedure performed by all surgeons. Routine ultrasound for suspected gallbladder stones should always be performed under the supervision of senior radiologists.