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Palepu J, Endo I, Chaudhari VA, Murthy GVS, Chaudhuri S, Adam R, Smith M, de Reuver PR, Lendoire J, Shrikhande SV, De Aretxabala X, Sirohi B, Kokudo N, Kwon W, Pal S, Bouzid C, Dixon E, Shah SR, Maroni R, Nervi B, Mengoa C, Patil S, Ebata T, Maithel SK, Lang H, Primrose J, Hirano S, Guevara OA, Ohtsuka M, Valle JW, Sharma A, Nagarajan G, Núñez Ju JJ, Arroyo GF, Torrez SL, Erdmann JI, Butte JM, Furuse J, Lee SE, Gomes AP, Park SJ, Jang JY, Oddi R, Barreto SG, Kijima H, Ciacio O, Gowda NS, Jarnagin W. 'IHPBA-APHPBA clinical practice guidelines': international Delphi consensus recommendations for gallbladder cancer. HPB (Oxford) 2024:S1365-182X(24)02223-8. [PMID: 39191539 DOI: 10.1016/j.hpb.2024.07.411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2024] [Revised: 07/12/2024] [Accepted: 07/16/2024] [Indexed: 08/29/2024]
Abstract
BACKGROUND The Delphi consensus study was carried out under the auspices of the International and Asia-Pacific Hepato-Pancreato-Biliary Associations (IHPBA-APHPBA) to develop practice guidelines for management of gallbladder cancer (GBC) globally. METHOD GBC experts from 17 countries, spanning 6 continents, participated in a hybrid four-round Delphi consensus development process. The methodology involved email, online consultations, and in-person discussions. Sixty eight clinical questions (CQs) covering various domains related to GBC, were administered to the experts. A consensus recommendation was accepted only when endorsed by more than 75% of the participating experts. RESULTS Out of the sixty experts invited initially to participate in the consensus process 45 (75%) responded to the invitation. The consensus was achieved in 92.6% (63/68) of the CQs. Consensus covers epidemiological aspects of GBC, early, incidental and advanced GBC management, definitions for radical GBC resections, the extent of liver resection, lymph node dissection, and definitions of borderline resectable and locally advanced GBC. CONCLUSIONS This is the first international Delphi consensus on GBC. These recommendations provide uniform terminology and practical clinical guidelines on the current management of GBC. Unresolved contentious issues like borderline resectable/locally advanced GBC need to be addressed by future clinical studies.
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Affiliation(s)
- Jagannath Palepu
- Continental Cancer Centre, Continental Hospitals, Hyderabad, India; Dept. of Surgical Oncology Lilavati Hospital & Research Centre and SL Raheja Hospital, Mumbai, India.
| | - Itaru Endo
- Department of Gastroenterological Surgery, Yokohama City University, Yokohama, Japan
| | - Vikram Anil Chaudhari
- GI and HPB Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - G V S Murthy
- PRASHO Foundation, Hyderabad, India; London School of Hygiene and Tropical Medicine, London, UK
| | | | - Rene Adam
- Department of Hepatobiliary Surgery, Cancer and Transplantation, AP-HP Hôpital Paul Brousse / Univ Paris-Saclay, Centre Hépato-Biliaire, Villejuif, France
| | - Martin Smith
- Surgery, University of the Witwatersrand Johannesburg, Johannesburg, South Africa
| | | | - Javier Lendoire
- HPB & Liver Transplantation, Instituto de Trasplantes y Alta Complejidad (ITAC), Buenos Aires, Argentina
| | - Shailesh V Shrikhande
- GI and HPB Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | | | - Bhawna Sirohi
- Medical Oncology, Vedanta Medical Research foundation (Balco Medical Centre), Raipur, India
| | - Norihiro Kokudo
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, National Center for Global Health and Medicine, Tokyo, Japan
| | - Wooil Kwon
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | - Sujoy Pal
- Deptt of GI Surgery and Liver transplantation, All India Institute of Medical Sciences, New Delhi, India
| | - Chafik Bouzid
- HPB and Digestive Oncology Surgery, Dept. of Surgical Oncology, DBK anti cancer center, Mouloud Mammeri University, Tizi Ouzou, Algeria
| | - Elijah Dixon
- Department of Surgery, University of Calgary, Calgary, Canada
| | | | - Rodrigo Maroni
- Head of Program of Surgery, Hospital Papa Francisco, Salta, Argentina
| | - Bruno Nervi
- Chief Department, Department of Hematology and Oncology, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Claudio Mengoa
- Surgery, Instituto Regional de Enfermedades Neoplasicas, Arequipa, Peru
| | | | - Tomoki Ebata
- Surgical Oncology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shishir K Maithel
- Professor of Surgery, Department of Surgery, Emory University, Atlanta, USA
| | - Hauke Lang
- Visceral- and Transplantation Surgery, Universitätsmedizin Mainz, Mainz, Germany
| | - John Primrose
- Department of Surgery, University of Southampton, Southampton, UK
| | - Satoshi Hirano
- Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Oscar A Guevara
- Surgery, Universidad Nacional de Colombia / Instituto Nacional de Cancerologia, Bogota, Colombia
| | - Masayuki Ohtsuka
- Department of General Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Juan W Valle
- Chief Medical Officer, Research Department, Cholangiocarcinoma Foundation, Herriman, UT, USA
| | - Atul Sharma
- Medical Oncology, Max Institute Of Cancer Care, New Delhi, India
| | - Ganesh Nagarajan
- Surgical oncology ( GI and HPB), Nanavati Max hospital mumbai, Mumbai, India
| | - Juan Jose Núñez Ju
- HPB General Surgery Service, Hospital Nacional Guillermo Almenara, Lima, Peru
| | | | | | | | - Jean M Butte
- Surgery, Instituto Oncologico FALP, Santiago, Chile
| | - Junji Furuse
- Gastroenterology, Kanagawa Cancer Center, Yokohama, Japan
| | - Seung Eun Lee
- Department of surgery, Chung-Ang University College of Medicine, Seoul, South Korea
| | - António Pedro Gomes
- Surgery Department, Hospital Vila Franca de Xira, Vila Franca de Xira, Portugal
| | - Sang-Jae Park
- Center for Liver and Pancreatobiliary Cancer, National Cancer Center, Goyang-si, South Korea
| | - Jin-Young Jang
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | - Ricardo Oddi
- Center for Clinical Medical Education and Research (CEMIC), Buenos Aires, Argentina
| | - Savio George Barreto
- HPB and Liver Transplant Unit, Flinders Medical Centre, Flinders University, Austraila
| | - Hiroshi Kijima
- Department of Pathology and Bioscience, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Oriana Ciacio
- Centre Hépato-Biliaire, AP-HP - Hôpital Paul Brousse / Paris-Saclay University, Villejuif, France
| | - Nagesh S Gowda
- Institute of Gastroenterology and Organ Transplantation, Bengaluru, India
| | - William Jarnagin
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, USA
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R K K, Ravipati C, Ramakrishnan KK, Ramaswami S, Natarajan P. Comparative Efficacy of Magnetic Resonance Cholangiopancreatography vs. Percutaneous Transhepatic Cholangiography With Percutaneous Transhepatic Biliary Drainage Stenting in Evaluating Obstructive Jaundice: A Prospective Study in South India. Cureus 2024; 16:e65241. [PMID: 39184628 PMCID: PMC11343331 DOI: 10.7759/cureus.65241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2024] [Accepted: 07/23/2024] [Indexed: 08/27/2024] Open
Abstract
Introduction Obstructive jaundice due to proximal biliary obstruction presents significant diagnostic and therapeutic challenges. Accurate and timely diagnosis is essential for effective management. Objective/aim This study aimed to evaluate and compare the diagnostic accuracy of magnetic resonance cholangiopancreatography (MRCP) and percutaneous transhepatic cholangiography (PTC) along with percutaneous transhepatic biliary drainage (PTBD) stenting in obstructive jaundice, while also incorporating the comparison of ultrasonography (USG) and computed tomography (CT) findings. Materials and methods A prospective study was conducted at a tertiary healthcare center in South India from January 2020 to June 2022. Comprehensive diagnostic evaluations were performed using USG, contrast-enhanced computed tomography (CECT), MRCP, and PTC. The diagnostic outcomes from USG and CECT were initially assessed, followed by MRCP for every patient. These results were then compared with PTC, focusing on identifying the causes and levels of biliary obstruction. Results Fifty patients with suspected obstructive jaundice were included in the study. The study predominantly involved patients aged between the fourth and eighth decades (80%). Choledocholithiasis was identified as the leading cause (30%). MRCP demonstrated superior sensitivity in identifying both the cause (80%) and level (88%) of obstruction. It was particularly effective in detecting hilar masses with 100% sensitivity. Conversely, PTC, while less sensitive in detection, offered the advantage of simultaneous therapeutic intervention through stenting, with a sensitivity rate of 93% in detecting hilar masses. Conclusion MRCP outperforms PTC in diagnostic sensitivity for obstructive jaundice caused by proximal biliary obstruction. However, the advantage of PTC lies in its capacity for immediate therapeutic intervention via stent placement, addressing both diagnostic and treatment needs.
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Affiliation(s)
- Karpagam R K
- Department of Radiology, Saveetha Medical College and Hospital, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai, IND
| | - Chakradhar Ravipati
- Department of Radiology, Saveetha Medical College and Hospital, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai, IND
| | - Karthik Krishna Ramakrishnan
- Department of Radiology, Saveetha Medical College and Hospital, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai, IND
| | - Sukumar Ramaswami
- Department of Radiology, Saveetha Medical College and Hospital, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai, IND
| | - Paarthipan Natarajan
- Department of Radiology, Saveetha Medical College and Hospital, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai, IND
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Boutin M, Krishnan T, Safro M, Yang J, Jafari H, Davies JM, Gill S. Real-world experience supporting the role of oncologic resection and adjuvant chemotherapy in biliary tract cancers. Ther Adv Med Oncol 2024; 16:17588359241247008. [PMID: 38628554 PMCID: PMC11020734 DOI: 10.1177/17588359241247008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 03/27/2024] [Indexed: 04/19/2024] Open
Abstract
Background Complete resection followed by adjuvant chemotherapy is the gold standard for patients with localized cholangiocarcinoma (CC) or gallbladder cancer (GBC). However, this is not always feasible, and recurrence rates remain high. Objectives To understand the real-world proportions and reason for treatment failure in resected biliary tract cancers. Design and methods We performed a retrospective population-based review of patients with GBC or CC [intrahepatic (IHCC) or extrahepatic (EHCC)] resected between 2005 and 2019 using the BC Cancer provincial database. A chart review was conducted to characterize demographics, treatments received and outcomes. Results In total, 594 patients were identified of whom 416 (70%) had disease recurrence. Most GBCs (96%) were diagnosed incidentally, and repeat oncologic resection was performed in 45%. Adjuvant chemotherapy was received in 51% of patients diagnosed after 2017 (mostly capecitabine). Patient co-morbidities, disease progression and patient preference were the commonest reasons for not proceeding with adjuvant chemotherapy. One-third of patients did not complete all planned cycles. Median overall survival was significantly higher in those with complete (R0) versus incomplete (R1) resection [31.6 versus 18 months, hazard ratio (HR): 0.43, 95% confidence interval (CI): 0.35-0.53] and in those with versus without re-resection for GBC [29.4 versus 19 months, HR: 0.55, 95% CI: 0.41-0.73]. There was a trend towards improved survival with versus without adjuvant therapy (HR: 0.79, 95% CI: 0.61-1.02). Only 25% in the more contemporary cohort (2017-2019) had an R0 resection and completed adjuvant chemotherapy. Conclusion Complete resection, including reresection for incidentally diagnosed GBCs, and adjuvant chemotherapy were associated with improved outcomes in this retrospective cohort, yet many patients were not able to complete these treatments. Neoadjuvant strategies may improve treatment delivery and ultimately, outcomes.
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Affiliation(s)
| | | | | | - Jenny Yang
- Department of Medical Oncology, University of British Columbia, Vancouver, BC, Canada
| | - Helia Jafari
- Department of Medical Oncology, University of British Columbia, Vancouver, BC, Canada
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Rhodin KE, Goins S, Kramer R, Eckhoff AM, Herbert G, Shah KN, Allen PJ, Nussbaum DP, Blazer DG, Zani S, Lidsky ME. Simple versus radical cholecystectomy and survival for pathologic stage T1B gallbladder cancer. HPB (Oxford) 2024; 26:594-602. [PMID: 38336604 DOI: 10.1016/j.hpb.2024.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 12/16/2023] [Accepted: 01/22/2024] [Indexed: 02/12/2024]
Abstract
BACKGROUND Radical cholecystectomy is recommended for T1B and greater gallbladder cancer, however, there are conflicting reports on the utility of extended resection for T1B disease. Herein, we characterize outcomes following simple and radical cholecystectomy for pathologic stage T1B gallbladder cancer. METHODS The National Cancer Database (NCDB) was queried for patients with pathologic T1B gallbladder cancer diagnosed from 2004 to 2018. Patients were stratified by surgical management. Overall survival (OS) was compared with Kaplan-Meier and multivariable Cox proportional hazards methods. RESULTS Altogether, 950 patients were identified with pathologic T1B gallbladder cancer: 187 (19.7 %) receiving simple and 763 (80.3 %) radical cholecystectomy. Median OS was 89.5 (95 % CI 62.5-137) and 91.4 (95 % CI 75.9-112) months for simple and radical cholecystectomy, respectively (log-rank p = 0.55). Receipt of simple cholecystectomy was not associated with greater hazard of mortality compared to radical cholecystectomy (HR 1.23, 95 % CI 0.95-1.59, p = 0.12). DISCUSSION In this analysis, we report comparable outcomes with simple cholecystectomy among patients with pathologic T1B gallbladder cancer. These findings suggest that highly selected patients, such as those with R0 resection and imaging at low risk for residual disease and/or nodal metastasis, may not benefit from extended resection; however, radical cholecystectomy remains standard of care until prospective validation can be achieved.
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Affiliation(s)
- Kristen E Rhodin
- Department of Surgery, Duke University, 2301 Erwin Rd, Durham, NC 27710, USA.
| | - Stacy Goins
- Duke University School of Medicine, 40 Duke Medicine Circle, Durham, NC 27710, USA
| | - Ryan Kramer
- Duke University School of Medicine, 40 Duke Medicine Circle, Durham, NC 27710, USA
| | - Austin M Eckhoff
- Department of Surgery, Duke University, 2301 Erwin Rd, Durham, NC 27710, USA
| | - Garth Herbert
- Department of Surgery, Duke University, 2301 Erwin Rd, Durham, NC 27710, USA
| | - Kevin N Shah
- Department of Surgery, Duke University, 2301 Erwin Rd, Durham, NC 27710, USA
| | - Peter J Allen
- Department of Surgery, Duke University, 2301 Erwin Rd, Durham, NC 27710, USA
| | - Daniel P Nussbaum
- Department of Surgery, Duke University, 2301 Erwin Rd, Durham, NC 27710, USA
| | - Dan G Blazer
- Department of Surgery, Duke University, 2301 Erwin Rd, Durham, NC 27710, USA
| | - Sabino Zani
- Department of Surgery, Duke University, 2301 Erwin Rd, Durham, NC 27710, USA
| | - Michael E Lidsky
- Department of Surgery, Duke University, 2301 Erwin Rd, Durham, NC 27710, USA
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5
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Shah S, Sweeney R, Wegner RE. Survival Benefit with Re-resection and Optimal Time to Re-resection in Gallbladder Cancer: a National Cancer Database Study. J Gastrointest Cancer 2023; 54:1331-1337. [PMID: 37231186 DOI: 10.1007/s12029-023-00934-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2023] [Indexed: 05/27/2023]
Abstract
PURPOSE Gallbladder cancer is often diagnosed incidentally after cholecystectomy. Most patients will then undergo re-resection for potential residual disease; however, overall survival (OS) benefit data in this scenario is variable. This National Cancer Database analysis (NCDB) compared OS in patients with T1b-T3 gallbladder cancer who underwent re-resection and evaluated if time to resection impacts OS. METHODS We reviewed the NCDB for patients who received initial cholecystectomy for gallbladder cancer and were subsequently eligible for re-resection based on tumor stage (T1b-T3 disease). Patients with re-resection were subdivided into four cohorts based on time to re-resection: 0-4 weeks, 5-8 weeks, 9-12 weeks, and > 12 weeks. We used a Cox proportional hazards ratio to identify factors associated with worse survival and logistic regression to evaluate characteristics associated with re-resection. OS was calculated using Kaplan Meier curves. RESULTS A total of 791 (5.82%) patients received re-resection. Cox proportional hazards analysis showed a comorbidity score of 1 was associated with worse survival. Patients with higher comorbidity scores and treatment at comprehensive community, integrated, or academic cancer programs were less likely to undergo re-resection. Re-resection showed significantly improved OS [HR 0.87; 95 CI 0.77-0.98; p = 0.0203]. Improved survival was appreciated when re-resection was completed at 5-8 weeks [HR 0.67; CI 0.57-0.81], 9-12 weeks [HR 0.64; CI 0.52-0.79], or > 12 weeks [HR 0.61; CI 0.47-0.78] compared to 0-4 weeks. CONCLUSION Optimal timing to re-resection in gallbladder cancer supports previous data showing benefit at > 4 weeks. However, there was no significant survival difference as to whether re-resection was completed at 5-8 weeks, 9-12 weeks, or > 12 weeks post initial cholecystectomy.
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Affiliation(s)
- Shivani Shah
- Department of Internal Medicine, Allegheny Health Network, 320 E. North Avenue, Pittsburgh, PA, 15212, USA.
| | - Ryan Sweeney
- Department of Internal Medicine, Allegheny Health Network, 320 E. North Avenue, Pittsburgh, PA, 15212, USA
| | - Rodney E Wegner
- Division of Radiation Oncology, Allegheny Health Network Cancer Institute, 320 E. North Avenue, Pittsburgh, PA, 15212, USA
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Vega EA, Mellado S, Chirban AM, Panettieri E, Sanhueza M, Mege R, Diaz C, Brañes A, Briceño E, Viñuela E. Analysis of the Extent of Liver Oncological Extended Resection for Incidental Gallbladder Cancer: How Much Is Too Much? Ann Surg Oncol 2023; 30:6594-6600. [PMID: 37460736 DOI: 10.1245/s10434-023-13861-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 06/19/2023] [Indexed: 09/20/2023]
Abstract
BACKGROUND Liver resection is pivotal in treating incidental gallbladder cancer (IGBC). However, the adequate volume of liver resection remains controversial. METHODS A cross-sectional retrospective analysis was performed on resected IGBC patients between 1999 and 2018. Morbidity was evaluated according to the Clavien-Dindo classification. The theoretical volume of a 2-cm and 1.5-cm wedge liver resection was calculated (105 cm3 and 77.5 cm3, respectively) and used as reference. Overall survival (OS) was estimated using Kaplan-Meier and Cox regression analyses. RESULTS Among 111 patients re-resected for IGBC, 84 provided sufficient data to calculate liver resection volume. Patients with a resection volume ≥ 105 cm3 had a higher rate of overall morbidity (P = 0.001) and length of stay (P = 0.012), with no difference in mortality. There was no significant difference in OS according to residual cancer or T-category. A resection volume ≥ 77.5 cm3 was more frequent in T ≥ 3 than in T1-2 patients (P = 0.026), and residual cancer was higher (P = 0.041) among patients with ≥ 77.5 cm3 resected. Cox multivariate regression showed that residual cancer (HR = 11.47, P < 0.001), perineural/lymphovascular invasion (HR = 2.48, P = 0.021), and Clavien-Dindo ≥ IIIa morbidity (HR = 5.03, P = 0.003) predict worse OS, but not liver volume resection. CONCLUSION There are no significant differences in OS based on resected liver volume of IGBC, when R0 is achieved. There is a significant difference in morbidity and length of stay when liver wedges are ≥ 105 cm3, which is lost when analyzed by Clavien-Dindo ≥ IIIa. A 77.5-105 cm3 resection is indicated in ≥ T3 patients, minimizing morbidity risk, while addressing concerns of overall survival.
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Affiliation(s)
- Eduardo A Vega
- Department of Surgery, St. Elizabeth's Medical Center, Hepato-Pancreato-BiliarySurgery, Boston University School of Medicine, Boston, MA, USA.
- Department of Digestive Surgery, Hepato-Pancreato-Biliary Surgery Unit, Surgery Service, Faculty of Medicine, Sotero del Rio Hospital, Pontificia Universidad Catolica of Chile, Santiago, Chile.
| | - Sebastian Mellado
- Department of Surgery, St. Elizabeth's Medical Center, Hepato-Pancreato-BiliarySurgery, Boston University School of Medicine, Boston, MA, USA
- Tufts University School of Medicine, Boston, MA, USA
| | - Ariana M Chirban
- Department of Surgery, St. Elizabeth's Medical Center, Hepato-Pancreato-BiliarySurgery, Boston University School of Medicine, Boston, MA, USA
- University of California San Diego School of Medicine, San Diego, CA, USA
| | - Elena Panettieri
- Department of Surgery, St. Elizabeth's Medical Center, Hepato-Pancreato-BiliarySurgery, Boston University School of Medicine, Boston, MA, USA
- Hepatobiliary Surgery Unit, Fondazione "Policlinico Universitario A. Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Marcel Sanhueza
- Department of Digestive Surgery, Hepato-Pancreato-Biliary Surgery Unit, Surgery Service, Faculty of Medicine, Sotero del Rio Hospital, Pontificia Universidad Catolica of Chile, Santiago, Chile
- Department of Digestive Surgery, Faculty of Medicine, Catholic University of Chile, Santiago, Chile
| | - Rosemarie Mege
- Department of Digestive Surgery, Hepato-Pancreato-Biliary Surgery Unit, Surgery Service, Faculty of Medicine, Sotero del Rio Hospital, Pontificia Universidad Catolica of Chile, Santiago, Chile
- Department of Digestive Surgery, Faculty of Medicine, Catholic University of Chile, Santiago, Chile
| | - Cristian Diaz
- Department of Digestive Surgery, Hepato-Pancreato-Biliary Surgery Unit, Surgery Service, Faculty of Medicine, Sotero del Rio Hospital, Pontificia Universidad Catolica of Chile, Santiago, Chile
- Department of Digestive Surgery, Faculty of Medicine, Catholic University of Chile, Santiago, Chile
| | - Alejandro Brañes
- Department of Digestive Surgery, Hepato-Pancreato-Biliary Surgery Unit, Surgery Service, Faculty of Medicine, Sotero del Rio Hospital, Pontificia Universidad Catolica of Chile, Santiago, Chile
- Department of Digestive Surgery, Faculty of Medicine, Catholic University of Chile, Santiago, Chile
| | - Eduardo Briceño
- Department of Digestive Surgery, Faculty of Medicine, Catholic University of Chile, Santiago, Chile
| | - Eduardo Viñuela
- Department of Digestive Surgery, Hepato-Pancreato-Biliary Surgery Unit, Surgery Service, Faculty of Medicine, Sotero del Rio Hospital, Pontificia Universidad Catolica of Chile, Santiago, Chile.
- Department of Digestive Surgery, Faculty of Medicine, Catholic University of Chile, Santiago, Chile.
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Yang WW, Fang YT, Niu YR, Sun YK. Comparison of clinicopathological characteristics and survival outcomes between gallbladder mucinous adenocarcinoma and gallbladder adenocarcinoma: A propensity score-matched study. World J Gastrointest Oncol 2023; 15:1436-1450. [PMID: 37663946 PMCID: PMC10473937 DOI: 10.4251/wjgo.v15.i8.1436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Revised: 06/03/2023] [Accepted: 06/19/2023] [Indexed: 08/10/2023] Open
Abstract
BACKGROUND Gallbladder mucinous adenocarcinoma (GBMAC) is a rare subtype of gallbladder adenocarcinoma (GBAC), with limited knowledge of its survival outcomes from small case series and single-center retrospective analysis. AIM To compare the clinicopathological characteristics of GBMAC with typical GBAC and its prognostic factors to gain insights into this field. METHODS This study was conducted using data from the Surveillance, Epidemiology, and End Results database, including cases of GBMAC and typical GBAC diagnosed from 2010 to 2017. The Pearson chi-square test or Fisher exact test was used to examine the differences in clinicopathological features between these two cohorts. In addition, propensity score matching (PSM) analysis was performed to balance the selection biases. Univariate and multivariate Cox hazards regression analyses were performed to determine independent prognostic factors for cancer-specific survival (CSS) and overall survival (OS). The Kaplan-Meier curves and log-rank tests were used to assess the OS and CSS of GBMAC and typical GBAC patients. RESULTS The clinicopathological and demographic characteristics of GBMAC were different from typical GBAC. They included a larger proportion of patients with unmarried status, advanced American Joint Committee on Cancer (AJCC) stage, higher T stage, higher N1 stage rate and lower N0 and N2 stage rates (P < 0.05). Multivariate analyses demonstrated that surgery [OS: Hazard ratio (HR) = 2.27, P = 0.0037; CSS: HR = 2.05, P = 0.0151], chemotherapy (OS: HR = 6.41, P < 0.001; CSS: HR = 5.24, P < 0.001) and advanced AJCC stage (OS: Stage IV: HR = 28.99, P = 0.0046; CSS: Stage III: HR = 12.31, P = 0.015; stage IV: HR = 32.69, P = 0.0015) were independent prognostic indicators for OS and CSS of GBMAC patients. Furthermore, after PSM analysis, there was no significant difference between GBMAC and matched typical GBAC patients regarding OS (P = 0.82) and CSS (P = 0.69). CONCLUSION The biological behaviors of GBMAC are aggressive and significantly different from that of typical GBAC. However, they show similar survival prognoses. Surgery, chemotherapy, and lower AJCC stage were associated with better survival outcomes. Further research is needed in the future to verify these results.
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Affiliation(s)
- Wen-Wei Yang
- Department of Medical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Yu-Ting Fang
- Department of Medical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Ya-Ru Niu
- Department of Medical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Yong-Kun Sun
- Department of Medical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
- Department of Medical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Hebei Cancer Hospital, Langfang 065001, Hebei Province, China
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Machado MAC, Mattos BV, Lobo Filho MM, Makdissi F. Robotic Hepatic Bisegmentectomy (s4b + s5) and Hilar Lymphadenectomy for Incidental Gallbladder Cancer Using Glissonian Approach. Ann Surg Oncol 2023; 30:3392-3397. [PMID: 36683100 DOI: 10.1245/s10434-023-13125-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Accepted: 01/09/2023] [Indexed: 01/23/2023]
Abstract
BACKGROUND Gallbladder carcinoma is a rare cancer with a poor prognosis and the most common biliary tract malignancy. This video shows robotic treatment of a patient with incidental gallbladder cancer diagnosed after laparoscopic cholecystectomy. The operation consisted of a robotic bisegmentectomy (liver segments 4b and 5) using a Glissonian approach and a hilar lymphadenectomy. METHODS A 73-year-old woman with no relevant history underwent a laparoscopic cholecystectomy at another hospital facility. The pathology revealed a gallbladder carcinoma. The patient was then referred for further treatment. Pathologic revision confirmed T2a carcinoma and staging was negative for distant metastases. The multidisciplinary team decided on a radical resection that will consist of a hilar lymphadenectomy and a frozen section of the cystic stump along the resection of segments 4b and 5. A robotic approach was proposed, and consent was obtained. RESULTS The operation time was 300 min and was performed 21 days after the cholecystectomy. Estimated blood loss was 120 mL with no transfusions required during or after the procedure. The postoperative recovery was uneventful, and the patient was discharged on the fourth postoperative day. The final pathology showed no residual disease in the liver specimen and no metastases among 16 removed lymph nodes. CONCLUSIONS The robotic approach is safe and feasible for radical treatment after incidentally discovered gallbladder cancer. The Glissonian approach is useful for anatomic resection of liver segments 4b and 5. This video can help oncologic surgeons to perform this challenging procedure.
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Vega EA, Mellado S, Salehi O, Freeman R, Conrad C. Treatment of Resectable Gallbladder Cancer. Cancers (Basel) 2022; 14:1413. [PMID: 35326566 PMCID: PMC8945892 DOI: 10.3390/cancers14061413] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 02/18/2022] [Accepted: 03/06/2022] [Indexed: 02/04/2023] Open
Abstract
Gallbladder cancer (GBC) is the most common biliary tract cancer worldwide and its incidence has significant geographic variation. A unique combination of predisposing factors includes genetic predisposition, geographic distribution, female gender, chronic inflammation, and congenital developmental abnormalities. Today, incidental GBC is the most common presentation of resectable gallbladder cancer, and surgery (minimally invasive or open) remains the only curative treatment available. Encouragingly, there is an important emerging role for systemic treatment for patients who have R1 resection or present with stage III-IV. In this article, we describe the pathogenesis, surgical and systemic treatment, and prognosis.
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Affiliation(s)
- Eduardo A. Vega
- Department of Surgery, St. Elizabeth’s Medical Center, Boston University School of Medicine, Boston, MA 02135, USA; (E.A.V.); (O.S.); (R.F.)
| | | | - Omid Salehi
- Department of Surgery, St. Elizabeth’s Medical Center, Boston University School of Medicine, Boston, MA 02135, USA; (E.A.V.); (O.S.); (R.F.)
| | - Richard Freeman
- Department of Surgery, St. Elizabeth’s Medical Center, Boston University School of Medicine, Boston, MA 02135, USA; (E.A.V.); (O.S.); (R.F.)
| | - Claudius Conrad
- Department of Surgery, St. Elizabeth’s Medical Center, Boston University School of Medicine, Boston, MA 02135, USA; (E.A.V.); (O.S.); (R.F.)
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10
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Feo CF, Ginesu GC, Fancellu A, Perra T, Ninniri C, Deiana G, Scanu AM, Porcu A. Current management of incidental gallbladder cancer: A review. Int J Surg 2022; 98:106234. [PMID: 35074510 DOI: 10.1016/j.ijsu.2022.106234] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 01/11/2022] [Accepted: 01/12/2022] [Indexed: 02/05/2023]
Abstract
Early-stage gallbladder cancer (GBC) is mostly discovered incidentally by the pathologist after cholecystectomy for a presumed benign disease. It is the most common malignancy of the biliary tract with a variable incidence rate all over the World. The majority of patients with GBC remain asymptomatic for a long time and diagnosis is usually late when the disease is at an advanced stage. Radical surgery consisting in resection of the gallbladder liver bed and regional lymph nodes seems to be the best treatment option for incidental GBC. However, recurrence rates after salvage surgery are still high and the addition of neoadjuvant/adjuvant chemotherapy may improve outcomes. The aim of the present review is to evaluate current literature for advances in management of incidental GBC, with particular focus on staging techniques and surgical options.
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Affiliation(s)
- Claudio F Feo
- Unit of General Surgery 2, Department of Medical, Surgical and Experimental Sciences, University of Sassari, 07100, Sassari, Italy
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11
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Chaudhari VA, Bhandare MS, Shrikhande SV. Incidental Gallbladder Cancer—Current Recommendations and Management Protocols. Indian J Surg 2021. [DOI: 10.1007/s12262-021-02828-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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12
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Patkar S, Patel S, Gupta A, Ramaswamy A, Ostwal V, Goel M. Revision Surgery for Incidental Gallbladder Cancer-Challenging the Dogma: Ideal Timing and Real-World Applicability. Ann Surg Oncol 2021; 28:6758-6766. [PMID: 33625635 DOI: 10.1245/s10434-021-09687-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 01/20/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND There is a lack of consensus on the ideal time interval and therapeutic value of revision surgery in patients with incidental gallbladder cancer (iGBC) in the context of multimodality management. PATIENTS AND METHODS Retrospective analysis of an institutional database of patients with iGBC who underwent surgery from January 2010 to December 2019 was performed. Patients who underwent upfront surgery were divided into four time interval groups: A, B, C, and D (< 6 weeks, 6-10 weeks, 10-14 weeks, and > 14 weeks, respectively). RESULTS A cohort of 517 patients planned for revision surgery was analyzed. Overall, 382 (73.9%) patients underwent upfront surgery while 135 (26.1%) were given neoadjuvant treatment. With median follow-up of 18 months, 2-year overall survival (OS) was 66% and disease-free survival (DFS) was 52.6%, with inferior survival outcomes observed with advancing stage and presence of residual disease on final histopathology. Propensity score-matched analysis after matching for pT stage of cholecystectomy specimen suggested a survival benefit for patients operated between 10 and 14 weeks in terms of OS (p = 0.049) and DFS (p = 0.006). Patients with locally advanced iGBC at presentation had superior OS when operated after neoadjuvant therapy [3-year estimated OS of 59.9% vs 32.3%, respectively (p = 0.001)]. CONCLUSIONS Revision surgery is at best the most accurate staging procedure guiding timely initiation of systemic therapy. Patients with iGBC operated between 10 and 14 weeks after initial cholecystectomy tend to have favorable survival outcomes, although this depends on final disease stage. Revision surgery should also be offered to all patients presenting at any later point of time, if deemed operable.
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Affiliation(s)
- Shraddha Patkar
- Hepatobiliary division of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Swapnil Patel
- Hepatobiliary division of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Amit Gupta
- Hepatobiliary division of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Anant Ramaswamy
- Department of Medical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Vikas Ostwal
- Department of Medical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Mahesh Goel
- Hepatobiliary division of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India.
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13
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Xiang JX, Zhang XF, Weber SM, Poultsides G, Fields RC, Hatzaras I, Weiss M, Scoggins C, Idrees K, Shen P, Maithel SK, Pawlik TM. Identification of patients who may benefit the most from adjuvant chemotherapy following resection of incidental gallbladder carcinoma. J Surg Oncol 2021; 123:978-985. [PMID: 33497466 DOI: 10.1002/jso.26389] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 12/23/2020] [Accepted: 01/10/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND To develop a scoring system to identify the subset of patients who may benefit the most from adjuvant chemotherapy following curative-intent resection for incidental gallbladder cancer (IGBC). METHODS A novel scoring system was utilized to stratify patients relative to overall survival (OS), as well as potential benefit from adjuvant chemotherapy following curative resection for IGBC. RESULTS Among 266 patients with IGBC, a total of 99 (37.2%) patients received adjuvant chemotherapy. Five risk factors were used to develop an integer-based score to predict OS. Risk of death at 5-years incrementally increased among patients in the low (n = 42, 69.0%), medium (n = 64, 56.3%) and high-risk groups (n = 40, 30.0%) (median OS, 99.4 vs. 33.5 vs. 15.6 months, all p < .001). Use of adjuvant chemotherapy did not provide a survival benefit among patients in the low-risk group (median survival, 99.4 vs. 60.7 months, p = .56). In contrast, utilization of adjuvant chemotherapy was associated with an improvement in survival among medium- (median survival, 21.7 vs. 59.5 months, p = .04) and high-risk patients (median survival, 11.6 vs. 20.1 months, p = .01). CONCLUSIONS While low-risk patients did not benefit from adjuvant chemotherapy, individuals with medium or high-risk scores had an improved survival with the utilization of adjuvant chemotherapy.
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Affiliation(s)
- Jun-Xi Xiang
- Department of Hepatobiliary Surgery, Institute of Advanced Surgical Technology and Engineering, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Xu-Feng Zhang
- Department of Hepatobiliary Surgery, Institute of Advanced Surgical Technology and Engineering, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China.,Department of Surgery, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
| | - Sharon M Weber
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - George Poultsides
- Department of Surgery, Stanford University Medical Center, Stanford, California, USA
| | - Ryan C Fields
- Department of Surgery, Washington University School of Medicine, St Louis, Missouri, USA
| | - Ioannis Hatzaras
- Department of Surgery, New York University, New York, New York, USA
| | - Matthew Weiss
- Department of Surgery, Northwell Health Cancer Institute, Zucker School of Medicine at Hofstra, Lake Success, New York, USA
| | - Charles Scoggins
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Kamron Idrees
- Division of Surgical Oncology, Department of Surgery, University of Louisville, Louisville, Kentucky, USA
| | - Perry Shen
- Department of Surgery, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Shishir K Maithel
- Division of Surgical Oncology, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Timothy M Pawlik
- Department of Surgery, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
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14
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Vega EA, De Aretxabala X, Qiao W, Newhook TE, Okuno M, Castillo F, Sanhueza M, Diaz C, Cavada G, Jarufe N, Munoz C, Rencoret G, Vivanco M, Joechle K, Tzeng CWD, Vauthey JN, Vinuela E, Conrad C. Comparison of oncological outcomes after open and laparoscopic re-resection of incidental gallbladder cancer. Br J Surg 2020; 107:289-300. [PMID: 31873948 DOI: 10.1002/bjs.11379] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 03/22/2019] [Accepted: 09/04/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND The safety and oncological efficacy of laparoscopic re-resection of incidental gallbladder cancer have not been studied. This study aimed to compare laparoscopic with open re-resection of incidentally discovered gallbladder cancer while minimizing selection bias. METHODS This was a multicentre retrospective observational cohort study of patients with incidental gallbladder cancer who underwent re-resection with curative intent at four centres between 2000 and 2017. Overall survival (OS) and recurrence-free survival (RFS) were analysed by intention to treat. Inverse probability of surgery treatment weighting using propensity scoring was undertaken. RESULTS A total of 255 patients underwent re-resection (190 open, 65 laparoscopic). Nineteen laparoscopic procedures were converted to open operation. Surgery before 2011 was the only factor associated with conversion. Duration of hospital stay was shorter after laparoscopic re-resection (median 4 versus 6 days; P < 0·001). Three-year OS rates for laparoscopic and open re-resection were 87 and 62 per cent respectively (P = 0·502). Independent predictors of worse OS were residual cancer found at re-resection (hazard ratio (HR) 1·91, 95 per cent c.i. 1·17 to 3·11), blood loss of at least 500 ml (HR 1·83, 1·23 to 2·74) and at least four positive nodes (HR 3·11, 1·46 to 6·65). In competing-risks analysis, the RFS incidence was higher for laparoscopic re-resection (P = 0·038), but OS did not differ between groups. Independent predictors of worse RFS were one to three positive nodes (HR 2·16, 1·29 to 3·60), at least four positive nodes (HR 4·39, 1·96 to 9·82) and residual cancer (HR 2·42, 1·46 to 4·00). CONCLUSION Laparoscopic re-resection for selected patients with incidental gallbladder cancer is oncologically non-inferior to an open approach. Dissemination of advanced laparoscopic skills and timely referral of patients with incidental gallbladder cancer to specialized centres may allow more patients to benefit from this operation.
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Affiliation(s)
- E A Vega
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - X De Aretxabala
- Department of Surgery, Hepato-Bilio-Pancreatic Surgery Unit, Clinica Alemana, Santiago, Chile
| | - W Qiao
- Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - T E Newhook
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - M Okuno
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - F Castillo
- Department of Surgery, Hepato-Bilio-Pancreatic Surgery Unit, Clinica Alemana, Santiago, Chile
| | - M Sanhueza
- Department of Digestive Surgery, Hepato-Bilio-Pancreatic Surgery Unit, Surgery Service, Hospital Sotero Del Rio, Santiago, Chile.,Department of Digestive Surgery, Faculty of Medicine, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - C Diaz
- Department of Digestive Surgery, Hepato-Bilio-Pancreatic Surgery Unit, Surgery Service, Hospital Sotero Del Rio, Santiago, Chile.,Department of Digestive Surgery, Faculty of Medicine, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - G Cavada
- Department of Biostatistics, Clínica Alemana-Universidad del Desarrollo, Santiago, Chile
| | - N Jarufe
- Department of Digestive Surgery, Faculty of Medicine, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - C Munoz
- Department of Digestive Surgery, Faculty of Medicine, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - G Rencoret
- Department of Surgery, Hepato-Bilio-Pancreatic Surgery Unit, Clinica Alemana, Santiago, Chile
| | - M Vivanco
- Department of Surgery, Hepato-Bilio-Pancreatic Surgery Unit, Clinica Alemana, Santiago, Chile
| | - K Joechle
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - C-W D Tzeng
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - J-N Vauthey
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - E Vinuela
- Department of Digestive Surgery, Hepato-Bilio-Pancreatic Surgery Unit, Surgery Service, Hospital Sotero Del Rio, Santiago, Chile.,Department of Digestive Surgery, Faculty of Medicine, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - C Conrad
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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15
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Ramos E, Lluis N, Llado L, Torras J, Busquets J, Rafecas A, Serrano T, Mils K, Leiva D, Fabregat J. Prognostic value and risk stratification of residual disease in patients with incidental gallbladder cancer. World J Surg Oncol 2020; 18:18. [PMID: 31980034 PMCID: PMC6982379 DOI: 10.1186/s12957-020-1794-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 01/16/2020] [Indexed: 12/13/2022] Open
Abstract
Background and aim Given their poor prognosis, patients with residual disease (RD) in the re-resection specimen of an incidental gallbladder carcinoma (IGBC) could benefit from a better selection for surgical treatment. The Gallbladder Cancer Risk Score (GBRS) has been proposed to preoperatively identify RD risk more precisely than T-stage alone. The aim of this study was to assess the prognostic value of RD and to validate the GBRS in a retrospective series of patients. Material and methods A prospectively collected database including 59 patients with IGBC diagnosed from December 1996 to November 2015 was retrospectively analyzed. Three locations of RD were established: local, regional, and distant. The effect of RD on overall survival (OS) was analyzed with the Kaplan-Meier method. To identify variables associated with the presence of RD, characteristics of patients with and without RD were compared using Fisher’s exact test. The relative risk of RD associated with clinical and pathologic factors was studied with a univariate logistic regression analysis. Results RD was found in 30 patients (50.8%). The presence of RD in any location was associated with worse OS (29% vs. 74.2%, p = 0.0001), even after an R0 resection (37.7% vs 74.2%, p = 0.003). There was no significant difference in survival between patients without RD and with local RD (74.2% vs 64.3%, p = 0.266), nor between patients with regional RD and distant RD (16.1% vs 20%, p = 0.411). After selecting patients in which R0 resection was achieved (n = 44), 5-year survival rate for patients without RD, local RD, and regional RD was, respectively, 74.2%, 75%, and 13.9% (p = 0.0001). The GBRS could be calculated in 25 cases (42.3%), and its usefulness to predict the presence of regional or distant RD (RDRD) was confirmed (80% in high-risk patients and 30% in intermediate risk p = 0.041). Conclusion RDRD, but not local RD, represents a negative prognostic factor of OS. The GBRS was useful to preoperatively identify patients with high risk of RDRD. An R0 resection did not improve OS of patients with regional RD.
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Affiliation(s)
- Emilio Ramos
- Department of Surgery, IDIBELL, Hospital Universitario de Bellvitge, CIBERehd, Servicio de Cirugía General y Digestiva, Universidad de Barcelona, Av Feixa Llarga s/n, 08907, L'Hospitalet de Llobregat, Barcelona, Spain.
| | - Nuria Lluis
- Department of Surgery, IDIBELL, Hospital Universitario de Bellvitge, CIBERehd, Servicio de Cirugía General y Digestiva, Universidad de Barcelona, Av Feixa Llarga s/n, 08907, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Laura Llado
- Department of Surgery, IDIBELL, Hospital Universitario de Bellvitge, CIBERehd, Servicio de Cirugía General y Digestiva, Universidad de Barcelona, Av Feixa Llarga s/n, 08907, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Jaume Torras
- Department of Surgery, IDIBELL, Hospital Universitario de Bellvitge, CIBERehd, Servicio de Cirugía General y Digestiva, Universidad de Barcelona, Av Feixa Llarga s/n, 08907, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Juli Busquets
- Department of Surgery, IDIBELL, Hospital Universitario de Bellvitge, CIBERehd, Servicio de Cirugía General y Digestiva, Universidad de Barcelona, Av Feixa Llarga s/n, 08907, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Antoni Rafecas
- Department of Surgery, IDIBELL, Hospital Universitario de Bellvitge, CIBERehd, Servicio de Cirugía General y Digestiva, Universidad de Barcelona, Av Feixa Llarga s/n, 08907, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Teresa Serrano
- Department of Pathology, Hospital Universitario de Bellvitge, L'Hospitalet de Llobregat, Spain
| | - Kristel Mils
- Department of Surgery, IDIBELL, Hospital Universitario de Bellvitge, CIBERehd, Servicio de Cirugía General y Digestiva, Universidad de Barcelona, Av Feixa Llarga s/n, 08907, L'Hospitalet de Llobregat, Barcelona, Spain
| | - David Leiva
- Department of Radiology, Hospital Universitario de Bellvitge, L'Hospitalet de Llobregat, Spain
| | - Joan Fabregat
- Department of Surgery, IDIBELL, Hospital Universitario de Bellvitge, CIBERehd, Servicio de Cirugía General y Digestiva, Universidad de Barcelona, Av Feixa Llarga s/n, 08907, L'Hospitalet de Llobregat, Barcelona, Spain
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16
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Vega EA, Sanhueza M, Viñuela E. Minimally Invasive Surgery for Gallbladder Cancer. Surg Oncol Clin N Am 2019; 28:243-253. [DOI: 10.1016/j.soc.2018.11.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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17
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Vega EA, Vinuela E, Sanhueza M, Mege R, Caracci M, Diaz C, Diaz A, Okuno M, Joechle K, Goumard C, Chun YS, Tzeng CWD, Lee JE, Vauthey JN, Conrad C. Positive cystic duct margin at index cholecystectomy in incidental gallbladder cancer is an important negative prognosticator. Eur J Surg Oncol 2019; 45:1061-1068. [PMID: 30704808 DOI: 10.1016/j.ejso.2019.01.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Accepted: 01/10/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Prognostic factors following index-cholecystectomy in patients with incidental gallbladder cancer (IGBC) are poorly understood. The aim of this study was to assess the value of the initial cystic duct margin status as a prognosticator factor and to aid in clinical decision making to move forward with curative intent oncologic extended resection (OER). METHODS This retrospective study included patients with IGBC who underwent subsequent OER with curative intent at 2 centers (USA and Chile) between 1999 and 2016., Patients with and without evidence of residual cancer (RC) at OER were included. Pathologic features were examined, and predictors of overall survival (OS) were analyzed. RESULTS The study included 179 patients. Thirty-three patients (17%) had a positive cystic duct margin at the index cholecystectomy. Forty-two patients (23%) underwent resection of the common bile duct. OS was significantly worse in the patients with a positive cystic duct margin at index cholecystectomy (OS rates at 5 years, 34% vs 57%; p = 0.032). Following multivariate analysis, only a positive cystic duct margin at index cholecystectomy was predictive of worse OS in patients with no evidence of residual cancer (RC) at OER (hazard ratio, 1.7 95%CI 1.04-2.78; p = 0.034). CONCLUSIONS A positive cystic duct margin at index-cholecystectomy is a strong independent predictor of worse OS even if no further cancer is found at OER. In patients with positive cystic duct margin and no RC at OER common bile duct resection leads to improved outcomes.
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Affiliation(s)
- Eduardo A Vega
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA; Department of Digestive Surgery, Hepato-Pancreato-Biliary Surgery Unit, Surgery Service, Sotero del Rio Hospital, Santiago, Chile
| | - Eduardo Vinuela
- Department of Digestive Surgery, Hepato-Pancreato-Biliary Surgery Unit, Surgery Service, Sotero del Rio Hospital, Santiago, Chile; Department of Digestive Surgery, Faculty of Medicine, Catholic University of Chile, Santiago, Chile
| | - Marcel Sanhueza
- Department of Digestive Surgery, Hepato-Pancreato-Biliary Surgery Unit, Surgery Service, Sotero del Rio Hospital, Santiago, Chile; Department of Digestive Surgery, Faculty of Medicine, Catholic University of Chile, Santiago, Chile
| | - Rosemarie Mege
- Department of Digestive Surgery, Hepato-Pancreato-Biliary Surgery Unit, Surgery Service, Sotero del Rio Hospital, Santiago, Chile; Department of Digestive Surgery, Faculty of Medicine, Catholic University of Chile, Santiago, Chile
| | - Mario Caracci
- Department of Digestive Surgery, Hepato-Pancreato-Biliary Surgery Unit, Surgery Service, Sotero del Rio Hospital, Santiago, Chile; Department of Digestive Surgery, Faculty of Medicine, Catholic University of Chile, Santiago, Chile
| | - Cristian Diaz
- Department of Digestive Surgery, Hepato-Pancreato-Biliary Surgery Unit, Surgery Service, Sotero del Rio Hospital, Santiago, Chile; Department of Digestive Surgery, Faculty of Medicine, Catholic University of Chile, Santiago, Chile
| | - Alfonso Diaz
- Department of Digestive Surgery, Hepato-Pancreato-Biliary Surgery Unit, Surgery Service, Sotero del Rio Hospital, Santiago, Chile; Department of Digestive Surgery, Faculty of Medicine, Catholic University of Chile, Santiago, Chile
| | - Masayuki Okuno
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Katharina Joechle
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Claire Goumard
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Yun Shin Chun
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ching-Wei D Tzeng
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jeffrey E Lee
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jean-Nicolas Vauthey
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Claudius Conrad
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Incidental Gallbladder Cancer: How Residual Disease Affects Outcome in Two Referral HPB Centers from South America. World J Surg 2018; 43:214-220. [DOI: 10.1007/s00268-018-4762-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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19
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ETHUN CECILIAG, LE NINA, LOPEZ-AGUIAR ALEXANDRAG, PAWLIK TIMOTHYM, POULTSIDES GEORGE, TRAN THUY, IDREES KAMRAN, ISOM CHELSEAA, FIELDS RYANC, KRASNICK BRADLEYA, WEBER SHARONM, SALEM AHMED, MARTIN ROBERTCG, SCOGGINS CHARLESR, SHEN PERRY, MOGAL HARVESHPD, SCHMIDT CARL, BEAL ELIZA, HATZARAS IOANNIS, SHENOY RIVFKA, RUSSELL MARIAC, MAITHEL SHISHIRK. Pathologic and Prognostic Implications of Incidental versus Nonincidental Gallbladder Cancer: A 10-Institution Study from the United States Extrahepatic Biliary Malignancy Consortium. Am Surg 2017; 83:679-686. [PMID: 28738935 PMCID: PMC5915617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
Most gallbladder cancers (GBCs) are discovered incidentally after routine cholecystectomy. The influence of timing of diagnosis on disease stage, treatment, and prognosis is not known. Patients with GBC who underwent resection at 10 institutions from 2000 to 2015 were included. Patients diagnosed incidentally (IGBC) and nonincidentally (non-IGBC) were compared. Primary outcome was overall survival (OS). Of 445 patients with GBC, 266 (60%) were IGBC and 179 (40%) were non-IGBC. Compared with IGBC, non-IGBC patients were more likely to have R2 resections (43% vs 19%; P < 0.001), advanced T-stage (T3/T4: 70% vs 40%; P < 0.001), high-grade tumors (50% vs 31%; P < 0.001), lymphovascular invasion (64% vs 45%; P = 0.01), and positive lymph nodes (60% vs 43%; P = 0.009). Receipt of adjuvant chemotherapy was similar between groups (49% vs 49%). Non-IGBC was associated with worse median OS compared with IGBC (17 vs 32 months; P < 0.001), which persisted among stage III patients (12 vs 29 months; P < 0.001), but not stages I, II, or IV. Despite accounting for other adverse pathologic factors (grade, T-stage, lymphovascular invasion, margin, lymph node), adjuvant chemotherapy was associated with improved OS only in stage III IGBC, but not in non-IGBC. Compared with incidental discovery, non-IGBC is associated with reduced OS, which is most evident in stage III disease. Despite being well matched for other adverse pathologic factors, adjuvant chemotherapy was associated with improved survival only in stage III patients with incidentally discovered cancer. This underscores the importance of timing of diagnosis in GBC and suggests that these two groups may represent a distinct biology of disease, and the same treatment paradigm may not be appropriate.
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Affiliation(s)
- CECILIA G. ETHUN
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - NINA LE
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - ALEXANDRA G. LOPEZ-AGUIAR
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - TIMOTHY M. PAWLIK
- Division of Surgical Oncology, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland,Division of Surgical Oncology, The Ohio State University, Columbus, Ohio
| | - GEORGE POULTSIDES
- Department of Surgery, Stanford University Medical Center, Stanford, California
| | - THUY TRAN
- Department of Surgery, Stanford University Medical Center, Stanford, California
| | - KAMRAN IDREES
- Division of Surgical Oncology, Department of Surgery, Vanderbilt University, Nashville, Tennessee
| | - CHELSEA A. ISOM
- Division of Surgical Oncology, Department of Surgery, Vanderbilt University, Nashville, Tennessee
| | - RYAN C. FIELDS
- Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - BRADLEY A. KRASNICK
- Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - SHARON M. WEBER
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - AHMED SALEM
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - ROBERT C. G. MARTIN
- Division of Surgical Oncology, Department of Surgery, University of Louisville, Louisville, Kentucky
| | - CHARLES R. SCOGGINS
- Division of Surgical Oncology, Department of Surgery, University of Louisville, Louisville, Kentucky
| | - PERRY SHEN
- Department of Surgery, Wake Forest University, Winston-Salem, North Carolina
| | - HARVESHP D. MOGAL
- Department of Surgery, Wake Forest University, Winston-Salem, North Carolina
| | - CARL SCHMIDT
- Division of Surgical Oncology, The Ohio State University, Columbus, Ohio
| | - ELIZA BEAL
- Division of Surgical Oncology, The Ohio State University, Columbus, Ohio
| | | | - RIVFKA SHENOY
- Department of Surgery, New York University, New York, New York
| | - MARIA C. RUSSELL
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - SHISHIR K. MAITHEL
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
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20
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Ethun CG, Le N, Lopez-Aguiar AG, Pawlik TM, Poultsides G, Tran T, Idrees K, Isom CA, Fields RC, Krasnick BA, Weber SM, Salem A, Martin RCG, Scoggins CR, Shen P, Mogal HD, Schmidt C, Beal E, Hatzaras I, Shenoy R, Russell MC, Maithel SK. Pathologic and Prognostic Implications of Incidental versus Nonincidental Gallbladder Cancer: A 10-Institution Study from the United States Extrahepatic Biliary Malignancy Consortium. Am Surg 2017. [DOI: 10.1177/000313481708300721] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Most gallbladder cancers (GBCs) are discovered incidentally after routine cholecystectomy. The influence of timing of diagnosis on disease stage, treatment, and prognosis is not known. Patients with GBC who underwent resection at 10 institutions from 2000 to 2015 were included. Patients diagnosed incidentally (IGBC) and nonincidentally (non-IGBC) were compared. Primary outcome was overall survival (OS). Of 445 patients with GBC, 266 (60%) were IGBC and 179 (40%) were non-IGBC. Compared with IGBC, non-IGBC patients were more likely to have R2 resections (43% vs 19%; P < 0.001), advanced T-stage (T3/T4: 70% vs 40%; P < 0.001), high-grade tumors (50% vs 31%; P < 0.001), lymphovascular invasion (64% vs 45%; P = 0.01), and positive lymph nodes (60% vs 43%; P = 0.009). Receipt of adjuvant chemotherapy was similar between groups (49% vs 49%). Non-IGBC was associated with worse median OS compared with IGBC (17 vs 32 months; P < 0.001), which persisted among stage III patients (12 vs 29 months; P < 0.001), but not stages I, II, or IV. Despite accounting for other adverse pathologic factors (grade, T-stage, lymphovascular invasion, margin, lymph node), adjuvant chemotherapy was associated with improved OS only in stage III IGBC, but not in non-IGBC. Compared with incidental discovery, non-IGBC is associated with reduced OS, which is most evident in stage III disease. Despite being well matched for other adverse pathologic factors, adjuvant chemotherapy was associated with improved survival only in stage III patients with incidentally discovered cancer. This underscores the importance of timing of diagnosis in GBC and suggests that these two groups may represent a distinct biology of disease, and the same treatment paradigm may not be appropriate.
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Affiliation(s)
- Cecilia G. Ethun
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Nina Le
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Alexandra G. Lopez-Aguiar
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Timothy M. Pawlik
- Division of Surgical Oncology, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
- Division of Surgical Oncology, The Ohio State University, Columbus, Ohio
| | - George Poultsides
- Department of Surgery, Stanford University Medical Center, Stanford, California
| | - Thuy Tran
- Department of Surgery, Stanford University Medical Center, Stanford, California
| | - Kamran Idrees
- Division of Surgical Oncology, Department of Surgery, Vanderbilt University, Nashville, Tennessee
| | - Chelsea A. Isom
- Division of Surgical Oncology, Department of Surgery, Vanderbilt University, Nashville, Tennessee
| | - Ryan C. Fields
- Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Bradley A. Krasnick
- Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Sharon M. Weber
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Ahmed Salem
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Robert C. G. Martin
- Division of Surgical Oncology, Department of Surgery, University of Louisville, Louisville, Kentucky
| | - Charles R. Scoggins
- Division of Surgical Oncology, Department of Surgery, University of Louisville, Louisville, Kentucky
| | - Perry Shen
- Department of Surgery, Wake Forest University, Winston-Salem, North Carolina
| | - Harveshp D. Mogal
- Department of Surgery, Wake Forest University, Winston-Salem, North Carolina
| | - Carl Schmidt
- Division of Surgical Oncology, The Ohio State University, Columbus, Ohio
| | - Eliza Beal
- Division of Surgical Oncology, The Ohio State University, Columbus, Ohio
| | | | - Rivfka Shenoy
- Department of Surgery, New York University, New York, New York
| | - Maria C. Russell
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Shishir K. Maithel
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
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21
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Ethun CG, Postlewait LM, Le N, Pawlik TM, Buettner S, Poultsides G, Tran T, Idrees K, Isom CA, Fields RC, Jin LX, Weber SM, Salem A, Martin RCG, Scoggins C, Shen P, Mogal HD, Schmidt C, Beal E, Hatzaras I, Shenoy R, Kooby DA, Maithel SK. Association of Optimal Time Interval to Re-resection for Incidental Gallbladder Cancer With Overall Survival: A Multi-Institution Analysis From the US Extrahepatic Biliary Malignancy Consortium. JAMA Surg 2017; 152:143-149. [PMID: 27784058 DOI: 10.1001/jamasurg.2016.3642] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Importance The current recommendation is to perform re-resection for select patients with incidentally discovered gallbladder cancer. The optimal time interval for re-resection for both patient selection and long-term survival is not known. Objective To assess the association of time interval from the initial cholecystectomy to reoperation with overall survival. Design, Setting, and Participants This cohort study was conducted from January 1, 2000, to December 31, 2014 at 10 US academic institutions. A total of 207 patients with incidentally discovered gallbladder cancer who underwent reoperation and had available data on the date of their initial cholecystectomy were included. Exposures Time interval from the initial cholecystectomy to reoperation: group A: less than 4 weeks; group B: 4 to 8 weeks; and group C: greater than 8 weeks. Main Outcomes and Measures Primary outcome was overall survival. Results Of 449 patients with gallbladder cancer, 207 cases (46%) were discovered incidentally and underwent reoperation at 3 different time intervals from the date of the original cholecystectomy: group A: less than 4 weeks (25 patients, 12%); B: 4 to 8 weeks (91 patients, 44%); C: more than 8 weeks (91 patients, 44%). The mean (SD) ages of patients in groups A, B, and C were 65 (9), 64 (11), and 66 (12) years, respectively. All groups were similar for baseline demographics, extent of resection, presence of residual disease, T stage, resection margin status, lymph node involvement, and postoperative complications. Patients who underwent reoperation between 4 and 8 weeks had the longest median overall survival (group B: 40.4 months) compared with those who underwent early (group A: 17.4 months) or late (group C: 22.4 months) reoperation (log-rank P = .03). Group A and C time intervals (vs group B), presence of residual disease, an R2 resection, advanced T stage, and lymph node involvement were associated with decreased overall survival on univariable Cox regression. Only group A (hazard ratio, 2.63; 95% CI, 1.25-5.54) and group C (hazard ratio, 2.07; 95% CI, 1.17-3.66) time intervals (vs group B), R2 resection (hazard ratio, 2.69; 95% CI, 1.27-5.69), and advanced Tstage (hazard ratio, 1.85; 95% CI, 1.11-3.08) persisted on multivariable Cox regression analysis. Conclusions and Relevance The optimal time interval for re-resection for incidentally discovered gallbladder cancer appears to be between 4 and 8 weeks after the initial cholecystectomy.
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Affiliation(s)
- Cecilia G Ethun
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Lauren M Postlewait
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Nina Le
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Timothy M Pawlik
- Division of Surgical Oncology, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland3Deputy Editor, JAMA Surgery
| | - Stefan Buettner
- Division of Surgical Oncology, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
| | - George Poultsides
- Department of Surgery, Stanford University Medical Center, Stanford, California
| | - Thuy Tran
- Department of Surgery, Stanford University Medical Center, Stanford, California
| | - Kamran Idrees
- Division of Surgical Oncology, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Chelsea A Isom
- Division of Surgical Oncology, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ryan C Fields
- Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Linda X Jin
- Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Sharon M Weber
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison
| | - Ahmed Salem
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison
| | - Robert C G Martin
- Division of Surgical Oncology, Department of Surgery, University of Louisville, Louisville, Kentucky
| | - Charles Scoggins
- Division of Surgical Oncology, Department of Surgery, University of Louisville, Louisville, Kentucky
| | - Perry Shen
- Department of Surgery, Wake Forest University, Winston-Salem, North Carolina
| | - Harveshp D Mogal
- Department of Surgery, Wake Forest University, Winston-Salem, North Carolina
| | - Carl Schmidt
- Division of Surgical Oncology, The Ohio State University Comprehensive Cancer Center, Columbus
| | - Eliza Beal
- Division of Surgical Oncology, The Ohio State University Comprehensive Cancer Center, Columbus
| | | | - Rivfka Shenoy
- Department of Surgery, New York University, New York
| | - David A Kooby
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Shishir K Maithel
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
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22
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Ethun CG, Postlewait LM, Le N, Pawlik TM, Buettner S, Poultsides G, Tran T, Idrees K, Isom CA, Fields RC, Jin LX, Weber SM, Salem A, Martin RCG, Scoggins C, Shen P, Mogal HD, Schmidt C, Beal E, Hatzaras I, Shenoy R, Merchant N, Cardona K, Maithel SK. A Novel Pathology-Based Preoperative Risk Score to Predict Locoregional Residual and Distant Disease and Survival for Incidental Gallbladder Cancer: A 10-Institution Study from the U.S. Extrahepatic Biliary Malignancy Consortium. Ann Surg Oncol 2017; 24:1343-1350. [PMID: 27812827 PMCID: PMC6054592 DOI: 10.1245/s10434-016-5637-x] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND This study was designed to develop a more robust predictive model, beyond T-stage alone, for incidental gallbladder cancer (IGBC) for discovering locoregional residual (LRD) and distant disease (DD) at reoperation, and estimating overall survival (OS). T-stage alone is currently used to guide treatment for incidental gallbladder cancer. Residual disease at re-resection is the most important factor in predicting outcomes. METHODS All patients with IGBC who underwent reoperation at 10 institutions from 2000 to 2015 were included. Routine pathology data from initial cholecystectomy was utilized to create the gallbladder cancer predictive risk score (GBRS). RESULTS Of 449 patients with gallbladder cancer, 262 (58 %) were incidentally discovered and underwent reoperation. Advanced T-stage, grade, and presence of lymphovascular (LVI) and perineural (PNI) invasion were all associated with increased rates of DD and LRD and decreased OS. Each pathologic characteristic was assigned a value (T1a: 0, T1b: 1, T2: 2, T3/4: 3; well-diff: 1, mod-diff: 2, poor-diff: 3; LVI-neg: 1, LVI-pos: 2; PNI-neg: 1, PNI-pos: 2), which added to a total GBRS score from 3 to 10. The scores were separated into three risk-groups (low: 3-4, intermediate: 5-7, high: 8-10). Each progressive GBRS group was associated with an increased incidence LRD and DD at the time of re-resection and reduced OS. CONCLUSIONS By accounting for subtle pathologic variations within each T-stage, this novel predictive risk-score better stratifies patients with incidentally discovered gallbladder cancer. Compared with T-stage alone, it more accurately identifies patients at risk for locoregional-residual and distant disease and predicts long-term survival as it redistributes T1b, T2, and T3 disease across separate risk-groups based on additional biologic features. This score may help to optimize treatment strategy for patients with incidentally discovered gallbladder cancer.
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Affiliation(s)
- Cecilia G. Ethun
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Lauren M. Postlewait
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Nina Le
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Timothy M. Pawlik
- Division of Surgical Oncology, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD
| | - Stefan Buettner
- Division of Surgical Oncology, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD
| | - George Poultsides
- Department of Surgery, Stanford University Medical Center, Stanford, CA
| | - Thuy Tran
- Department of Surgery, Stanford University Medical Center, Stanford, CA
| | - Kamran Idrees
- Division of Surgical Oncology, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Chelsea A. Isom
- Division of Surgical Oncology, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Ryan C. Fields
- Department of Surgery, Washington University School of Medicine, St Louis, MO
| | - Linda X. Jin
- Department of Surgery, Washington University School of Medicine, St Louis, MO
| | - Sharon M. Weber
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Ahmed Salem
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Robert C. G. Martin
- Division of Surgical Oncology, Department of Surgery, University of Louisville, Louisville, KY
| | - Charles Scoggins
- Division of Surgical Oncology, Department of Surgery, University of Louisville, Louisville, KY
| | - Perry Shen
- Department of Surgery, Wake Forest University, Winston-Salem, NC
| | | | - Carl Schmidt
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - Eliza Beal
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | | | - Rivfka Shenoy
- Department of Surgery, New York University, New York, NY
| | - Nipun Merchant
- Division of Surgical Oncology, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN,Division of Surgical Oncology, Department of Surgery, University of Miami, Miami, FL
| | - Kenneth Cardona
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Shishir K. Maithel
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA
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23
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Ethun CG, Postlewait LM, Le N, Pawlik TM, Poultsides G, Tran T, Idrees K, Isom CA, Fields RC, Krasnick BA, Weber SM, Salem A, Martin RCG, Scoggins CR, Shen P, Mogal HD, Schmidt C, Beal E, Hatzaras I, Shenoy R, Cardona K, Maithel SK. Routine port-site excision in incidentally discovered gallbladder cancer is not associated with improved survival: A multi-institution analysis from the US Extrahepatic Biliary Malignancy Consortium. J Surg Oncol 2017; 115:805-811. [PMID: 28230242 DOI: 10.1002/jso.24591] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Revised: 01/30/2017] [Accepted: 02/01/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Current data on the utility of port-site excision (PSE) during re-resection for incidentally discovered gallbladder cancer (IGBC) in the US are conflicting and limited to single-institution series. METHODS All patients with IGBC who underwent curative re-resection at 10 institutions from 2000 to 2015 were included. Patients with and without PSE were compared. Primary outcome was overall survival (OS). RESULTS Of 449 pts with GBC, 266 were incidentally discovered, of which 193(73%) underwent curative re-resection and had port-site data; 47 pts(24%) underwent PSE, 146(76%) did not. The PSE rate remained similar over time (2000-2004: 33%; 2005-2009: 22%; 2010-2015:22%; P = 0.36). Both groups had similar demographics, operative procedures, and post-operative complications. There was no difference in T-stage (T1: 9 vs. 11%; T2: 52 vs. 52%; T3: 39 vs. 38%; P = 0.96) or LN involvement (36 vs. 41%; P = 0.7) between groups. A 3-year OS was similar between PSE and no PSE groups (65 vs. 43%; P = 0.07). On univariable analysis, residual disease at re-resection (HR = 2.1, 95% CI 1.4-3.3; P = 0.001), high tumor grade, and advanced T-stage were associated with decreased OS. Only grade and T-stage, but not PSE, persisted on multivariable analysis. Distant disease recurrence-rate was identical between PSE and no PSE groups (80 vs. 81%; P = 1.0). CONCLUSION Port-site excision during re-resection for IGBC is not associated with improved overall survival and has the same distant disease recurrence compared to no port-site excision. Routine port-site excision is not recommended.
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Affiliation(s)
- Cecilia G Ethun
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Lauren M Postlewait
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Nina Le
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Timothy M Pawlik
- Division of Surgical Oncology, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland.,Division of Surgical Oncology, The Ohio State University, Columbus, Ohio
| | - George Poultsides
- Department of Surgery, Stanford University Medical Center, Stanford, California
| | - Thuy Tran
- Department of Surgery, Stanford University Medical Center, Stanford, California
| | - Kamran Idrees
- Division of Surgical Oncology, Department of Surgery, Vanderbilt University, Nashville, Tennessee
| | - Chelsea A Isom
- Division of Surgical Oncology, Department of Surgery, Vanderbilt University, Nashville, Tennessee
| | - Ryan C Fields
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Bradley A Krasnick
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Sharon M Weber
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Ahmed Salem
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Robert C G Martin
- Division of Surgical Oncology, Department of Surgery, University of Louisville, Louisville, Kentucky
| | - Charles R Scoggins
- Division of Surgical Oncology, Department of Surgery, University of Louisville, Louisville, Kentucky
| | - Perry Shen
- Department of Surgery, Wake Forest University, Winston-Salem, North Carolina
| | - Harveshp D Mogal
- Department of Surgery, Wake Forest University, Winston-Salem, North Carolina
| | - Carl Schmidt
- Division of Surgical Oncology, The Ohio State University, Columbus, Ohio
| | - Eliza Beal
- Division of Surgical Oncology, The Ohio State University, Columbus, Ohio
| | | | - Rivfka Shenoy
- Department of Surgery, New York University, New York, New York
| | - Kenneth Cardona
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Shishir K Maithel
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
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Watson H, Dasari B, Wyatt J, Hidalgo E, Prasad R, Lodge P, Toogood G. Does a second resection provide a survival benefit in patients diagnosed with incidental T1b/T2 gallbladder cancer following cholecystectomy? HPB (Oxford) 2017; 19:104-107. [PMID: 27986417 DOI: 10.1016/j.hpb.2016.11.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Revised: 11/07/2016] [Accepted: 11/13/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Incidental T1b/T2 gallbladder cancers are often managed with a second resection. However it is unclear whether the additional surgical risk is associated with any survival advantage. The aim of this study was to examine the outcomes of patients who underwent a second resection following a diagnosis of incidental T1b/T2 gallbladder cancer. METHODS A retrospective analysis of patients undergoing surgical management following a diagnosis of incidental T1b/T2 gallbladder cancer between 1994 and 2014. Survival outcomes were analysed using the Kaplan-Meier method. RESULTS Twenty two patients underwent completion surgery following diagnosis of T1b/T2 gallbladder cancer at initial cholecystectomy, 11 of which were found to have residual disease. The presence of residual disease at second surgery in T1b/T2 disease was associated with worse overall survival (residual disease: median survival 12 months, absence of residual disease: median survival not reached, p = 0.025). CONCLUSION A significant percentage of patients with T1b/T2 disease have identifiable residual disease following second surgery. Residual disease is associated with poor survival. It is therefore important to inform patients that completion cholecystectomy is primarily performed to inform staging rather than to improve prognosis.
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Affiliation(s)
- Henry Watson
- Department of HPB & Transplant Surgery, St James University Hospital, Beckett Street, Leeds, LS97TF, UK
| | - Bobby Dasari
- Department of HPB & Transplant Surgery, St James University Hospital, Beckett Street, Leeds, LS97TF, UK
| | - Judy Wyatt
- Department of Histopathology, St James University Hospital, Beckett Street, Leeds, LS97TF, UK
| | - Ernest Hidalgo
- Department of HPB & Transplant Surgery, St James University Hospital, Beckett Street, Leeds, LS97TF, UK
| | - Raj Prasad
- Department of HPB & Transplant Surgery, St James University Hospital, Beckett Street, Leeds, LS97TF, UK
| | - Peter Lodge
- Department of HPB & Transplant Surgery, St James University Hospital, Beckett Street, Leeds, LS97TF, UK
| | - Giles Toogood
- Department of HPB & Transplant Surgery, St James University Hospital, Beckett Street, Leeds, LS97TF, UK.
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25
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Martins-Filho ED, Batista TP, Kreimer F, Martins ACDA, Iwanaga TC, Leão CDS. PREVALENCE OF INCIDENTAL GALLBLADDER CANCER IN A TERTIARY-CARE HOSPITAL FROM PERNAMBUCO, BRAZIL. ARQUIVOS DE GASTROENTEROLOGIA 2016; 52:247-9. [PMID: 26486295 DOI: 10.1590/s0004-28032015000300017] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Accepted: 03/16/2015] [Indexed: 11/22/2022]
Abstract
BACKGROUND Gallbladder cancer is sometimes incidentally uncovered following cholecystectomy for gallstones diseases. The supposed highly variable prevalence of incidental gallbladder cancer through our country is unknown. OBJECTIVE To explore the prevalence of incidental gallbladder cancer in our tertiary-care hospital. METHODS A cross-sectional study was carried out on patients who consecutively underwent cholecystectomy due to gallstones disease at Faculdade Pernambucana de Saúde, Instituto de Medicina Integral Professor Fernando Figueira - FPS/IMIP, from January, 2007 to December, 2010. Data on incidental gallbladder cancer patients were explored for prevalence estimation and description of our experience with the management of this malignancy. RESULTS Our analysis involved 2018 patients with a marked predominance of women (n=1.697; 84.1%) over men (n=321; 15.9%). The 3-year prevalence estimate of 0.34% was recorded for incidental gallbladder cancer in our sample. Regarding tumor staging, there were 1 T1a, 1 T1b, and 5 T2 adenocarcinoma tumors. Laparoscopic cholecystectomy alone was performed for the T1a tumor, and additional radical surgery was performed in five others. One patient presented metastatic disease at the time of repeat surgery. The final pathology revealed residual/additional disease in all T2 tumors after radical surgery whereas the T1b patient underwent a salvage Whipple's procedure due to a secondary distal cholangiocarcinoma. The patient with T1a tumor is alive after 3-year follow-up but all of the others died because of disease recurrence/progression up to 12 months. CONCLUSION This study confirms the poor prognosis of Gallbladder cancer even when incidentally diagnosed following cholecystectomy and supposes a 3-year prevalence estimate of 0.34% for incidental gallbladder cancer in our Center from Pernambuco State, Brazil.
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Affiliation(s)
- Euclides Dias Martins-Filho
- Departamento de Cirurgia, Faculdade Pernambucana de Saúde, Instituto de Medicina Integral Professor Fernando Figueira, Recife, PE, BR
| | - Thales Paulo Batista
- Departamento de Cirurgia, Faculdade Pernambucana de Saúde, Instituto de Medicina Integral Professor Fernando Figueira, Recife, PE, BR
| | - Flávio Kreimer
- Departamento de Cirurgia, Faculdade Pernambucana de Saúde, Instituto de Medicina Integral Professor Fernando Figueira, Recife, PE, BR
| | | | - Tiago Cavalcanti Iwanaga
- Departamento de Cirurgia, Faculdade Pernambucana de Saúde, Instituto de Medicina Integral Professor Fernando Figueira, Recife, PE, BR
| | - Cristiano de Souza Leão
- Departamento de Cirurgia, Faculdade Pernambucana de Saúde, Instituto de Medicina Integral Professor Fernando Figueira, Recife, PE, BR
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Benefit of extended radical surgery for incidental gallbladder carcinoma. Surg Today 2015; 46:453-9. [DOI: 10.1007/s00595-015-1198-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Accepted: 04/30/2015] [Indexed: 02/06/2023]
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Machado MA, Makdissi FF, Surjan RC. Totally Laparoscopic Hepatic Bisegmentectomy (s4b+s5) and Hilar Lymphadenectomy for Incidental Gallbladder Cancer. Ann Surg Oncol 2015; 22 Suppl 3:S336-9. [PMID: 26059653 DOI: 10.1245/s10434-015-4650-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Indexed: 12/18/2022]
Abstract
BACKGROUND Gallbladder cancer is suspected preoperatively in only 30 % of all patients, while the remaining 70 % of cases are discovered incidentally by the pathologist. The increasing rate of cholecystectomies via laparoscopy has led to the detection of more gallbladder cancers in an early stage, and extended resection with regional lymph node dissection has been suggested. We present a video of a totally laparoscopic liver resection (segments 5 and 4b) with regional lymphadenectomy in a patient with an incidental gallbladder cancer. METHODS A 50-year-old woman underwent laparoscopic cholecystectomy, and pathology revealed a T1b gallbladder carcinoma. The patient was referred for further treatment. Contact with the primary surgeon revealed that no intraoperative cholangiogram was performed, and the gallbladder was removed intact, with no perforation, and inside a plastic retrieval bag. Pathology revision confirmed T1b, and positron emission tomography/computed tomography was negative. The multidisciplinary tumor board recommended radical re-resection, and a decision was made to perform a laparoscopic extended hilar lymphadenectomy, along the resection of segments 5 and 4b. RESULTS Operative time was 5 h, with an estimated blood loss of 240 mL. Recovery was uneventful and the patient was discharged on the fourth postoperative day. Final pathology showed no residual disease and no lymph node metastasis. CONCLUSIONS Laparoscopic resection of liver segments 5 and 4b combined with a locoregional lymphadenectomy of the hepatoduodenal ligament is an oncologically appropriate technique, provided it is performed in a specialized center with experience in hepatobiliary surgery and advanced laparoscopic surgery. This video may help oncological surgeons to perform this complex procedure.
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Affiliation(s)
| | - Fabio F Makdissi
- Department of Surgery, Sirio Libanes Hospital, São Paulo, Brazil.,Department of Gastroenterology, University of Sao Paulo, São Paulo, Brazil
| | - Rodrigo C Surjan
- Department of Surgery, Sirio Libanes Hospital, São Paulo, Brazil
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Choi KS, Choi SB, Park P, Kim WB, Choi SY. Clinical characteristics of incidental or unsuspected gallbladder cancers diagnosed during or after cholecystectomy: A systematic review and meta-analysis. World J Gastroenterol 2015; 21:1315-1323. [PMID: 25632207 PMCID: PMC4306178 DOI: 10.3748/wjg.v21.i4.1315] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2014] [Revised: 07/23/2014] [Accepted: 09/19/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To perform a systematic review of incidental or unsuspected gallbladder (GB) cancer diagnosed during or after cholecystectomy.
METHODS: Data in PubMed, EMBASE, and Cochrane Library were reviewed and 26 publications were included in the meta-analysis. The inclusion criterion for incidental GB cancer was GB cancer diagnosed during or after cholecystectomy that was not suspected at a preoperative stage. Pooled proportions of the incidence, distribution of T stage, and revisional surgery of incidental GB cancer were analyzed.
RESULTS: The final pooled population comprised 2145 patients with incidental GB cancers. Incidental GB cancers were found in 0.7% of cholecystectomies performed for benign gallbladder diseases on preoperative diagnosis (95%CI: 0.004-0.012). Nearly 50% of the incidental GB cancers were stage T2 with a pooled proportion of 47.0% (95%CI: 0.421-0.519). T1 and T3 GB cancers were found at a similar frequency, with pooled proportions of 23.0% (95%CI: 0.178-0.291) and 25.1% (95%CI: 0.195-0.317), respectively. The pooled proportion that completed revisional surgery for curative intent was 40.9% (95%CI: 0.329-0.494). The proportion of patients with unresectable disease upon revisional surgery was 23.0% (95%CI: 0.177-0.294).
CONCLUSION: A large proportion of incidental GB cancers were T2 and T3 lesions. Revisional surgery for radical cholecystectomy is warranted in T2 and more advanced cancers.
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Yip VS, Gomez D, Brown S, Byrne C, White D, Fenwick SW, Poston GJ, Malik HZ. Management of incidental and suspicious gallbladder cancer: focus on early referral to a tertiary centre. HPB (Oxford) 2014; 16:641-7. [PMID: 24279377 PMCID: PMC4105902 DOI: 10.1111/hpb.12189] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2013] [Accepted: 09/03/2013] [Indexed: 12/12/2022]
Abstract
OBJECTIVES This study was conducted to assess the management of incidental gallbladder cancer and indeterminate gallbladder lesions. Its secondary aim referred to the devising of a management pathway for these patients. METHODS Patients referred with incidental gallbladder cancer and indeterminate gallbladder lesions during 2002-2011 were identified from a prospectively maintained database. Collated data included operative findings, histopathological data and survival outcomes. RESULTS The study included a total of 104 patients, 40 of whom had incidental gallbladder cancer following cholecystectomy. In this group, the index cholecystectomy was considered curative (T-is/T1a stage) in three patients; 11 patients underwent further resection, and 26 patients were inoperable. One-, 3- and 5-year overall survival rates were 91.1%, 91.0% and 60.7%, respectively, in patients who underwent re-resection. Of the 64 patients with indeterminate gallbladder lesions, 54 patients underwent modified radical cholecystectomy. Seven patients were found to have gallbladder cancer. One-, 3- and 5-year overall survival rates were 85.9%, 43.1% and 42.8%, respectively. Five-year overall survival in patients treated with surgery for gallbladder cancer was 59.9%. CONCLUSIONS The majority of patients with incidental gallbladder cancer were not amenable to further potentially curative resection. The radiological suspicion of gallbladder cancer should lead to prompt referral to a tertiary hepatobiliary unit for further management.
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Affiliation(s)
- Vincent S Yip
- North Western Hepatobiliary Unit, Aintree University Hospital National Health Service Foundation TrustLiverpool, UK
| | - Dhanwant Gomez
- North Western Hepatobiliary Unit, Aintree University Hospital National Health Service Foundation TrustLiverpool, UK
| | - Sean Brown
- North Western Hepatobiliary Unit, Aintree University Hospital National Health Service Foundation TrustLiverpool, UK
| | - Clare Byrne
- North Western Hepatobiliary Unit, Aintree University Hospital National Health Service Foundation TrustLiverpool, UK
| | - David White
- Department of Radiology, Aintree University Hospital National Health Service Foundation TrustLiverpool, UK
| | - Stephen W Fenwick
- North Western Hepatobiliary Unit, Aintree University Hospital National Health Service Foundation TrustLiverpool, UK
| | - Graeme J Poston
- North Western Hepatobiliary Unit, Aintree University Hospital National Health Service Foundation TrustLiverpool, UK
| | - Hassan Z Malik
- North Western Hepatobiliary Unit, Aintree University Hospital National Health Service Foundation TrustLiverpool, UK
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Butte JM, Kingham TP, Gönen M, D'Angelica MI, Allen PJ, Fong Y, DeMatteo RP, Jarnagin WR. Residual disease predicts outcomes after definitive resection for incidental gallbladder cancer. J Am Coll Surg 2014; 219:416-29. [PMID: 25087941 DOI: 10.1016/j.jamcollsurg.2014.01.069] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2013] [Revised: 12/24/2013] [Accepted: 01/13/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND Residual disease (RD) at definitive resection of incidental gallbladder cancer (IGBCA) influences outcome, but its clinical relevance with respect to anatomic site is incompletely characterized. STUDY DESIGN Consecutive patients with IGBCA undergoing re-exploration from 1998 to 2009 were identified; those submitted to a complete resection were analyzed. Demographics and tumor- and treatment-related variables were correlated with RD and survival. Cancer-specific survival was stratified by site of RD (local [gallbladder bed]; regional [bile duct, lymph nodes]; distant [discontiguous liver, port site, peritoneal]). RESULTS Of the 135 patients submitted to re-exploration, RD was found in 82 (61%) overall and in 63 (54%) of 116 patients submitted to resection; the most common site was regional (n = 27, 43%). The T stage of the gallbladder specimen was the only independent predictor of RD (T1b = 35.7%, T2 = 48.3%, T3 = 70%, p = 0.015). The presence of RD at any site dramatically reduced median disease-free survival (DFS) (11.2 vs 93.4 months, p < 0.0001) and disease-specific survival (DSS) (25.2 months vs not reached, p < 0.0001) compared with no RD, respectively. Disease-specific survival did not differ according to RD location, with all anatomic sites being equally poor (p = 0.87). Residual disease at any site predicted DFS (hazard ratio [HR] 3.3, 95% CI 1.9 to 5.7, p = 0.0003) and DSS (HR 2.4, 95% CI 1.2 to 4.6, p = 0.01), independent of all other tumor-related variables. CONCLUSIONS Survival in patients with RD at local or regional sites was not significantly different than that seen in stage IV disease, with neither subgroup clearly benefiting from reoperation. Outcomes were poor in all patients with RD, regardless of location.
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Affiliation(s)
- Jean M Butte
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - T Peter Kingham
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Mithat Gönen
- Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, NY
| | | | - Peter J Allen
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Yuman Fong
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Ronald P DeMatteo
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - William R Jarnagin
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY.
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Pilgrim CHC, Groeschl RT, Turaga KK, Gamblin TC. Key factors influencing prognosis in relation to gallbladder cancer. Dig Dis Sci 2013; 58:2455-62. [PMID: 23695876 DOI: 10.1007/s10620-013-2713-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2013] [Accepted: 05/02/2013] [Indexed: 12/11/2022]
Abstract
INTRODUCTION The 5-year survival of patients with gallbladder cancer remains low. However, patients can be stratified into prognostic categories based on established factors such as T, N, and R status. New concepts regarding prognostic significance of lymph node disease, the importance of residual gallbladder fossa disease, and the gravity of presentation with jaundice are reviewed. In addition, a number of new prognostic factors proposed in recent years are considered. METHODS PubMed was searched for "gallbladder cancer" with builder "date-completion" 2008 to present. A total of 1,490 articles were screened from which 168 were retrieved. From this, 40 articles specifically related to prognosis form the basis for this review. DISCUSSION Key factors of prognostic significance remain T and N stage and R0 resection. Residual disease either in the gallbladder fossa, lymph nodes, or cystic duct margin dictates hepatectomy, lymphadenectomy and bile duct resection, respectively. Adequate lymphadenectomy requires removal of six nodes, and hepatectomy must be sufficient to achieve R0. Subtleties regarding lymph node ratio, significance of pathological features such as dedifferentiation, and budding may hold value for stratifying patients with early stage disease, but require further investigation.
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Affiliation(s)
- Charles Henry Caldow Pilgrim
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, 9200 W Wisconsin Ave, Milwaukee, WI 53226, USA.
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Comparison of the sixth and seventh editions of the AJCC TNM classification for gallbladder cancer. J Gastrointest Surg 2013; 17:925-30. [PMID: 23299221 DOI: 10.1007/s11605-012-2134-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2012] [Accepted: 12/14/2012] [Indexed: 01/31/2023]
Abstract
BACKGROUND This study aimed to compare the seventh edition of the tumor node metastasis (TNM) staging system to the sixth edition to validate its usefulness in predicting prognosis for gallbladder cancer. METHODS Gallbladder cancer patients were staged according to both the sixth and seventh editions of the American Joint Committee on Cancer (AJCC) staging system. RESULTS A total of 142 patients underwent cholecystectomy for gallbladder cancer. According to the seventh edition, the survival time of N1 and N2 was different (P = 0.006), and the survival difference between N0 and N1 became significant after excluding cases with no lymph node dissection (P = 0.035). The -2 log likelihoods of the sixth and seventh edition TNM stages were 216.282 and 217.460, respectively, suggesting non-superiority of the seventh edition. Excluding cases with no lymph node dissection resulted in a lower -2 log likelihood score for both editions (sixth, 157.002; seventh, 158.758). CONCLUSIONS Sufficient lymph node dissection allows better prognostic stratification by application of the AJCC staging system. Even though the new N stage of the seventh edition showed some improvement in predicting prognosis, the overall performance of the seventh edition was not much better than the sixth. Further improvement is needed in the gallbladder cancer staging system.
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