A prospective analysis of the preoperative assessment of duodenal involvement in gallbladder cancer

Gallbladder cancer: Progress in the Indian subcontinent

Gallbladder cancer (GBC) is one of the commonest biliary malignancies seen in India, Argentina, and Japan. The disease has dismal outcome as it is detected quite late due to nonspecific symptoms and signs. Early detection is the only way to improve the outcome. There have been several advances in basic as well as clinical research in the hepatobiliary and pancreatic diseases in the West and other developed countries but not enough has been done in GBC. Therefore, it is important and the responsibility of the countries with high burden of GBC to find solutions to the many unanswered questions like etiopathogenesis, early diagnosis, treatment, and prognostication. As India being one of the largest hubs for GBC in the world, it is important to know how the country has progressed on GBC. In this review, we will discuss the outcome of the publications from India highlighting the work and the developments taken place in past several decades both in basic and clinical research.

Gastrointestinal involvement in gallbladder cancer: Computed tomography findings and proposal of a classification system

BACKGROUND

There is relatively scarce data on the computed tomography (CT) detection of gastrointestinal (GI) involvement in gallbladder cancer (GBC). We aim to assess the GI involvement in GBC on CT and propose a CT-based classification.

METHODS

This retrospective study comprized consecutive patients with GBC who underwent contrast-enhanced computed tomography (CECT) for staging between January 2019 and April 2022. Two radiologists evaluated the CT images independently for the morphological type of GBC and the presence of GI involvement. GI involvement was classified into probable involvement, definite involvement and GI fistulization. The incidence of GI involvement and the association of GI involvement with the morphological type of GBC was evaluated. In addition, the inter-observer agreement for GI involvement was assessed.

RESULTS

Over the study period, 260 patients with GBC were evaluated. Forty-three (16.5%) patients had GI involvement. Probable GI involvement, definite GI involvement and GI fistulization were seen in 18 (41.9%), 19 (44.2%) and six (13.9%) patients, respectively. Duodenum was the most common site of involvement (55.8%), followed by hepatic flexure (23.3%), antropyloric region (9.3%) and transverse colon (2.3%). There was no association between GI involvement and morphological type of GBC. There was substantial to near-perfect agreement between the two radiologists for the overall GI involvement (k = 0.790), definite GI involvement (k = 0.815) and GI fistulization (k = 0.943). There was moderate agreement (k = 0.567) for probable GI involvement.

CONCLUSION

GBC frequently involves the GI tract and CT can be used to categorize the GI involvement. However, the proposed CT classification needs validation.

Gallbladder cancer

Gallbladder cancer (GBC) is the most common cancer of the biliary tract, characterized by a very poor prognosis when diagnosed at advanced stages owing to its aggressive behaviour and limited therapeutic options. Early detection at a curable stage remains challenging because patients rarely exhibit symptoms; indeed, most GBCs are discovered incidentally following cholecystectomy for symptomatic gallbladder stones. Long-standing chronic inflammation is an important driver of GBC, regardless of the lithiasic or non-lithiasic origin. Advances in omics technologies have provided a deeper understanding of GBC pathogenesis, uncovering mechanisms associated with inflammation-driven tumour initiation and progression. Surgical resection is the only treatment with curative intent for GBC but very few cases are suitable for resection and most adjuvant therapy has a very low response rate. Several unmet clinical needs require to be addressed to improve GBC management, including discovery and validation of reliable biomarkers for screening, therapy selection and prognosis. Standardization of preneoplastic and neoplastic lesion nomenclature, as well as surgical specimen processing and sampling, now provides reproducible and comparable research data that provide a basis for identifying and implementing early detection strategies and improving drug discovery. Advances in the understanding of next-generation sequencing, multidisciplinary care for GBC, neoadjuvant and adjuvant strategies, and novel systemic therapies including chemotherapy and immunotherapies are gradually changing the treatment paradigm and prognosis of this recalcitrant cancer.

Gallbladder Cancer: Diagnosis, Surgical Management, and Adjuvant Therapies

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

Gallbladder cancer: expert consensus statement

An American Hepato-Pancreato-Biliary Association (AHPBA)-sponsored consensus meeting of expert panellists was convened on 15 January 2014 to review current evidence on the management of gallbladder carcinoma in order to establish practice guidelines. In summary, within high incidence areas, the assessment of routine gallbladder specimens should include the microscopic evaluation of a minimum of three sections and the cystic duct margin; specimens with dysplasia or proven cancer should be extensively sampled. Provided the patient is medically fit for surgery, data support the resection of all gallbladder polyps of >1.0 cm in diameter and those with imaging evidence of vascular stalks. The minimum staging evaluation of patients with suspected or proven gallbladder cancer includes contrasted cross-sectional imaging and diagnostic laparoscopy. Adequate lymphadenectomy includes assessment of any suspicious regional nodes, evaluation of the aortocaval nodal basin, and a goal recovery of at least six nodes. Patients with confirmed metastases to N2 nodal stations do not benefit from radical resection and should receive systemic and/or palliative treatments. Primary resection of patients with early T-stage (T1b-2) disease should include en bloc resection of adjacent liver parenchyma. Patients with T1b, T2 or T3 disease that is incidentally identified in a cholecystectomy specimen should undergo re-resection unless this is contraindicated by advanced disease or poor performance status. Re-resection should include complete portal lymphadenectomy and bile duct resection only when needed to achieve a negative margin (R0) resection. Patients with preoperatively staged T3 or T4 N1 disease should be considered for clinical trials of neoadjuvant chemotherapy. Following R0 resection of T2-4 disease in N1 gallbladder cancer, patients should be considered for adjuvant systemic chemotherapy and/or chemoradiotherapy.

Role of routine 16b1 lymph node biopsy in the management of gallbladder cancer: an analysis

BACKGROUND

Involvement of the 16b1 (interaortocaval) lymph node (LN) in gallbladder cancer (GBC) is considered to represent metastatic disease. Although this is universally accepted, the role of routine frozen-section histopathological examination (HPE) of the 16b1 LN in the management of GBC has not been previously reported.

METHODS

A prospective study (August 2009-November 2011) using routine biopsy of 16b1 LNs and frozen-section HPE prior to radical resection in patients deemed operable on preoperative evaluation and staging laparoscopy was carried out.

RESULTS

Of the 451 GBC patients assessed, 251 (55.7%) were deemed operable on preoperative imaging. Of these, 68 (27.1%) were found to have disseminated disease on staging laparoscopy/laparotomy. Of the 183 patients in whom 16b1 LN biopsy was performed, 34 (18.6%) had evidence of metastases on frozen-section HPE and the planned surgical resection was abandoned (Group A). Of the remaining 149 patients (Group B), 142 (95.3%) underwent curative resection and seven (4.7%) were found to be unresectable as a result of locoregionally advanced disease. A comparison of findings in Group A with those in Group B showed no significant difference in the clinical stage of the tumour. The proportions of patients with jaundice, elevated carcinoembryonic antigen (CEA) and carbohydrate antigen (CA) 19-9 levels were significantly higher in Group A than in Group B (P = 0.008, P = 0.012 and P = 0.023, respectively).

CONCLUSIONS

Routine 16b1 LN biopsy prevented non-therapeutic radical resection and its associated morbidity in 18.6% of patients deemed resectable on preoperative imaging and staging laparoscopy. The yield was higher in patients with jaundice and elevated preoperative tumour marker levels.

Squamous variant of gallbladder cancer: is it different from adenocarcinoma?

BACKGROUND

Literature on squamous variants of gallbladder cancer (GBC) is limited.

METHODS

This was a retrospective analysis of GBC patients operated on between August 2009 and March 2012. Patients with adenosquamous carcinoma or squamous cell carcinoma were compared with adenocarcinoma for clinicopathologic features and surgical outcomes.

RESULTS

Of the primary GBC patients resected with curative intent, 14 had adenosquamous carcinoma (10) or squamous cell carcinoma (4) (group A), whereas 122 had adenocarcinoma (group B). Abdominal pain was the most common symptom in both groups; however, presentation with vomiting and an abdominal lump was more common in group A (P = .04 and <.01, respectively). Group A had a significantly larger tumor size (7.9 vs 4.8 cm, P = .01) and a higher incidence of adjacent organ involvement requiring extended resections (85.7% vs 26.2%, P < .01). Despite the higher T stage, node-negative disease was significantly higher in group A (42.9% vs 17.2%, P = .03). There was no significant difference in the median survival after curative resection between the 2 groups (28 vs 31 months, P = .24).

CONCLUSIONS

The squamous variant of GBC presented at an advanced T stage; however, nodal involvement and distant metastasis were less common. Despite the higher T stage, curative resection could be achieved in the majority with a comparable survival.

Mass-forming xanthogranulomatous cholecystitis masquerading as gallbladder cancer

BACKGROUND

Mass-forming xanthogranulomatous cholecystitis (XGC), an uncommon inflammatory pathology of gallbladder (GB), masquerades as gallbladder cancer (GBC) and diagnosis is often a histological surprise.

METHODS

A retrospective analysis of prospectively collected database of patients with GB mass operated between August 2009 and September 2012 was conducted to determine clinical, radiological, and intraoperative findings that might aid in the preoperative diagnosis of mass-forming XGC and ascertain their optimal management strategy.

RESULTS

Of the 566 patients with GB mass and suspected GBC, 239 were found to be inoperable on preoperative workup and 129 patients had unresectable disease on staging laparoscopy/laparotomy. Of the 198 with resectable disease, 31 were reported as XGC on final histopathology (Group A), while 167 were GBC (Group B). Of these 31 patients, six with an intraoperative suspicion of benign pathology underwent cholecystectomy with segments IVb and V resection, and frozen section histopathology. Twenty-five underwent radical cholecystectomy, with (n = 10) or without (n = 15) adjacent organ resection. In comparison, anorexia and weight loss were significantly more in Group B (p = 0.001 and <0.001). Intraoperatively, empyema and associated gallstones were more common in Group A (p = 0.011 and <0.001). On computed tomography (CT) of the abdomen, continuous mucosal line enhancement and intramural hypodense bands were significantly more in Group A (p < 0.001 and 0.025). While CT abdomen revealed one or more features suggestive of XGC in 64.5 % (20/31) of patients in Group A, 11(35.5 %) did not have any findings suggestive of XGC on imaging.

CONCLUSION

Mass-forming XGC mimics GBC, making preoperative and intraoperative distinction difficult. While imaging findings can help in suspecting XGC, definitive diagnosis require histopathological examination. Presence of typical radiological findings, however, can help in avoiding extended radical resection in selected cases.