The standardized surgical approach improves outcome of gallbladder cancer

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Laparoscopic versus open extended cholecystectomy with bi-segmentectomy (s4b and s5) in patients with gallbladder cancer

Introduction:

The outcome of laparoscopic extended cholecystectomy (EC) with wedge hepatic resection (LECW) in patients with gallbladder cancer (GBC) has been compared with that of open EC with wedge hepatic resection (OECW), but studies comparing laparoscopic EC with bi-segmentectomy (LECB) with open EC with bi-segmentectomy (OECB) are lacking.

Patients and Methods:

This retrospective study comprised of 68 patients with GBC who were offered either LECB or OECB from July 2011 to July 2018. Patients were divided into laparoscopic group (LG) and open group (OG), and appropriate statistical methods were used for comparison.

Results:

Out of the total 68 patients, 30 patients were in LG and 38 patients were in OG. Demographic, clinical and biochemical characteristics were similar except significantly higher number of male patients in OG (P = 0.01). In LG versus OG, the mean operation time was 286 versus 274 min (P = 0.565), mean blood loss was 158 versus 219 ml (P = 0.006) and mean hospital stay was 6.4 versus 9 days (P = 0.0001). The complication rate was 16.6% in LG and 31.5% in OG, but this difference was not statistically significant (P = 0.259). The median number of lymph nodes was 12 in both LG and OG (P = 0.62). Distribution of patients among American Joint Committee on Cancer stages I to IV was similar in both the groups (P = 0.5). Fifty percent of the patients in both the groups received adjuvant treatment (P = 1). In LG versus OG, the recurrence rate was 20% versus 28.9% (P = 0.4), mean recurrence-free survival was 48 months versus 44 months (P = 0.35) and overall survival was 51 months versus 46 months (P = 0.45). In LG versus OG, 1, 3 and 5-year survival was 96% versus 94%, 79% versus 72% and 79% versus 62% (P = 0.45). The median follow-up was statistically significantly shorter (24 vs. 36 months) in LG versus OG (P = 0.0001).

Conclusions:

The oncological outcome and survival after LECB in patients with resectable GBC is not inferior to that after OECB. Laparoscopic approach has a potential to improve perioperative outcome in patients with GBC.

Development and validation of a nomogram for survival benefit of lymphadenectomy in resected gallbladder cancer

Background

Due to absence of large, prospective, randomized, clinical trial data, the potential survival benefit of lymphadenectomy with different number of regional lymph nodes (LNs) remains controversial. We aim to create a predicting model to help estimate individualized potential survival benefit of lymphadenectomy with more regional LNs for patients with resected gallbladder cancer (GBC).

Methods

Patients with resected GBC were selected from the Surveillance, Epidemiology, and End Results database who were diagnosed between 2004 and 2014. Covariates included age, race, sex, grade, histological stage, tumor sizes and receipt of non-primary surgery. Two types of multivariate survival regression models were constructed and compared. The best model performance was tested by the external validation data from our hospital.

Results

A total of 1,669 patients met the inclusion criteria for this study. The lognormal survival model showed the best performance and was tested by the external validation data, including 193 patients with resected GBC from our hospital. Nomograms, which based on the accelerated failure time parametric survival model, were built to estimate individualized survival. C-index, was up to 0.754 and 0.710 in internal validation for more and less regional LNs removed, respectively. Both of internal and external calibration curves showed good agreement between predicted and observed outcomes in the 1-, 3-, and 5-year overall survival (OS).

Conclusions

A predicting model can be used as a decision model to predict which patients may obtain benefit from lymphadenectomy with more regional LNs.

A Nomogram for Prediction of Overall Survival in Patients with Node-negative Gallbladder Cancer

Background & Aims: According to the stage of tumor, it's hard suitable to predict the prognosis for gallbladder cancer, especially for node-negative gallbladder cancer. Therefore, we aimed to create a nomogram based on demographic and clinicopathologic characteristics to estimate individualized potential impacts on postoperative overall survival.

Methods: 789 patients with node-negative gallbladder cancer were selected from the Surveillance, Epidemiology, and End Results and randomly divided into training and internal validation group. Univariate and multivariate survival analysis were used to identify prognostic factors. The nomogram was constructed using Cox proportional hazards models. We evaluated the performance of the nomogram with Harrell's concordance index and calibration curve. The nomogram was externally validated in 115 patients with node-negative gallbladder cancer from the Sir Run Run Shaw hospital.

Results: The nomogram for overall survival was built on the basis of five independent factors, such as age, sex, histology, T-stage, and number of examined lymph nodes. The C-index of nomogram for overall survival in the internal and external validation group was up to 0.724 and 0.716, respectively. Both of those calibration curves showed good agreement between predicted and observed outcomes in the 1-, 3-, 5-year overall survival. Compared to the 7th edition AJCC stage, the nomogram had a better difference in predicting overall survival, even could further classify patients into four risk subgroups in each stage.

Conclusion: This nomogram can be used as a decision model to predict the outcomes of postoperative overall survival for node-negative gallbladder cancer, and may give useful guidance to clinicians for next treatment.

Surgical treatment of gallbladder cancer: Strategy and optimization

Gallbladder cancer is the most common malignant tumor of the biliary tract. It is difficult to diagnose early due to the lack of special symptoms and physical signs. Most cases are diagnosed in advanced stages and the response to traditional chemotherapy and radiotherapy is extremely limited, with modest impact on overall survival. Despite improvements in outcome associated with extended resections, selection of patients for such extensive surgery remains controversial. In this article, we analyze and discuss the key issues about the surgical management of gallbladder cancer, with the hope of a more comprehensive recognition of this malignancy.

[Radical surgery for incidental gallbladder cancer: the value of a deferred pathological finding of residual disease]

BACKGROUND

Surgical treatment of gallbladder cancer is still controversial. The extent of the radical surgery and its therapeutic efficacy continue to be debated.

OBJECTIVE

Analyze the efficacy of radical resection in patients with incidental gallbladder cancer evaluating the presence of residual disease in the resection specimen and analyzing the associated factors of survival.

METHODS

A retrospective analysis of patients with incidental GC between June 1999 and June 2010 was performed. Incidental (I) tumors were included. Data covering demographic features, clinical characteristics, local pathological stage, histological features and factors for long term survival were analyzed. p< 0.05 were considered significant.

RESULTS

A total of 28 patients: 78,6% females. Median age 56 years. All treated by resection of segments 4b/5 and lymphadenectomy. Histological examination revealed residual disease in 42% (37% liver), residual disease was related to tumoral (T) stage (p 0,001). Patients with residual disease presented a DSS and DFS of 10 and 6.5 months respectively vs 56 months in those without residual disease (p 0,001). Variables associated with survival were T stage (P .006), TNM stage (P<.001), and residual disease in the resected specimen (P<.001).

CONCLUSIONS

Aggressive re-resection of incidental GC offers the only chance for cure but its efficacy depends on the extent of the disease found at the time of repeated surgery and in the deferred pathological study.

Relevance of residual disease after liver resection for incidental gallbladder cancer

OBJECTIVES

In patients diagnosed with incidental gallbladder cancer (GC), the benefit and optimal extent of further surgery remain unclear. The aims of this study were to analyse outcomes in patients who underwent liver resection following a diagnosis of incidental GC and to determine factors associated with longterm survival.

METHODS

A retrospective analysis of patients diagnosed with incidental GC between June 1999 and June 2010 was performed. Data covering demographics, clinical and surgical characteristics and local pathological stage were analysed.

RESULTS

A total of 24 patients were identified. All patients underwent a resection of segments IVb and V and lymphadenectomy. Histological examination revealed residual disease in 10 patients, all of whom presented with recurrent disease at 3-12 months. Overall 5-year survival was 53%. Increasing T-stage (P < 0.001), tumour-node-metastasis (TNM) stage (P= 0.003), and the presence of residual tumour in the resected liver (P < 0.001) were all associated with worse survival.

CONCLUSIONS

Aggressive re-resection of incidental GC offers the only chance for cure, but its efficacy depends on the extent of disease found at the time of repeat surgery. The presence of residual disease correlated strongly with T-stage and was the most relevant prognostic factor for survival in patients treated with curative resection.

Is adjuvant radiotherapy needed after curative resection of extrahepatic biliary tract cancers? A systematic review with a meta-analysis of observational studies

BACKGROUND

The role for adjuvant radiotherapy (ART) after curative resection in extrahepatic cholangiocarcinoma remains unclear. Due to the lack of randomized trials, available data comes from single center experiences or data-based population studies with inconclusive results.

OBJECTIVE

To assess the impact of radiotherapy (with or without concurrent chemotherapy) on toxicity and survival of radically resected patients with extrahepatic bile duct cancer (extrahepatic cholangiocarcinoma, gallbladder cancer and pure ampullary cancer).

DATA SOURCES AND STUDY SELECTION

Eligible studies with data on survival, recurrence and toxicity were retrieved from the MEDLINE, ISI web of science, EMBASE and Cochrane databases from January 1995 to December 2008, to ensure that all ART treatments were performed with conventional 3D techniques. In the absence of randomized controlled-studies, all observational cohort studies (longitudinal and historical) were initially considered. Ten retrospective cohort studies (where the use of concurrent CT was reported only in 2), met all inclusion criteria and were enrolled for final meta-analysis. Hazard ratio (HR) had to be extracted from survival curves using the Tierney et al. methods. MIX 1.7 statistical software was used for meta-analysis.

RESULTS

All studies on ART used conventional 3D-techniques. Patients in the ART cohorts were more likely to have involved surgical margins and positive lymph nodes. For extrahepatic cholangiocarcinoma location, ART significantly improved overall survival (HR 0.62; 95% CI 0.48 to 0.78, p<0.001). Meta-analysis was not feasible for gallbladder cancer and ampullary cancer locations. Late radiation-induced toxicity was low (2-9% late obstruction or GI bleeding).

CONCLUSION

In the absence of randomized controlled studies, we found in the present systematic review and meta-analysis of observational studies that, patients with extrahepatic cholangiocarcinoma treated with adjuvant RT have a significant lower risk of dying compared to patients treated with surgery alone.

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

AIMS

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

METHODS

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

OBSERVATIONS

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

CONCLUSIONS

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

A review of the surgical strategies for the management of gallbladder carcinoma based on T stage and growth type of the tumour

AIMS

Surgery for gallbladder carcinoma is a technically challenging exercise. The extent of resection varies based on a number of factors, and controversy exists regarding what constitutes an acceptable resection. A review of current recommendations and practice was undertaken.

METHODS

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

OBSERVATIONS

The extent of hepatic resection and lymph node dissection required varies in particular with T stage. Growth pattern and anatomical location of the tumour within the gallbladder also influence surgical management.

CONCLUSIONS

Discrepancy exists between the Eastern and Western literature in terms of what constitutes an acceptable limit of resection, and these issues are discussed.

Ten-year experience in the management of gallbladder cancer from a single hepatobiliary and pancreatic centre with review of the literature

BACKGROUND

There is no consensus regarding the optimum surgical approach to gallbladder cancer. This study reviews the management of gallbladder cancer in a single unit.

METHODS

Retrospective study of 73 consecutive patients diagnosed with gallbladder cancer. Twenty-three patients underwent surgery with curative intent (surgical group), 28 patients underwent exploratory surgery but had inoperable disease (surgically inoperable group) and 22 patients had inoperable disease radiologically (radiologically inoperable group). Within the surgical group, nine patients (cholecystectomy group) were diagnosed with gallbladder cancer after routine cholecystectomy.

RESULTS

The inoperable groups had significantly higher bilirubin and alkaline phosphatase (ALP) than the surgical group (p=0.02 and p<0.01, respectively). Age>68, white cell count (WCC)>7.6 x 109/L, platelet>345 x 109/L, bilirubin>16 mol/L, ALP >124 iu/L and sodium < or = 137 mmol/L were markers of inoperability. Age, haemoglobin and neutrophil:lymphocyte ratio (NLR) were predictors for survival following surgery (p=0.04, p=0.01 and p<0.01, respectively). The surgical and cholecystectomy groups had significantly higher median survivals than the surgically and radiologically inoperable groups (18.97 and 26.17 months versus 5.03 and 12.20 months, p=0.04).

CONCLUSION

Curative surgical resection of gallbladder cancer improved survival. Exploratory laparotomy which revealed inoperable disease reduced survival. Preoperative WCC, platelet, bilirubin and ALP may be used as additional discriminators during the investigation and work up prior to surgery.