Metastasis of primary gallbladder carcinoma in lymph node and liver

Fatty Acid Binding Protein 1 is an Independent Prognostic Biomarker for Gallbladder Cancer with Direct Hepatic Invasion

Background: Direct liver invasion (DI) is a predominant pathway of gallbladder cancer (GBC) metastasis, but the molecular alterations associated with DI remain addressed. This study identified specific genes correlated with DI, which may offer a potential biomarker for the diagnosis and prognosis of advanced GBC. Methods: RNA samples from 3 patients with DI of GBC were used for RNA-seq analysis. Differentially expressed genes and metabolic pathways between primary tumor (T) and DI tissue was used to analyze aberrant gene expressions. Immunohistochemistry (IHC) of fatty acid binding protein 1 (FABP1) in 62 patients with DI was engaged to evaluate its association with clinicopathological characteristics and prognosis. IHC of CD3+ and CD8+ T cells was analyzed for their correlation with FABP1 expression, clinicopathological features and prognosis. Univariate and multivariate Cox hazards regression analyses were performed to identify independent prognostic factors for disease-free survival (DFS) and overall survival (OS). Results: FABP1 mRNA levels were significantly upregulated in DI region compared to T tissue. IHC results showed identical results with elevated FABP1 (p < 0.0001). Expression of FABP1 in DI region was significantly associated with lymph node metastasis (P = 0.028), reduced DFS (P = 0.013) and OS (P = 0.022); in contrast, its expression in T region was not associated with clinicopathological characteristics and prognosis (P > 0.05). The density of CD8+ T cells in DI region with higher FABP1 expression was significantly lower than that with lower FABP1 expression (p = 0.0084). Multivariate analysis unveiled those hepatic metastatic nodules (HR = 3.35, 95%CI: 1.37-8.15, P = 0.008) and FABP1 expression in DI region (HR = 2.01, 95%CI: 1.05-3.88, P = 0.036) were high risk factors for OS, and FABP1(HR = 2.05, 95%CI: 1.04-4.06, P = 0.039) was also a high risk factor for DFS. Conclusions: Elevated expression of FABP1 in DI region serves as a potential prognostic biomarker for advanced GBC with DI.

Proposal for a new morphological "combined type" of gallbladder cancer: description of radiopathological characteristics and comparison with other morphological types

OBJECTIVE

To describe the radiopathological characteristics of a new morphological "combined type" of gallbladder cancer (GBC) and compare it with the mass replacing gallbladder and thickening types of GBC.

MATERIALS AND METHODS

The imaging and pathological details of consecutive patients with GBC between August 2020 and December 2022 were retrospectively reviewed. Two radiologists reviewed computed tomography/magnetic resonance imaging in consensus for the morphological type of GBC. The radiologists classified GBC as mass replacing gallbladder, wall thickening, and combined type. The combined type was defined as a mass arising from the thickened wall of an adequately distended gallbladder that extended exophytically into the adjacent liver parenchyma. The presence of calculi, site, and size of lesion, biliary/portal vein involvement, liver, lymph node, and omental metastases was compared among the various types. The pathological characteristics were also compared.

RESULTS

Of the 481 patients (median age 55 years, 63.2% females) included in the study, mass replacing gallbladder, wall thickening, and combined-type GBC were seen in 42.8% (206/481), 40.5% (195/481), and 16.6% (80/481) of patients, respectively. In the combined type of GBC, biliary/portal vein involvement was seen in 63.7% (51/80) and 7.5% (6/80) of patients. Liver, lymph node, and omental metastases were seen in 67.5% (54/80), 40% (32/80), and 41.2% (33/80) patients, respectively. Liver metastases were significantly more common in the combined type (p = 0.002). There were no significant differences in pathological characteristics among the various types.

CONCLUSION

Combined-type GBC is less common than the mass replacing gallbladder and thickening types and is associated with a higher risk of liver metastases.

Imaging patterns of wall thickening type of gallbladder cancer

Gallbladder cancer (GBC) has a high incidence in certain geographical regions. Morphologically, GBC presents as a mass replacing the gallbladder, a polypoidal lesion, or wall thickening. The incidence of preoperative diagnosis of wall thickening type of GBC is less well studied. The patterns of mural involvement and extramural spread are not well described in the literature. Additionally, wall thickening in the gallbladder does not always indicate malignancy and can be secondary to inflammatory or benign gallbladder diseases and extracholecystic causes and systemic pathologies. Objective reporting of gallbladder wall thickening will help us appreciate GBC's early features. In this review, we illustrate the imaging patterns of wall thickening type of GBC.

FDG PET-MRI evaluation of synchronous gallbladder adenocarcinoma and POEMS syndrome

POEMS syndrome is a rare paraneoplastic syndrome associated with a plasma cell proliferative disorder. Gallbladder adenocarcinoma is a rare malignancy, with no association with POEMS syndrome. The plasma cell dyscrasia is routinely evaluated with advanced hybrid imaging to assess both anatomic and functional components. We present a case of a 59-year-old female with a known diagnosis of POEMS syndrome who underwent a whole-body restaging evaluation with hybrid positron emission tomography (PET) and magnetic resonance imaging (MR) to restage her plasma cell dyscrasia. She also had a prior diagnosis of gallbladder adenocarcinoma. Our case focuses on the value of PET/MR in this scenario as well as a rare case of osseous metastasis from gallbladder carcinoma.

Gallbladder Carcinoma and Its Differential Diagnosis at MRI: What Radiologists Should Know

Gallbladder carcinoma is the most common cancer of the biliary system. It is challenging to diagnose because patients are often asymptomatic or present with nonspecific symptoms that mimic common benign diseases. Surgical excision is the only curative therapy and is best accomplished at early non-locally advanced stages. Unfortunately, gallbladder cancer often manifests at late locally advanced stages, precluding cure. Early tumors are often incidentally detected at imaging or at cholecystectomy performed for another indication. Typical imaging features of localized disease include asymmetric gallbladder wall thickening, polyps larger than 1.0 cm, and a solid mass replacing the gallbladder lumen. Advanced tumors are often infiltrative and can be confusing at CT and MRI owing to their large size. Determination of the origin of the lesion is paramount to narrow the differential diagnosis but is often challenging. It is important to identify gallbladder cancer and distinguish it from other benign and malignant hepatobiliary processes. Since surgical resection is the only curative treatment option, radiologist understanding and interpretation of pathways of nodal and infiltrative tumor spread can direct surgery or preclude patients who may not benefit from surgery. While both CT and MRI are effective, MRI provides superior soft-tissue characterization of the gallbladder and biliary tree and is a useful imaging tool for diagnosis, staging, and evaluation of treatment response. ^©RSNA, 2020.

CT-based nomogram for predicting survival after R0 resection in patients with gallbladder cancer: a retrospective multicenter analysis

OBJECTIVES

To establish a prognostic nomogram for patients undergoing R0 resection for gallbladder cancer based on preoperative CT.

METHODS

A total of 151 patients (64 males, 87 females; mean age, 73.26 years) with gallbladder cancer who underwent CT and surgery with margin-negative resection were retrospectively collected at two tertiary institutions. The demographic and radiologic parameters were analyzed using univariate and multivariate Cox regression analyses to identify independent prognostic factors. The final CT-based nomogram was constructed to predict prognosis after curative resection of gallbladder cancer. Calibration curves for the survival probabilities were obtained for internal validation.

RESULTS

Mass-forming type (hazard ratio [HR], 28.80), bile duct invasion (HR, 4.76), duodenal invasion (HR, 6.32), colon invasion (HR, 4.37), gallstones (HR, 0.09), and cholecystitis (HR, 2.56) were significant independent predictors for recurrence-free survival (p < .05). Mass-forming type (HR, 8.16, p < .001), bile duct invasion (HR, 2.92, p = .013), duodenal invasion (HR, 3.72, p = .012), and regional lymph node metastasis (HR, 2.07, p = .043) were independent predictors of poor cancer-specific survival (CSS) and were used to construct the nomogram. The nomogram showed a good predictive ability for the probabilities of survival on the calibration curves, and the concordance index of the model in predicting CSS was .768.

CONCLUSION

Preoperative CT findings could predict the prognosis of gallbladder cancer, and the CT-based nomogram accurately predicted CSS in patients with gallbladder cancer after attempted curative resection.

KEY POINTS

• Among the preoperative imaging features, mass-forming type, bile duct invasion, duodenal invasion, and regional lymph node metastasis were independent predictors of poor cancer-specific survival. • The nomogram constructed using preoperative CT findings showed a good predictive ability for the survival on calibration curves, and the concordance index of the model in predicting cancer-specific survival was 0.768.

Prognostic impact of tumor location in resected gallbladder cancer: A national cohort analysis

BACKGROUND AND OBJECTIVES

Tumor location (peritoneal vs hepatic) has been incorporated in the 8th edition of the American Joint Committee on Cancer Staging system for gallbladder cancer. However, larger studies are needed to confirm the prognostic impact of tumor location.

METHODS

Patients with pathologically-confirmed gallbladder cancer with information on primary tumor location were included from the National Cancer Database (2009-2012). We compared patients with hepatic-side tumors to those on the peritoneal side. Survival data were plotted using the Kaplan-Meier method. Prognostic factors were modeled with a multivariate Cox Proportional Hazards Model. Primary outcome was overall survival (OS).

RESULTS

A total of 1251 patients were included. In comparison to patients with peritoneal-sided tumors, patients with hepatic-sided tumors were more likely to: be of higher pT stage (pT3: 49% vs 24%; P < .001); node positive (31% vs 24%; P = .016); undergo liver resection (53% vs 25%; P < .001); or have positive margins (29% vs 16%; P < .001). However, on multivariate analysis, there was no difference in OS between the groups (HR, 0.97; 95% CI, 0.79-1.18; P = .753). Liver resection was associated with improved survival regardless of tumor location in pT2 tumors (peritoneal: HR, 0.57; P = .034; hepatic: HR, 0.67; P < .001).

CONCLUSIONS

This study failed to demonstrate the independent prognostic value of primary tumor location in patients with gallbladder cancer.

Lymph Nodal Metastatic Pattern in Carcinoma Gallbladder with Multidetector Computed Tomography: An Institutional Experience

Objective This work aimed to study the distribution of lymph nodal metastatic pattern in carcinoma gallbladder with multidetector computed tomography (CT).

Materials and Methods A retrospective observational study was conducted including 80 patients with carcinoma gallbladder who underwent triple-phase CT angiography or single-phase contrast-enhanced CT scan of the abdomen between January 2019 and November 2019.

Results In our study, 75 (93.7%) out of 80 cases showed metastasis to lymph nodes, with distribution as follows: periportal (69), peripancreatic (62), and aortocaval (47). The most common involved combination included all three lymph nodal groups (periportal, peripancreatic, and aortocaval), involving 40 (50%) cases. The combination of only periportal and peripancreatic lymph nodes was seen in 17 (21%) cases. Isolated periportal lymph nodes were seen in eight cases (10%) cases. The combination of only periportal and aortocaval lymph nodes was seen in four (5%) cases. Isolated peripancreatic lymph nodes were seen in three (3.7%) cases. The combination of periportal and aortocaval was seen in four (5%) cases followed by peripancreatic and aortocaval lymph nodes that was seen in two (2.5%) cases. Isolated aortocaval lymph nodes were seen in one (1.2%) case.

Conclusion Periportal lymph nodes were the single most commonly involved station followed by peripancreatic and aortocaval lymph nodes. The combination of periportal, peripancreatic, and aortocaval lymph nodes was seen most commonly. The second most commonly involved combination was found to be periportal and peripancreatic lymph nodes followed by isolated periportal lymph nodes.

Nodal CTV selection according to primary tumour location and pT stage for biliary tract cancer

INTRODUCTION/PURPOSE

To assist radiation oncologists in determining the elective nodal CTV for biliary tract cancer, we aimed to provide the rules for selection of the CTV for each subsite of biliary tract with respect to the pT stage, based on the analysis of the incidence and location of metastatic lymph nodes.

METHODS

Systematic review and meta-analysis was performed to determine the rate of pathological nodal involvement of each individual lymph node station (LNS) as a function of the primary tumour pT stage (pT1-2 vs. pT3-4) separately for right intrahepatic cholangiocarcinoma (rIHC), left/hilar intrahepatic cholangiocarcinoma l/hIHC), proximal extrahepatic cholangiocarcinoma (pEHC), middle extrahepatic cholangiocarcinoma (mEHC), distal extrahepatic cholangiocarcinoma (dEHC) and gall bladder cancer (GBC). A 5% or higher risk of involvement was assumed to justify inclusion of the LNS in the CTV.

RESULTS

Coeliac LNS, which is usually included in the CTV in clinical practice, has a low risk of involvement and can presumably be omitted for pT1-2 GBC, for dEHC irrespective of pT stage and for mEHC. Para-aortic and superior mesenteric artery (SMA) LNS that are usually omitted have a high risk of involvement. Para-aortic LNS should be considered for inclusion for all the subsites except for pT1-2 dEHC, and SMA LNS for all the subsites except for pT1-2 dEHC, pT1-2 GBC and pEHC. Left gastric artery, lesser curvature and paracardial LNS should be considered for inclusion for l/hIHC.

CONCLUSION

This systematic review provides an evidence-based strategy for nodal CTV selection in biliary tract cancer according to primary tumour location and pT stage.

Therapeutic outcomes and prognostic factors in unresectable gallbladder cancer treated with gemcitabine plus cisplatin

BACKGROUND

Gallbladder cancer (GBC) is likely to be diagnosed at progressive stages and shows a very poor prognosis. Combination therapy with gemcitabine and cisplatin (GEMCIS) has been widely used as first-line palliative chemotherapy for advanced GBC. This study was designed to investigate the efficacy of GEMCIS and identify prognostic factors in patients with unresectable GBC.

METHODS

Patients with GBC who were treated with GEMCIS from January 2008 to June 2017 in a single tertiary hospital were included. All cases of GBC were diagnosed by pathologic findings and extent of the tumour was assessed by imaging tests. Combination chemotherapy consisted of cisplatin 25 mg/m² and gemcitabine 1000 mg/m² intravenously on days 1 and 8 every 3 weeks. To determine factors affecting prognosis, Kaplan-Meier survival analysis, log-rank test and the Cox proportional hazard regression linear model were used. All variables with P < 0.1 in univariable analysis were included in the multivariable model.

RESULTS

A total of 173 patients received a median of 5.3 ± 4.4 cycles of chemotherapy over 3.8 ± 3.9 months. Most of the patients (94.8%) were stage IVB at the time of diagnosis and the most common site of metastasis was the liver (42.8%). Disease control rate was 59.5%: 2 (1.2%) patients with complete response, 26 (15.0%) patients with partial response and 75 (43.4%) patients with stable disease. Overall survival (OS) and progression-free survival were 8.1 (95% confidence interval [CI], 7.1-10.2) and 5.6 (95% CI 4.5-6.8) months, respectively. Multivariable regression model indicated that metastasis to liver (hazard ratio [HR] = 1.63, 95% CI 1.11-2.40; P = 0.013), neutrophil-to-lymphocyte ratio (NLR) ≥3 (HR 1.65, 95% CI 1.09-2.49; P = 0.017), CEA ≥ 5 ng/mL (HR 1.50, 95% CI 1.02-2.19; P = 0.038), and CA19-9 ≥ 500 U/mL (HR 1.59, 95% CI 1.01-2.50; P = 0.043) were significantly associated with OS.

CONCLUSIONS

GEMCIS demonstrated a high disease control rate in patients with unresectable GBC. Factors independently related to OS were metastasis to liver, NLR ≥ 3, CEA ≥ 5 ng/mL and CA19-9 ≥ 500 U/mL.

Positive relationship between number of negative lymph nodes and duration of gallbladder cancer cause-specific survival after surgery

Background

Although the prognostic implications of negative lymph nodes (NLNs) has been reported for a variety of tumors, little information has been published about the NLNs in gallbladder cancer (GBC).

Patients and methods

In this study, clinicopathological characteristics and survival times of patients who had undergone surgery for GBC were collected from the Surveillance, Epidemiology, and End Results Program-registered TNM stage database and analyzed. Univariate and multivariate Cox proportional hazards models were used to identify the predictors of survival.

Results

It was found that a cutoff of one to two NLNs is optimal when assessing the association with survival, survival rates being consistently better with two or more NLNs than with fewer than two. This optimal cutoff value of 2 was identified as an independent prognostic factor by univariate and multivariate analyses (all P<0.001). Specifically, patients with two or more NLNs had better 5-year gallbladder cancer cause-specific survival than those with fewer than NLNs examined for stage I/II, stage III/IV, and all TNM stages (all P<0.001).

Conclusion

Our findings indicate that the number of NLNs is an independent prognostic factor after GBC surgery, and, together with the number of positive lymph nodes, this will provide better prognostic information than the number of positive lymph nodes alone.

Computed Tomographic Features of Primary Small Cell Neuroendocrine Tumors of the Gallbladder

PURPOSE

This study aimed to report the computed tomography (CT) imaging features of primary small cell neuroendocrine tumors of the gallbladder (PSCNETGs).

MATERIALS AND METHODS

The CT examinations of 9 patients (5 women, 4 men; median age, 57 years) with histopathologically proven PSCNETG were reviewed. Computed tomographic images were analyzed with respect to morphologic features of primary tumors and accompanying lymph nodes.

RESULTS

All PSCNETGs were visible on CT, with a median largest axial diameter of 60 mm (Q1, 30 mm; Q3 mm, 82; range, 25-86 mm). These tumors presented with extraluminal growth (8/9; 89%), heterogeneous enhancement (8/9; 89%), gallbladder replacement greater than 50% (5/9; 56%), hepatic metastases (5/9; 56%), and direct liver involvement by tumor (4/9; 44%). Enlarged lymph nodes were present in all patients (9/9; 100%) with a median largest axial diameter of 39 mm (Q1, 23 mm; Q3, 48 mm; range, 12-62 mm). Vessel encasement by lymph nodes was present in 6 (67%) of 9 patients.

CONCLUSION

Primary small cell neuroendocrine tumors of the gallbladder predominantly presents as a large, heterogeneous gallbladder mass with extraluminal growth in association with large metastatic lymph nodes and intrahepatic metastases.

Nodal areas of potential geographic error in adjuvant radiotherapy for biliary tract cancer

PURPOSE

To determine the areas of potential geographic error in adjuvant radiotherapy (RT) for biliary-tract cancer (BTC) by comparing pathological-surgical data on the pattern of nodal spread with the extent of elective nodal CTV used in published RT studies in this setting.

MATERIAL/METHODS

A literature search was performed to select articles on: 1/adjuvant RT for BTC, that provided information on the lymph node stations (LNS) included in the CTV; 2/the pathological-surgical data on the patterns of nodal involvement/recurrence in BTC. Risk of nodal involvement/recurrence and frequency of inclusion in the CTV in RT studies for each of the LNS were compared to determine the areas of potential geographic misses and unnecessary irradiation, separately for intrahepatic cholangiocarcinoma (IHC), extrahepatic cholangiocarcinoma (EHC) and gallbladder-cancer (GBC).

RESULTS

Areas of potential geographic misses include: for right IHC: paraaortic and superior mesenteric artery (SMA) LNS; for left or hilar IHC: left gastric, lesser gastric curvature, paraaortic, and SMA LNS; for proximal EHC: paraaortic LNS; for middle EHC: paraaortic and SMA LNS; for distal EHC: paraaortic, SMA, and anterior pancreatico-duodenal LNS; for GBC: paraaortic, SMA, and posterior pancreatico-duodenal LNS. Celiac-LNS is unnecessarily irradiated for middle/distal EHC.

CONCLUSIONS

In view of discrepancies between pathological-surgical data and the CTVs used in common practice, there is an obvious need for international consensus guidelines.

A genetic model for gallbladder carcinogenesis and its dissemination

Gallbladder cancer, although regarded as the most common malignancy of the biliary tract, continues to be associated with a dismal overall survival even in the present day. While complete surgical removal of the tumour offers a good chance of cure, only a fraction of the patients are amenable to curative surgery owing to their delayed presentation. Moreover, the current contribution of adjuvant therapies towards prolonging survival is marginal, at best. Thus, understanding the biology of the disease will not only enable a better appreciation of the pathways of progression but also facilitate the development of an accurate genetic model for gallbladder carcinogenesis and dissemination. This review provides an updated, evidence-based model of the pathways of carcinogenesis in gallbladder cancer and its dissemination. The model proposed could serve as the scaffolding for elucidation of the molecular mechanisms involved in gallbladder carcinogenesis. A better understanding of the pathways involved in gallbladder tumorigenesis will serve to identify patients at risk for the cancer (and who thus could be offered prophylactic cholecystectomy) as well as aid oncologists in planning the most suitable treatment for a particular patient, thereby setting us on the vanguard of transforming the current treatment paradigm for gallbladder cancer.

Modern perspectives on factors predisposing to the development of gallbladder cancer

BACKGROUND

Gallbladder cancer (GBC) is a rare malignancy, yet certain groups are at higher risk. Knowledge of predisposing factors may facilitate earlier diagnosis by enabling targeted investigations into otherwise non-specific presenting signs and symptoms. Detecting GBC in its initial stages offers patients their best chance of cure.

METHODS

PubMed was searched for recent articles (2008-2012) on the topic of risk factors for GBC. Of 1490 initial entries, 32 manuscripts reporting on risk factors for GBC were included in this review.

RESULTS

New molecular perspectives on cholesterol cycling, hormonal factors and bacterial infection provide fresh insights into the established risk factors of gallstones, female gender and geographic locality. The significance of polyps in predisposing to GBC is probably overstated given the known dysplasia-carcinoma and adenoma-carcinoma sequences active in this disease. Bacteria such as Salmonella species may contribute to regional variations in disease prevalence and might represent powerful targets of therapy to reduce incidences in high-risk areas. Traditional risk factors such as porcelain gallbladder, Mirizzi's syndrome and bile reflux remain important as predisposing factors.

CONCLUSIONS

Subcentimetre gallbladder polyps rarely become cancerous. Because gallbladder wall thickening is often the first sign of malignancy, all gallbladder imaging should be scrutinized carefully for this feature.

Incidentally-discovered gallbladder cancer: When, why and which reoperation?

Cancer of the gallbladder, a rare entity with a poor prognosis, is often discovered incidentally during or after cholecystectomy. It tends to disseminate early via lymphatic, peritoneal, endobiliary, and hematogenous pathways. Diagnosis is made intra-operatively in only a quarter of cases, by examination of the opened cholecystectomy specimen in the operating room by the surgeon; this procedure should be routine. For incidentally-discovered cancers, survival was 28% at five years. Prognostic factors include age, TNM stage, gallbladder perforation during cholecystectomy and less-than-optimal resection at re-operation. Whether the laparoscopic route for the initial cholecystectomy has an impact on survival remains a subject of debate. R0 surgery is the only potentially curative treatment: simple cholecystectomy with clear margins is adequate resection for stage T1a tumors; extended cholecystectomy with lymphadenectomy and possibly resection of the bile duct is required for more advanced stages. After curative resection, neo-adjuvant or adjuvant chemotherapy and radiotherapy have not, so far, proven effective. Improvement of surgical practices (systematic review of cholecystectomy specimens in the OR, prevention of gallbladder perforation with bile spillage during surgery, early re-intervention for optimal resection) could improve the prognosis of these cancers.

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.

Identification of metastasis-associated proteins involved in gallbladder carcinoma metastasis by proteomic analysis and functional exploration of chloride intracellular channel 1

Advanced gallbladder cancer has an extremely poor prognosis because of metastasis. Identification of metastasis-related biomarkers is essential to improve patient survival. In the present study, metastasis-associated proteins were identified by comparative proteomic analysis and the metastasis-related function of the candidate protein, chloride intracellular channel 1 (CLIC1), was further elucidated. Two cell lines with high or low metastatic potential (termed GBC-SD18H and GBC-SD18L, respectively), originating from the same parental gallbladder carcinoma GBC-SD cell line, were identified by spontaneous metastasis in vivo and characterized by metastatic phenotypes analysis in vitro. Subsequently, a proteomic approach comprised of two-dimensional gel electrophoresis analysis and mass spectroscopy was used to identify and compare the protein expression patterns between GBC-SD18L and GBC-SD18H. Twenty-six proteins were identified and further verified by one-dimensional Western blotting and semiquantitative reverse transcriptase polymerase chain reaction analysis. It was determined that CLIC1, ezrin, vimentin, annexin A3, WD repeat domain 1, triosephosphate isomerase, C1-tetrahydrofolate synthase, Rho GDP-dissociation inhibitor 1, T-complex protein 1, heterogeneous nuclear ribonucleoprotein K, glutamate dehydrogenase 1, proteasome activator complex subunit 3 and Rab GDP-dissociation inhibitor beta were significantly up-regulated in the highly metastatic GBC-SD18H cell line compared to the poorly metastatic GBC-SD18L cell line. However, phosphoglycerate kinase 1 and programmed cell death protein 8 were significantly down-regulated in the highly metastatic GBC-SD18H cell line compared to GBC-SD18L. Considering that CLIC1 was profuse in highly metastatic GBC-SD18H but scarce in poorly metastatic GBC-SD18L, the association of CLIC1 with metastasis was further elucidated by the overexpression and RNA interference of CLIC1 in GBC-SD18L cells and GBC-SD18H cells, respectively. The results demonstrated that the overexpression of CLIC1 promoted cell motility and invasion of GBC-SD18L in vitro, while RNA interference of CLIC1 remarkably decreased cell motility and invasive potency of GBC-SD18H in vitro, indicating that CLIC1 might play an important role in metastasis of gallbladder carcinoma.

Gallbladder cancer--a comprehensive review

AIM

Gallbladder cancer is the fifth most common cancer involving the gastrointestinal tract, but it is the most common malignant tumour of the biliary tract worldwide. The percentage of patients diagnosed to have gallbladder cancer after simple cholecystectomy for presumed gallbladder stone disease is 0.5-1.5%. This tumour is traditionally regarded as a highly lethal disease with an overall 5-year survival of less than 5%. The marked improvement in the outcome of patients with gallbladder cancer in the last decade is because of the aggressive radical surgical approach that has been adopted, and improvements in surgical techniques and peri-operative care. This article aims to review the current approach to the management of gallbladder cancer.

METHODS

A Medline, PubMed database search was performed to identify articles published from 1990 to 2007 using the keywords 'carcinoma of gallbladder', 'gallbladder cancer', 'gallbladder neoplasm' and 'cholecystectomy'.

RESULTS AND CONCLUSIONS

The overall 5-year survival for patients with gallbladder cancer who underwent Ro curative resection was reported to range from 21% to 69%. Laparoscopic cholecystectomy is absolutely contraindicated when gallbladder cancer is known or suspected pre-operatively. Patients with a pre-operative suspicion of gallbladder cancer should undergo open exploration and cholecystectomy after proper pre-operative assessment. For patients whose cancer is an incidental finding on pathological review, a second radical resection is indicated except for Tis and T1a disease. There is still controversy for the optimal management of T1b disease. Although the role of surgery for advanced disease remains controversial, patients with advanced gallbladder cancer can benefit from radical resection, provided a potentially curative Ro resection is possible. There is still no effective adjuvant therapy for gallbladder cancer.

Hepatectomy for colorectal metastases in the presence of extrahepatic disease

This article focuses on hepatectomy for colorectal liver metastases (CLM) in the presence of intra-abdominal extrahepatic disease. The results reported in the literature are reviewed, and the indications and contraindications for hepatectomy in patients who have CLM with extrahepatic disease are discussed in light of the available evidence.