Article

Incidental pT2-T3 gallbladder cancer after a cholecystectomy: Outcome of staging at 3 months prior to a radical resection

Authors:
  • Saint Savvas General Oncology Hospital of Athens
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Abstract

Introduction: Patients with incidental pT2-T3 gallbladder cancer (IGC) after a cholecystectomy may benefit from a radical re-resection although their optimal treatment strategy is not well defined. In this Unit, such patients undergo delayed staging at 3 months after a cholecystectomy to assess the evidence of a residual tumour, extra hepatic spread and the biological behaviour of the tumour. The aim of this study was to evaluate the outcome of patients who had delayed staging at 3 months after a cholecystectomy. Methods: From July 2003 to July 2011, 56 patients with T2-T3 gallbladder cancer were referred to this Unit of which 49 were diagnosed incidentally on histology after a cholecystectomy. All 49 patients underwent delayed pre-operative staging using multi-detector computed tomography (MDCT) followed selectively by laparoscopy at 3 months after a cholecystectomy. Data were collected from a prospectively held database. The peri-operative and long-term outcomes of patients were analysed. SPSS software was used for statistical analysis. Results: There were 38 pT2 and 11 pT3 tumours. After delayed staging, 24/49 (49%) patients underwent a radical resection, 24/49 (49%) were found to be inoperable on pre-operative assessment and 1/49 (2%) patient underwent an exploratory laparotomy and were found to be unresectable. The overall median survival from referral was 20.7 months (54.8 months for the group who had a radical re-resection versus 9.7 months for the group who had unresectable disease, P < 0.001). These results compare favourably with the reported outcome of fast-track management for incidental pT2-T3 gallbladder cancer from other major series in the literature. Conclusion: Delayed staging in patients with incidental T2-T3 gallbladder cancer after a cholecystectomy is a useful strategy to select patients who will benefit from a resection and avoid unnecessary major surgery.

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... However, outcomes for IGBC patients seem to be largely driven by the ability to achieve margin-negative surgery and the presence of residual disease. Most reported experiences with IGBC show that 15-30% of patients selected for re-exploration will undergo a non-curative surgery (i.e., disclosing metastatic disease or leaving residual disease), which entails a dismal prognosis ( Table 2) (21,26,27,31,42,54,71,81,82). The likelihood of successful margin-clearing surgery after previous exploration decreases in a stepwise fashion according to the T-stage of the primary tumor (57% for T2 tumors, 32% for T3, and 16% for T4) (9). ...
... In general, re-resection for patients who have already undergone simple cholecystectomy occurs at the discretion of the treating surgeon with consideration of several factors, including recovery from the initial cholecystectomy, completion of preoperative staging, and addressing complications/optimizing comorbidities for a major operation. Most patients undergo reoperation within 2-3 months of their initial cholecystectomy, but across series, the reintervention interval spans weeks to years (9,31,71,81,82). While some surgeons are concerned about disease progression while waiting for reoperation, there is no evidence that reoperation timing influences disease progression, the proportion of unresectable tumors, or survival for patients able to undergo margin-negative resection (21,54,83). ...
... Given the difficulties in predicting unresectable residual disease and the uncertain influence of re-resection on IGBC natural history, several groups have reported their experience using a 'test of time' approach, either with or without chemotherapy, to allow disease biology to manifest and facilitate patient selection for margin-clearing surgery (81,89). In these studies, fewer than half of patients selected for deferred intervention underwent re-resection, mostly due to metastatic disease progression (peritoneal and/or liver metastases) or lack of response on imaging. ...
Article
Gallbladder cancer is the most common biliary tract malignancy. Margin-clearing surgery is a cornerstone of gallbladder cancer management, but several aspects of surgical management are controversial. This review will discuss the current state of surgical management for gallbladder cancer as well as aspects of gallbladder surgery that remain debated, including operative extent, lymphadenectomy extent, and management of incidentally discovered gallbladder cancer.
... De estos, se encontró evidencia directa asociada a el rol de la cirugía (colecistectomía extendida) en el estadio III del CaVB en 5 documentos (Ausania et al., 2013;Goetze & Paolucci, 2014;Lee et al., 2014, NCI), a pesar que algunos sólo lo tocan de forma tangencial. Sin embargo, ninguno de ellos, se refiere a estadio IIIb. ...
... EO (n= 49) Ausania et al. (2013) Resultados de la estadificación a 3 meses antes de una resección radical en pacientes con CaVB incidental post colecistectomía. ...
... Apoya rol de la cirugía? Ausania et al. (2013) EO (n= 49) Sí, pero después de realizar estadificación preoperatoria con TAC y laparoscopia. En los resecados se observó mejor SV que en los no rese cados. ...
Article
Full-text available
Gallbladder cancer (GBC), is a common neoplasm in our country. The overall survival rate (OSR) does not exceed 40% at 5 years. The invasion of the serosa and IIIB stage, are associated with lower OSR seen it are an advanced stage of the disease, so there is no consensus on the role of surgery in this type ofpatients. The aim of this study is to analyze the existing evidence concerning the role of surgery in the treatment of a patient with stage IIIb GBC. A systematic search of available evidence in the databases Clinical Evidence, National Health Service, Health Technology Assessment, Tripdatabase, Cochrane Library and PubMed search was performed. Evidence summary documents (overviews, GRADE tables, Clinical Guidelines/CG), secondary articles (systematic reviews) and primary articles (Clinical trials/CT) and observational studies/OS) were searched. Subsequently, evidence was classified as proposed by EMBC 2009. A total of 420 related documents were found: 25 overviews, 15 GRADE tables, 30 CG, 37 SR, 99 CT and 214 OS. In reviewing at length all documents; It was verified that only 17 were related to results of surgical treatment of GC that stage III was mentioned and 5 refer to this (3 OS, 1 CG and a recommendation from NCI), but none of them to the IIIb stage. There are few related studies, most of them are retrospective, with a small number of patients included, heterogeneous population and surgical procedures; thereby, it is difficult to draw conclusions and make recommendations based on the evidence.
... De estos, se encontró evidencia directa asociada a el rol de la cirugía (colecistectomía extendida) en el estadio III del CaVB en 5 documentos (Ausania et al., 2013;Goetze & Paolucci, 2014;Lee et al., 2014, NCI), a pesar que algunos sólo lo tocan de forma tangencial. Sin embargo, ninguno de ellos, se refiere a estadio IIIb. ...
... EO (n= 49) Ausania et al. (2013) Resultados de la estadificación a 3 meses antes de una resección radical en pacientes con CaVB incidental post colecistectomía. ...
... Apoya rol de la cirugía? Ausania et al. (2013) EO (n= 49) Sí, pero después de realizar estadificación preoperatoria con TAC y laparoscopia. En los resecados se observó mejor SV que en los no rese cados. ...
Article
Full-text available
Gallbladder cancer (GBC), is a common neoplasm in our country. The overall survival rate (OSR) does not exceed 40% at 5 years. The invasion of the serosa and IIIB stage, are associated with lower OSR seen it are an advanced stage of the disease, so there is no consensus on the role of surgery in this type ofpatients. The aim of this study is to analyze the existing evidence concerning the role of surgery in the treatment of a patient with stage IIIb GBC. A systematic search of available evidence in the databases Clinical Evidence, National Health Service, Health Technology Assessment, Tripdatabase, Cochrane Library and PubMed search was performed. Evidence summary documents (overviews, GRADE tables, Clinical Guidelines/CG), secondary articles (systematic reviews) and primary articles (Clinical trials/CT) and observational studies/OS) were searched. Subsequently, evidence was classified as proposed by EMBC 2009. A total of 420 related documents were found: 25 overviews, 15 GRADE tables, 30 CG, 37 SR, 99 CT and 214 OS. In reviewing at length all documents; It was verified that only 17 were related to results of surgical treatment of GC that stage III was mentioned and 5 refer to this (3 OS, 1 CG and a recommendation from NCI), but none of them to the IIIb stage. There are few related studies, most of them are retrospective, with a small number of patients included, heterogeneous population and surgical procedures; thereby, it is difficult to draw conclusions and make recommendations based on the evidence.
... One of the important factors affecting survival is the timing of re-intervention. While an early surgery is advocated to decrease the chances of dissemination, an intentional delay of three months has been suggested by few for biological staging [9,10]. The present study was conducted to evaluate the factors influencing survival in incidental GBC including the timing of re-intervention. ...
... This study lacked a control group. Though the authors could avoid unnecessary laparotomy but for one (2%), the median survival of 20.7 months for the entire cohort was much below the existing international standards [9]. A contrasting report from China stressed on intervention within two weeks. ...
Article
Introduction Incidental discovery of gallbladder cancer (GBC) on postoperative histopathology or intra-operative suspicion is becoming increasingly frequent since laparoscopic cholecystectomy became the standard of care for gallstone disease. Incidental GBC (IGBC) portends a better survival than primarily detected GBC. Various factors affect the outcome of re-resection with the timing of re-intervention an important determinant of survival. Methods All patients of IGBC who underwent curative resection from January 2009 to December 2018 were considered for analysis. Details of demographic profile, index surgery, and operative findings on re-resection, histopathology and follow-up were retrieved from the prospectively maintained database. Patients were evaluated in three groups based on the interval between index cholecystectomy and re-resection: Early (<4 weeks), Intermediate (4-12 weeks) and Late (>12 weeks), using appropriate statistical tests. Results Ninety-one patients were admitted with IGBC during the study period of which 48 underwent re-resection with curative intent. The median age of presentation was 55 years (31-77 years). The median duration of follow-up was 40.6 months (Range: 1.2-130.6 months). Overall and disease-free survival among the above-mentioned three groups was the best in the early group (104 and 102 months) as compared to the intermediate (84 and 83 months) and late groups (75 and 73 months), though the difference failed to achieve statistical significance (p=0.588 and 0.581). On univariate analysis, factors associated with poor outcome were node metastasis, need for common bile duct (CBD) excision and high-grade tumor. However, on multivariate analysis, poor differentiation was the only independent factor affecting survival. Conclusion Early surgery, preferably within four weeks, possibly entails better survival in incidentally detected GBC. The grade of a tumor, however, is the most important determinant of survival in IGBC.
... Similarly, a few other studies have showed that, compared with WH or AH, major hepatectomy has not been associated with improved survival, but has been linked to increased postoperative complications. 2,9,29 In this study, we found that pT3 UGC patients receiving WH of the gallbladder fossa with a 3-4 cm margin had similar OS to those receiving AH. Furthermore, data comparison using the PSM analysis showed no significant difference in OS between the WH and AH groups. ...
... The reported median interval time from initial cholecystectomy to re-resection vary from 14 to 90 days. 11,12,29 The decision on early or delayed re-resection often results from an interplay of technical issues and patient selection. Although reoperation within 4-8 weeks after the initial cholecystectomy is strongly recommended, 30 we did not observe a significant impact of re-resection time on outcomes. ...
Article
Full-text available
Background: Re-radical surgery is the only curative therapy for unsuspected gallbladder carcinoma (UGC). The aim of this study was to compare prognosis of pT3 UGC patients receiving anatomic hepatectomy (AH) or wedge hepatectomy (WH) combined with en bloc local-regional lymphadenectomy of the hepatoduodenal ligament using propensity score-matching (PSM) analysis. Materials and Methods: A retrospective study was carried out on 81 consecutive pT3 UGC patients who underwent radical re-resection at Eastern Hepatobiliary Surgery Hospital from 2006 to 2015. Overall survival (OS) was estimated using Kaplan-Meier method. The difference in OS between the AH and WH groups was analyzed using the log-rank test and the PSM method. Result: The AH and WH groups showed no significant difference in OS (P > .05) by either log-rank test or PSM analysis. Conclusions: Both AH and WH radical re-resections are effective treatments for UCG patients with pT3 tumors.
... Given the limitations of imaging studies for preoperative staging [12,14,15], attempts have been made to predict RD risk from the pathological data of the cholecystectomy specimen. In this sense, the Gallbladder Cancer Predictive Risk Score (GBRS) [16] has been proposed but not yet validated. ...
... This could be explained by the small size of the tumoral disease that in many cases may be microscopic. It has been suggested that delaying preoperative staging up to 3 months after cholecystectomy may improve their results [15]. ...
Article
Full-text available
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.
... Among them, 3 studies including 9 patients operated with robotic approaches were successfully resected without conversion to open procedure [18,19,28]. Timing of OER, the role of minimally invasive surgery, risk of port-site metastasis, and extent of resection remain debated [29,30]. In 2014, the American Hepato-Pancreato Biliary Association (AHPBA) sponsored experts consensus meeting suggested that laparoscopic radical cholecystectomy could be attempted in the biliary center that can meet the following conditions: (1) enough lymph nodes sampling beside the portal vein, vena cava, and aorta; (2) R0 hepatectomy; and (3) choledochectomy and reconstruction [31]. ...
... Estimated intraoperative blood loss and postoperative hospital stay were significantly lower in the laparoscopic group. The time interval from IC to OER remains debated [29,30]. However, one multicenter retrospective study showed comparatively better outcomes for patients undergoing re-resection within 4-8 weeks window than those treated within the first 4 weeks or more than 8 weeks following IC [33]. ...
Article
Full-text available
Background Surgical treatment is still the most effective treatment for gallbladder cancer. For the patients with stage T1b and above, the current guidelines recommend the extended radical operation, and oncologic extended resection can benefit the survival of the patients. The laparoscopic approach is still in the early phase, and its safety and oncological outcomes are not well known. Objective To evaluate the technical feasibility and oncological outcomes of laparoscopic surgery for oncologic extended resection of early-stage incidental gallbladder carcinoma. Results This study included 18 male and 32 female patients. Twenty patients underwent laparoscopic oncologic extended resection and 30 patients underwent open oncologic extended resection. All of the patients had R0 resection. A laparoscopic approach was associated with less intraoperative blood loss (242 ± 108.5 vs 401 ± 130.3; p < 0.01) and shorter duration of postoperative hospital stay (6.2 ± 2.4 vs 8.6 ± 2.3; p < 0.01). There was no statistically significant difference between two groups for lymph nodes yield (5.4 ± 3.5 vs 5.8 ± 2.1; p > 0.05), incidence of lymphatic metastasis (15% vs 16.67%; p > 0.05), residual disease (20% vs 23.3%; p > 0.05), and postoperative morbidity (15% vs 20%; p > 0.05). During follow-up time of median 20.95 (12–29.5) months, no significant difference was found between the two groups for early tumor recurrence (10% vs 13.33%; p > 0.05) and disease-free survival (p > 0.05). Conclusion Laparoscopic surgery may offer similar intraoperative, perioperative, and short-term oncological outcomes as an open oncologic extended resection for incidental gallbladder carcinoma.
... 9,10 However, the index cholecystectomy more often than not complicates the management of these patients and nearly half of them do not undergo radical resection owing to disseminated disease. 11,13 First, the depth of invasion through the dissection plane during cholecystectomy and the commonly misleading inflammation may result in incomplete resection or a breach of the tumour plane with occult or overt seeding during the initial operation. 14,15 Second, the initial pathological staging can be inaccurate because of missing information such as invasion of the cystic artery lymph node and the cystic duct margin. ...
... We have shown previously that the approach of delayed interval restaging eliminates exploratory laparotomies and significantly improves survival in the group of patients who undergo radical re-resection. 11 However, similarly to other reports, only 49% of the referred patients had resectable disease at interval restaging. In this study, the same cohort was reviewed to investigate whether the index cholecystectomy, the tumour characteristics, and the timing of management in the community hospitals and in a tertiary referral centre are associated with the re-resection of advanced, potentially curable IGBC. ...
Article
Full-text available
Advanced (pT2/T3) incidental gallbladder cancer is often deemed unresectable after restaging. This study assesses the impact of the primary operation, tumour characteristics and timing of management on re-resection. The records of 60 consecutive referrals for incidental gallbladder cancer in a single tertiary centre from 2003 to 2011 were reviewed retrospectively. Decision on re-resection of incidental gallbladder cancer was based on delayed interval restaging at three months following cholecystectomy. Demographics, index cholecystectomy data, primary pathology, CA19-9 tumour marker levels at referral and time from cholecystectomy to referral as well as from referral to restaging were analysed. Thirty-seven patients with pT2 and twelve patients with pT3 incidental gallbladder cancer were candidates for radical re-resection. Following interval restaging, 24 patients (49%) underwent radical resection and 25 (51%) were deemed inoperable. The inoperable group had significantly more patients with positive resection margins at cholecystectomy (p=0.002), significantly higher median CA19-9 levels at referral (p=0.018) and were referred significantly earlier (p=0.004) than the patients who had resectable tumours. On multivariate analysis, urgent referral (p=0.036) and incomplete cholecystectomy (p=0.048) were associated significantly with inoperable disease following restaging. In patients with incidental, potentially resectable, pT2/T3 gallbladder cancer, inappropriate index cholecystectomy may have a significant impact on tumour dissemination. Early referral of breached tumours is not associated with resectability.
... The timing of completion radical cholecystectomy for optimal results remains a matter of debate. Some suggest an early intervention to improve the resectability rate while others advocate delaying the definitive surgery for biological selection [12,13]. Presentations of IGBC are variable, ranging from intraoperative recognition/suspicion to unexpected pathological finding. ...
... Optimum timing for reoperation in IGBC lacks consensus. Ausania et al. [12] have evaluated outcomes of patients with IGBC following an intentional delay of three months and found that the curative resection rate with this approach is 49% at 12 weeks. In a multi-institutional study by Ethun et al. [13], patients operated within 4 to 8 weeks of the index cholecystectomy had the best prognosis, with poor differentiation and higher primary T-stage being the most important parameters predicting metastatic or unresectable disease. ...
Article
Full-text available
Backgrounds/aims: Re-resection of incidental gallbladder carcinoma (IGBC) is possible in a select group of patients. However, the optimal timing for re-intervention lacks consensus. Methods: A retrospective analysis was performed for a prospective database of 91 patients with IGBC managed from 2009 to 2018. Patients were divided into three groups based on the duration between the index cholecystectomy and re-operation or final staging: Early (E), < 4 weeks; Intermediate (I), > 4 weeks and < 12 weeks; and Late (L), > 12 weeks. Demographic data, tumor characteristics, and operative details of patients were analyzed to determine factors affecting the re-resectability of IGBC. Results: Twenty-two patients in 'E', 48 in 'I', and 21 in 'L' groups were evenly matched. Nearly two thirds were asymptomatic. Curative resection was possible in 48 (52.7%) patients. Metastasis was detected during staging laparoscopy (SL)/laparotomy in 26 (28.6%) patients. The yield of SL was more in the 'L' group (30.8%) than in the 'I' (11.1%) or 'E' (nil) group, avoiding unnecessary laparotomy in 13.6%. Only 28.5% of patients in the 'L' group could undergo curative resection (R0/R1 resection), significantly less than that in the 'E' (50.0%) or 'I' group (64.6%) (both p < 0.001). On multivariate analysis, presentation in intermediate period and tumor differentiation increased the chance of curative resection (p < 0.05). Conclusions: Asymptomatic patients in the 'I' group with well differentiated IGBC have the best chance of obtaining a curative resection.
... Gallbladder cancer is a rare disease that occurs mostly in women and the elderly, and is related to gallstones and chronic gallbladder inflammation [1]. Gallbladder cancer is dangerous because it is often diagnosed at a late stage; it is reported that the overall 5-year survival rate is only 19% [2][3][4][5], and the average overall survival is 3 to 11 months [6]. Most patients with gallbladder cancer have gallstones. ...
... Guidelines for the treatment of localized GBC are mainly based on retrospective evidence and expert opinion due to the minimal availability of randomized evidence. Previous studies investigating GBC have typically been conducted in high-volume, non-Western centers and included patients with various biliary tract cancers [15,18,19]. Due to presumed different etiologies, results in GBC may differ from those in other biliary tract tumors [20]. ...
Article
Full-text available
Gallbladder cancer (GBC) is rare in Western populations and data about treatment and outcomes are scarce. This study aims to analyze survival and identify opportunities for improvement using population-based data from a low-incidence country. GBC patients diagnosed between 2005 and 2016 with GBC were identified from the Netherlands Cancer Registry. Patients were grouped according to time period (2005–2009/2010–2016) and disease stage. Trends in treatment and overall survival (OS) were analyzed. In total 1834 patients were included: 661 (36%) patients with resected, 278 (15%) with non-resected non-metastatic, and 895 (49%) with metastatic GBC. Use of radical versus simple cholecystectomy (12% vs. 26%, p < 0.001) in early (pT1b/T2) GBC increased. More patients with metastatic GBC received chemotherapy (11% vs. 29%, p < 0.001). OS improved from 4.8 months (2005–2009) to 6.1 months (2010–2016) (p = 0.012). Median OS increased over time (2005–2009 vs. 2010–2016) in resected (19.4 to 26.8 months, p = 0.038) and metastatic (2.3 vs. 3.4 months, p = 0.001) GBC but not in unresected, non-metastatic GBC. In early GBC, patients with radical cholecystectomy had a median OS of 76.7 compared to 18.4 months for simple cholecystectomy (p < 0.001). Palliative chemotherapy showed superior (p < 0.001) survival in metastatic (7.3 versus 2.1 months) and non-resected non-metastatic (7.7 versus 3.5 months) GBC. In conclusion, survival of GBC remains poor. Radical surgery and palliative chemotherapy appear to improve prognosis but remain under-utilized.
... Gallbladder cancer is a rare disease that occurs mostly in women and the elderly, and is related to gallstones and chronic gallbladder inflammation [1] . Gallbladder cancer is dangerous because it is often diagnosed at a late stage; it is reported that the overall 5-year survival rate is only 19% [2][3][4][5] , and the average overall survival is 3 to 11 months [6] . Most patients with gallbladder cancer have gallstones. ...
Article
Full-text available
Gallbladder cancer can be difficult to detect in its early stages and is prone to metastasize, causing bile duct obstruction, which is usually treated by stent implantation in clinic. However, the commonly used biliary stents are non-degradable, which not only prone to secondary blockage, but also need to be removed by secondary surgery. Biodegradable magnesium (Mg) is expected to one of the promising candidates for degradable biliary stents due to its excellent physicochemical property and biocompatibility. In this work, we studied the influence of high-purity Mg wires on gallbladder cancer through in vitro and in vivo experiments and revealed that the degradation products of Mg could significantly inhibit the growth of gallbladder cancer cells and promote their apoptosis. Our findings indicate that Mg biliary stent possesses the function of draining bile and treating gallbladder cancer, suggesting that Mg has good application prospects in biliary surgery. Statement of significance Current research and development of biomedical magnesium are mainly concentrated in the cardiovascular and orthopedics field. Degradable magnesium bile duct stents have great application prospects in the treatment of bile duct blockage caused by bile duct-related cancers. At present, the effect of magnesium implants on gallbladder cancer is not clear. Our work verified the effectiveness of magnesium wire implants in inhibiting gallbladder cancer through in vivo and in vitro experiments, and studied the effect of magnesium degradation products on gallbladder cancer cells from the perspective of cell proliferation, apoptosis and cycle. This study provided new understanding for the application of magnesium in biliary surgery.
... Few authors (35) have advocated a deliberate delaying of restaging for incidental gallbladder cancer in order to permit careful evaluation for residual disease and extrahepatic spread, as well as observation of the biologic behavior of the tumor. Proponents of this concept believe that this strategy avoids unnecessary laparotomies in patients who may not have benefited from surgical resection, without adversely affecting survival in patients who remained candidates for resection. ...
Article
Full-text available
Gallbladder cancer is a highly aggressive disease with variable prevalence across the globe. Particularly the Indo-Gangetic belt in Northern India has an incidence as high as 21/100,000. Majority of cases are detected either incidentally on pathological evaluation of cholecystectomy specimens or present with advanced disease. Radical surgery remains the mainstay of cure but only a small subset of patients is operable at presentation, and even with curative surgery recurrence rates remain high. Much debate surrounds the management of gallbladder cancer, with continuously evolving standards regarding the extent of hepatic resection and lymphadenectomy, curative resection in patients presenting with jaundice, routine excision of bile duct, and the role of neoadjuvant chemoradiotherapy. In this review we present a synopsis of currently available evidence and emerging approaches in the management of gallbladder cancer in India.
... This should include assessment of deep liver lesions with laparoscopic intraoperative US, of residual disease in the gallbladder fossa, of local and para-aortic lymphadenopathy especially assessment for aortocaval lymphadenopathy after performance of a laparoscopic Kocher maneuver (recommended by some but not all experts), and of the presence of peritoneal disease, which we have observed to develop in as little as 30 days from bile spillage at laparoscopic cholecystectomy [25]. Consistent with this observation, some authors have advocated delaying reoperation for a period of 3 months [48,49] to identify patients at high risk for not benefiting from MIS or open extended resection due to evidence of disease progression in the this time interval. Such patients include those with bile spillage and with higher T stage, especially T3. ...
Article
Full-text available
Minimally invasive surgery (MIS) for gallbladder cancer (GBC) has been increasingly performed, including an increasing number of reports of radical cholecystectomy with hepatectomy, lymphadenectomy and excision of the extrahepatic biliary tree, but continues to be controversial. Here, we highlight these controversies and review the management of incidental GBC, and the MIS management of early and advanced nonincidental GBC. While initial results are promising, and are likely to improve, adequate long-term survival data are lacking and for now MIS for GBC should be limited to high-volume centers with adequate expertise in both MIS and hepatobiliary surgery.
... The optimal timing of re-resection for incidental gallbladder cancer has been discussed in previous studies 37,38 . In the present study, curative re-resection was performed a median of 72 days after index cholecystectomy. ...
Article
Background: Incidental gallbladder cancer is a rare event, and its prognosis is largely affected by the tumour stage and treatment. The aim of this study was to analyse the management, treatment and survival of patients with incidental gallbladder cancer in a national cohort over a decade. Methods: Patients were identified through the Swedish Registry of Gallstone Surgery (GallRiks). Data were cross-linked to the national registry for liver surgery (SweLiv) and the Cancer Registry. Medical records were collected if registry data were missing. Survival was measured as disease-specific survival. The study was divided into two intervals (2007-2011 and 2012-2016) to evaluate changes over time. Results: In total, 249 patients were identified with incidental gallbladder cancer, of whom 92 (36·9 per cent) underwent re-resection with curative intent. For patients with pT2 and pT3 disease, median disease-specific survival improved after re-resection (12·4 versus 44·1 months for pT2, and 9·7 versus 23·0 months for pT3). Residual disease was present in 53 per cent of patients with pT2 tumours who underwent re-resection; these patients had a median disease-specific survival of 32·2 months, whereas the median was not reached in patients without residual disease. Median survival increased by 11 months for all patients between the early and late periods (P = 0·030). Conclusion: Re-resection of pT2 and pT3 incidental gallbladder cancer was associated with improved survival, but survival was impaired when residual disease was present. A higher re-resection rate and more R0 resections in the later time period may have been associated with improved survival.
... In another retrospective analysis by Patkar et al. [38], 382 subjects underwent upfront surgery for incidental GBC and a favorable outcome was observed in patients operated between 10 and 14 weeks after primary cholecystectomy. Moreover, Ausania et al. [39], studied 49 GBC patients with incidental diagnosis and concluded that delayed staging (i.e., three months after cholecystectomy) is a useful strategy to In a retrospective analysis on 127 patients who underwent reresection for incidental GBC, Barreto et al. [40] found that the TNM stage rather than delaying revision surgery influenced oncologic outcomes. He et al. [41] evaluated the outcomes of 84 patients with GBC who underwent radical resection, they concluded that subjects undergoing delayed surgery had non-inferior survival compared with those treated with simultaneous radical resection. ...
Article
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.
... It is also important to note that while this study analyzed patients with chemotherapy administration for locally advanced disease, it is possible that the observation time alone helps improve patient selection. Ausania et al showed that a technique of delayed-restaging (instead of neoadjuvant chemotherapy) in incidental gallbladder cancer prevented 49% of patients from being subjected to an operation with early progression (23). However, a subset of patients in our sample responded to chemotherapy, and this would not have occurred with observation alone. ...
Article
Background: Preoperative chemotherapy is a strategy for conversion to resection and/or assessing disease biology prior to operation. The utility of such an approach in gallbladder carcinoma (GBCA) is unknown. This study evaluates outcomes of GBCA patients treated with chemotherapy for locally advanced or lymph node involved tumors. Study design: Patients that received systemic chemotherapy for locally advanced or lymph node positive GBCA were identified from a departmental database. Patients were excluded if there was any evidence of distant metastases or if records were inadequate to determine initial chemotherapy and response. Response (RECIST), operative results, and overall survival (OS) were assessed. Results: Seventy-four patients were included from 1992-2015. Eighty-nine percent of patients (n=64) were treated with gemcitabine and 57% with gemcitabine/platinum (n=42). At initial response assessment, 17 patients (23%) had progression. The remaining patients had stable disease (n=38, 51%) or partial response (n=19, 26%). Twenty-two patients (30%) underwent attempt at resection which was definitive for 10 patients (14%). Median OS for the entire cohort was 14 months (95% CI:11.3-17.9). Among patients with surgery, definitive resection was associated with a median OS of 51 months (95% CI:11.7-55.3) compared to 11 months (95% CI:4.1-23.6) for those that were unresectable (p=0.003). Conclusions: Even without distant metastases, locally advanced or lymph node positive GBCA is associated with poor outcomes. Definitive resection was possible in a subset of patients selected for surgery after a favorable response to chemotherapy and was associated with long-term survival. We recommend surgical re-evaluation following chemotherapy to select potential operative candidates.
... 23 The data on the advantage of timely OER presented here conflicts with reports suggesting that delaying OER may allow for unfavorable tumor biology to declare and thereby avoiding non-therapeutic laparotomy. 24 Several reason may explain why there is a survival benefit of resecting specifically T2b gallbladder cancer in one stage. T1a and T1b tumors have overall favorable outcome and a negative effect due to microscopic cancer left behind is less likely since the cancer is confined to or above the serosal plane. ...
Article
Background: Conflicting data exists whether non-oncologic index cholecystectomy (IC) leading to discovery of incidental gallbladder cancer (IGBC) negatively impacts survival. This study aimed to determine whether a subgroup of patients derives a disadvantage from IC. Methods: Patients with IGBC and non-IGBC treated at an academic USA and Chilean center during 1999-2016 were compared. Patients with T1, T4 tumor or preoperative jaundice were excluded. T2 disease was classified into T2a (peritoneal-side tumor) and T2b (hepatic-side tumor). Disease-specific survival (DSS) and its predictors were analyzed. Results: Of the 196 patients included, 151 (77%) had IGBC. One hundred thirty-six (90%) patients of whom 118 (87%) had IGBC had T2 disease. Three-year DSS rates were similar between IGBC and non-IGBC for all patients. However, for T2b patients, 3-year survival rate was worse for IGBC (31% vs 85%; p = 0.019). In multivariate analysis of T2 patients, predictors of poor DSS were hepatic-side tumor hazard ratio [HR], 2.9; 95% CI, 1.6-5.4; p = 0.001) and N1 status (HR, 2.4; 95% CI, 1.6-3.6; p < 0.001). Conclusions: Patients with T2b gallbladder cancer specifically benefit from a single operation. These patients should be identified preoperatively and referred to hepatobiliary center.
... GBC is generally associated with a poor prognosis with a reported 5-year survival rate of 5% [1,2]. The overall 5-year survival rate is currently reported to be 5-13% [1][2][3], with a mean overall survival of 3-11 months [4]. Biliary tract carcinoma, including GBC, is the eighth most common malignancy in Japanese men and the seventh in Japanese women according to the National Cancer Center 2016 [5]. ...
Article
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Owing to the advantages of a laparoscopic approach, laparoscopic cholecystectomy (LC) is thought to be the treatment of choice in gallbladder disease, even in cases of suspected malignancy. However, it is difficult to differentiate between cholecystitis and gallbladder carcinoma (GBC). We performed radical hepatectomy in patients with pT2 GBC diagnosed by full-thickness frozen biopsy. A 75-year-old Japanese man presented to our hospital with discomfort in the right upper quadrant of the abdomen. This patient was diagnosed with suspected GBC and was scheduled to undergo LC and intraoperative histological examination. Following the procedure, we made a diagnosis of GBC with negative invasion of the cystic duct stump. We converted the laparoscopic procedure to an open surgery involving wedge liver resection with lymphadenectomy. The patient was discharged from our hospital in remission 14 days following the radical hepatectomy. Histological examination showed that the GBC had invaded the liver (T3a), but there was no lymph node metastasis (N0): stage IIIA. Between April 2009 and September 2018, 580 patients underwent cholecystectomy for gallbladder disease at our hospital. Among these, 8 (1.4%) were suspected to have GBC preoperatively and underwent laparoscopic excisional cholecystectomy. We performed elective surgery in the early stage in two patients and second-look surgery in two patients recently. We were able to perform what we termed a laparoscopic excisional cholecystectomy, involving LC with a full-thickness frozen biopsy, even in situations where intraoperative histological examination was not available. Altogether, laparoscopic excisional cholecystectomy is an effective surgical treatment for suspected early GBC.
... Gallbladder cancer is the most common cancer of the biliary tract and is recognized to have both a poor prognosis and poor survival rate. The overall 5-year survival rate is currently reported to be 5%-13% [4][5][6], with a mean overall survival of three to eleven months [7]. The etiology of GBC is not yet fully understood, because of the significant difficulties associated with its diagnosis. ...
Article
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Purpose This paper presents an overview of the surgical strategy for patients with suspected gallbladder carcinoma (GBC), including incidental GBC cases, preoperatively or intraoperatively, as well as their outcomes. Methods Between April 2009 and December 2017, 529 patients underwent cholecystectomy for gallbladder disease at our hospital. Both intraoperative and postoperative histological examinations of the excised gallbladder facilitated the diagnosis of GBC. Surgery-related variables and surgical approaches were evaluated according to the extent of tumor invasion. Results Of 529 patients, eight were diagnosed with GBC during/after cholecystectomy, including four women and four men. Mean age was 75.4 (range, 59–89) years. Five patients had gallbladder stones and three had cholecystitis. Three patients with stages T1b and T2 underwent additional liver bed wedge resections with or without prophylactic common bile duct excision. Five of the eight patients are still alive and two of the remaining three died from other diseases; one patient with pT3 died of recurrent GBC (peritonitis carcinomatosa). Conclusion Because of the ability to obtain full-thickness frozen biopsies during laparoscopic cholecystectomy, we could diagnose GBC intraoperatively, allowing for rapid diagnosis and tumor resection. We recommend developing a surgical treatment strategy for suspected early GBC in advance of cholecystectomy.
... GBC and nearby large bile duct cancers accounted for an estimated 11,420 new cases and 3710 deaths in the United States in 2016. GBC has a dismal prognosis and majority of the cases are asymptomatic and are incidentally diagnosed during gall stone exploration or after cholecystectomy performed for a non-malignant indication [3]. Therefore, the index surgical procedure is often a simple resection of the gallbladder and a revision surgery is planned based on the staging results [4]. ...
Article
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Background There is limited literature about the clinicopathological characteristics and outcomes of rare histologic variants of gallbladder cancer (GBC). Methods Using SEER database, surgically managed GBC patients with microscopically confirmed adenocarcinoma, adenosquamous/squamous cell carcinoma and papillary carcinoma were identified from 1988 to 2009. Patients with second primary cancer and distant metastasis at presentation were excluded. The effect of clinicopathological variables on overall survival (OS) and disease specific survival (DSS) were analyzed using univariate and multivariate proportional hazards modeling. All associations were considered statistically significant at an alpha error of 0.01. Results Out of 4738 cases, 217 adenosquamous/squamous (4.6%), 367 papillary (7.7%), and 4154 adenocarcinomas (87.7%) were identified. Median age was 72 years. Higher tumor grade (grade 2, 3, 4 versus grade 1), higher T stage (T2, T3, T4 versus T1), lymph node positivity (N1 versus N0) and adenosquamous/squamous histology (versus adenocarcinoma) had worse OS and DSS (p < .001). Papillary GBC had better OS and DSS than adenocarcinoma (HR = 0.7; p < .001). Radical surgery (versus simple cholecystectomy) had better OS (HR = 0.83, p = 0.002) in multivariate analysis. OS rates at 3 and 5 years were 0.56 and 0.44 for papillary, 0.3 and 0.22 for adenocarcinoma, and 0.14 and 0.12 for adenosquamous/squamous histology, while DSS rates at 3 and 5 years were 0.67 and 0.61 for papillary, 0.38 and 0.31 for adenocarcinoma, and 0.17 and 0.16 for adenosquamous/squamous subtypes respectively. Conclusion Papillary GBC had better survival outcomes while adenosquamous/squamous GBC had worse survival outcomes compared to gallbladder adenocarcinoma.
Article
In this review, the authors present an updated description of gallbladder cancer in 2 sections based on presentation: disease that presents incidentally following laparoscopic cholecystectomy and malignancy that is suspected preoperatively. Elements pertaining to technical aspects of surgical resection provide the critical focus of this review and are discussed in the context of evidence-based literature on gallbladder cancer today.
Article
Background: Gallbladder cancer is a rare neoplasm with a poor prognosis. Early diagnosis and correct treatment strategy is important. The aim of this study was to identify predictors for incidental gallbladder cancer. Methods: Data from cholecystectomies registered in the nationwide Swedish Register for Gallstone Surgery between 2007 and 2014 were analyzed for incidental gallbladder cancer. Exclusion criteria were patients with a gallbladder not sent for histopathology, preoperative suspicion of polyps/gallbladder cancer, and indication for operation for other reasons than gallstone disease. Predictive factors for incidental gallbladder cancer were identified using multivariable logistic regression. Results: A total of 86,154 procedures were registered in the Swedish Register for Gallstone Surgery. Of these, 36,355 patients were included in the analysis, and 215 of the included patients had incidental gallbladder cancer (0.59%). Mean age was 70 ± 11 years for index cases and 54 ± 16 years for the control group, and 80% of cases and 60% of controls were female. Predictors for incidental gallbladder cancer were older age (odds ratio = 1.08; P < .001), female sex (odds ratio = 3.58; P < .001), previous cholecystitis (odds ratio = 1.37; P = .045), and the combination of acute cholecystitis without jaundice (odds ratio = 1.39; P = .041) and jaundice without acute cholecystitis (odds ratio = 2.02; P = .009). A preoperative risk model including these factors gave an area under receiver operating characteristic curve of 0.82. By adding macroscopic evaluation of the gallbladder by the surgeon, the area under receiver operating characteristic curve increased to 0.87. Intraoperatively suspected gallbladder cancer was confirmed as cancer in 31% of the cases. Conclusion: Incidental gallbladder cancer is more likely to be diagnosed in older patients, women, and after previous cholecystitis. Jaundice and acute cholecystitis were also shown to be important risk factors. Intraoperative inspection of the gallbladder improved the risk model.
Article
Introduction: Re-operation is advised for patients with T1b or greater incidental gallbladder cancer (GBCA). The presence of residual disease (RD) impacts resectability, chemotherapy, and survival. This study created a preoperative model to predict RD at re-operation. Methods: Patients with re-operation for incidental GBCA from 1992-2015 were included. The relationship between pathology data from initial cholecystectomy and RD at re-operation was assessed with logistic regression and classification and regression tree (CART) analysis. Results: Two hundred fifty-four patients were included and 188 underwent definitive re-resection (74.0%). Distant RD was identified in 69 (27.2%) patients and locoregional only RD in 82 (32.3%). On multivariate analysis, T3 (OR 22.7, 95% CI 5.5-94.4) and poorly differentiated tumors (OR 4.3, 95% CI 1.4-13.3) were associated with RD (p < 0.001-0.012). AUC of multivariate model was 0.78 (95% CI 0.72-0.83). CART analysis split patients into groups based on percentage with RD: 87% RD with T3, 67% RD with T1b/T2 and poorly differentiated, and 35% RD with T1b/T2 and well/moderate differentiated tumors. Conclusion: Based on T stage and grade from cholecystectomy, this study developed a model for predicting RD at re-operation in incidental GBCA. This model delineates patient groups with variable percentages of RD and could be used to stratify high-risk patients for prospective trials.
Article
Background Gallbladder cancer is rare, but cancers detected incidentally after cholecystectomy are increasing. The aim of this study was to review the available data for current best practice for optimal management of incidental gallbladder cancer. Methods A systematic PubMed search of the English literature to May 2018 was conducted. Results The search identified 12 systematic reviews and meta‐analyses, in addition to several consensus reports, multi‐institutional series and national audits. Some 0·25–0·89 per cent of all cholecystectomy specimens had incidental gallbladder cancer on pathological examination. Most patients were staged with pT2 (about half) or pT1 (about one‐third) cancers. Patients with cancers confined to the mucosa (T1a or less) had 5‐year survival rates of up to 100 per cent after cholecystectomy alone. For cancers invading the muscle layer of the gallbladder wall (T1b or above), reresection is recommended. The type, extent and timing of reresection remain controversial. Observation time may be used for new cross‐sectional imaging with CT and MRI. Perforation at initial surgery had a higher risk of disease dissemination. Gallbladder cancers are PET‐avid, and PET may detect residual disease and thus prevent unnecessary surgery. Routine laparoscopic staging before reresection is not warranted for all stages. Risk of peritoneal carcinomatosis increases with each T category. The incidence of port‐site metastases is about 10 per cent. Routine resection of port sites has no effect on survival. Adjuvant chemotherapy is poorly documented and probably underused. Conclusion Management of incidental gallbladder cancer continues to evolve, with more refined suggestions for subgroups at risk and a selective approach to reresection.
Article
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.
Article
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Since the American Joint Committee on Cancer (AJCC) subdivided the T2 stage of gallbladder carcinoma (GBC) into T2a and T2b, the diagnosis and treatment of those stages have been a subject of heated discussion and controversy. T2 is a stage of GBC that might be treatable. Based on the extent of lymph node metastasis and distant metastasis, T2 GBC can be classified into various pathological stages such as IIA, IIB, IIIB, and IVB, leading to controversy in clinical settings. This review aims to discuss the effectiveness of and controversies concerning S4b+5 resection, the acceptable extent of lymph node dissection, the timing for treatment of incidental gallbladder cancer, and adjuvant therapy. This review also aims to suggest directions for and recommendations regarding clinical research in the future.
Article
At MSKCC, over 50% of the patients presenting with gallbladder cancer have been diagnosed incidentally following elective cholecystectomy for presumed benign disease. While traditional management of incidental gallbladder cancer (IGBC) dictates re-resection with the ultimate goal of achieving cure, surgical decision-making must take into account that this malignancy is characterized by poor tumor biology with frequent distant recurrence. Since early and frequent distant recurrence is the most common cause of surgical failure, the surgical oncologist’s goal should be to selectively re-resect only those patients most likely to benefit from an operation. The astute surgeon recognizes the high-risk patients who likely have micrometastatic disease at the time of diagnosis and alters the treatment sequence, delivering neoadjuvant chemotherapy. This strategy acts as a selection tool, as those progressing at distant sites during therapy are spared the morbidity and mortality of surgery and furthermore has the potential to treat micrometastatic disease. However, a chemotherapy first approach must be applied selectively since a poor response risks local progression to unresectability and a decrease in functional status that comes from the toxicities of dual agent chemotherapy that can impair surgical candidacy. To balance these risks and benefits, two other criteria for a neoadjuvant approach must be met: i) reliable identification of those patients who are at high risk of distant recurrence and who are, therefore, most likely to benefit from a systemic therapy first approach and ii) availability of effective chemotherapy options. In this review, we will outline the data and judgement we use to select a treatment sequence at our institution.
Article
Background Although gallbladder cancer (GBCA) is characterized by a dismal prognosis, there is a proportion of patients who are cured. The aim of this study was to analyze the profile of these patients. Methods A database was queried for patients who underwent curative resection with a follow-up of at least 5 years. Patients were prospectively treated and registered by the same surgical team. A multivariate regression analysis was used to identify factors associated with long-term survival. Results From 1988 to 2013, 461 patients were evaluated and 112 who underwent resection were analyzed. Among the patients, five year survival was 57% while lymph node and liver compromise were the only independent factors associated with survival. On the other hand, the elapsed time between the cholecystectomy and the resection, the differentiation grade and the level of wall invasion did not have an independent effect on the prognosis. Conclusion Despite its poor prognosis, a subset of patients can be cured of GBCA. R0 resection of patients without lymph and liver infiltration are key to GBCA survival.
Chapter
Incidental gall bladder cancer is one which is diagnosed on the histopathological examination of a grossly normal gall bladder removed with a preoperative diagnosis of gall stone disease. Majority of patients with incidental gall bladder cancer require reoperation for completion extended cholecystectomy, i.e., liver wedge resection and lymphadenectomy. The role of port-site excision is debatable. In addition to the T stage, presence of residual disease at reoperation is the most important factor for predicting outcome. Histopathological examination of all gall bladders is strongly recommended so as not to miss an incidental gall bladder cancer, which is eminently curable.
Article
Background: The surgical approach to gallbladder cancer (GBCA) has evolved in recent years, but the impact on outcomes is unknown. This study describes differences in presentation, surgery, chemotherapy strategy, and survival for patients with GBCA over two decades at a tertiary referral center. Methods: A single-institution database was queried for patients with GBCA who underwent surgical evaluation and exploration and was studied retrospectively. Univariate logistic regression was used to assess the relationship between time and treatment. Univariate Cox proportional hazard regression assessed the association between year of diagnosis and survival. Results: From 1992 to 2015, 675 patients with GBCA were evaluated and 437 underwent exploration. Complete resection rates increased over time (p < 0.001). In those submitted to complete resection (n = 255, 58.4%), more recent years were associated with lower likelihood of bile duct resection and major hepatectomy but greater odds of neoadjuvant and adjuvant chemotherapy (p < 0.05). No significant association was found between year of diagnosis and OS or RFS (p > 0.05) for patients with complete resection. Conclusion: Over the study period, GBCA treatment evolved to include fewer biliary and major hepatic resections with no apparent adverse impact on outcome. Further prospective trials, specifically limited to GBCA, are needed to determine the impact of adjuvant chemotherapy.
Article
In selected patients with incidental gallbladder carcinoma (GBCA) diagnosed after laparoscopic cholecystectomy (LC), definitive resection is warranted. Port site excision has been advocated but remains controversial. Patients with GBCA were identified through institutional/departmental databases. The subset of patients with incidental tumors identified after LC and submitted to definitive surgical therapy were selected. Those subjected to port site resection were compared with patients who underwent resection without port site removal and analyzed for differences in recurrence patterns and survival. From 1992 to 2009, 113 patients with incidental GBCA presented for definitive resection after LC; 69 patients had port site resection and 44 did not. In the resected port site group, depth of tumor invasion was T1b = 6, T2 = 35, T3 = 28, and 13 (19%) had port site metastases. Port site disease was seen only in patients with T2 or T3 tumors and correlated with the development of peritoneal metastases (P = 0.01). Median survival of patients with T2/T3 tumors without port site metastases was 42 months compared to 17 months in patients with port site disease (P = 0.005). When only R0 resected patients were compared and adjusted for T and N stage, port site resection was not associated with overall survival (P = 0.23) or recurrence-free survival (P = 0.69). In patients with incidental GBCA, port site metastases were associated with peritoneal disease and decreased survival. Port site resection was not associated with improved survival or disease recurrence and should not be considered mandatory during definitive surgical treatment.
Article
Incidental gallbladder cancer (GBC) is frequently discovered on the specimen when cholecystectomy for a benign disease is performed. The objective of the present study was to assess the management of incidental GBC patients in a French registry. Data on patients with GBC treated between 1998 and 2008 were retrospectively collated in a French, multicenter database. The registry contained 218 patients with incidental GBC (67 men and 151 women; median age = 64 years; age range = 31-88). One hundred forty-eight (68%) patients underwent re-resection after a median time interval of 48 days (range = 2-245). The most common complete procedure (66% of cases) was 4b + 5 segmentectomy with lymphadenectomy but not bile duct resection. Port-site excision was performed in 54 patients. The mortality and morbidity rates were 3 and 37%, respectively. Resection of the common bile duct (43%) increased postoperative complications (60 vs. 23%, p = 0.0001). Local residual tumor was found in 83 (56%) patients; it was significantly correlated with the T stage and influenced long-term survival. R0 was obtained in 143 (97%) patients and port-site invasion was histologically confirmed in one patient (1.8%). After a median follow-up period of 34 months, the 1-, 3-, and 5-year survival rates for the 148 patients with re-resection were 76, 54, and 41%, respectively. Re-resection significantly increased survival in patients with T2 (p = 0.0001) and T3 (p = 0.04) disease. Resection of the common bile duct increased neither R0 resection nor overall survival (p = 0.06). This study validates the concept of re-resection in T2 and T3 GBC. Bile duct resection increases postoperative morbidity but does not improve survival. There is currently a modification in the surgical management of incidental GBC, with minor liver resection and no common bile duct resection.
Article
Incidental gallbladder cancer (IGBCA) has risen worldwide and its prognosis depends on complete radical cholecystectomy (CRC). This study evaluated surgical findings during re-operation and survival of patients with IGBCA. Demographics, surgical treatment, staging, and survival data for all IGBCA patients who underwent surgery at Instituto Oncológico Fundación Arturo López Pérez (FALP) between 2000 and 2008 were analyzed. Differences between groups were analyzed by Student's t-test, Mann-Whitney, chi-square, or Fisher log-rank tests. Forty-nine patients were studied (38 women/11 men, median age = 58 years). Pathology reports from cholecystectomy showed that 32 patients had a T2 tumor and 12 had positive resection margin. Thirty-six patients underwent surgical re-exploration and 20 underwent CRC; 10 with (+) residual disease and 10 with (-). For patients with at least T1b tumor, median survival was 28 months and 5-year disease-specific survival (DSS) was 29%. The 3-year DSS was 64% for CRC (-), 30% for CRC (+), and 8% for non-resected cases (P < 0.007). The 3-year DSS was better for patients with stage Ib than those with stages II and IV (P < 0.007). Patients with IGBCA have a high chance of intra-abdominal metastases or local residual disease. In CRC patients, intra-abdominal metastases were associated with a worse prognosis.
Article
The impact of computed tomography (CT)-based follow-up for the detection of resectable disease recurrence following surgery for colorectal liver metastases (CRLM) was evaluated. Some 705 patients undergoing resection of CRLM between January 1993 and March 2007 were included. Surveillance comprised 3-monthly CT (thorax, abdomen and pelvis) in the first 2 years after surgery, 6 monthly for 3 years and annually from years 6 to 10. Survival differences following recurrence between patients managed surgically and palliatively were determined, and the cost was calculated. Five-year disease-free and overall survival rates were 28.3 and 32.3 per cent respectively. Of 402 patients who developed recurrence within 2 years, 88 were treated with liver resection alone and 36 with lung and/or liver resection. Their 5-year overall survival rates were 31 and 30 per cent respectively, compared with 3.9 per cent in 278 patients managed palliatively (P < 0.001). For each 3-month interval during the first year of follow-up, patients with recurrence treated surgically had better overall survival than those treated palliatively. The cost of surveillance that identified 124 patients amenable to further resection was 12,338 pounds per operated recurrence. Assuming that patients with recurrence gained 5 years' survival, the mean survival gain was 4.28 years per resection and the cost per life-year gained was 2883 pounds. Intensive 3-monthly CT surveillance after liver resection for CRLM detects recurrence that is amenable to further resection in a considerable number of patients. These patients have significantly better survival with a reasonable cost per life-year gained.
Article
Complete surgical resection is the only potentially curative treatment of gallbladder cancer. Gallbladder carcinoma is suspected preoperatively in 30% of patients, and 70% are incidentally discovered by the pathologist (incidental gallbladder carcinoma, IGBC). If IGBC is detected postoperatively, a re-resection, including liver resection and lymph node dissection, in T2 tumor cases and more advanced stages is recommended. It remains unclear whether the prognosis of wedge resection (2-3-cm margin) of the gallbladder bed is the same as that of resection of segments IVb/V. The German Registry, founded in 1997, aims to prospectively record all IGBC cases in Germany. In this study patients with a radical re-resection were treated according to the S3 Guidelines in Germany. The aim of this study was to clarify whether different techniques of liver re-resection show comparable results or if they differ depending on the tumor stage in IGBC patients (n = 624). A significant survival advantage in patients who have an early re-resection was observed. There was a trend of better survival in T1 tumor stage patients who undergo the less radical re-resection, especially the wedge-resection technique of 3 cm in the gallbladder bed. In T2 tumor stage patients there is a tendency for better survival with the IVb/V-resection technique compared to the 3-cm wedge resection in the gallbladder bed, and a significant survival benefit for these two techniques compared to less radical resection was evident. T3 tumor cases showed better survival with the more radical resection techniques. The wedge-resection technique combined with lymph node dissection may be the surgical strategy of choice in T1 tumor cases. For T2 tumors, IVb/V resection combined with lymph node dissection of the hepatoduodenal ligament appears to be the minimum volume of resection required. More radical procedures are needed for tumors infiltrating the serosa or beyond.
Article
Background: Little is known about the long-term survival of patients with incidental gallbladder carcinoma (IGBC). The role of radical resection for this disease is discussed controversially in the literature. We present the long-term survival and the results of re-resection versus simple cholecystectomy of the database of the Swiss Association for Laparoscopic and Thoracoscopic Surgery (SALTS) from 1994 to 2004. Methods: Eighty-nine patients with histologically confirmed carcinoma of the gallbladder were identified out of 30,960 patients undergoing laparoscopic cholecystectomy. Sixty-nine patients were included in our study. Long-term survival by different T-stage and comparison of patients with extended resection versus simple cholecystectomy were calculated using the log-rank test. The time-to-event data are demonstrated by Kaplan-Meier curves. Results: The overall incidence of IGBC in patients who underwent laparoscopic cholecystectomy was 0.28% (89 of 30,960). Fifty patients underwent simple cholecystectomy [n = 2: carcinoma in situ (CIS); n = 2: pT1a; n = 10: pT1b; n = 23: pT2; n = 8: pT3; n = 5: pT4], whereas extended resection was performed in 19 cases (n = 2: pT1b; n = 11: pT2; n = 6: pT3). The comparison of simple cholecystectomy versus extended re-resection of the gallbladder bed and regional lymph node resections showed a significant benefit in overall survival for the pT2 and pT3 group (p < 0.05). The pT1b group showed no significant benefit in overall survival (p = 0.34). Conclusion: IGBC has a low incidence (0.28%). We present a large study of patients with IGBC, comparing the overall survival by different histological findings. We observed a significant benefit for the group with pT2 and pT3. Therefore we recommend extended resection of the gallbladder bed and the regional lymph nodes for patient with incidental histologically confirmed pT2 and pT3 carcinoma of the gallbladder after performance of laparoscopic cholecystectomy. For patients with pT1b stage no recommendations can be given based on this study.
Article
Gallbladder cancer is an uncommon cancer that has traditionally been associated with a poor prognosis. In the era of laparoscopic cholecystectomy, incidental gallbladder cancer has dramatically increased and now constitutes the major way patients present with gallbladder cancer. While patients with incidental gallbladder cancer have a better survival than patients with nonincidental gallbladder cancer, incidental gallbladder cancer can be associated with a varied prognosis. Imaging with computed tomography (CT), magnetic resonance imaging (MRI), and [18]F-fluorodeoxyglucose (FDG) positron emission tomography (PET), as well as diagnostic laparoscopy, all have varying roles in the workup of patients with incidental gallbladder cancer. For patients with T1b, T2, and T3 incidental gallbladder cancer re-resection is generally recommended. At re-exploration, many patients with incidental gallbladder cancer will have residual disease. Definitive oncologic management requires re-resection of the liver, portal lymphadenectomy, and attention to the common bile duct. The extent of the hepatic resection should be dictated by the ability to achieve a microscopically negative (R0) margin. Routine resection of the common bile duct is unnecessary but should be undertaken in the setting of a positive cystic duct margin. If an incidental gallbladder cancer is discovered at the time of surgery, whether the surgeon should directly proceed with a more definitive oncologic operation should depend on the surgeon's skill-set and experience. Gallbladder cancer has a propensity to recur. Although data for adjuvant therapy following resection are limited, some data do suggest a survival benefit for adjuvant chemoradiation therapy. Management of patients with gallbladder cancer requires a multidisciplinary approach with input from a surgeon skilled in hepatobiliary surgery.
Article
There is no consensus regarding the optimum surgical approach to gallbladder cancer. This study reviews the management of gallbladder cancer in a single unit. 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. 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). 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.
Article
There is a need to increase the available data on revision radical surgery for incidental gallbladder cancer and to determine factors influencing operability. We aimed to assess the impact of stage of disease (pT) and the type of primary surgery (laparoscopy versus open) on resectability rates. The data of 90 consecutive patients referred to the Tata Memorial Hospital between 1 January 2003 and 30 April 2007 for revision radical surgery for incidental gallbladder cancer were reviewed retrospectively. Of the 90 patients who underwent revision surgery, accurate data on T-stage was available in 76, and of these 76 patients, 44 (57.8%) had prior laparoscopic simple cholecystectomy, while 32 (42.2%) had undergone open surgery. The median time interval between the two surgeries was 2 months (range 4 weeks to 11 months). By T-stage, 23 patients had T1b disease, while 33 and 20 patients had T2 and T3 disease, respectively. Successful revision surgery could be undertaken in 71% of patients (54/76) and 29.6% of these had residual disease confirmed by histopathological examination. T-stage is an important factor in determining operability as confirmed by our study. As the T-stage of the disease increased, the chances of finding residual disease increased, while operability decreased. Furthermore, the case for revision surgery is strengthened because the incidence of lymph nodal disease is high even for pT1b cancers. The type of primary surgery does not affect operability in patients undergoing revision radical surgery for incidental gallbladder cancer.
Article
The objective of this study was to evaluate the benefit of an aggressive approach to gallbladder carcinoma on long-term survival. Recent studies have shown that an aggressive surgical treatment of bile duct carcinoma can be associated with a surprising long-term survival. However, recent data on gallbladder carcinoma are not available. Data were obtained from a questionnaire sent to 73 institutions in France, Europe, and overseas, and they were analyzed retrospectively. The review included an analysis of patient sex and age, associated hepatobiliary diseases, symptoms and signs, diagnostic tests, operative management, pathology reports, and survival. Seventy-eight per cent of the patients were women, and 22% were men (p < 0.001). Gallstones were present in 86% of the cases. Four per cent of the patients had Tis stage lesions, 11% had T1 to T2 stage lesions, and 85% had T3 to T4 stage lesions (p < 0.001). Pain was the most frequent symptom (77%). Twenty-three per cent of the patients underwent curative operations, and 77% had a palliative treatment (25% of the patients underwent exploratory laparotomy). Exploratory laparotomy was followed by the highest mortality rate (66%), and older patients (> 70 years) had a higher operative risk (p < 0.04). The overall median survival was 3 months, and long-term survival correlated with the cancer stage (Tis, > 60 months; T1 to T2, > 22 months, and T3 to T4, 2 to 8 months). No differences were observed among the different surgical procedures adopted. No progress has been made in the last 10 years in the treatment of gallbladder malignancies.
Article
To examine the results of treatment of laparoscopically discovered gallbladder cancer. Retrospective review of clinical data for the 10 patients with laparoscopically discovered gallbladder cancer who were referred to our institution for definitive surgical therapy. An oncologic referral center. All patients in the 24-month period from November 1990 to November 1992 with this entity who were referred for surgical therapy. Exploratory laparotomy was performed on all patients. Resection with curative intent was performed when possible. Resectability and outcome of cancer treatment. In three patients, a subsequent radical resection was performed and as a result, two patients are currently free of disease. Intraperitoneal spread, not present at the original laparoscopy and associated with violation of tumor at laparoscopy, precluded potentially curative resection for four patients. In two of these patients, there was obvious tumor growth within the laparoscopy tracts. Tumor dissemination is a real hazard of laparoscopic violation of gallbladder integrity in the presence of gallbladder cancer. Modification of management based on awareness of such a hazard is needed to improve resectability and outcome of future cases of laparoscopically discovered gallbladder cancer.
Article
The surgical management of gallbladder cancer is controversial. There is no consensus among surgeons as to the indications for reoperation or radical resection. The purpose of this study was to examine results of reoperation after an incidental finding of gallbladder cancer after cholecystectomy, and results of radical resection in patients with advanced disease. A retrospective review of 149 patients with the diagnosis of gallbladder cancer treated from 1985 to 1993 was performed. Fifty-eight patients were explored and 23 underwent resection for cure. Resection included trisegmentectomy in nine patients and bile duct resection in ten patients. Seventeen patients underwent re-exploration after an incidental finding of gallbladder cancer at initial cholecystectomy. Surgical resection is associated with an actuarial 51% 5-year disease-free survival rate, with a median follow-up time of 48 months. Eight patients are alive beyond 50 months. There were no operative deaths; the perioperative morbidity rate was 26%. Nodal status is the most powerful predictor of outcome. Two patients with T4, NO disease are alive without evidence of disease beyond 4 years. Thirteen of the 17 patients (76%) undergoing reoperation after simple cholecystectomy for T2 or T3 tumors had residual disease. Patients with nodal metastasis beyond the pericholedochal nodes should not be considered for curative resection. Tumors staged T4, NO should be included with stage III disease, and resection should be considered. Re-resection of T2 or T3 tumors after simple cholecystectomy is likely to include residual disease and should thus provide the only chance for long-term survival.
Article
To compare patients with gallbladder cancer presenting for therapy with and without prior operation elsewhere to determine if an initial noncurative procedure alters outcome. Nihilism has traditionally surrounded treatment of gallbladder cancer, particularly since the majority of cases are discovered during exploration for presumed gallstone disease when unsuspected cancers cannot be handled definitively and tumor is often violated. Presentation, operative data, complications, and survival were examined for 410 patients presenting between July 1986 and March 2000. In particular, the 248 patients presenting for therapy after prior operation elsewhere were compared with the remainder who presented without prior operation to determine if an initial noncurative procedure alters outcome. Overall Outcome: 51 patients were inoperable, 92 were subjected to exploration and biopsy only, 135 to noncurative cholecystectomy, 30 to surgical bypass, and 102 to potentially curative resections consisting of portal lymph node dissection and liver parenchymal resections. Operative mortality was 3.9%. T-stage predicted likelihood of distant metastases and resectability. Median survival for resected patients was 26 months and 5-year survival was 38%, and for patients not resected, 5.4 months and 4% (P <.0001). Effect of Prior Operation: 22 patients subjected to potentially curative resection as the first surgical procedure were compared to 80 patients resected after prior exploration elsewhere. Mortality, complication, and long-term survival were the same. By multivariate analysis (Cox regression), resectability and stage were independent predictors (P <.001) of long-term survival, but prior surgical exploration was not. Unresected gallbladder cancer is a rapidly fatal disease. Radical resection can provide long-term survival, even for large tumors with extensive liver invasion. Long-term survival can be achieved for patients presenting after prior noncurative surgical exploration.
Article
Gallbladder cancer is an aggressive disease with dismal results of surgical treatment and a poor prognosis. However, over the last few decades selected groups have reported improved results with aggressive surgery for gallbladder cancer. Review of recent world literature was done to provide an update on the current concepts of surgical treatment of this disease. Long-term survival is possible in early stage gallbladder carcinoma. Tis and T1a gallbladder carcinoma can be treated with simple cholecystectomy only. However, in T1b and beyond cancers, aggressive surgery (extended cholecystectomy) is important in improving the long-term prognosis. Laparoscopic cholecystectomy should not be performed where there is a high index of suspicion of malignancy due to the frequent association with factors (such as gallbladder perforation and bile spill) which may lead to implantation of cancer cells and dissemination. Surgical resection for advanced carcinoma gallbladder is recommended only if a potentially curative R0 resection is possible. Aggressive surgery with vascular and multivisceral resection has been shown to be feasible albeit with an increase in mortality and morbidity. However, the true benefit of these radical resections is yet to be realized, as the actual number of long-term survivors of advanced gallbladder carcinoma is few. Surgery for gallbladder carcinoma, like other malignancies, has the potential to be curative only in local or regional disease. Pattern of loco-regional spread of disease dictates the surgical procedure. Radical surgery improves survival in early gallbladder carcinoma. The long-term benefit of aggressive surgery for advanced disease is unclear and may be offset by the high mortality and morbidity.
Article
Little is known about the trends in the incidence, survival, and treatment patterns of gallbladder cancer over the last decade. Data of patients in the Surveillance, Epidemiology and End Results Program of the National Cancer Institute (SEER 13) with a diagnosis of primary gallbladder cancer from 1973-2002 were examined. The effect of surgery and radiotherapy on survival was examined. Incidence of disease, survival, use of surgery, and radiotherapy for patients diagnosed between 1993 and 2002 (Group B) were compared to the others (Group A). Median age of the 10301 included patients was 73. 72.4% were female and median survival was 4 months. SEER histologic stage was classified as localized (23.7%), regional (37.4%), and distant (38.9%) patients. Median survival for these stages was 20 months, 5 months, and 2 months, respectively. 81.5% patients underwent surgery and 13.3% radiotherapy. Median survival of patients undergoing surgery was significantly longer (8 versus 2 months, P < 0.0001). Radiotherapy in addition to surgery was associated with prolonged survival for patients with regional and distant stages but not localized stage. Over the 3 decades, the incidence of gallbladder cancer gradually decreased in patients older than 50 years, but increased in younger patients. Significantly fewer Group B patients underwent surgery compared with Group A (74.6% versus 89.9%, P < .001). However, the use of radiotherapy was higher in Group B (14.5% versus 12.4%, P < 0.01). Over the last decade, the incidence of gallbladder cancer has reduced in patients older than 50 years with an increased incidence in younger patients. Survival of patients has also improved over the last decade. The number of patients undergoing surgery has reduced with an increase in the use of radiotherapy.
Article
We assess how laparoscopy has altered the presentation of patients with gallbladder cancer and determine whether radical resection in patients with gallbladder cancer is beneficial. The widespread adoption of laparoscopic cholecystectomy has led to an increased frequency of incidentally discovered gallbladder carcinoma. Little data exist to guide surgeons in the optimum management of patients with gallbladder cancer, particularly with respect to the potential advantages of radical resection. Records of 107 patients with gallbladder cancer admitted to a tertiary academic medical center between 1995 and 2004 were reviewed. Gallbladder cancer was found incidentally in 53 patients (50%). Fifty-two of these patients underwent a routine laparoscopic cholecystectomy and were found to have gallbladder cancer intraoperatively or following the operation by subsequent pathologic evaluation of the specimen. Gallbladder cancer had been diagnosed preoperatively by radiology in the other 54 patients (50%). These patients did not undergo laparoscopic cholecystectomy and were explored electively. The median age at presentation was 67 years and 66% were female. Patients who were found to have gallbladder carcinoma incidentally at laparoscopic cholecystectomy had a significant increase in survival when compared with those who were admitted electively with a known diagnosis (P < 0.001). All patients who presented with a known diagnosis had stage II or greater disease, and 36% of these were stage IV carcinomas. However, 82% of those patients who were found incidentally were stage I or II. The overall 5-year survival for all patients was 15%; those discovered incidentally at laparoscopic cholecystectomy had a 5-year survival of 33%. This difference was significant among patients with stage II carcinomas. In the laparoscopic group, there was no difference in survival between the patients who were immediately converted to an open resection when identified to have gallbladder cancer intraoperatively (n = 6) and those who had a completed laparoscopic cholecystectomy and were re-explored at a later point when found to have gallbladder cancer by subsequent pathology (n = 33). There was a significant improvement in survival in 50 patients (47%) who underwent some form of radical resection (P < 0.001). Stage for stage comparison showed that this was significant in stage II disease. Patients who underwent hepatic resection along with lymphadenectomy and extra hepatic biliary resection had similar survival compared with those who had hepatic resection and lymphadenectomy alone. Laparoscopic cholecystectomy appears to have resulted in the earlier discovery of gallbladder cancer in some patients, resulting in increased probability of survival. Patients discovered with gallbladder carcinoma during a laparoscopic cholecystectomy do not have to be converted immediately to an open resection and should be referred to a tertiary care center for further exploration. Adjunctive radical surgical resection, either at the time of cholecystectomy or subsequently, increases survival significantly in early stage disease.
Article
Re-resection for gallbladder carcinoma incidentally discovered after cholecystectomy is routinely advocated. However, the incidence of finding additional disease at the time of re-resection remains poorly defined. Between 1984 and 2006, 115 patients underwent re-resection at six major hepatobiliary centers for gallbladder carcinoma incidentally discovered during cholecystectomy. Data on clinicopathologic factors, operative details, TNM tumor stage, and outcome were collected and analyzed. Data on the incidence and location of residual/additional carcinoma discovered at the time of re-resection were also recorded. On pathologic analysis, T stage was T1 7.8%, T2 67.0%, and T3 25.2%. The median time from cholecystectomy to re-resection was 52 days. At the time of re-resection, hepatic surgery most often consisted of formal segmentectomy (64.9%). Patients underwent lymphadenectomy (LND) (50.5%) or LND + common bile duct resection (43.3%). The median number of lymph nodes harvested was 3 and did not differ between LND alone (n = 3) vs LND + common duct resection (n = 3) (P = 0.35). Pathology from the re-resection specimen noted residual/additional disease in 46.4% of patients. Of those patients staged as T1, T2, or T3, 0, 10.4, and 36.4%, respectively, had residual disease within the liver (P = 0.01). T stage was also associated with the risk of metastasis to locoregional lymph nodes (lymph node metastasis: T1 12.5%; T2 31.3%, T3 45.5%; P = 0.04). Cystic duct margin status predicted residual disease in the common bile duct (negative cystic duct, 4.3% vs positive cystic duct, 42.1%) (P = 0.01). Aggressive re-resection for incidental gallbladder carcinoma is warranted as the majority of patients have residual disease. Although common duct resection does not yield a greater lymph node count, it should be performed at the time of re-resection for patients with positive cystic duct margins because over one-third will have residual disease in the common bile duct.
Article
The aim of this retrospective study was to review all patients diagnosed with gallbladder cancer over a 10-year period to assess variables affecting survival. Patients diagnosed with gallbladder cancer from January 1990 to December 1999 were identified from the Lothian Surgical Audit database and a case-note review was performed. The 44 patients who were studied (33 women, 11 men) had a mean age of 66 years (range 42-90 years). The diagnosis was established preoperatively in 25 patients (57%), intraoperatively in 5 patients (11%) and incidentally following pathological examination of cholecystectomy specimens in 14 patients (32%). None of the 25 patients diagnosed preoperatively underwent curative operations (median survival 4 months). All five patients diagnosed at the time of attempted cholecystectomy had advanced irresectable disease (median survival 1 month). The overall median survival in 14 patients with an incidental diagnosis of gallbladder cancer was 16 months; however, in eight of these patients who were considered to have had a potentially curative resection, the median survival was 38 months. The prognosis for patients diagnosed preoperatively or at the time of cholecystectomy is very poor. Patients with an incidental finding of gallbladder cancer have a significantly better prognosis and should be considered for further radical re-resection.
Gallbladder Cancer. TNM Classification of Malignant Tumours, 6th edn. Sobin LH, Wittekind C
  • L H Sobin
  • C Wittekind
Sobin LH, Wittekind C. (2002) Gallbladder Cancer. TNM Classification of Malignant Tumours, 6th edn. Sobin LH, Wittekind C. ed. New York: Wiley-Liss.
  • D Fuks
  • J M Regimbeau
  • Le Treut
  • Y P Bachellier
  • P Raventos
  • A Pruvot
Fuks D, Regimbeau JM, Le Treut YP, Bachellier P, Raventos A, Pruvot FR et al. (2011) World J Surg 35:1887-1897. Incidental gallbladder cancer by the AFC-GBC-2009 Study Group.