Adjacent Organ Involvement Research Articles

Phase I/II Trial of Bevacizumab and Radiotherapy for Locally Advanced Inoperable Colorectal Cancer: Vasculature-Independent Radiosensitizing Effect of Bevacizumab

Anti-vascular endothelial growth factor therapy enhances the activity of radiotherapy in experimental models, and bevacizumab has therapeutic activity in patients with metastatic colorectal cancer. Twenty-two patients with locally advanced inoperable colorectal carcinomas (LA/I-CRC) were treated with conformal hypofractionated (3.4 Gy/fraction x 15) split-course accelerated radiotherapy (biological equivalent dose, 67.2 Gy) supported with amifostine, capecitabine (600 mg/m2 daily, 5 days/week), and bevacizumab (5 mg/kg every 2 weeks, five cycles). Biopsies from nine patients, performed before and 1 week after bevacizumab administration, were analyzed for changes in mRNA expression with Illumina gene arrays. No serious grade 3 chemotherapy-related side effects were recorded. There was low acute toxicity, with moist perineal desquamation noted in 2 of 22 patients, diarrhea grade 2 to 3 in 5 of 22 patients, and severe proctalgia in 2 of 22 patients. One patient died from Fournier's gangrene before treatment completion. Within a median follow-up of 18 months, two patients with preradiotheraphy direct involvement of adjacent organs expressed recto-vaginal/perineal fistula. Out of 19 evaluable cases, 13 (68.5%) showed complete response and 4 showed (21.1%) partial response. Fourteen patients are alive with no evidence of loco-regional relapse. In the gene array analysis, 30 known genes associated with transcription factors, DNA repair, and proliferation were downregulated by bevacizumab. DUSP1 gene was the most consistently downregulated transcript. The combination of radiotherapy with bevacizumab is feasible and results in a high rate of durable complete responses in patients with LA/I-CRC. Radiosensitization may occur through a direct effect on tumor cells followed by a wide scale suppression of transcription factors and genes involved in DNA repair and proliferation.

A Rare Cause of Failure to Thrive: A Case of a Primary Gastric Cancer in a Patient with Metastatic Renal Cell Carcinoma and a Review of the Literature on Management

Purpose: Renal cell carcinoma(RCC) accounts for approximately 3% of all adult malignancies. Papillary carcinoma, which is the second most common type of RCC, accounts for approximately 15% of RCC. RCC has a metastasis rate of approximately 25%, which is most commonly to the lungs (>50%). On the contrary, RCC metastasis to the GI (Gastrointestinal) tract (excluding liver) is very uncommon and ranges from 0.2-0.7%. Thus, a gastric cancer in a patient with known metastatic RCC would most likely secondary to metastasis. We present the first reported case of a metastatic RCC coexisting with a new onset primary gastric cancer and a review of management. A 82-year-old male with Papillary RCC status post left nephrectomy with recurrence of liver metastasis presented with failure to thrive shortly after his third cycle of chemotherapy despite stable disease by imaging studies. He had received 7 chemotherapy cycles of Gemzar®, Nexavar®, and Avastin® prior to admission. Catheter related infection was suspected due to a leukocytosis of 19,000. However, he had no evidence of infection. He subsequently dropped his Hct and was found to have Hemoccult positive stool in the setting of having received Avastin®. Endoscopic evaluation of his anemia showed a 3 cm ulcerated mass in the cardia, which was subsequently biopsied. The biopsy showed invasive and poorly differentiated gastric adenocarcinoma unrelated to his RCC. H. pylori was considered negative. The patient subsequently underwent partial gastrectomy with loop gastrojejunostomy for resection of his Stage 1 primary gastric adenocarcioma. The patient did not receive adjuvant chemoradiation for his Gastric cancer due to his comorbidities at the time and did well at a 1 month follow-up. There are no guidelines to manage a primary gastric cancer coexisting with a metastatic RCC. Review of the literature shows that the management of a solitary gastric cancer secondary to RCC metastasis without adjacent organ involvement is ideally surgical (gastrectomy) if the tumor is greater than 2 cm. There is a role of endoscopic resection for non-surgical candidates and for early gastric cancer with differentiated tumors that are slightly raised and less than 2 cm in diameter, or in differentiated tumors that are ulcerated and less than 1 cm in diameter. In our patient, the gastric cancer was 3 cm in size without nodal involvement, thus, not a candidate for endoscopic mucosal resection. Surgical management was the therapy of choice due to the patient's clinical presentation as well as future consideration of RCC chemotherapy. Conclusion: Metastatic RCC and primary gastric cancer can coexist and surgical management can still be considered for the primary gastric carcinoma.

Retroperitoneal Tumour Masquerading as Mesenchymal Neoplasm of the Liver

Retroperitoneal tumours usually attain large size until they present with symptoms of lump in the abdomen or with features of adjacent organ involvement. Occasionally, by virtue of their location, they may mimic pathologies of organs in their vicinity. We report a case of Retroperitoneal Leiomyosarcoma which masqueraded as Primary Liver Schwannoma.

Laparoscopic En Bloc Resection of Locally Advanced Colon Cancer With Involvement of the Liver, Small Bowel, Omentum, and Abdominal Wall

Locally advanced colon cancer with the involvement of adjacent organs is treated radically with en bloc resection with negative margins. Laparoscopy is seldom recommended for such patients. Operative laparoscopic technique is presented for radical en bloc resection of locally advanced right colon cancer. The patient is a 56-year-old morbidly obese (body mass index 47) male, who was scheduled to undergo a routine laparoscopic right hemicolectomy and at exploration was found to have a large mass involving segments V and VI of the liver, small bowel, omentum, and abdominal wall. A laparoscopic-assisted en bloc resection was performed. The patient went home in 7 days. The tumor was staged as T4N0M0, American Joint Commission on Cancer stage IIb with 21 negative nodes. Laparoscopic resection for selected patients with locally advanced colonic neoplasms should be considered an option in tertiary referral centers.

Helical CT Evaluation of the Preoperative Staging of Gastric Cancer in the Remnant Stomach

The objective of our study was to evaluate the diagnostic performance of helical CT for evaluating the preoperative staging of gastric cancer in the remnant stomach. Preoperative helical CT images of 67 patients with gastric cancer in the remnant stomach were independently analyzed regarding staging of the tumor by two radiologists who were blinded to histopathologic and surgical results. The differences in their assessments were resolved by consensus including the opinion of a third radiologist. The radiologists were asked to determine the depth of tumor invasion of the gastric wall (T stage), classifying it as </= T2, T3, or T4; local lymph node involvement (N stage); and solid organ metastasis or peritoneal involvement (M stage). TNM staging on CT was correlated with the histopathologic results of the resected specimen or with the surgical findings. Interobserver agreement was assessed using weighted kappa statistics. The overall accuracy of T staging for reviewers 1 and 2 and for the consensus reading were 83.6%, 78.2%, and 85.4%, respectively. Five of 34 </= T2 lesions were misdiagnosed as T3. The cause of the overstaging was the misconception of the postoperative fibrotic change of the anastomotic site as perigastric tumoral infiltration. Three of 18 T4 lesions were understaged because of inadequate gastric distention (n = 1) and misinterpretation of adjacent organ involvement as partial volume averaging (n = 2). The accuracy of N staging and M staging were 81.8% and 94.0% for reviewer 1; 78.2% and 91.0% for reviewer 2; and 81.8% and 94.0% for the consensus reading, respectively. The weighted kappa values of T staging, N staging, and M staging were 0.676, 0.619, and 0.924, respectively. Contrast-enhanced helical CT can be used successfully to preoperatively evaluate the staging of remnant stomach cancer in patients who have undergone previous gastric resection.

A Selective Policy Ensures Safe Integration of Laparoscopic Colorectal Resection into the Practice of a Newly Appointed Consultant Surgeon

Introduction: Integration of laparoscopic colorectal surgery into consultant practice can be a challenge. We pre- sent the first year of practice for a suitably trained surgeon using a selective policy. Materials and Methodology: Patients requiring an elective colorectal resection under the care of a newly appointed con- sultant surgeon were considered for laparoscopic surgery. Exclusion criteria included multiple previous abdominal opera- tions, rectal cancer less than 12cm from the anal verge, radiological/clinical suspicion of tumor involvement of adjacent organs and a mass � 6cm. Prospective data collected from August 2007 to August 2008 included types of surgeries, body mass index (BMI), median operating time, lymph node yield, complications, 30 days mortality, length of stay and 30 days readmissions. Results: Laparoscopic colorectal resection was performed in 42 patients (26 females), with a median age of 65 years (range 14-83 years). There were 18 right hemicolectomies/ileocaecal resections, 15 sigmoid colectomies/high anterior re- sections, 7 subtotal colectomies and 2 reversal of Hartmann's. Indications for surgery were colorectal cancer (n=27), in- flammatory bowel disease (n=10), diverticular disease (n=3) and others (n=2). There were 5 (11.9%) conversions. Median operating time was 150 minutes (range 75-280 minutes) and BMI was 25.5 (range 16-38). There were no deaths reported. Eight (19%) patients had complications. Median lymph node yield in malignant cases was 13 (range 8-30). Median length of stay was 4 days (range 3 to 20 days) and there were 3 (7%) readmissions. Conclusions: Laparoscopic colorectal resection can be safely integrated into the practice of a suitably trained, newly ap- pointed consultant surgeon if a selective policy is employed. With greater experience, a less selective policy may become appropriate.

Advanced‐stage renal cell carcinoma treated by radical nephrectomy and adjacent organ or structure resection

To examine the effect of radical nephrectomy (RN) with adjacent organ and structure resection on survival, as invasion of adjacent organs in patients with renal cell carcinoma (RCC) is rare. After institutional review board approval, we reviewed our database and statistically analysed of patients with pathological stage T3 or T4 RCC who had RN and resection of a contiguous organ or structure. We identified 38 patients of 2464 (1.5%) who had RN with adjacent organ or structure resection. The median (interquartile range) size of the mass was 11 (8-14) cm, and the follow-up 13 (5-33) months. Most patients (68%) were pT4 stage and had conventional clear cell carcinoma (95%). Fourteen patients (37%) had positive surgical margins. The liver (10) was the most commonly resected adjacent organ or structure. Only one patient remains alive with no evidence of disease at 5 years, while three are currently alive with disease. Overall, 34 of 38 patients (90%) ultimately died from disease at a median (range) of 11.7 (5.4-29.2) months after surgical resection. The surgical margin status was the only statistically significant factor for recurrence and death (P = 0.006). The prognosis for patients with advanced RCC and adjacent organ or structure involvement is extremely poor and similar to that of patients with metastatic disease. These patients should be thoroughly counselled about the impact of surgical management and considered for entry into neoadjuvant or adjuvant clinical trials with new targeted systemic agents.

Echinococcose alvéolaire: comment affirme-t-on le diagnostic?

Ultrasonography is the first-step exam for the diagnosis of alveolar echinococcosis. Liver involvement commonly appears as an ill-defined infiltration of the liver parenchyma. Lesions are heterogeneous and in most cases hyperechoic, related to fibro-parasitic tissue associated to scattered calcifications. Hypoechoic foci can also be observed, related to necrosis. In 25 % of the cases, ultrasonography discovers atypical aspects that must be known by radiologists working in endemic region for alveolar echinococcosis. Specific serological tests, particularly ELISA and western blot, usually confirm the diagnosis. Therefore, per-cutaneous punction is exceptionally needed to assess the diagnosis. Other imaging techniques are very useful to complete the diagnosis step and to specify vascular and biliary extension, a crucial information for the therapeutic choice. Computed tomography may show small additional parasitic foci, non visualized by ultrasonography. It allows an accurate examination of the lesions particularly in case of very calcified images that could have made ultrasonographic analysis more difficult. Magnetic resonance imaging may be useful for diagnosis showing on T2 weighted images, in cases of fertile lesions, numerous clustered small cysts. Moreover, it is an excellent technique to analyse vascular involvement, particularly for vena cava and hepatic veins, and to diagnose involvement of adjacent organs. Coupled to cholangio-MR, it allows a precise examination of the biliary tree invasion, particularly in the hilum area.

Endosonographic diagnosis in uterine tumors

Endosonography offers two major advantages in the pretherapeutic examinations of a histologically verified carcinoma of the uterus. Endosonography allows (1) an overview of the size and location of the tumour and (2) an evaluation of the spreading and/or involvement of adjacent organs. Both add up to a more objective staging of the tumour and, therefore, may cause a more effective therapeutic approach. Especially in cases with endometrial carcinoma the uterine walls can be visualized either by the well-tolerated method of vaginosonography or by hysterosonography which can be performed only in general anaesthesia. Applying either endosonographical method, the infiltration depth of the myometrium and/or involvement of the cervix can be determined, which seems to be very valuable, particularly when differentiating between stages I and II. Rectosonography, with its transversal scanning probes, offers the advantage of demonstrating the infiltration of a cervical tumour into the parametrium. Here again, the benefit is seen in a more objective evaluation of tumour size and extension. However, tumour growth into the urinary bladder is best shown by cystosongraphy. With this method one cannot only have a view of the epithelium (as in cystoscopy) but one is also able to evaluate the underlying layers of the bladder wall. This seems to be an advantage in findings of a bullous oedema. Once again, rectosonography is advantageous in enhancing the diagnosis of recurrences of malignant tumours in the pelvic region. Like a prolongation of the palpating finger rectosonography is able to depict less echogenic areas located high up on the pelvic wall as local recurrences or tumours.(ABSTRACT TRUNCATED AT 250 WORDS)

Well-differentiated prostate cancer in core biopsy specimens may be associated with extraprostatic disease.

Accurate determination of the Gleason score in prostate core biopsy specimens is crucial in selecting the type of prostate cancer treatment, especially for patients with well-differentiated tumors (Gleason score 2 to 4). For such patients, an inaccurate biopsy score may result in a therapeutic intervention that is too conservative. We evaluate the role of Gleason score 2-4 in prostate core-needle biopsies for predicting the final pathological staging following radical prostatectomy. Retrospective study at Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo. We analyzed the medical records of 120 consecutive patients who underwent radical retropubic prostatectomy to treat clinical localized prostate cancer at our institution between December 2001 and July 2006. Thirty-two of these patients presented well-differentiated tumors (Gleason score 2 to 4) in biopsy specimens and were included in the study. The Gleason scores of the core-needle biopsies were compared with the pathological staging of the surgical specimens. Sixteen of the 32 patients (50%) presented moderately differentiated tumors (Gleason score 5 to 7) in surgical specimens. Eighteen patients (56%) had tumors with involvement of the prostate capsule and ten (31%) had involvement of adjacent organs. Evaluating the 16 patients that maintained Gleason scores of 2 to 4 in the pathological staging of the surgical specimens, 11 (68.7%) had focal invasion of the prostate capsule and five (31.25%) had organ-confined disease. Well-differentiated tumors (Gleason score 2 to 4) seen in biopsies are not predictive of organ-confined disease.

Renal cell carcinoma clinically involving adjacent organs: Experience with aggressive surgical management: Margulis V, Sánchez-Ortiz RF, Tamboli P, Cohen DD, Swanson DA, Wood CG, Department of Urology, University of Texas, M.D. Anderson Cancer Center, Houston, TX

Historically, patients with nonmetastatic renal cell carcinoma (RCC) involving adjacent organs have been considered inoperable and incurable. The oncologic efficacy of an aggressive surgical approach was evaluated in a selected subpopulation of RCC patients. Further, an attempt was made to define the clinical and pathologic characteristics predictive of surgical failure. With Institutional Review Board approval, the institutional nephrectomy database of 3,470 patients treated at M. D. Anderson Cancer Center from 1990 to 2006 was searched for RCC patients treated with radical nephrectomy and resection of at least 1 adjacent organ thought to be directly involved by RCC. Patients with nonmetastatic RCC and a minimum follow-up of 6 months were included in the analysis. In all, 30 patients with clinical T4NxM0 RCC and median follow-up of 32.3 months (range, 8.5–140.1) met the study inclusion criteria and comprise the dataset for the analysis. On pathologic evaluation 60% of patients were clinically overstaged, as only 12 (40%) of 30 patients demonstrated direct invasion into adjacent organs resected. None of the clinical tumor characteristics predicted a finding of pathologic T4 RCC. Nodal involvement and pathologic T stage were significant independent predictors of disease recurrence (hazard ratio [HR] 3.726, P = 0.043, and HR 2.414, P = 0.045, respectively) and cancer-specific survival (HR 17.145, P = 0.002, and HR 3.791, P = 0.024, respectively). Disease recurred in 11 of 18 (61.1%) of <pT4 patients and in 10 of 12 (83.3%) of pT4 patients at a median 13.3 and 2.3 months, respectively; 13 (73.3%) <pT4 patients and 5 (41.7%) pT4 patients were alive at the time of analysis. True pathologic involvement of adjacent organs by RCC cannot be predicted from pre- or intraoperative parameters. A significant proportion of patients clinically suspected of having T4 RCC are downstaged, and benefit from aggressive surgical resection with en bloc removal of involved organs.

Renal cell carcinoma clinically involving adjacent organs

Historically, patients with nonmetastatic renal cell carcinoma (RCC) involving adjacent organs have been considered inoperable and incurable. The oncologic efficacy of an aggressive surgical approach was evaluated in a selected subpopulation of RCC patients. Further, an attempt was made to define the clinical and pathologic characteristics predictive of surgical failure. With Institutional Review Board approval, the institutional nephrectomy database of 3470 patients treated at MD Anderson Cancer Center from 1990 to 2006 was searched for RCC patients treated with radical nephrectomy and resection of at least 1 adjacent organ thought to be directly involved by RCC. Patients with nonmetastatic RCC and a minimum follow-up of 6 months were included in the analysis. In all, 30 patients with clinical T4NxM0 RCC and median follow-up of 32.3 months (range, 8.5-140.1) met the study inclusion criteria and comprise the dataset for the analysis. On pathologic evaluation 60% of patients were clinically overstaged, as only 12 (40%) of 30 patients demonstrated direct invasion into adjacent organs resected. None of the clinical tumor characteristics predicted a finding of pathologic T4 RCC. Nodal involvement and pathologic T stage were significant independent predictors of disease recurrence (hazard ratio [HR] 3.726, P = .043, and HR 2.414, P = .045, respectively) and cancer-specific survival (HR 17.145, P = .002, and HR 3.791, P = .024, respectively). Disease recurred in 11 of 18 (61.1%) of <pT4 patients and in 10 of 12 (83.3%) of pT4 patients at a median 13.3 and 2.3 months, respectively; 13 (73.3%) <pT4 patients and 5 (41.7%) pT4 patients were alive at the time of analysis. True pathologic involvement of adjacent organs by RCC cannot be predicted from pre- or intraoperative parameters. A significant proportion of patients clinically suspected of having T4 RCC are downstaged, and benefit from aggressive surgical resection with en bloc removal of involved organs.

Justification for staging of epidermoid anal carcinoma after salvage surgery: a pathological guideline

The currently accepted first line treatment for epidermoid anal cancer is chemoradiotherapy (CRT). Tumour size and adjacent organ involvement are the key in the pretreatment assessment for T1-T4 tumours respectively. Residual or recurrent disease following initial CRT, is best treated by salvage anorectal excision. Pathological staging systems of resections were historically validated when surgery was the primary treatment and are therefore in need of revision. We propose a new pathological staging system for salvage anorectal excision specimens to allow improved prognostic guidelines postoperatively.

Management of duodenal involvement in locally advanced colonic carcinoma

Removal of locally advanced right-sided colonic carcinoma involving the duodenum can be challenging. There are few data on the optimal surgical approach. Adjacent organ involvement is associated with a poor prognosis and may be classified as inoperable with patients having palliative bypass procedures rather than primary resection. Survival is however improved after en bloc resection of adjoining viscera compared with intestinal bypass. We present a variety of surgical options depending on the extent of local invasion and the debility of the patient.

Surgical resection for locally invasive renal cell carcinoma: Is it worthwhile?

Background:Many patients with renal cell carcinoma (RCC) present with disease involving the adjacent viscera. Although survival in such patients is poor, surgery remains the only proven modality of treatment. We describe our experience with radical nephrectomy for locally invasive RCC over a five-year period.Study Design:A retrospective analysis of the records of all patients who had undergone surgery for locally invasive RCC between January 1999 and December 2004 at our institute.Materials and Methods:During the study period, 102 patients with RCC underwent surgery at our institute, out of which 18 (17.6%) patients had adjacent organ involvement. The survival and outcomes in terms of symptom relief are described.Statistical Analysis:The survival rates were calculated by the Kaplan-Meier method using EGRET statistical software package.Results:Of the 18 patients, two patients had inoperable disease. Fifteen out of the 18 patients succumbed to their disease after a median period of 7.5 months. Three patients are still alive, having survived for 13, 16 and 25 months. Most patients derived considerable benefit with respect to relief of symptoms, which was long-lasting.Conclusion:For selected patients with locally invasive RCC, radical nephrectomy with en bloc resection of involved organs may provide the opportunity for long-term survival. In others, it may provide considerable symptomatic relief.

A Paradigm for the Management of Complex Perineal Crohn’s Disease in the Anti-TNF Era

Perineal disease affects up to 40% of patients with Crohn’s disease. Perinal Crohn’s disease can be either simple or complex. A simple shallow fistula without rectal disease is treated with fistulotomy. Complex fistulous disease is characterized by numerous tracts, deep fistuli threatening the sphincter, adjacent organ involvement, and severe rectal disease. Complex disease is a multidisciplinary problem that requires the coordinated care of surgeon, gastroenterologist, stomal therapists, and other support personnel. Control of sepsis using surgical drainage, setons, and antibiotics should be rapidly instituted with a simultaneous investigation of the entire digestive tract. Infliximab, frequently used in conjunction with immunosuppressive therapy, may allow subsequent seton removal indicated by decrease in purulence with contraction of the tract around the seton. Removal of the seton under such circumstances will heal fistulous disease in 40 to 60% of patients. Chronic infliximab and/or immunosuppressive therapy is frequently necessary. Failures may still be salvaged using alternate surgical and medical means. Severe proctitis unresponsive to medical management bodes poorly for long-term preservation of anal function and frequently necessitates proctectomy.

Population Based Survival Data on Urachal Tumors

Urachal carcinoma accounts for less than 1% of all bladder cancers. Limited data exist on disease related outcomes originating from case reports and select referral centers. We describe a population based outcomes analysis with long-term followup in patients in the province of Ontario. We reviewed the data source of the Ontario Cancer Registry for patients diagnosed with urachal cancer during 1976 to 2001. A cohort of 40 patients with urachal adenocarcinoma was found. Primary outcome measures were overall and disease specific survival. The effect of patient age, sex, grade, stage and university vs nonacademic treating hospital as predictors of outcome was determined. Median patient age was 52 years. Median followup was 72.7 months. Mean overall survival +/- SD was 121.6 +/- 21 months. Mean disease specific survival in patients treated operatively was 165 +/- 27 months with 5 and 10-year disease specific survival of 61.3% and 49.2%, respectively. Disease specific mortality was not evident after 7 years from diagnosis. Well differentiated tumors in a third of the patients were associated with a 90% cure rate when treated operatively. Well differentiated tumors, and noninvolvement of adjacent organs and the peritoneum correlated with better prognosis (p = 0.004, p = 0.03 and 0.045, respectively). Urachal adenocarcinoma occurs in all age groups. Long-term disease specific survival can be achieved with partial cystectomy. Covariates associated with better disease specific survival are well differentiated tumor grade and the absence of adjacent organ or peritoneal involvement. No relapses were observed after 7 years.

Palliative operations for lung cancer

The goal of the palliative resection can be threefold: relief of symptoms without expected survival benefit, obviation of an urgent situation and maintenance or restoration of a good quality survival. Clear distinction should be made between this type of operation and incomplete resection: in spite of a curative intent, the latter type of operation is characterized either by residual disease or positive most distal lymph node station. Classification of palliative operations for lung cancer based on the underlying pathology seems to be most suitable for clinical use: 1) tumours without extrapulmonary extension; 2) tumours with direct involvement of adjacent organs; 3) metastatic involvement of intrathoracic or distant organs; 4) lung tumours associated with nonmalignant pathology (lung suppuration, pleural empyema). Although palliative operations for lung cancer can be considered in carefully selected patients, they should always be avoided if other, less aggressive non-surgical procedures offer the same quality of palliation.

Extended surgical resection for xanthogranulomatous cholecystitis mimicking advanced gallbladder carcinoma: A case report and review of literature

Xanthogranulomatous cholecystitis (XGC) is a destructive inflammatory disease of the gallbladder, rarely involving adjacent organs and mimicking an advanced gallbladder carcinoma. The diagnosis is usually possible only after pathological examination. A 46 year-old woman was referred to our center for suspected gallbladder cancer involving the liver hilum, right liver lobe, right colonic flexure, and duodenum. Brushing cytology obtained by endoscopic retrograde cholangiography (ERC) showed high-grade dysplasia. The patient underwent an en-bloc resection of the mass, consisting of right lobectomy, right hemicolectomy, and a partial duodenal resection. Pathological examination unexpectedly revealed an XGC. Only six cases of extended surgical resections for XGC with direct involvement of adjacent organs have been reported so far. In these cases, given the possible coexistence of XGC with carcinoma, malignancy cannot be excluded, even after cytology and intraoperative frozen section investigation. In conclusion, due to the poor prognosis of gallbladder carcinoma on one side and possible complications deriving from highly aggressive inflammatory invasion of surrounding organs on the other side, it seems these cases should be treated as malignant tumors until proven otherwise. Clinicians should include XGC among the possible differential diagnoses of masses in liver hilum.

Radical surgery for advanced gallbladder carcinoma.

Forty-four patients with advanced gallbladder carcinoma (18 with stage pT3 and 26 with stage pT4 of the Union Internacional Contra la Cancrum classification) were aggressively managed by extended heptatic resection in 33 patients, bile duct resection in 28, pancreaticoduodenectomy in seven, gastrointestinal resection in eleven and portal vein resection and reconstruction in seven. Adjacent organ involvement was classified as follows: type I, hepatic involvement with or without gastrointestinal invasion (Ia, Ib); type II, bile duct involvement with or without gastrointestinal invasion (IIa, IIb); type III, hepatic and bile duct involvement with or without gastrointestinal invasion (IIIa, IIIb); type IV, gastrointestinal involvement without hepatic or bile duct invasion. Fourteen of 15 patients with type I tumours had a curative resection compared with seven of 26 with type III lesions (P < 0.0001). The surgical mortality rate was two of 15 patients with type I tumours, seven of 26 with type III tumours and nine of 44 for the whole group. The long-term survival rate after curative resection was four and two of 23 at 3 and 5 years respectively, significantly better than two and none of 21 at 1 and 2 years after non-curative resection (P < 0.01). The survival rate after curative resection for patients with type I tumours was four and two of 14 at 3 and 5 years respectively, significantly better than for other types (P < 0.05). This classification of advanced gallbladder carcinoma according to involvement of adjacent organs might be helpful in planning surgery for this condition; in particular, type I tumours should be treated by a radical surgical procedure to achieve a favourable outcome.