Management Of Gallbladder Cancer Research Articles

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

BackgroundInvolvement of the 16b1 (interaortocaval) lymph node (LN) in gallbladder cancer (GBC) is considered to represent metastatic disease. Although this is universally accepted, the role of routine frozen-section histopathological examination (HPE) of the 16b1 LN in the management of GBC has not been previously reported. MethodsA prospective study (August 2009–November 2011) using routine biopsy of 16b1 LNs and frozen-section HPE prior to radical resection in patients deemed operable on preoperative evaluation and staging laparoscopy was carried out. ResultsOf the 451 GBC patients assessed, 251 (55.7%) were deemed operable on preoperative imaging. Of these, 68 (27.1%) were found to have disseminated disease on staging laparoscopy/laparotomy. Of the 183 patients in whom 16b1 LN biopsy was performed, 34 (18.6%) had evidence of metastases on frozen-section HPE and the planned surgical resection was abandoned (Group A). Of the remaining 149 patients (Group B), 142 (95.3%) underwent curative resection and seven (4.7%) were found to be unresectable as a result of locoregionally advanced disease. A comparison of findings in Group A with those in Group B showed no significant difference in the clinical stage of the tumour. The proportions of patients with jaundice, elevated carcinoembryonic antigen (CEA) and carbohydrate antigen (CA) 19-9 levels were significantly higher in Group A than in Group B (P = 0.008, P = 0.012 and P = 0.023, respectively). ConclusionsRoutine 16b1 LN biopsy prevented non-therapeutic radical resection and its associated morbidity in 18.6% of patients deemed resectable on preoperative imaging and staging laparoscopy. The yield was higher in patients with jaundice and elevated preoperative tumour marker levels.

The Role of Staging Laparoscopy in Primary Gall Bladder Cancer—An Analysis of 409 Patients

To evaluate the role of staging laparoscopy (SL) in the management of gallbladder cancer (GBC). A prospective study of primary GBC patients between May 2006 and December 2011. The SL was performed using an umbilical port with a 30-degree telescope. Early GBC included clinical stage T1/T2. A detectable lesion (DL) was defined as one that could be detected on SL alone, without doing any dissection or using laparoscopic ultrasound (surface liver metastasis and peritoneal deposits). Other metastatic and locally advanced unresectable disease qualified as undetectable lesions (UDL). Of the 409 primary GBC patients who underwent SL, 95 had disseminated disease [(surface liver metastasis (n = 29) and peritoneal deposits (n = 66)]. The overall yield of SL was 23.2% (95/409). Of the 314 patients who underwent laparotomy, an additional 75 had unresectable disease due to surface liver metastasis (n = 5), deep parenchymal liver metastasis (n = 4), peritoneal deposits (n = 1), nonlocoregional lymph nodes (n = 47), and locally advanced unresectable disease (n = 18), that is, 6-DL and 69-UDL. The accuracy of SL for detecting unresectable disease and DL was 55.9% (95/170) and 94.1% (95/101), respectively. Compared with early GBC, the yield was significantly higher in locally advanced tumors (n = 353) [25.2% (89/353) vs 10.7% (6/56), P = 0.02]. However, the accuracy in detecting unresectable disease and a DL in locally advanced tumors was similar to early GBC [56.0%, (89/159) and 94.1%, (89/95) vs 54.6% (6/11) and 100% (6/6), P = 1.00]. In the present series with an overall resectability rate of 58.4%, SL identified 94.1% of the DLs and thereby obviated a nontherapeutic laparotomy in 55.9% of patients with unresectable disease and 23.2% of overall GBC patients. It had a higher yield in locally advanced tumors than in early-stage tumors; however, the accuracy in detecting unresectable disease and a DL were similar.

Aggressive surgical management of gallbladder cancer: At what cost?

An aggressive operative approach to gallbladder cancer has been advocated because of improved long-term survival, but data on short-term outcomes are lacking. Therefore, the purpose of this study was to analyze the postoperative outcomes of patients undergoing operative management of gallbladder cancer. Data from the American College of Surgeons-National Surgical Quality Improvement Program (2005-2009) were queried for patients with a diagnosis of gallbladder cancer. Outcomes included serious morbidity, overall morbidity, and mortality. For the 613 patients identified, the median age was 67 years, and 64% were female. A potentially curative operation was performed in 424 (69%) patients, including cholecystectomy alone (n =150, 35%), partial hepatectomy (n = 249, 59%), and extensive hepatectomy (n = 25, 6%). Overall morbidity rates for these procedures were 21%, 19%, and 28%, respectively. Mortality was greater (P < .001) in patients undergoing extensive hepatectomy (16%) compared with those undergoing cholecystectomy (7%) or partial hepatectomy (2%). Partial hepatectomy is the most common procedure performed for gallbladder cancer and is a safe operation. A small minority of younger, healthier patients undergoes an extensive hepatectomy, but the mortality of this operation is greater. This analysis suggests that patients with gallbladder cancer should be managed at high-volume centers.

Gallbladder cancer management impacted by coexistent tuberculosis

In endemic areas, gallbladder cancer (GBC) and tuberculosis may coexist. This study aimed to ascertain the impact of coexistent tuberculosis on the management of patients with GBC. Data of patients with proven GBC with coexistent tuberculosis managed at our centre between January 2003 and December 2007 were analysed from a prospective gallbladder cancer database to highlight the management issues and ascertain the impact that coexistent tuberculosis had on the outcome in these patients. Of the 340 patients of GBC evaluated at our centre, 7 patients had concomitant tuberculosis and constituted the study group. All the patients were women (mean age 56.3 years). The commonest presenting symptoms were abdominal pain, decreased appetite and significant weight loss. Two patients were found to have tuberculosis on preoperative evaluation on a fine-needle aspiration cytology from the left supraclavicular lymph nodes; 3 patients were detected intraoperatively (1 had peritoneal tuberculosis on staging laparoscopy and 2 had tubercular lymphadenitis on interaortocaval lymph node sampling) and 2 were detected postoperatively with histopathological examination showing GBC with tubercular lymphadenitis of the hepatoduodenal lymph nodes. Six of these 7 patients underwent surgery with curative intent and 1 underwent a surgical bypass. Five of the 7 patients of GBC with coexistent tuberculosis could have been denied the chance of curative surgery had a preoperative/intraoperative biopsy confirmation not been done. Thus, histopathological confirmation is mandatory before labelling a cancer as metastatic and denying the patient a chance for cure.

Is port-site resection necessary in the surgical management of gallbladder cancer?

Gallbladder carcinoma is frequently discovered incidentally on pathologic examination of the specimen after laparoscopic cholecystectomy (LC) performed for presumed "benign" disease. The objective of the present study was to assess the role of excision of port-sites from the initial LC for patients with incidental gallbladder carcinoma (IGBC) in a French registry. Data on patients with IGBC identified after LC between 1998 and 2008 were retrospectively collated in a French multicenter database. Among those patients undergoing re-operation with curative intent, patients with port-site excision (PSE) were compared with patients without PSE and analyzed for differences in recurrence patterns and survival. Among 218 patients with IGBC after LC (68 men, 150 women, median age 64 years), 148 underwent re-resection with curative intent; 54 patients had PSE and 94 did not. Both groups were comparable with regard to demographic data (gender, age > 70, co-morbidities), surgical procedures (major resection, lymphadenectomy, main bile duct resection) and postoperative morbidity. In the PSE group, depth of tumor invasion was T1b in six, T2 in 24, T3 in 22, and T4 in two; this was not significantly different from patients without PSE (P = 0.69). Port-site metastasis was observed in only one (2%) patient with a T3 tumor who died with peritoneal metastases 15 months after resection. PSE did not improve the overall survival (77%, 58%, 21% at 1, 3, 5 years, respectively) compared to patients with no PSE (78%, 55%, 33% at 1, 3, 5 years, respectively, P = 0.37). Eight percent of patients developed incisional hernia at the port-site after excision. In patients with IGBC, PSE was not associated with improved survival and should not be considered mandatory during definitive surgical treatment.

Aggressive Surgical Management of Gallbladder Cancer: At What Cost?

Background An aggressive operative approach to gallbladder cancer has been advocated because of improved long-term survival, but data on short-term outcomes are lacking. Therefore, the purpose of this study was to analyze the postoperative outcomes of patients undergoing operative management of gallbladder cancer. Methods Data from the American College of Surgeons-National Surgical Quality Improvement Program (2005–2009) were queried for patients with a diagnosis of gallbladder cancer. Outcomes included serious morbidity, overall morbidity, and mortality. Results For the 613 patients identified, the median age was 67 years, and 64% were female. A potentially curative operation was performed in 424 (69%) patients, including cholecystectomy alone (n =150, 35%), partial hepatectomy (n = 249, 59%), and extensive hepatectomy (n = 25, 6%). Overall morbidity rates for these procedures were 21%, 19%, and 28%, respectively. Mortality was greater (P Conclusion Partial hepatectomy is the most common procedure performed for gallbladder cancer and is a safe operation. A small minority of younger, healthier patients undergoes an extensive hepatectomy, but the mortality of this operation is greater. This analysis suggests that patients with gallbladder cancer should be managed at high-volume centers.

Frontline in the management of gallbladder cancer

Frontline in the management of gallbladder cancer

Terapias perioperatorias en el cáncer de vesícula biliar resecable: conclusiones del Consenso Latinoamericano de Manejo del Cáncer de Vesícula Biliar

No randomized controlled trials have been conducted in gallbladder cancer to establish standard treatments. We therefore conducted the first Latin American Consensus meeting for the management of gallbladder cancer. In this paper we report the conclusions of the experts' panel for (neo) adjuvant treatment of resectable gallbladder cancer. These are based on the review of the literature, the discussion of the participating experts and the vote of the assistants (surgical oncologists, medical oncologists, radiation oncologists and others). The reviewed topics were the role or adjuvant radiochemotherapy in T1 bN0M0, T2-3 N0-1M0 and T4 N0-1 M0 disease and doses, schedules and drugs for radiochemotherapy.

Patterns of Initial Disease Recurrence after Resection of Biliary Tract Cancer

Objectives: This study aimed to provide further insights into the indications for adjuvant therapeutic strategies via analysis of the sites of initial recurrence after resection of gallbladder cancer (GBC) and intrahepatic (IHC) and extrahepatic cholangiocarcinoma (EHC). Methods: Patients with biliary tract cancer who underwent potentially curative resection were identified from the database. Sites of initial disease recurrence were categorized as locoregional or distant. Results: Between March 2001 and April 2009, 231 patients underwent curative resection. Initial GBC and IHC recurrence involving a distant site occurred in 70.8 and 86.8% patients, respectively, compared to 56.9% patients with EHC (p = 0.002). The median time to disease recurrence (TTR) was shorter among the GBC and IHC groups compared with that in EHC patients (6.3 and 6.7 vs. 13.1 months, respectively; p = 0.003). Moreover, median times to distant recurrence in GBC and IHC groups were shorter than that in EHC (5.8 and 6.5 vs. 14.1 months, respectively; p = 0.002). Conclusions: After resection, recurrent GBC and IHC are more likely to involve a distant site and are associated with significantly shorter TTR than recurrent EHC. These findings suggest that an adjuvant therapeutic strategy targeting distant disease is likely to have a significant impact on the overall management of GBC and IHC.

Assessment of lymph node status in gallbladder cancer: location, number, or ratio of positive nodes

BackgroundAssessment of lymph node status is a critical issue in the surgical management of gallbladder cancer. The aim of this study was to compare the anatomical location of positive nodes, number of positive nodes, and lymph node ratio (LNR) as prognostic predictors in gallbladder cancer.MethodsWe conducted a retrospective analysis of 135 patients with gallbladder cancer who underwent a radical resection with regional lymphadenectomy. A total of 2,245 regional lymph nodes were retrieved (median, 14 per patient). The location of positive nodes was classified according to the AJCC staging manual (7th edition). ‘Optimal’ cutoff values were determined for the number of positive nodes and LNR based on maximal χ2 scores calculated with the Cox proportional hazards regression model.ResultsLymph node metastasis was found histologically in 59 (44%) patients. The ‘optimal’ cutoff values for the number of positive nodes and LNR were determined to be three nodes and 10%, respectively. Univariate analysis identified location of positive nodes (pN0, pN1, pN2; P < 0.001), number of positive nodes (0, 1 to 3, ≥4; P < 0.001), and LNR (0%, 0 to 10%, >10%; P < 0.001) as significant prognostic factors. Multivariate analysis identified number of positive nodes as an independent prognostic factor ( P = 0.004); however, location of positive nodes and LNR failed to remain as an independent variable.ConclusionsThe number of positive lymph nodes better predicts patient outcome after resection than either the location of positive lymph nodes or LNR in gallbladder cancer. Dividing the number of positive lymph nodes into three categories (0, 1 to 3, or ≥4) is valid for stratifying patients based on the prognosis after resection.

Diagnosis and management of gallbladder cancer

Gallbladder cancer (GBC) is a rather uncommon disease, but at the time when it gives symptoms it has usually reached no longer curable stage. Therefore, all attempts must be made to make the diagnosis earlier to have better opportunity for cure. The author searched PubMed, and reviewed literatures on diagnoses and treatment of GBC.

Current Curative Surgical Management of Gallbladder Cancer: A Brief Review

G allbladder cancer has a dismal prognosis, radical surgical resection offers the only chance of cure, but it is possible in only small proportion due to advanced disease and the recurrence is high. The extent of resection depends on the extent of disease. The aim of any therapeutic operation must be the radical removal of the tumor with no residual disease (R0 resection). Crucial for the surgical strategy is the TNM staging and the planning is decided in accordance with the T stage. In T1a simple cholecystectomy is considered as an adequate treatment. In T1b there is a controversy; some advocate simple cholecystectomy and others more extensive radical cholecystectomy. In T2 either extended radical cholecystectomy or resection of liver segments IV b and V . In all cases a radical lymph node dissection along the hepatoduodenal ligament is needed additionally. In T3 either hepatic segmentectomy IV b and V at least or extended right hepatectomy, both combined always with radical lymph node dissection. In T4 usually palliative operation; an extensive en-block resection with removal of included organs is rarely attempted. doi:10.4021/ jcs50w

Incidental gallbladder cancer: what management?

Gallbladder cancer (GBC) represents 3.8% of all gastrointestinal cancers and usually known to be of a poor prognosis. In 0.2–2.9% of cases, this cancer is found in cholecystectomy specimens. A better understanding of spread mode of this tumor helps a better surgical management. The aim of the present review is to underline the management of GBC based on the comprehension of risk factors and anatomic features. A Medline, PubMed database search was performed to identify articles published from 2000 to 2011 using the keywords ‘carcinoma of gallbladder’, ‘incidental gallbladder cancer’, ‘gallbladder neoplasm’ and ‘cholecystectomy’. Some pathological situations such as chronic lithiasis and biliopancreatic junction abnormalities have been clearly identified as predisposing to GBC. Laparoscopy increases peritoneal and parietal tumor dissemination, thus, it should not be performed when GBC is suspected. Most determinant prognostic factors are nodal, perineural and venous involvement, invasion of the cystic duct and the tumor differentiation. The simple cholecystectomy is sufficient for tumors classified as T1a; for other cancers exceeding the muscularis, radical re-resection is required due to the high risk of recurrence. This aggressive surgery improved the overall survival of patients. There is still no standard adjuvant treatment; patients should be included in prospective trials.

Incidental gallbladder cancer: what management?

Gallbladder cancer (GBC) represents 3.8% of all gastrointestinal cancers and usually known to be of a poor prognosis. In 0.2–2.9% of cases, this cancer is found in cholecystectomy specimens. A better understanding of spread mode of this tumor helps a better surgical management. The aim of the present review is to underline the management of GBC based on the comprehension of risk factors and anatomic features. A Medline, PubMed database search was performed to identify articles published from 2000 to 2011 using the keywords ‘carcinoma of gallbladder’, ‘incidental gallbladder cancer’, ‘gallbladder neoplasm’ and ‘cholecystectomy’. Some pathological situations such as chronic lithiasis and biliopancreatic junction abnormalities have been clearly identified as predisposing to GBC. Laparoscopy increases peritoneal and parietal tumor dissemination, thus, it should not be performed when GBC is suspected. Most determinant prognostic factors are nodal, perineural and venous involvement, invasion of the cystic duct and the tumor differentiation. The simple cholecystectomy is sufficient for tumors classified as T1a; for other cancers exceeding the muscularis, radical re-resection is required due to the high risk of recurrence. This aggressive surgery improved the overall survival of patients. There is still no standard adjuvant treatment; patients should be included in prospective trials.

Incidental gallbladder cancer: what management?

Gallbladder cancer (GBC) represents 3.8% of all gastrointestinal cancers and usually known to be of a poor prognosis. In 0.2–2.9% of cases, this cancer is found in cholecystectomy specimens. A better understanding of spread mode of this tumor helps a better surgical management. The aim of the present review is to underline the management of GBC based on the comprehension of risk factors and anatomic features. A Medline, PubMed database search was performed to identify articles published from 2000 to 2011 using the keywords ‘carcinoma of gallbladder’, ‘incidental gallbladder cancer’, ‘gallbladder neoplasm’ and ‘cholecystectomy’. Some pathological situations such as chronic lithiasis and biliopancreatic junction abnormalities have been clearly identified as predisposing to GBC. Laparoscopy increases peritoneal and parietal tumor dissemination, thus, it should not be performed when GBC is suspected. Most determinant prognostic factors are nodal, perineural and venous involvement, invasion of the cystic duct and the tumor differentiation. The simple cholecystectomy is sufficient for tumors classified as T1a; for other cancers exceeding the muscularis, radical re-resection is required due to the high risk of recurrence. This aggressive surgery improved the overall survival of patients. There is still no standard adjuvant treatment; patients should be included in prospective trials.

Audit of Management of Gallbladder Cancer in a Nigerian Tertiary Health Facility

Gallbladder cancer is a rare malignancy with a variable incidence worldwide. It ranks number eight among all gastrointestinal cancer seen in Nigeria. It is associated with high mortality and morbidity because it is usually diagnosed very late. Adequate surgical resection is the only modality with hope of cure. This requires advanced surgical skills which is quite rare in most developing countries like Nigeria. In this current work, we audit the management and outcome of gallbladder cancer in our hospital, highlighting peculiarity associated with our setting. Consecutive patients managed as cases of gallbladder cancer at Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Nigeria between January 1990 and December 2010 were studied retrospectively. Patient demographics, disease and treatment-related variables, and outcomes were analyzed by SPSS version 16.0. Thirty-one cases of gallbladder cancer were diagnosed over the 21-year period, and this accounts for about 0.3% of all cancer cases seen in our hospital. The median age of this patient cohort was 58 years (range 28 to 79 years). Seventeen (54.8%) patients were age below 60 while 14 (45.2%) were age 60 and above. Twenty-seven patients (87.1%) were female and four (12.9%) were male, with a male to female ratio approximately 1:7. Over 80% of the patients presented with a triad of upper abdominal pain, weight loss, and jaundice. Majority (67.7%) of the patients were diagnosed intraoperatively. Only four patients underwent complete resection as they had radical cholecystectomy including regional lymph node dissection and wedge resection of the gallbladder fossa of the liver. The stages of the resected patients were T3 in three patients and T2 in one. Overall 1- and 5-year survival rates for our entire patient cohort were 32% and 10%, respectively. In conclusion, this study showed that preoperative diagnosis of gallbladder cancer could be challenging in our environment. A triad of upper abdominal pain, jaundice, and weight loss with judicious use of available radiological modality will increase the chances of making the preoperative diagnosis of the cancer. It also showed that good outcome can be obtained when radical surgery is offered to these few patients within the limitation of resources in few patients with resectable tumor.

Expression profile of cholecystokinin type-A receptor in gallbladder cancer and gallstone disease

Regulatory peptide receptors have attracted the interest of oncologists as a new promising approach for cancer pathology, imaging and therapy. Although cholecystokinin (CCK) is a potent modulator of gallbladder contractility and plays a potential role in pancreatic carcinogenesis through CCK type-A receptor (CCKAR), its role in gallbladder cancer (GBC) is still unknown and immunohistochemical detection of CCKAR in the gallbladder has not yet been reported. This novel case-control study aimed to investigate the expression profile of CCKAR in GBC and gallstone disease (GSD). This study included 162 samples of gallbladder: 94 from GBC and 68 from GSD. Expression of CCKAR was analyzed by immunohistochemistry and immunoblotting. The results were statistically correlated with disease history including age, sex, presence of gallstone, stage and differentiation. CCKAR was positive in 30/68 (44.1%) of GSD and 72/94 (76.6%) of GBC samples. Fifty-one of the 72 (70.8%) CCKAR-positive GBC samples showed over-expression. Interestingly, consistent results also appeared in the immunoblotting study. CCKAR expression was significantly increased in GBC compared to GSD. Moreover, CCKAR expression was associated with the degree of tumor differentiation, i.e., less expression in poorly-differentiated tumors. Thus, it has future prognostic and therapeutic implications in the management of GBC.

Is Port Site Resection Necessary in the Surgical Management of Gallbladder Cancer?

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.

Comprehensive management of gallbladder cancer

Gallbladder cancer is the most common malignancy of biliary tract with a very poor prognosis. The therapeutic strategy of gallbladder cancer has been improved in some aspects. Identifying the accurate stage is the basis of surgical treatment. Radical resection is the only choice of treatment which provides patients long survival. For most patients in T1a stage, simple cholecystectomy is adequate, but dissection of hepatoduodenal ligament should be added when the lesions located in neck and duct of gallbladder. Patients in T1b stage often need radical cholecystectomy. Radical cholecystectomy with Ⅳb and Ⅴ segmentectomy and lymphadenectomy of N2 nodes should be performed to patients in T2 stage. Extended right lobe resection can improve the prognosis of selected T3 and T4 patients.The effect of chemotherapy for gallbladder cancer remains unsatisfactory, and current chemotherapeutic regimens were based on 5-FU, gemcitabine or S-1. The effect of a new chemotherapeutic sensitization scheme with continuous infusion of somatostatin,epirubicin 5-FU/CF and cisplatin is under research, and the preliminary results are promising. Radiation shows some benefits to patients with gallbladder cancer, but its effects are still uncertain. Key words: Gallbladder neoplasms; Surgical treatment; Chemotherapy; Radiotherapy

Manejo paliativo del cáncer de vesícula biliar irresecable o metastásico: Conclusiones del Consenso Latinoamericano de Manejo del Cáncer de Vesícula Biliar

Gallbladder cancer is a rare disease in Western developed countries, but it is a highly prevalent and lethal disease in Chile and other countries in Latin America. No randomized controlled trials have been performed in gallbladder cancer to establish standard treatments. We therefore performed the first Latin American consensus meeting for the management of gallbladder cancer. In this article we present the conclusions of the panel of experts for the palliative treatment of unresectable or metastatic gallbladder cancer based on a review of the literature, the discussion of the participating experts and the opinion of the assistants. The topics reviewed included: (1) Gallbladder cancer and cholangiocarcinoma--are they the same disease?; (2) Palliative chemotherapy: indications, drugs and schedules; (3) Palliative radiotherapy; (4) Palliative Surgery; (5) Management of malignant biliary obstruction.