Re-resection Of Incidental Gallbladder Cancer Research Articles

Nodal Metastases Impacts Residual Disease Status Following Definitive Oncological Resection of Gallbladder Cancer

Introduction: Most of gallbladder cancer (GBCA) cases are diagnosed incidentally following cholecystectomy. Due to the high recurrence rate following re-resection of incidental GBCA, the OPT-IN trial is examining the benefit of doublet neoadjuvant chemotherapy for patients with incidental T2/T3 GBCA. The aim of this study is to predict demographic and clinicopathological factors that influence residual disease (RD) status following definitive oncological resection. Methods: This is a retrospective study of patients who underwent radical resection for GBCA between 2012-2020. Multivariate logistic regression was performed to predict factors affecting R1 resection following initial procedure and RD status following re-resection. Results: A total of 43 patients underwent initial resection for GBCA including cholecystectomy (n=36) and radical cholecystectomy (n=7). Thirty-five (81.4%) were diagnosed incidentally. R1 resection was found in 14 patients (33%). Pathological T3 (pT3) stage was associated with a higher rate of R1 resection following the initial procedure (8 out of 11 patients; p=0.001). On multivariate analysis, pT3 stage demonstrated an odd ratio (OR) of 41.05 for R1 resection (p=0.046) in this group. Thirty-three patients eventually underwent definitive oncological resection following cholecystectomy. Nodal disease was significantly associated with RD in final specimens on both univariate (83.3%, p=0.002) and multivariate analyses (OR:17.12; p=0.009). Conclusion: Following initial resection, pT3 stage is a significant predictor of R1 resection for both incidental and non-incidental GBCA. RD after definitive resection correlates with the presence of nodal metastases. Patients with incidental GBCA may benefit from systemic chemotherapy prior to definitive resection as being examined in the OPT-IN trial.

Anatomic location of residual disease after initial cholecystectomy independently determines outcomes after re-resection for incidental gallbladder cancer.

This study aimed to elucidate the impact of anatomic location of residual disease (RD) after initial cholecystectomy on survival following re-resection of incidental gallbladder cancer (IGBC). Patients with pT2 or pT3 gallbladder cancer (36 with IGBC and 171 with non-IGBC) who underwent resection were analyzed. Patients with IGBC were classified as follows according to the anatomic location of RD after initial cholecystectomy: no RD (group 1); RD in the gallbladder bed, stump of the cystic duct, and/or regional lymph nodes (group 2); and RD in the extrahepatic bile duct and/or distant sites (group 3). Timing of resection (IGBC vs. non-IGBC) did not affect survival in either multivariate or propensity score matching analysis. RD was found in 16 (44.4%) of the 36 patients with IGBC; R0 resection following re-resection was achieved in 32 patients (88.9%). Overall survival (OS) following re-resection was worse in group 3 (n = 7; 5-year OS, 14.3%) than in group 2 (n = 9; 5-year OS, 55.6%) (p = 0.035) or in group 1 (n = 20; 5-year OS, 88.7%) (p < 0.001). There was no survival difference between groups 1 and 2 (p = 0.256). Anatomic location of RD was independently associated with OS (group 2, HR 2.425, p = 0.223; group 3, HR 9.627, p = 0.024). The anatomic location of RD independently predicts survival following re-resection, which is effective for locoregional disease control in IGBC, similar to resection for non-IGBC. Not all patients with RD have poor survival following re-resection for IGBC.

Implications of the index cholecystectomy and timing of referral for radical resection of advanced incidental gallbladder cancer.

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.