T1b Gallbladder Research Articles

Gallbladder polypoid lesions >15 mm as indicators of T1b gallbladder cancer risk

Background and study aimsGallbladder polyps (GBPs) are found in 5–7% of the adult population. However, it is very important to differentiate between benign and malignant polyps to establish an appropriate treatment. The present study aimed to determine the relevance of the 10-mm size criterion and attempted to determine the cut-off diameter of T1b tumours, which requires additional surgical intervention. Patients and methodsCases with GBPs were collected between January 2005 and January 2015. A total of 109 patients were enroled retrospectively. Information on age, sex, ultrasound findings, and blood laboratory tests was reviewed. The 10-mm criterion and T1b tumours were examined. ResultsSixty-nine females and 40 males were included in the study. Patient age was 45±10.7years (range 27–70years). The 10-mm cut-off sensitivity and specificity for predicting malignant polyps was 93.6% and 85.2%, respectively. Fifteen patients had malignant pathologic results, and one patient had GBP <10mm (intraepithelial, 8mm). Two patients had intraepithelial tumours of 12 and 13mm. Twelve malignant patients had T1b tumours with polyp sizes >15mm. ConclusionGallbladder cancer may occur in polyps of <10mm. Larger size and older age were predictors of neoplastic GBPs. We suggest 15mm as the optimal cut-off point to predict T1b cancer.

Predicting Residual Disease in Incidental Gallbladder Cancer: Risk Stratification for Modified Treatment Strategies

IntroductionRe-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. MethodsPatients 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. ResultsTwo 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. ConclusionBased 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.

Cholecystectomy and IVB-V hepatic segmentectomy with complete lymphadenectomy in a T1b gallbladder carcinoma. A video case report

Objective: Gallbladder carcinoma (GBC) is a rare disease, often diagnosed incidentally after a routine cholecystectomy. At the earliest stage T1a, cholecystectomy alone is curative in 90–100% cases. However, T1b carcinomas have been the focus of several publications, as weather extended resection could increase survival rates, with adequate morbidity. Most experts agree that en-bloc central hepatic resection should be done, in addition to lymph node dissection and resection of the porta hepatis and along the hepatoduodenal ligament, although there are no standards established as to the minimum number of lymph nodes examined. Methods: We report the case of a 67 years old woman, referred from another center with the diagnosis of GBC T1b after a routine cholecystectomy. Open IVb and V hepatic segmentectomy with lymphadenectomy of periaortic, pericava and hepatoduodenal ligament's nodes was done at our center. Results: We expose a detailed, well-structured video in which we evidence this procedure, with clear anatomic dissection. No complications were reported after surgery, and the patient continues alive with follow up studies up to the moment. Histopathological result of the lymphadenectomy showed no neoplastic infiltration. Conclusion: We believe radical R0 surgery is the only treatment capable of increasing GBC survival rates, especially when diagnosed at early stages.

Determining the extent of cholecystectomy using intraoperative specimen ultrasonography in patients with suspected early gallbladder cancer.

Accumulating evidence and guidelines recommend extended cholecystectomy for T1b or greater gallbladder cancers. This study aimed to evaluate the feasibility of intraoperative ultrasonography of a resected gallbladder specimen (specimen US) for the determination of the extent of cholecystectomy. We included 45 patients (34 women; median [interquartile range] age, 66 [57-74] years) who underwent specimen US. After simple laparoscopic cholecystectomy, a gallbladder specimen was examined to evaluate the depth of tumor invasion by specimen US and frozen section examination. With the results of those two examinations, the operating surgeon decided whether to perform extended cholecystectomy. The sensitivity and specificity of specimen US and frozen section examination in diagnosing T1b or greater cancer were, respectively, measured using permanent pathology as the reference standard. The surgeons' final decisions were evaluated in the same manner as the intraoperative examinations. Among 22 patients in whom adenocarcinomas were confirmed, 17 patients had T1b or greater cancers. The sensitivity and specificity of specimen US alone were 81% (95% CI, 54-96%) and 85% (65-96%), respectively. The sensitivity and specificity of frozen section examination alone were 43% (10-82%) and 95% (75-100%), respectively. Except one patient in whom extended cholecystectomy was intentionally not performed, 14 out of 16 patients (88%; 95% CI, 62-98%) who were finally confirmed as having T1b or greater cancers underwent extended cholecystectomy by the surgeons' decision based on both specimen US and frozen examination. Out of 28 patients who were finally confirmed as having benign lesions or T1a cancers, 25(89 %; 72-98%) underwent simple cholecystectomy. Specimen US was feasible to be incorporated in clinical practice. Although the diagnostic accuracy of specimen US alone was moderate, the combined use of specimen US and frozen section examination could help the surgeons make correct decisions on the extent of cholecystectomy.

Preoperative differentiation between T1a and ≥T1b gallbladder cancer: combined interpretation of high-resolution ultrasound and multidetector-row computed tomography.

To determine the diagnostic value of combined interpretation of high-resolution ultrasound (HRUS) and multidetector-row computed tomography (MDCT) for preoperative differentiation between T1a and ≥T1b gallbladder (GB) cancer. Eighty-seven patients with pathologically confirmed GB cancers (T1a, n = 15; ≥T1b, n = 72), who preoperatively underwent both HRUS and MDCT, were included in this retrospective study. Two reviewers independently determined the T-stages of the GB cancers on HRUS and MDCT using a five-point confidence scale (5, definitely T1a; 1, definitely ≥T1b). For individual modality interpretation, the lesions with scores ≥4 were classified as T1a, and, for combined modality interpretation, the lesions with all scores ≥4 in both modalities were classified as T1a. The McNemar test was used to compare diagnostic performance. The diagnostic accuracy of differentiation between T1a and ≥T1b GB cancer was higher using combined interpretation (90.8% and 88.5% for reviewers 1 and 2, respectively) than individual interpretation of HRUS (82.8% and 83.9%) or MDCT (74.7% and 82.8%) (P < 0.05, reviewer 1). Combined interpretations demonstrated 100% specificity for both reviewers, which was significantly higher than individual interpretations (P < 0.05, both reviewers). Combined HRUS and MDCT interpretation may improve the diagnostic accuracy and specificity for differentiating between T1a and ≥T1b GB cancers. • Differentiating between T1a and ≥T1b gallbladder cancer can help surgical planning. • HRUS and MDCT are useful for local staging of gallbladder cancer. • HRUS and MDCT may be synergistic for T-staging of gallbladder cancer.

Surgical Strategy for T1 Gallbladder Cancer: A Nationwide Multicenter Survey in South Korea

The aim of this study was to investigate the clinical features and clinical outcomes of T1 gallbladder (GB) cancer and to determine an appropriate surgical strategy for T1 GB cancer. A nationwide multicenter study, in which 16 University Hospitals in Korea participated, was performed from 1995 to 2004. A total of 258 patients, 117 patients with T1a and 141 patients with T1b disease were enrolled. Clinicopathologic findings and long-term follow-up results were analyzed after a consensus meeting of the Korean Pancreas Surgery Club was held. Simple cholecystectomy was performed in 95 patients (81.2%) with T1a tumor and in 89 patients (63.1%) with T1b tumor (p<0.01). Lymph node metastasis was observed in 2.9% of T1a patients and in 9.9% of T1b patients (p=0.391). A significant difference in 5-year disease-specific survival (DSS) rates was observed between T1a and T1b patients (96.4 vs 84.8%, respectively, p=0.03). However, no significant 5-year DSS rate difference was observed between those who underwent simple cholecystectomy or extended cholecystectomy, regardless of whether lymph node dissection was performed or whether lymph node metastasis was present. There was no significant difference in recurrence-free survival between simple cholecystectomy and extended cholecystectomy. There was no superiority of extended cholecystectomy over simple cholecystectomy in the aspect of survival and recurrence especially in T1b gallbladder cancer. Furthermore, the effectiveness of regional lymphadenectomy for treatment purpose remains questionable. Therefore, simple cholecystectomy could be recommended as a surgical strategy of T1 gallbladder cancer.

Systematic review on the surgical treatment for T1 gallbladder cancer

To evaluate the efficacy of simple and extended cholecystectomy for mucosa (T1a) or muscularis (T1b) gallbladder (GB) cancer. Original studies on simple and extended cholecystectomy for T1a or T1b GB cancer were searched from MEDLINE (PubMed), Cochrane Library, EMBase, and CancerLit using the search terms of GB, cancer/carcinoma/tumor/neoplasm. Twenty-nine out of the 2312 potentially relevant publications met the eligibility criteria. Of the 1266 patients with GB cancer included in the publications, 706 (55.8%) and 560 (44.2%) had T1a and T1b GB cancer, respectively. Simple cholecystectomy for T1a and T1b GB cancer was performed in 590 (83.6%) and 375 (67.0%) patients, respectively (P < 0.01). In most series, the treatment of choice was simple cholecystectomy for T1a GB cancer patients with a 5-year survival rate of 100%. Lymph node metastasis was detected in 10.9% of the T1b GB cancer patients and in 1.8% of the T1a GB cancer patients, respectively (P < 0.01). Eight patients (1.1%) with T1a GB cancer and 52 patients (9.3%) with T1b GB cancer died of recurrent GB cancer (P < 0.01). Simple cholecystectomy represents the adequate treatment of T1a GB cancer. There is no definite evidence that extended cholecystectomy is advantageous over simple cholecystectomy for T1b GB cancer.

Regional lymphadenectomy strongly recommended in T1b gallbladder cancer

This article discusses the adequate treatment of early gallbladder cancer (T1a, T1b) and is based on published studies extending over nearly 3 decades. Randomized studies and meta analyses comparing different surgical treatments do not exist. The literature shows that in up to 20% of patients lymph node metastasis are found in T1b gallbladder cancer. Due to high malignancy with early angiolymphatic spread and resistance to chemotherapy and radiation on the one hand, and the relative low operative risk of extended cholecystectomy (cholecystectomy and regional lymphadenectomy) on the other hand, we believe that this procedure is mandatory in early gallbladder cancer.

Radical resection for T1b gallbladder cancer: a decision analysis

BackgroundGallbladder cancer is the most common malignancy of the biliary tract. Radical surgery (including liver resection and regional lymphadenectomy) is applied for some gallbladder cancers, but the benefits of these procedures are unproven. For patients with T1b cancers discovered incidentally on cholecystectomy specimens, the utility of radical surgery remains debated. MethodsA decision analytic Markov model was created to estimate and compare life expectancy associated with management strategies for a simulated cohort of patients with incidentally discovered T1b gallbladder cancer after routine cholecystectomy. In one strategy, patients were treated with no additional surgery; in another, patients were treated with radical resection. The primary (base-case) analysis was calculated based on a cohort of 71-year-old females and incorporated best available input estimates of survival and surgical mortality from the literature. Sensitivity analysis was performed to assess the effects of model uncertainty on outcomes. ResultsIn the base-case analysis, radical resection was favoured over no further surgical resection, providing a survival benefit of 3.43 years for patients undergoing radical resection vs. simple cholecystectomy alone. Sensitivity analysis on the age at diagnosis demonstrated that the greatest benefit in gained life-years was achieved for the youngest ages having radical resection, with this benefit gradually decreasing with increasing age of the patient. High peri-operative mortality rates (≥36%) led to a change in the preferred strategy to simple cholecystectomy alone. ConclusionsDecision analysis demonstrates that radical resection is associated with increased survival for most patients with T1b gallbladder cancer.

Evolving Treatment Strategies for Gallbladder Cancer

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.

Prognostic analysis of T1 and T2 stage gallbladder cancer with invasion within the gallbladder wall

To explore the impact of different treatment procedure on the prognosis of T1 and T2 stage gallbladder cancer with the invasion within the gallbladder wall. A retrospective analysis was conducted on 45 patients with pathologic stage T1 and T2 gallbladder cancer who had undergone surgical resection from 1990 and 2005. Depth of invasion (T), radical cholecystectomy and postoperative adjuvant chemotherapy were independent prognostic factors on Cox multivariate analysis. The 5-year survival rates of patients with T1a, T1b and T2 stage gallbladder cancer who underwent simple cholecystectomy without postoperative adjuvant chemotherapy were 100%, 67% and 0, respectively. The survival rate in T2 was significantly lower than those in T1a and T1b. Without postoperative adjuvant chemotherapy, the 5-year survival rates of patients with T2 stage gallbladder cancer who underwent simple cholecystectomy and radical cholecystectomy were 0 and 63%, respectively. There was significant difference between the survival time of T2 patients who had undergone simple cholecystectomy with and without postoperative adjuvant chemotherapy. The prognosis of patients with T1 stage gallbladder cancer is much better than that of T2 stage. The 5-year survival rates of patients with T1a and T1b stage gallbladder cancer who received simple cholecystectomy are relatively good. Radical cholecystectomy and postoperative adjuvant chemotherapy can improve the prognosis of patients with T2 gallbladder cancer.

Laparoscopic cholecystectomy for treatment of unexpected early‐stage gallbladder cancer

Laparoscopic cholecystectomy (LC) may result in the incidental diagnosis of early stage (T1 and T2) gallbladder cancer. LC is useful for T1 patients, however, its role in T2 patients remains controversial. We sought to determine the effect of initial LC on patient outcome in early-stage gallbladder cancer. Twenty-nine patients with T1 or T2 disease were reviewed retrospectively to assess preoperative diagnosis, intraoperative findings, and outcomes. Diagnoses included gallbladder stones (5), gallstones with polyps (5), and gallbladder polyps (19). Malignancy was suspected in 15 patients (14 polyp lesions and 1 gallbladder stone with wall thickening). After frozen sections, two T2 patients were immediately treated with radical operation owing to positive margins. Of 14 patients diagnosed by pathology, 4 T2 patients with positive margins underwent a second radical operation. Five-year survival rate was 100% and 49.6 % (T1 and T2 patients). No mortality or recurrence was detected in T1 patients (mean follow-up, 45.8 months; range, 6-98 months). Three T2 patients died, and one T2 patient relapsed after LC. No port site metastasis was detected. LC for T1a and T1b gallbladder cancer needs no additional treatment, however, radical operation for T2 patients is recommended, regardless of the margin condition.