Union Internacional Contra La Cancrum Research Articles

Prediction of survival from carcinoma of oesophagus and oesophago‐gastric junction following surgical resection using an artificial neural network

Aim The aim of this study was to assess the ability of artificial neural network (ANN) in predicting survival in patients undergoing surgical resection for carcinoma of oesophagus and oesophago‐gastric junction. Methods From January 1995 to August 2004 patients who underwent surgery for oesophageal and gastric carcinoma were identified. Biographical data, body mass index and pathological minimal cancer dataset were used to design an ANN. Post-operative survival was assessed at 1 and 3 years. Sixty percent of data was used to train and validate the ANN and 40% was used to evaluate the accuracy of trained ANN in predicting survival. This was compared with Union Internacional Contra la Cancrum UICC TNM classification system. Results Two hundred and sixteen patients underwent resectional surgery for oesophageal and OGJ carcinoma. The accuracy of the ANN in predicting survival at 1 and 3 years was 88% (sensitivity: 92.3%, specificity: 84.5%, DP=2.3) and 91.5% (sensitivity of 94.61%, specificity: 88%, DP=2.72), respectively. These figures were significantly better than 1- and 3-year survival predictions using the UICC TNM classification system 71.6% (sensitivity of 66.4%, specificity: 75.5%, and DP<1) and 74.7% (sensitivity of 70.5%, specificity: 74.9%, DP<1), respectively ( P<0.01) ( P<0.05). Conclusion ANNs are superior to the UICC TNM classification system in correlating with survival following resection of carcinoma of oesophagus and OG junction and can become valuable tools in the management of patients with oesophageal carcinoma.

Prognostic relevance of systematic lymph node dissection in gastric carcinoma. German Gastric Carcinoma Study Group.

In a prospective multicentre study of 2394 patients with gastric carcinoma the prognostic relevance of systematic lymph node dissection was evaluated. Of 1654 patients undergoing resection, 558 had a standard lymph node dissection, defined as fewer than 26 nodes in the specimen, and 1096 underwent radical lymphadenectomy, i.e. 26 or more nodes in the specimen. Radical dissection significantly improved the survival rate in patients with Union Internacional Contra la Cancrum (UICC) stages II and IIIA tumours. Multivariate analysis identified radical dissection as an independent prognostic factor in the subgroups of patients with UICC tumour stages II and IIA. Radical dissection conferred no survival advantage in patients with pN2 tumours. There was no significant difference in morbidity and mortality rates between radical and standard lymph node dissection. Radical lymphadenectomy improves survival in patients with UICC gastric cancer stages II and IIIA, and should be the recommended treatment for such patients.

Indications for primary tamoxifen therapy in elderly women with breast cancer.

A group of 66 elderly women with primary breast cancer were treated with tamoxifen and followed for a minimum of 2 years. Of these, 32 whose disease remained controlled for the 2-year period were considered to have had a 'worthwhile' response, 27 in whom disease progressed were considered to have had an unsatisfactory result and seven opted for alternative treatment. By Union Internacional Contra la Cancrum (UICC) criteria, 14 women had a complete response, 20 a partial response, in five disease remained static and in 20 it progressed without response. Prediction of outcome after assessment according to UICC criteria at 3 and 6 months was unsatisfactory (19 and 34 of 59 correctly predicted respectively). Analysis of multiple tumour measurements over 12 weeks was no better (33 of 59 correctly predicted). Immunocytochemical assay of fine-needle aspirates for oestrogen receptor (ER) provided a better predictor (38 of 47 correct) and the difference in survival between patients with and without ER activity was significant (P < 0.001). Conventional assessments of response at 3 and 6 months are unsatisfactory for judging the long-term benefit to the patient. ER status is the best predictor of response and outcome.

Prognostic factors after resection of ampullary carcinoma: multivariate survival analysis in comparison with ductal cancer of the pancreatic head.

Resection was performed in 85 patients with ampullary and in 150 with ductal pancreatic head carcinoma. Curative resection was achieved in 98 and 87 per cent respectively. Patient survival at 5 years after exclusion of hospital deaths was 38 versus 16 per cent respectively. The patients were compared retrospectively in a multivariate survival analysis. For patients with pancreatic carcinoma, residual tumour stage, tumour size and grading were independent prognostic factors, but for those with ampullary carcinoma only tumour size was a prognostic factor. Lymph node metastasis impaired prognosis, but this effect was demonstrable for both groups only after univariate analysis. The Union Internacional Contra la Cancrum classification system was not a reliable parameter of prognosis after resection of ampullary carcinoma. Patients with ampullary cancer appear to have a better prognosis intrinsically than those with pancreatic head tumours, and not simply because they present at an earlier stage. The difference in prognosis cannot be explained sufficiently by a differential importance of the various survival variables.

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.

Stereotactic cytology in a regional breast-screening programme.

Stereotactic localization and fine-needle aspiration are new procedures for the management of non-palpable mammographic abnormalities. In this prospective study, stereotactically guided cytology with immediate reporting was performed before biopsy in a consecutive series of 166 patients with screen-detected non-palpable abnormalities. All specimens were obtained by multiple stereotactically guided passes with a 22-G Franzén needle and graded as: 1, acellular or inadequate; 2, benign; 3, atypical, probably benign; 4, probably malignant; or 5, malignant. After definitive surgery all tumours were staged according to the Union Internacional Contra la Cancrum classification. Of 71 patients with malignancy, 56 were correctly diagnosed by cytology before operation. Twelve patients with malignancy had grade 1 cytology and 50 of the 52 with grade 2 cytology had benign disease. This study confirms that stereotactic cytology is a valuable diagnostic test in a breast-screening programme.

Ratio of invaded to removed lymph nodes as a predictor of survival in squamous cell carcinoma of the oesophagus.

Prognostic factors that may alter the indications for primary surgical resection or that can be influenced by the extent of the procedure were analysed in a homogeneous group of 186 patients with squamous cell carcinoma of the oesophagus. All patients underwent standardized en bloc oesophagectomy and lymph node dissection with prospective documentation of the histopathological findings; follow-up was complete. Multivariate analysis identified the Union Internacional Contra la Cancrum R category (i.e. the presence of residual tumour after resection) as the most important independent prognostic factor (P < 0.001) followed by the ratio of invaded to removed lymph nodes (P < 0.001). These data suggest that only patients in whom R0 resection can be anticipated based on preoperative assessment should undergo primary resection for oesophageal cancer. Extended lymphadenectomy may improve survival in patients with a limited number of invaded mediastinal nodes.

Selective approach to the treatment of oesophageal cancer.

Between September 1985 and December 1994, 322 patients with oesophageal cancer were treated. Of the 190 patients who underwent operation, 173 had an oesophageal resection; in 124 this was performed as an abdominothoracic resection and in 49 by the transhiatal approach. The assessment of radicality after histological examination revealed a curative (R0) resection in 121 patients (70 per cent) and a palliative (R1-R2) resection in 52 (30 per cent). Prognosis was correlated with the extent of mediastinal lymph node dissection. In 77 patients with stage pT1-3 pN0-1 pM0 the 5-year survival rate was 40 per cent after abdominothoracic resection with two-field lymph node dissection and zero after transhiatal resection (P = 0.01). The authors propose a differentiated surgical approach involving abdominothoracic resection with two-field lymph node dissection for patients with limited tumours (pT1-3 pN0-1 M0) if the operative risk is tolerable. Transhiatal resection appears to be effective only in patients with early tumours (Union Internacional Contra la Cancrum stage 0).

Liver resection for hepatocellular carcinoma in patients with cirrhosis

Although liver resection is now a safe procedure, its role for hepatocellular carcinoma (HCC) in patients with cirrhosis remains controversial. This study compared the results of liver resection for HCC in patients with cirrhosis over two time intervals. One hundred and sixty-one patients had resection during period 1 (1991-1996) and 265 in period 2 (1997-2002). Early and long-term results after liver resection in the two periods were compared, and clinicopathological characteristics that influenced survival were identified. Tumour size was smaller, indocyanine green retention rate was higher, patients were older and a greater proportion of patients were asymptomatic in period 2 than period 1. Operative blood loss, need for blood transfusion, operative mortality rate, postoperative hospital stay and total hospital costs were significantly reduced in period 2. The 5-year disease-free survival rates were 28.2 and 33.9 per cent in periods 1 and 2 respectively (P = 0.042), and 5-year overall survival rates were 45.9 and 61.2 per cent (P < 0.001). Multivariate analysis identified serum alpha-fetoprotein level, need for blood transfusion and Union Internacional Contra la Cancrum tumour node metastasis stage as independent determinants of disease-free and overall survival. The results of liver resection for HCC in patients with cirrhosis improved over time. Liver resection remains a good treatment option in selected patients with HCC arising from a cirrhotic liver.

Assessment of the accuracy of transrectal ultrasonography in anorectal neoplasia.

Accurate preoperative staging of anorectal neoplasia is required to identify patients for whom local excision or adjuvant therapy may be appropriate. The objectives of this study were to review the accuracy of endoluminal transrectal ultrasonography (TRUS) in the staging of rectal cancers and to determine the learning curve before optimal staging accuracy can be achieved. The results of all TRUS examinations for the assessment of anorectal neoplasia performed by two colorectal surgeons at two teaching hospitals of the University of Sydney from 1991 to 2001 were collected prospectively. Of the 433 patients examined by TRUS, 356 were included, of whom 263 (73.9 per cent) had nodal status assessed histologically. Of the 77 patients excluded, 50 had undergone radiotherapy before operation. TRUS achieved excellent accuracy when compared with histopathology reports using kappa statistics for standard Union Internacional Contra la Cancrum (UICC) staging (kappa = 0.89), tumour wall penetration (kappa = 0.70), lymph node detection (kappa = 0.66) and a proposed new staging system (kappa = 0.94). In addition, the increase in TRUS accuracy with operator experience demonstrates the need to perform 50 or more procedures before optimal accuracy is achieved. TRUS provides an appropriate investigation with which to select patients with T1 tumours for local excision, and patients with T3 or T4 tumours for preoperative radiotherapy. The relative inaccuracy of staging T2 tumours by TRUS has led to a proposed alternative ultrasonographic staging system.

Laparoscopic ultrasonography is accurate for staging large pancreatic tumours

Abstract Background The accuracy of laparoscopic ultrasonography in staging pancreatic and periampullary tumours in a referral unit was determined and its use for the subgroup of tumours of stage T3 or greater was assessed. Methods From a larger series of staging laparoscopies 22 patients with pancreatic lesions and five with periampullary tumours who were being considered for resection were staged with laparoscopy and laparoscopic ultrasonography. Only patients with computed tomography (CT) or magnetic resonance imaging (MRI) scans indicating potentially or equivocally resectable disease were included. The laparoscopist was blinded to the results of CT and MRI. Laparoscopy and laparoscopic ultrasonography were undertaken according to a standard protocol using a B &amp; K Medical Diagnostic Ultrasound System 3535 with a colour flow Doppler module. Ascitic fluid was sent for cytology and metastatic disease was biopsied. Results were recorded on a pro forma which included an assessment of resectability. In the case of large tumours this included an assessment of the potential for a positive resection margin or the need for portal vein resection to obtain tumour clearance. The decision to pursue resection was made by the consultant surgeon, based on all the information available including that from laparoscopic ultrasonography. No patient was denied a surgical exploration on the basis of local irresectability determined only by laparoscopic ultrasonography. The predictions regarding resectability were compared with findings at open surgery and with histology. Results Assessment of irresectability by laparoscopic ultrasonography resulted in nine true positives, 16 true negatives, no false positives and one false negative. For pancreatic adenocarcinoma there were eight true positives, 13 true negatives and one false negative. Among the pancreatic group ten of 13 tumours correctly predicted as resectable were stage T3 or greater (Union Internacional Contra la Cancrum, 1997). Of those predicted to be irresectable, all eight were T3 or greater. Among this latter group three were predicted to be irresectable on the basis of local factors alone, two on the basis of metastatic disease alone and three on the basis of both local factors and metastases. Overall, for detection of irresectable disease laparoscopic ultrasonography had a positive predictive value of 100 per cent, a negative predictive value of 94 per cent and an accuracy of 96 per cent. Accuracy was 95 per cent for both the pancreatic tumour subgroup and the T3 pancreatic subgroup. Conclusion Laparoscopic ultrasonography was accurate for predicting irresectability in this group of referred patients. The technique was also accurate for the subgroup with T3 or greater pancreatic tumours.

Hepatitis viral status in patients undergoing liver resection for hepatocellular carcinoma.

Hepatitis B and C viruses are the main causative agents of hepatocellular carcinoma (HCC). The influence of hepatitis viral status on liver resection for HCC remains undetermined. Patients who underwent curative resection for HCC were divided into four groups: group 1, seronegative for hepatitis B surface antigen (HBsAg) and antihepatitis C antibody (HCVAb); group 2, seropositive for HBsAg only; group 3, seropositive for HCVAb only; and group 4, seropositive for HBsAg and HCVAb. The clinicopathological characteristics and surgical results of the four groups were compared. Resection of HCC was determined according to liver functional reserve and tumour extent. There were 40, 131, 70 and 20 patients in groups 1, 2, 3 and 4 respectively. Due to patient selection bias, there were significant differences in some background features, resectional extent and pathological characteristics among the four groups. Postoperative morbidity and mortality, as well as the Union Internacional Contra la Cancrum tumour node metastasis stages, did not differ. Patients in group 1 had a higher disease-free survival rate than those in group 2 (P = 0. 02). The actuarial survival rates of patients in groups 2 and 4 were lower than those of groups 1 and 3. With careful patient selection, the hepatitis viral status does not influence the surgical risks of hepatectomy for HCC. After liver resection for HCC, the long-term survival rate of patients seronegative for HBsAg is greater than that of patients seropositive for HBsAg.

Retrospective analysis of prognostic factors after liver resection and transplantation for cholangiocellular carcinoma.

Cholangiocellular carcinoma is an uncommon primary liver cancer, which may be mixed with hepatocellular carcinoma. A retrospective analysis was undertaken to evaluate the results of surgical treatment and to identify prognostic factors. Between 1978 and 1996, 162 patients underwent surgery for cholangiocellular carcinoma: liver resection (n = 95), liver transplantation (n = 24) and exploratory laparotomy with and without drainage (n = 43). Univariate and multivariate analyses of prognostic factors were performed. Overall survival was 47 per cent at 1 year, 28 per cent at 2 years and 13 per cent at 5 years. Survival rates for patients with resectable tumours were 64, 43 and 21 per cent respectively, and for those who underwent liver transplantation 21, 8 per cent and zero respectively. Univariate analysis showed that the following variables had an effect on survival: age, jaundice, liver resection, T, N and M stage in the tumour node metastasis classification, Union Internacional Contra la Cancrum (UICC) tumour stage, tumour-free margins, vascular infiltration, tumour number, tumour size and serum level of carcinoembryonic antigen. Multivariate analysis identified jaundice, N and M category, and UICC tumour stage as independent prognostic factors. The data underscore the importance and prognostic value of the UICC tumour classification for cholangiocellular carcinoma. The prognosis of mixed tumours is no different. Liver resection remains the treatment of choice; transplantation offers no solution for otherwise unresectable tumours.

Appraisal of compliance with the UICC/AJCC staging system in the staging of gastric cancer. Union Internacional Contra la Cancrum/American Joint Committee on Cancer.

In the surgical management of gastric carcinoma, regional lymphatic spread is of prognostic importance. The fifth edition of the Union Internacional Contra la Cancrum classification has been shown to be reproducible, practical and of significant prognostic use. The tumour node metastasis (TNM) system requires at least 15 lymph nodes to be acquired and examined for staging to be accurate. This has raised concern over the consistency with which the requisite numbers of nodes would be acquired. This study was performed to assess how consistently surgically managed cases of gastric cancer in the West Midlands fulfilled this requirement to allow accurate staging. Data from the West Midlands Cancer Intelligence Unit on all cases of gastric cancer registered from 1998 to 1999 were obtained and the number of lymph nodes documented for each surgically managed case was assessed. Overall, only 31.0 per cent of surgically resected cases could be assessed accurately according to the TNM system. The proportion staged accurately varied widely across hospitals from 10.9 to 76.0 per cent. These results reflect the need for improved N staging across the region to aid the appropriate multimodal treatment of patients.

Influence of the number of lymph nodes examined on staging of gastric cancer.

Nodal staging for gastric cancer according to the 1997 Union Internacional Contra la Cancrum tumour node metastasis classification is based on the number of metastatic lymph nodes. The aim of this study was to evaluate whether the number of lymph nodes examined affected staging of gastric cancer. A retrospective study was performed in 4789 consecutive patients with gastric cancer, who had undergone curative resection (R0) from 1986 to 1995. Patients were classified according to the number of nodes examined. The number of metastatic lymph nodes and stage-stratified survival were compared. There were significant differences in the number of metastatic lymph nodes and survival in stage IIIA between patients with 15 or more lymph nodes and those with fewer than 15 nodes. In analysis restricted to patients with 15 or more nodes, stage-stratified survival did not vary significantly with lymph node yields for any stage except IIIB, in which there was a significant difference between the subgroup with fewer than 20 examined lymph nodes and patients with 35 or more nodes. The number of lymph nodes examined did not significantly affect node staging of gastric cancer as long as at least 15 nodes were examined. For stage IIIB, more than 15 lymph nodes may be required for optimal staging.

Gender differences in long-term survival of patients with colorectal cancer

Significant differences exist in the immunological response to surgery. This raises the possibility that gender differences exist concerning the outcome after curative colorectal cancer resection. To study this hypothesis, a database of patients with colorectal cancer was analysed prospectively. Some 894 patients were included, 500 (55.9 per cent) were men and 394 (44.1 per cent) were women. Median follow-up was 54.5 months for the entire group and 63.3 months for survivors. The mean(s.e.m.) patient age was 65.3(0.4) years (women 66.1(0.6), men 64.7(0.5) years; P < 0.05). Women lived significantly longer after cancer resection than men (57.8(1.5) versus 52.0(1.3) months; P < 0.05, log rank 0.009). Disease-free survival was significantly longer in women than in men (51.6(1.7) versus 46.0(1.4) months; P < 0.05). Subgroup analysis revealed significant gender differences in Union Internacional Contra la Cancrum (UICC) stages I (n = 195, log rank 0.01) and UICC IV (n = 38, log rank 0.021). Survival analysis after rectal cancer resection revealed significant advantages for women (log rank 0.02), while no gender differences were detected when comparing patients after resection for colonic cancer. Moreover, patients older than 50 years (n = 635) showed significant gender-related survival differences (log rank 0.015). Significant gender differences following curative rectal cancer resection were observed. In women disease-free and overall survival were significantly longer. Whether or not these gender differences are related to gender-specific immune functions or to other gender-related local or systemic factors remains to be determined.

Perineural invasion has a negative impact on survival of patients with gallbladder carcinoma.

The clinical significance of perineural invasion of gallbladder carcinoma remains unclear. The aim of this study was to elucidate the incidence and mode of perineural invasion of gallbladder carcinoma and clarify its prognostic significance. A clinicopathological study was conducted on 68 patients who underwent attempted curative resection for gallbladder carcinoma. According to the pathological tumour node metastasis (pTNM) classification of the Union Internacional Contra la Cancrum, there were five (7 per cent), nine (13 per cent), 20 (29 per cent) and 34 (50 per cent) patients with pT1, pT2, pT3 and pT4 disease respectively. Twenty patients (29 per cent) had pM1 disease, including involved para-aortic nodes, liver metastases and localized dissemination. The overall incidence of perineural invasion was 71 per cent (48 of 68 patients). Forty-four (96 per cent) of 46 patients with extrahepatic bile duct invasion had perineural invasion. Although several histological factors were associated with perineural invasion, multivariate analysis demonstrated that extrahepatic bile duct invasion was the only significant factor correlated with perineural invasion (odds ratio 99.0, P < 0.001). The perineural invasion index, defined as the ratio of the number of involved nerves to the total number of nerves examined, was significantly higher at the centre than in the proximal and distal parts of the tumour in the 46 patients with extrahepatic bile duct invasion (P < 0.001). The 5-year survival rate for patients with perineural invasion was significantly lower than that for patients with no invasion (7 versus 72 per cent; P < 0.001). Cox proportional hazard analysis identified perineural invasion (relative risk (RR) 5.3, P < 0.001) and lymph node metastasis (RR 2.5, P = 0.008) as significant independent prognostic factors. Perineural invasion is common in advanced gallbladder carcinoma and has a significant negative impact on patient survival.

Comparison of five systems for staging lymph node metastasis in gastric cancer

There are several systems for staging lymph node metastasis in gastric cancer. Their relative merits are not clear. In this retrospective analysis, the nodal status was classified according to the Union Internacional Contra la Cancrum (UICC) and Japanese staging systems, the number and frequency of lymph node metastasis, and the level of involved nodes. Each staging system was scored as good (+1), fair (0) or poor (-1) with respect to prognostic value, theoretical value, convenience, reproducibility and surgical applicability. There were no differences between the five staging systems in predicting survival. The Japanese staging system was most arbitrary owing to the complexity of the system, although it had an advantage in surgical application. The same disadvantage was found in the UICC system and the level system. Determination of the number and frequency of involved nodes was convenient and reproducible, but the number of lymph nodes dissected must be considered when the number of positive nodes is used for staging. The classification of metastasis to the regional lymph nodes as N0 (no nodal metastasis), N1 (metastasis in 1-25 per cent of dissected nodes) and N2 (metastasis in more than 25 per cent of dissected nodes) would be a simple, convenient, reproducible staging system with an ability to predict surgical results.

Fibrinogen levels correlate with stage of disease in patients with oesophageal cancer

A hypercoagulable state is well recognized in association with cancer and results in a greatly increased risk of thromboembolic disease during surgery in these patients. This study examines routine laboratory measurements of coagulation and attempts to correlate these with disease stage in patients with oesophageal cancer. Fibrinogen concentration, platelet count and routine coagulation tests were examined before operation in a consecutive group of 73 patients with oesophageal carcinoma. All patients were staged according to standard Union Internacional Contra la Cancrum criteria. The fibrinogen concentration was significantly higher in patients with oesophageal carcinoma than in age- and sex-matched control patients with benign disease (P < 0.005). Fibrinogen concentration was higher in patients with greater depth of invasion (P < 0.005) and those with metastatic disease (P < 0.01). This study demonstrates a stage-dependent phenomenon of hyperfibrinogenaemia in association with oesophageal carcinoma.

Is there a role for radical surgery in 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 I 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.