Impact of recent advances in hepatobiliary imaging techniques on the preoperative diagnosis of carcinoma of the gallbladder

Update on immunotherapy in the management of gallbladder cancer

Gallbladder cancer (GBC) is a relatively infrequent but highly lethal cancer with a poor prognosis. Management remains challenging and controversial, and most patients are diagnosed at an advanced stage. However, with the progressive advances in the use of immunotherapies, new treatment modalities are being implemented. In September 2022, the US FDA approved durvalumab (a PD-L1 inhibitor) in combination with chemotherapy for adult patients with locally advanced or metastatic GBC. This groundbreaking news is the first FDA approval for the use of immunotherapy in biliary tract cancers. This article reviews the newest advances and trials regarding immunotherapy for GBC.

Trends in Primary Gallbladder Cancer Incidence and Incidence-based Mortality in the United States, 1973 to 2015

OBJECTIVES

Primary gallbladder cancer (GBC) is the most common biliary tract cancer with poor survival despite aggressive treatment. This study aimed to investigate the trends of GBC incidence and incidence-based mortality (IBM) over the last 4 decades.

MATERIALS AND METHODS

GBC cases diagnosed between 1973 and 2015 were retrieved from the Surveillance, Epidemiology, and End Results (SEER) database. Incidence rates, IBM rates, and annual percent changes (APCs) were calculated and stratified according to population and tumor characteristics.

RESULTS

The cohort consisted of 10,792 predominantly white (81%) and female (71%) GBC patients. The overall GBC incidence decreased by 1.65% (95% confidence interval [CI]: 1.45% to 1.84%) per year since 1973, but has plateaued since 2002. IBM decreased by 1.69% (95% CI: 1.22% to 2.16%) per year from 1980 to 2015; the rate of decrease in IBM rates was lower during 1997 to 2015 (APC: -1.19%, 95% CI: -1.68% to -0.71%) compared with 1980 to 1997 (APC: -3.13%, 95% CI: -3.68% to -2.58%).

CONCLUSIONS

The incidence and IBM rates of GBC have been decreasing over the last 40 years, but the decrease plateaued over the last 2 decades. The effects of treatment modalities, including laparoscopic cholecystectomy, adjuvant chemotherapy, and radiation on the incidence and IBM of GBC need to be further investigated.

Transabdominal ultrasound and endoscopic ultrasound for diagnosis of gallbladder polyps

BACKGROUND

Approximately 0.6% to 4% of cholecystectomies are performed because of gallbladder polyps. The decision to perform cholecystectomy is based on presence of gallbladder polyp(s) on transabdominal ultrasound (TAUS) or endoscopic ultrasound (EUS), or both. These polyps are currently considered for surgery if they grow more than 1 cm. However, non-neoplastic polyps (pseudo polyps) do not need surgery, even when they are larger than 1 cm. True polyps are neoplastic, either benign (adenomas) or (pre)malignant (dysplastic polyps/carcinomas). True polyps need surgery, especially if they are premalignant or malignant. There has been no systematic review and meta-analysis on the accuracy of TAUS and EUS in the diagnosis of gallbladder polyps, true gallbladder polyps, and (pre)malignant polyps.

OBJECTIVES

To summarise and compare the accuracy of transabdominal ultrasound (TAUS) and endoscopic ultrasound (EUS) for the detection of gallbladder polyps, for differentiating between true and pseudo gallbladder polyps, and for differentiating between dysplastic polyps/carcinomas and adenomas/pseudo polyps of the gallbladder in adults.

SEARCH METHODS

We searched the Cochrane Library, MEDLINE, Embase, Science Citation Index Expanded, and trial registrations (last date of search 09 July 2018). We had no restrictions regarding language, publication status, or prospective or retrospective nature of the studies.

SELECTION CRITERIA

Studies reporting on the diagnostic accuracy data (true positive, false positive, false negative and true negative) of the index test (TAUS or EUS or both) for detection of gallbladder polyps, differentiation between true and pseudo polyps, or differentiation between dysplastic polyps/carcinomas and adenomas/pseudo polyps. We only accepted histopathology after cholecystectomy as the reference standard, except for studies on diagnosis of gallbladder polyp. For the latter studies, we also accepted repeated imaging up to six months by TAUS or EUS as the reference standard.

DATA COLLECTION AND ANALYSIS

Two authors independently screened abstracts, selected studies for inclusion, and collected data from each study. The quality of the studies was evaluated using the QUADAS-2 tool. The bivariate random-effects model was used to obtain summary estimates of sensitivity and specificity, to compare diagnostic performance of the index tests, and to assess heterogeneity.

MAIN RESULTS

A total of 16 studies were included. All studies reported on TAUS and EUS as separate tests and not as a combination of tests. All studies were at high or unclear risk of bias, ten studies had high applicability concerns in participant selection (because of inappropriate participant exclusions) or reference standards (because of lack of follow-up for non-operated polyps), and three studies had unclear applicability concerns in participant selection (because of high prevalence of gallbladder polyps) or index tests (because of lack of details on ultrasound equipment and performance). A meta-analysis directly comparing results of TAUS and EUS in the same population could not be performed because only limited studies executed both tests in the same participants. Therefore, the results below were obtained only from indirect test comparisons. There was significant heterogeneity amongst all comparisons (target conditions) on TAUS and amongst studies on EUS for differentiating true and pseudo polyps.Detection of gallbladder polyps: Six studies (16,260 participants) used TAUS. We found no studies on EUS. The summary sensitivity and specificity of TAUS for the detection of gallbladder polyps was 0.84 (95% CI 0.59 to 0.95) and 0.96 (95% CI 0.92 to 0.98), respectively. In a cohort of 1000 people, with a 6.4% prevalence of gallbladder polyps, this would result in 37 overdiagnosed and seven missed gallbladder polyps.Differentiation between true polyp and pseudo gallbladder polyp: Six studies (1078 participants) used TAUS; the summary sensitivity was 0.68 (95% CI 0.44 to 0.85) and the summary specificity was 0.79 (95% CI 0.57 to 0.91). Three studies (209 participants) used EUS; the summary sensitivity was 0.85 (95% CI 0.46 to 0.97) and the summary specificity was 0.90 (95% CI 0.78 to 0.96). In a cohort of 1000 participants with gallbladder polyps, with 10% having true polyps, this would result in 189 overdiagnosed and 32 missed true polyps by TAUS, and 90 overdiagnosed and 15 missed true polyps by EUS. There was no evidence of a difference between the diagnostic accuracy of TAUS and EUS (relative sensitivity 1.06, P = 0.70, relative specificity 1.15, P = 0.12).Differentiation between dysplastic polyps/carcinomas and adenomas/pseudo polyps of the gallbladder: Four studies (1,009 participants) used TAUS; the summary sensitivity was 0.79 (95% CI 0.62 to 0.90) and the summary specificity was 0.89 (95% CI 0.68 to 0.97). Three studies (351 participants) used EUS; the summary sensitivity was 0.86 (95% CI 0.76 to 0.92) and the summary specificity was 0.92 (95% CI 0.85 to 0.95). In a cohort of 1000 participants with gallbladder polyps, with 5% having a dysplastic polyp/carcinoma, this would result in 105 overdiagnosed and 11 missed dysplastic polyps/carcinomas by TAUS and 76 overdiagnosed and seven missed dysplastic polyps/carcinomas by EUS. There was no evidence of a difference between the diagnostic accuracy of TAUS and EUS (log likelihood test P = 0.74).

AUTHORS' CONCLUSIONS

Although TAUS seems quite good at discriminating between gallbladder polyps and no polyps, it is less accurate in detecting whether the polyp is a true or pseudo polyp and dysplastic polyp/carcinoma or adenoma/pseudo polyp. In practice, this would lead to both unnecessary surgeries for pseudo polyps and missed cases of true polyps, dysplastic polyps, and carcinomas. There was insufficient evidence that EUS is better compared to TAUS in differentiating between true and pseudo polyps and between dysplastic polyps/carcinomas and adenomas/pseudo polyps. The conclusions are based on heterogeneous studies with unclear criteria for diagnosis of the target conditions and studies at high or unclear risk of bias. Therefore, results should be interpreted with caution. Further studies of high methodological quality, with clearly stated criteria for diagnosis of gallbladder polyps, true polyps, and dysplastic polyps/carcinomas are needed to accurately determine diagnostic accuracy of EUS and TAUS.

Image-guided radiation therapy for carcinoma of gallbladder: implication on margin for set-up errors

Purpose

A retrospective study was undertaken to analyse set-up variations in patients being treated with post-operative radiation therapy for carcinoma of gall bladder by image-guided radiotherapy (IGRT) using cone-beam computed tomography (CBCT) scans and paired kilovoltage beam portals (kVps).

Materials and methods

Three consecutive patients receiving post-operative radiation therapy for carcinoma of gall bladder were studied. A total of 32 imaging studies were performed. The immobilisation system was an all-in-one system along with a thermoplastic mask, with knees either resting on the knee rest or in a vacuum cushion. The CBCT scans and kVps were reviewed in an off-line mode. The surrogate markers used for matching during co-registration were 12th rib, coeliac trunk, vertebral bodies and canal. Individual readings were used to calculate mean shifts (m); the mean of these means (M) was calculated to arrive at the systematic error in each direction and its standard deviation (Σ) was calculated. The margins for set-up error (SM) were then calculated.

Results

There were a total of 32 readings of which 21 were CBCTs and 11 were kVps. The mean shifts in each direction for each patient were 0·06, 0·25 and 0·15 cm in vertical, longitudinal and lateral directions, respectively. The resultant planning target volume margins calculated were 0·24, 0·9 and 0·47 cm in vertical, longitudinal and lateral directions.

Conclusions

IGRT for upper abdominal malignancies using CBCT and kVps is a useful method to keep the margins for set-up error low. The use of surrogates for matching should be relevant to the target volume. Good immobilisation system helps in keeping the margins low.

Role of radical surgery in patients with stage IV gallbladder cancer

OBJECTIVES

The role of surgery in stage IV gallbladder (GB) cancer is not well established. This study analyses prognostic factors in patients with stage IV GB cancer following surgical resection with the aim of identifying a subgroup of patients who might benefit from surgical resection.

METHODS

Clinicopathological details were analysed for 94 patients who were surgically treated for stage IV GB cancer at Seoul National University Hospital.

RESULTS

Median survival was 8 months in patients with either stage IVa or IVb disease. Sixteen patients (17.0%) underwent resection with curative intent, which increased overall survival over that in patients undergoing palliative surgery (P < 0.001). No survival benefit was seen following surgery with curative intent in patients with stage IVa disease (P = 0.764). Surgery with curative intent resulted in a survival benefit in patients with stage IVb disease, patients with an isolated liver metastasis near the GB bed (median survival: 31 months vs. 9 months; P < 0.001) and patients with limited numbers of peritoneal implantations (median survival: 20 months vs. 6 months; P = 0.002). Preoperative serum carcinoembryonic antigen (CEA) (P = 0.018), surgery with curative intent (P = 0.045) and adjuvant chemotherapy (P = 0.002) were independent prognostic factors in patients with stage IV GB cancer.

CONCLUSIONS

Surgery in combination with systemic chemotherapy may be beneficial in carefully selected patients with stage IVb GB cancer.

Incidental gallbladder cancer diagnosed following laparoscopic cholecystectomy

BACKGROUND

Laparoscopic cholecystectomy (LC) is the treatment of choice for benign gallbladder disease. Gallbladder cancers have been found following LC. The aim of the present study was to evaluate the survival outcome and prognosis of incidental gallbladder cancer diagnosed after LC.

METHODS

From January 2002 to December 2007, 3,145 patients underwent LC at the Department of Surgery, Korea University Medical Center. Of these, 33 patients (1.05%) were diagnosed with gallbladder cancer after LC. Clinicopathological characteristics were retrospectively reviewed in this study.

RESULTS

Of the 33 patients studied, 9 were men and 24 were women. Laparoscopic cholecystectomy alone was performed in 26 patients, and additional radical surgery was performed in 7 others. Regarding tumor staging, there were 2 Tis, 6 T1a, 4 T1b, 17 T2, and 4 T3 tumors. Male patients had a significantly higher incidence of moderately and poorly differentiated tumors (P < 0.001), T2 and T3 tumors (P = 0.02), additional second operations (P = 0.046), and recurrence (P = 0.016). The cumulative 1-, 3-, and 5-year survival rates were 87.2, 73.1, and 47.0%, respectively. Univariate analysis revealed that significant prognostic factors for poorer survival were male gender (P = 0.026), age older than 65 years (P = 0.013), the presence of inflammation (P = 0.009), moderately or poorly differentiated tumor (P < 0.001), nonpolypoid gross type (P = 0.003), and pT stage (P < 0.001). Tumor differentiation was a significantly independent predictor of poor prognosis.

CONCLUSIONS

Male patients exhibited aggressive tumor characteristics. Laparoscopic cholecystectomy is an adequate treatment for pT1 tumors. For pT2 and pT3 patients, additional radical surgery might be needed to achieve a tumor-free surgical margin, along with lymph node dissection.

Surgical outcomes and prognostic factors for T2 gallbladder cancer following surgical resection

BACKGROUND

Depth of tumor invasion is an important prognostic factor for gallbladder cancer. The aim of this study was to investigate the clinicopathological prognostic factors of T2 gallbladder cancer.

METHODS

We retrospectively reviewed the clinicopathological data and survival for 83 patients with T2 gallbladder cancers who underwent surgical resection between January 1995 and December 2007.

RESULTS

The overall survival rates were 48.9% at 3 years and 29.3% at 5 years. Univariate analysis revealed that R0 resection (P < 0.001), extended surgery (P = 0.028), lymph node dissection (P = 0.024), non-infiltrative tumors (P = 0.001), well differentiation (P = 0.001), absence of lymphatic (P = 0.025), perineural (P = 0.001), and vascular (P = 0.025) invasion, absence of lymph node metastasis (P = 0.001), negative resection margin (P = 0.016), and stage (P = 0.002) were significantly better predictors for survival. A significant difference in survival between Rx and R1 was not found. R0 resection, lymph node dissection, well differentiation, and absence of perineural and vascular invasion were significantly independent prognostic factors for overall survival. Recurrence occurred in 48 patients (57.8%). Age older than 65 years, R0 resection, non-infiltrative tumors, and good differentiation were significant independent predictors of disease-free survival by multivariate analysis.

CONCLUSIONS

For T2 tumors, radical surgery including lymph node dissection should be performed to achieve R0 resection. Tumors with infiltrative types and suspicious lymph node metastasis in the intraoperative findings were candidates for aggressive surgical management to improve patient survival.

Cushing’s syndrome caused by an ACTH-producing large cell neuroendocrine carcinoma of the gallbladder

Malignancies of the gallbladder, including neuroendocrine tumors, are uncommon, mostly found incidentally after cholecystectomy and are frequently asymptomatic in the early stages, but highly fatal. Limited data is available on adrenocorticotropic hormone (ACTH)-producing neuroendocrine tumors specifically originating from the gallbladder. We report the clinical and radiographic findings, which included positron emission tomography and computed tomography, of a patient with a gallbladder mass who presented with Cushing’s syndrome. Subsequently, a diagnosis of ACTH-producing large cell neuroendocrine carcinoma of the gallbladder was made. Despite being rare and having a poor prognosis, hormone-producing neuroendocrine tumors should be part of the differential diagnosis in the approach of patients with Cushing’s syndrome.

Does "clinical" R0 have validity in the choice of simple cholecystectomy for gallbladder carcinoma?

BACKGROUND

This study was designed to evaluate the survival outcomes of patients undergoing simple cholecystectomy and to investigate which patients would benefit from cholecystectomy alone in treating gallbladder carcinoma.

METHODS

The available medical records of patients who underwent cholecystectomy alone for gallbladder carcinomas from August 1992 to February 2005 were retrospectively reviewed. Cancer stages were evaluated by clinical meaning based on the AJCC Cancer Staging Manual, 6th edition. "Clinical" R0, defined as gallbladder confined tumor (pT1-3 with negative resection margin) with cN0 and cM0, was tentatively established to evaluate the quality of simple cholecystectomy.

RESULTS

Seventy-five patients underwent cholecystectomy alone for gallbladder carcinomas. Twenty-eight patients were male, and forty-seven patients were female, with their mean age 63.5 years (range, 29-80 years). Forty-one patients (54.7%) underwent laparoscopic cholecystectomy, and thirty-four patients (45.3%) underwent open cholecystectomy. T3 lesions were most common (26 patients), followed by T1 (24 patients), T2 (19 patients), and T4 (6 patients). "Clinical R0" could be defined in 48 patients (63%) after simple cholecystectomy. Multivariate analysis showed that incidental gallbladder carcinoma, T stage, and clinical R0 status were independent prognostic factors of long-term survival. When comparing survival outcomes of clinical R0 according to the T stage, no patients with Tis, T1a, and T1b had cancer-related mortality during follow-up. Especially, in patients with T2 gallbladder carcinomas, the mean survival rate was 68.9 months, and the 5-year survival rate was 77.8%. On the contrary, those with T3 lesions had poor prognoses.

CONCLUSION

Cholecystectomy alone could be proper management for well-selected patients with gallbladder carcinomas (incidental gallbladder carcinoma, gallbladder confined carcinoma, clinical R0). More experiences and a proper prospective study must be performed to confirm the meaning of clinical R0 in treating gallbladder carcinoma.

A curative resection improves the postoperative survival rate even in patients with advanced gallbladder carcinoma

The aim of this study was to evaluate the results of our series of 90 operations for gallbladder carcinoma according to the Japanese Society of Biliary Surgery (JSBS) classification system and to clarify the appropriate surgical strategy for advanced gallbladder carcinoma based on the depth of primary tumor invasion and lymph node metastasis. Generally, only a surgical resection can achieve a prognostic improvement of the advanced gallbladder carcinoma. The survival of patients with this neoplasm depends strictly on the depth of histological primary tumor invasion and lymph node metastasis. A retrospective analysis was conducted on 90 patients from 1990 to 2004 who underwent a surgical resection of gallbladder carcinoma. The factors influencing survival were examined. Thirty-nine patients with palliative treatment (not resected cases), which was diagnosed as T3 or T4 by preoperative imagings, were also included in this study. The significance of the variables for survival was examined by the Kaplan-Meier method and the log-rank test followed by multivariate analyses using Cox's proportional hazard model. Portal invasion, lymph node metastasis, the surgical margin (+ vs. -) and the final curability (fCurA, B vs. C) were all found to be independent prognostic factors in the multivariate analysis. In pT2 gallbladder carcinoma, a better survival was achieved in an aggressive surgical approach, in order of a S4a+S5 hepatic resection, an extended cholecystectomy and a cholecystectomy. In pT3 and pT4, although radical extended surgery did not provide the opportunity for good survival even after lobectomy of the liver, the survival of patients with curative surgery was statistically better than in those without curative surgery. In addition, the nodal involvement of pN1 to pN2 was better than that with pN3. A S4a+S5 hepatectomy, therefore, appears to be adequate for the treatment of pT2 gallbladder carcinoma. Even in patients with pT3 and pT4 gallbladder carcinoma, long-term survival can be expected by an operation with a tumor-free surgical margin. The role of radical surgery, however, is considered to be limited in patients with pN3 lymph node metastasis.

Retrospective analysis of outcome in 63 gallbladder carcinoma patients after radical resection

BACKGROUND/PURPOSE

The aim of this study was to evaluate factors influencing outcome in gallbladder carcinoma after radical resection, in order to identify those patients benefiting from radical surgery.

METHODS

Sixty-three patients (13 pT1, 28 pT2, 14 pT3, and 8 pT4) who underwent surgical resection for gallbladder carcinoma were retrospectively reviewed. Correlations were sought between survival and factors such as the depth of invasion (pT) including the status of infiltration of the hepatoduodenal ligament (pBinf) and liver bed (pHinf), the extent of lymph node metastasis, and other pathologic factors.

RESULTS

Multivariate analysis showed that pBinf, pHinf, and lymph node metastasis were significant prognostic factors. We also analyzed survival rates for each operative procedure. There was no difference in survival between patients with or without bile duct resection for lymph node metastasis. The 5-year survival rates of pHinf-negative patients with stage 1B or more advanced disease after gallbladder bed resection or bisegmentectomy 4a,5 versus those without liver resection were 66% and 0%, respectively. Twelve patients survived for more than 5 years after surgery, including one patient undergoing HPD (liver resection with pancreatoduodenectomy) with positive lymph node metastasis; none was pBinf-positive.

CONCLUSIONS

Several factyors were identified as having prognostic significance for survival in patients with gallbladder carcinomas, and we suggest that radical surgery may be indicated for selected patients with advanced disease.

Diagnostic imaging of carcinomas of the gallbladder and the bile ducts

Early diagnosis and accurate staging of carcinomas of the gallbladder and the bile ducts are helpful in improving the prognosis. Ultrasonography (US), a useful initial modality when exploring the background of jaundice or non-specific gastrointestinal complaints, sensitively reveals bile duct obstruction in particular. In unclear cases, or if US suggests a resectable biliary malignancy, computed tomography (CT), magnetic resonance imaging (MRI) with magnetic resonance cholangiography (MRC) and / or traditional cholangiography often provide additional information, and imaging-guided fine-needle biopsy or an endoscopic brush sample may verify the malignant nature of the tumor. Complementary modalities are usually needed for accurate staging, and traditional cholangiography is often performed for therapeutic purposes as well. Comparative studies of MRI with MRC and multidetector CT in biliary cancers would be welcome.

Significance of extensive surgery including resection of the pancreas head for the treatment of gallbladder cancer--from the perspective of mode of lymph node involvement and surgical outcome

The present study aimed to clarify the efficacy of extensive surgery, including pancreas head resection, for more complete lymphadenectomy in the treatment of gallbladder carcinoma. The study involved retrospective analyses of 65 consecutive patients with gallbladder carcinoma who underwent surgical resection between 1982 and 2003. Of these 65 patients, 41.5% displayed node-positive disease and among them 23.1% had positive para-aortic nodes. Of six node-positive 5-year survivors, five underwent pancreatoduodenectomy combined with S4aS5 hepatic subsegmentectomy. The 5-year survival rates were 76.2% for pN0, 30.0% for pN1, 45.8% for pN2, and 0% for pM1[lymph], respectively. Significant differences existed in survival rates. Postoperative recurrence was observed in 24.1% (13/54) of patients who underwent R0 resection. Of the four patients who displayed lymph node recurrence, two had pericholedocal and/or posterior pancreatoduodenal lymph node metastasis at the time of surgery and underwent pancreas-preserving regional lymphadenectomy. These results suggest that extensive resection, including resection of the pancreatic head, is effective in selected patients with up to pN2 lymph node metastasis, as long as complete removal of the cancer can be achieved. Pancreatoduodenectomy combined with S4aS5 hepatic subsegmentectomy should be considered when lymph node metastasis is obvious and the patient is in good condition.

Clinicopathological study of depth of subserosal invasion in patients with pT2 gallbladder carcinoma

BACKGROUND

We examined whether depth of subserosal cancer invasion predicts lymph node involvement and survival in gallbladder carcinoma (GBC) patients with pathologicial subserosal invasion (pT2), to explore which patients benefit from radical second resection among patients with inapparent pT2 tumor.

METHODS

Subjects comprised 31 patients with pT2 GBC. Thickness of the subserosal layer and vertical length of carcinoma invasion into the subserosa were measured under microscopy. Depth of subserosal invasion was divided subjectively into three categories: ss1, ss2, and ss3 (invasion of upper, middle, and lower thirds of the subserosal layer, respectively). Relationships between subserosal subclassification, histopathological factors, and prognosis were examined.

RESULTS

Subserosal layers were significantly thicker (P < 0.001) in portions with cancer invasion (5.46 +/- 0.68 mm; range 1.0 approximately 13.75 mm) than those without cancer invasion (1.89 +/- 0.16 mm, range, 0.88 approximately 4.50 mm). Depth of carcinoma invasion into subserosa was 4.20 +/- 0.65 mm (range, 0.25 approximately 12.5 mm). Rate of lymphatic permeation, venous permeation, and lymph node involvement significantly increased with deeper subserosal invasion (P = 0.014, P = 0.027, P = 0.018, respectively). Among histopathological factors examined, only subserosal subclassification had a significant correlation with presence or absence of lymph node metastasis. Further, there was a significant correlation (P = 0.043) between the degree of subserosal invasion (ss1, ss2, and ss3) and involved nodal disease (pN0, pN1, and pM1 [lymph]). Although 5-year survival rates, according to the degree of subserosal invasion, tended to decrease with deeper invasion into the subserosal layer (ss1, 83.3%; ss2, 62.5%; ss3, 50.0%), no significant differences were noted.

CONCLUSIONS

Pathological characteristics tend to become more aggressive with increasing depth of subserous carcinoma invasion in pT2 GBC. Depth of subserosal invasion is a predictor of presence and degree of lymph node metastasis in pT2 GBC. A sampling biopsy of the para-aortic nodes is recommended for inapparent pT2 GBC patients with subserosal invasion beyond one-thirds of the subserosal layer when they undergo radical second resection.

Biliary tract cancers: current concepts and controversies

Biliary tract cancer, which consists of gall bladder cancer and cholangio-carcinoma, presents many challenges to practising physicians. It is a relatively rare cancer that often causes a diagnostic dilemma, as its presentation may be similar to that of non-malignant conditions. In many cases, histological or cytological confirmation of a cancer diagnosis is not possible preoperatively. The management of this disease is also complex due to a morbid patient population and limited data on the optimal therapeutic approach. Surgery remains the mainstay of treatment, although the extent of resection required is still debated. The role of adjuvant therapy is also controversial, but a combined modality approach appears to be beneficial in patients with a high risk of recurrence, such as those with node positive tumors or positive resection margins. When surgery is not possible, the prognosis of patients with biliary tract cancer is very poor. In unresectable patients, the combination of chemotherapy and radiotherapy can result in a prolonged survival for some patients. In the palliative setting, biliary stenting and other supportive measures can alleviate symptoms and improve survival. Gemcitabine-based combination chemotherapy may also provide successful palliation and has achieved response rates of approximately 30% and a median survival of > 15 months in one study. Ultimately, treatment decisions should be individualised and participation in clinical trials is encouraged. Further progress in the management of biliary tract cancer is anticipated using biological therapies and continued research is essential to discover the optimal treatment for this challenging disease.

Gallbladder Carcinoma with Biliary Invasion: Clinical Analysis of the Differences from Nonbiliary Invasion

Gallbladder carcinoma is the most common malignancy of the biliary tract. Because of a lack of specific presentations, this condition frequently is diagnosed only at an advanced stage. The clinical difference between gallbladder carcinoma with and without biliary involvement remains uncertain. This study recruited all patients with gallbladder carcinoma treated at Chang Gung Memorial Hospital (Taoyuan, Taiwan) from 1987 to 2002. The sample included 120 patients aged 28 to 91 years (mean 65.5 +/- 12.3 years) (39 men, 81 women), whose medical records were reviewed retrospectively. Based on the 2002 newly revised TNM classification, 25, 38, 28, and 29 patients had stage I, II, III, and IV disease, respectively. After we excluded patients with stage I, the other patients were classified into two groups as follows: group I, gallbladder carcinoma with biliary invasion (n = 41); group II, carcinoma without biliary involvement (n = 54). The clinical presentations, laboratory data, operative methods, and outcome of these two groups were compared. The two groups did not differ in terms of age, sex distribution, cholelithiasis, and most clinical presentations. Chemistry laboratory data also identified patients in group I with significantly elevated liver function tests. Group II had a borderline tendency toward better curative resectability than group I (p = 0.09). Survival was significantly better for group I patients who underwent curative resection (n = 5) via cholecystectomy, partial hepatectomy, and bile duct resection than for those with noncurative resection (p < 0.05). However, long-term survival demonstrated that gallbladder carcinoma had the same poor prognosis in the two groups. In conclusion, gallbladder carcinoma with biliary invasion has been found to a more overt clinical presentation and abnormal laboratory data, which might alert clinicians to consider gallbladder carcinoma at an advanced stage or biliary invasion and examine the underlying disease. Generally, the outcome of gallbladder carcinoma is dismal, and radical curative resection combined with cholecystectomy, partial hepatectomy, and bile duct resection perhaps may offer good benefits for advanced gallbladder carcinoma. Furthermore, surgical resection should be performed whenever possible in patients with gallbladder carcinoma to increase life expectancy.

Preoperative diagnosis and staging of gallbladder carcinoma by EUS

BACKGROUND

EUS has recently been shown to be efficacious for the preoperative assessment of depth of invasion of gallbladder carcinoma. This study assessed the value of EUS for determining T stage (International Union Against Cancer).

METHODS

Preoperative EUS findings in 41 patients with gallbladder carcinoma were analyzed retrospectively. EUS images were classified according to the shape of the tumor and the adjacent gallbladder wall structure as follows: type A, pedunculated mass with preserved adjacent wall structures; type B, sessile and/or broad-based mass with a preserved outer hyperechoic layer of the gallbladder wall; type C, sessile and/or broad-based mass with a narrowed outer hyperechoic layer; type D, sessile and/or broad-based mass with a disrupted outer hyperechoic layer. EUS and histopathologic findings were compared, including the depth of invasion of the tumor in the resection specimen.

RESULTS

The 4 categories of EUS images of gallbladder carcinoma correlated with the histologic depth of invasion and T stage. Accuracies for the EUS classification as type A corresponding to pTis, type B to pT1, type C to pT2, and type D to pT3-4 were, respectively, 100%, 75.6%, 85.3%, and 92.7%.

CONCLUSIONS

Preoperative EUS imaging accurately depicts T stage of gallbladder carcinoma and allows for effective therapeutic decision making.

Carcinoma of the gallbladder

Carcinoma of the gallbladder is the most common malignant tumour of the biliary tract and a particularly high incidence is observed in Chile, Japan, and northern India. The aetiology of this tumour is complex, but there is a strong association with gallstones. Owing to its non-specific symptoms, gallbladder carcinoma is generally diagnosed late in the disease course, but if a patient with gallstones experiences a sudden change of symptoms, then a cancer diagnosis should be considered. Treatment with radical or extended cholecystectomy is potentially curative, although these procedures are only possible in 10-30% of patients. There is no role for cytoreductive surgery in this disease. If a gallbladder carcinoma is discovered via pathological examination of tissue samples, then the patient should be examined further and should have radical surgery if the tumour is found to be T1b or beyond. Additional port-site excision is necessary if the patient has already had their gallbladder removed during laparoscopy; however, patients with an intact gallbladder who are suspected to have gallbladder carcinoma should not undergo laparoscopic cholecystectomy. Patients with advanced inoperable disease should receive palliative treatment; however, the role of chemotherapy and radiation in these patients needs further evaluation.

The role of ultrasound in biliary and pancreatic diseases

The possibilities and the limits of transabdominal ultrasonography (US) in the diagnosis of bilio-pancreatic diseases are reviewed here in the light of the last 10 years' research. US remains the method of choice for the diagnosis of gallstones and is generally accepted as an initial imaging technique in gallstone complications, such as acute cholecystitis. Moreover the method can be useful for the detection of the biliary complications after laparoscopic cholecystectomy and after liver transplantation. US is still considered the first diagnostic procedure when stones are suspected in the common bile duct. The use of color Doppler can provide a differential diagnosis of gallbladder cancer with respect to other benign inflammatory or polypoid lesions. Color Doppler US allows to detect vascular complications of acute pancreatitis such as pseudoaneurysms. US is still considered useful for the initial screening of the pancreatic cancer. However, for staging other imaging techniques must be employed. With US useful informations are obtained in the diagnosis of cystic tumors of the pancreas and of pancreatic metastases. US is generally of little use for the diagnosis of endocrine tumors.

Does radical resection improve the survival in patients with carcinoma of the gallbladder who are 75 years old and older?

Radical resections have been reported to improve the surgical outcome for patients with carcinoma of the gallbladder. In recent years surgeons have had more opportunities to operate on elderly patients. We investigated whether the survival rate of aged patients who had radical resections were better than rates for those who had simple cholecystectomy. Of the 300 patients treated for carcinoma of the gallbladder between 1971 and 1999, 206 resected cases (except pancreaticoduodenectomy and hepatectomy) were divided into two groups: age 75 years or older, 54 patients (the older group), and age less than 75 years, 152 patients (the younger group). Clinical features and progression of the carcinomas did not differ between the two groups. In the older group, 22 patients (40.7%) had simple cholecystectomy, 32 (59.3%) had radical resections; in the younger group, 65 patients (42.8%) had simple cholecystectomy, and 87 (57.3%) had radical resection. None of the older patients who had radical resection died postoperatively. Postoperative survival was not different between the two groups. In the older group the 5-year survival rate for patients who had radical resections was better (60.9%) than the rate for those who had simple cholecystectomy (14.1%) (p = 0.0098). Radical resection is effective for the aged patients with the carcinoma of gallbladder.

Colelitíase e câncer de vesícula biliar

OBJETIVO: O presente estudo tem por objetivo analisar os achados histológicos da vesícula biliar de pacientes submetidos à colecistectomia eletiva no Hospital Universitário Presidente Dutra, São Luís-MA. MÉTODO: Foram avaliados 2.008 pacientes, 359 do sexo masculino (17,9%) e 1.649 do sexo feminino (82,1%), com média de idade de 46,3 anos, operados no período de janeiro de 1990 a dezembro de 1998. A vesícula biliar, imediatamente após a colecitectoma era aberta e examinada macroscopicamente pelo cirurgião e em seguida enviada para exame histopatológico. RESULTADOS: A prevalência de câncer da vesícula biliar foi de 2,3 % (46 pacientes). Trinta e três pacientes (71,7%) apresentavam idade superior a 60 anos. CONCLUSÕES: Os autores concluem que a colecistectomia profilática eletiva deve ser realizada em pacientes assintomáticos com colelitíase, com idade superior a 60 anos e em boas condições cirúrgicas.

Adjuvant external beam radiation therapy with concurrent chemotherapy in the management of gallbladder carcinoma

PURPOSE

This study was performed to evaluate the outcome of patients with gallbladder cancer who received postoperative concurrent chemotherapy and radiation therapy.

METHODS AND MATERIALS

Curative resection followed by adjuvant combined modality therapy with external beam radiation therapy (EBRT) and chemotherapy was attempted in 21 consecutive gallbladder carcinoma (GBC) patients at the Mayo Clinic from 1985 through 1997. All patients received concurrent 5-fluorouracil during EBRT. EBRT fields encompassed the tumor bed and regional lymph nodes (median dose of 54 Gy in 1.8-2.0-Gy fractions). One patient received 15 Gy intraoperatively after EBRT. A retrospective analysis was performed for the end points of local control, distant failure, and overall survival.

RESULTS

After maximal resection, 12 patients had no residual disease on pathologic evaluation, 5 had microscopic residual disease, and 4 had gross residual disease. One patient had Stage I disease, and 20 had Stage III-IV disease. With median follow-up of 5 years (range: 2.6-11.5 years), 5-year survival for the entire cohort was 33%. The 5-year survival rate of patients with Stage I-III disease was 65% vs. 0% for those with Stage IV disease (p < 0.02). For patients with no residual disease, 5-year survival was 64% vs. 0% for those with residual disease (p = 0.002). The median survival was 0.6, 1.4, and 5.1 years for patients with gross residual, microscopic residual, and no residual disease, respectively (p = 0.02). The 5-year local control rate for the entire cohort was 73%. Two-year local control rates were 0%, 80%, and 88% for patients with gross residual, microscopic residual, or no residual disease, respectively (p < 0.01). Five-year local control rates were 100% for the 6 patients who received total EBRT doses >54 Gy (microscopic residual, 3 patients; gross residual, 1 patient; negative but narrow margins, 2 patients) vs. 65% for the 15 who received a lower dose (3, gross residual; 2, microresidual; 10, negative margins).

CONCLUSION

Patients with completely resected (negative margins) GBC followed by adjuvant EBRT plus 5-fluorouracil chemotherapy had a relatively favorable prognosis, with a 5-year survival rate of 64%. These results seem to be superior to historical surgical controls from the Mayo Clinic and other institutions, which report 5-year survival rates of approximately 33% with complete resection alone. Both tumor stage and extent of resection seemed to influence survival and local control. More aggressive measures using current cancer therapies and integration of new cancer treatment modalities will be required to favorably impact on the poor prognosis of patients with Stage IV or subtotally resected GBC. Additional investigation leading to earlier diagnosis is warranted, because most patients with GBC present with advanced disease.

Current perspectives in gallbladder carcinoma

Carcinoma gallbladder (CaGB) is not a common malignancy in a large number of countries in the world, except Chile, Japan, some parts of India, and a few other regions. Lacunae exist even today in terms of understanding of its epidemiology, aetiopathogenesis, and in the early pick up of malignanacy, as well as in choosing the most appropriate treatment option for a given case. While Japanese surgeons have advocated radical resections for CaGB and have shown good outcome resulting in long- term survival, others have not felt convinced about the desirability of undertaking such morbid surgical procedures in all patients. Also, radical resections have not always resulted in a tumor-free state and a cure in a large percentage of cases. Under the circumstances, the clinician's mind is often confused as to the most beneficial option for that patient once curative resection is not possible. Palliation of the jaundice and/or gastric outlet obstruction relieves the symptoms but does not prolong survival. The role of adjuvant chemotherapy with or without cytoreductive surgery has not been fully explored in CaGB. The present review quotes experience that seems to support the above contention. However, a number of well-designed multicentric trials are required to confirm the above philosophy of treatment for the benefit of patients suffering from CaGB.

[Prognostic factors in gallbladder cancer]

BACKGROUND AND AIM

Carcinoma of the gallbladder is the most frequent biliary tract lesion but the 5-year survival is less than 5%. The aim of this study was to analyze the influence of several clinico-pathological variables on survival in a series of 226 carcinomas of the gallbladder.

PATIENTS AND METHODS

The results were retrospectively analyzed and prognostic factors were identified by univariate statistical analysis and Cox regression model. All patients underwent surgery and in 67 of these (29.6%), surgery was potentially curative. In 63 patients (27.9%) diagnosis was made when the resected gallbladder was studied for benign disease. Tumor node metastasis (TNM) stage was 0 in 7 patients (3.1%), stage I in 19 patients (8.4%), stage II in 21 patients (9.3%), stage III in 61 patients (27%) and stage IV in 118 patients (52%).

RESULTS

Overall 5-year survival was 17.3%. In the univariate analysis, significant variables were the presence of jaundice, weight loss, palpation of abdominal tumors at diagnosis, surgical technique, TNM stage and the three variables of this system (T: size, N: adenopathies; M: distant metastasis). In the multivariate analysis, the three variables of the TNM system and surgical technique were significantly associated with survival.

CONCLUSIONS

The most important prognostic factor was TNM stage. Currently, radical cholecystectomy in stages II and III has become another important prognostic factor.

Diagnosis of the depth of invasion of gallbladder carcinoma by EUS

BACKGROUND

The prognosis of gallbladder carcinoma is dismal and relates to the depth of invasion as expressed by the T factor in TNM staging. We evaluated the utility of endoscopic ultrasound (EUS) in the diagnosis of the depth of invasion of gallbladder cancer.

METHODS

Thirty-nine patients who underwent both EUS and surgery were included in this study. The EUS images were classified according to the relation between tumor echo pattern and gallbladder-wall structure, and the resulting types were compared with depth of invasion as determined histologically. Based on the results, a set of diagnostic criteria is proposed.

RESULTS

The EUS images were classified into four categories. Type A is a pedunculated mass with a fine-nodular surface and intact neighboring wall. Type B is a broad-based mass with an irregular surface and intact outer hyperechoic layer of the adjacent wall. In type C, the outer hyperechoic layer is irregular due to a mass echo, whereas, in type D, the outer hyperechoic layer is disrupted by a mass echo. Each of the four categories of EUS images correlated well with the histologic depth of invasion.

CONCLUSION

EUS is useful in the T staging of gallbladder cancer.

Erythrocyte membrane stearic to oleic acid ratio in carcinoma of the gallbladder: a preliminary study

AIMS

The role of erythrocyte membrane stearic to oleic acid ratio (saturation index) as a marker of malignancy is still unclear, though an association has been found in colorectal carcinoma, bronchogenic carcinoma, leukaemia, lymphoma and in hepatic malignancies. This study aims to investigate the role of the saturation index in primary carcinoma of the gallbladder.

METHODS

This paper describes the results of the stearic to oleic acid ratio determination in 26 subjects with either cholelithiasis or carcinoma of the gallbladder, also including a group of age- and sex-matched controls, using gas chromatography. This is the first report of the saturation index in carcinoma of the gallbladder.

RESULTS

A significantly lower saturation index was observed in patients with carcinoma of the gallbladder than with cholelithiasis (t = 2.19, P = 0.043, T = 47, P < 0.05, Wilcoxon P < 0.001, F = 2192.23, P < 0.001; 95% CI 18.45-30.44) and controls (t = 2.5, P = 0.024, T = 36, P < 0.05, F = 10904.11, P < 0.001, Wilcoxon P < 0.001; 95% CI 52.42-63.39). Among the carcinoma patients a further lowering was noted in stage IV disease compared with stage III (T = 6, P < 0.05).

CONCLUSIONS

These changes are probably due to a marked increase in oleic acid content at the expense of stearic acid. This lowering of the saturation index in carcinoma of the gallbladder is similar to that observed previously in the other malignancies.

NATURAL HISTORY OF CARCINOMA OF THE GALLBLADDER AND ITS INFLUENCES ON MANAGEMENT

There were 45 patients (8.8%) of carcinoma of the gall bladder among 506 patients of gall bladder disease admitted during January 1993 to June 1995. Female to male ratio was 4:1 and average age at detection was 52 years. Pain right hypochondrium and jaundice were prominent clinical features. Ultrasonography accurately diagnosed 33 (73.3%) cases while computed tomography was correct in 15/22 (75%) of cases. Cholelithiasis was present in 37 (80%) patients. Sixteen patients were not offered surgery due to either widespread disease or due to poor general health. Cholecystectomy with wedge or segmental resection of liver and lymphadenectomy was performed in 18 out of 29 patients. In 6 patients segmental resection of the contiguous involved organ was performed. Perioperative mortality was 8 per cent. Two patients were alive for more than 24 months, 7 for more than 12 months and 11 were being followed-up for 1 to 12 months. All patients not offered surgery died within 4 months.

Retrospective analysis of 70 operations for gallbladder carcinoma

BACKGROUND

The clinical course of patients with carcinoma of the gallbladder depends on the depth of tumour invasion. This study was conducted to clarify the prognostic factors affecting survival and appropriate surgical strategy based on depth of invasion of gallbladder carcinoma according to the pathological tumour node metastasis (pTNM) classification.

METHODS

A total of 70 patients who underwent surgical resection were reviewed retrospectively with regard to the type of operation, histopathological findings of the resected gallbladder carcinoma and clinical follow-up after operation.

RESULTS

Twelve patients with pT1 gallbladder carcinoma fared favourably following cholecystectomy or extended cholecystectomy. In 13 of 26 patients with pT2 gallbladder carcinoma, lymph node metastasis was evident: pN1 in eight and pN2 in five. The 3-year survival rate of patients with pT2 gallbladder carcinoma was 28 per cent after cholecystectomy, 91 per cent after extended cholecystectomy and 67 per cent after hepatectomy. In 21 of 28 patients with pT3 or pT4 gallbladder carcinoma, surgical margins were affected by malignant cells. The 1-year survival rate of patients with pT3 or pT4 gallbladder carcinoma was 24 per cent, even after hepatectomy. Significant prognostic factors were age, macroscopic type, histological grade, depth of invasion, lymph node metastasis, pathological stage, lymphatic invasion, venous invasion, perineural invasion and involved surgical margins.

CONCLUSION

Cholecystectomy was adequate for pT1 gallbladder carcinoma. Extended cholecystectomy or hepatectomy with extrahepatic bile duct resection and lymph node dissection (pN1 and pN2) were justified for pT2 gallbladder carcinoma. The survival of patients with more advanced gallbladder carcinoma remains dismal.

Intrahepatic segment III cholangiojejunostomy in advanced carcinoma of the gallbladder

The majority of patients with advanced carcinoma of the gallbladder have irresectable disease and require palliation for jaundice, pruritus and cholangitis. Intrahepatic segment III cholangiojejunostomy has been described for palliation of high biliary obstruction in these patients. Forty-one patients with stage IV gallbladder cancer underwent intrahepatic segment III cholangiojejunostomy. Subsequent jaundice, pruritus and cholangitis were documented; liver function tests and isotope hepatobiliary scans were performed. All patients had jaundice, 29 had pruritus and 12 had cholangitis. Postoperative complications included anastomotic leak in six patients and wound infection in six. Five patients died within 30 days of operation. Thirty-two patients were available for follow-up. The procedure failed to relieve jaundice, pruritus or cholangitis in four patients; 18 were free of jaundice, pruritus and cholangitis until death or last follow-up, and ten had recurrent jaundice or cholangitis. Isotope scanning was found to be useful to predict success of the procedure. Intrahepatic segment III cholangiojejunostomy provided excellent palliation from jaundice, pruritus and cholangitis with acceptable mortality and morbidity rates in patients with advanced carcinoma of the gallbladder.

Early carcinoma of the gallbladder: an elusive disease

Prognosis of carcinoma of the gallbladder can be improved by diagnosing the disease in the early stages. Records of 14 patients with early (UICC AJCC TNM stages I and II) carcinoma of the gallbladder were analyzed. Clinical presentation in all these patients was like benign biliary disease. Ultrasonography could diagnose carcinoma of the gallbladder in only five patients; in the remaining nine patients, even the ultrasonographic diagnosis was benign biliary disease. All patients were operated; carcinoma of the gallbladder was diagnosed at operation in two more patients, but it was first detected only after histological examination in seven patients. All patients except four had associated gallstones. Preoperative diagnosis of early carcinoma of the gallbladder is difficult. The only way to diagnose early carcinoma of the gallbladder is by early surgical treatment of patients with clinical features of benign biliary disease.

Laparoscopy for staging and palliation of gastrointestinal malignancy

The use of laparoscopy in the treatment of malignant diseases is one of the great advances of surgery in the last few decades. Its roles as a diagnostic modality, a staging tool, and a therapeutic avenue for the various malignancies of the abdominal cavity continue to expand. The benefits to cancer patients with regard to reduced morbidity and shorter hospitalizations are well established. As video, optical, insufflation, and instrumentation technologies advance further, laparoscopic techniques for the treatment of cancer can only multiply in depth and breadth.

Carcinoma of the gall-bladder: an experience and review of the literature

This paper summarizes the treatment results of 28 cases of gall-bladder carcinoma at Toowoomba Base Hospital, Toowoomba, Queensland, Australia. The literature is reviewed in order to determine whether more extensive resection is improving the outcome of a disease generally understood to have a deplorable prognosis. The complete records of 28 patients with this malignancy were obtained from the period 1978 to 1994 and analysed retrospectively. Twenty-three patients had cholecystectomy, but only one underwent formal lymph node dissection. Overall, the 5 year survival rate was 13%, and long-term survivors all had stage I or II disease. Those with stage III or IV disease had a median survival of 46 days. Recent literature confirms that simple cholecystectomy is not always curative for early lesions discovered incidentally and also that some patients with advanced disease can achieve long-term survival if treated with radical resection. Wedge resection of the liver and nodal clearance of the hepatoduodenal ligament at least has been recommended in patients with T2 lesions (subserosal/perimuscular), and in selected patients with stage III disease.

Radiological findings in cases of gallbladder carcinoma

Radiological findings in 80 cases of gallbladder carcinoma are analysed retrospectively. Seventy-nine of the patients had been examined by US (ultrasonography), 37 by CT (computed tomography), 26 by PTC (percutaneous transhepatic cholangiography), 17 by ERCP (endoscopic retrograde cholangio-pancreaticography), nine by angiography and 27 by US-guided FNB (fine needle biopsy). US showed the primary tumour in 68% and CT in 57%. In 67 cases the tumour had spread outside the gallbladder area, causing bile duct obstruction in 41. US showed the bile duct obstruction in 39 of these cases and CT in 20 out of 22 cases. US showed 73% of the cases that had spread to the liver; the sensitivity being 68% for direct invasion and 88% for peripheral liver metastases. The corresponding percentages for CT were 68, 67 and 75%, respectively. In lymph node enlargement, US showed the nodes in 70% of cases and CT in 52%. PTC showed either stenosis or total obstruction in 25 cases and failed in one case. ERCP showed a tumour in 76% and failed in 24%. Angiography failed to show the primary tumour in two instances out of nine. The results indicate that current imaging methods are insufficient for the accurate staging of gallbladder carcinoma.