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

Preoperative clinical and contrasted-enhanced CT features to predict perineural invasion in gallbladder carcinoma: focus on clinical T3-4 stage

PURPOSE

To investigate the utility of combining clinical and contrasted-enhanced tomography (CECT) parameters for the preoperative evaluation of perineural invasion (PNI) in gallbladder carcinoma (GBC).

METHODS

A total of 134 patients with GBC (male/female, 52/82; age, 64.4 ± 9.7 years) were divided into PNI-positive (n = 63) and PNI-negative groups (n = 71). Clinical characteristics (demographic information, liver function indicators and tumor markers) and CECT parameters (tumor type, tumor size, gallbladder stone, invasion of gallbladder neck/cystic duct, clinical T stage and N stage) were collected and compared between two groups. Binary logistic regression analysis, receiver operating characteristic curves analyses and Delong test were used in further statistical analyses in clinical T3-4 stage (cT3-4) GBC patients. Overall survival (OS) rates after surgery were compared between PNI-negative group and PNI-positive group of cT3-4 GBC patients.

RESULTS

The majority of GBC patients with PNI were classified as cT3-4 (61/63, 96.8%), while only 3.2% (2/63) of PNI-positive cases were identified at cT1-2. Among cT3-4 GBC, OS was significantly lower in the PNI-positive group than the PNI-negative group after surgery (HR,1.661; 95% CI, 1.044-2.643; P = 0.032). Gender and gallbladder neck/cystic duct invasion were independent predictive factors for cT3-4 GBC patients with PNI. A combination of gender and gallbladder neck/cystic duct invasion showed the best diagnostic performance than that of individual parameters (all P < 0.05).

CONCLUSIONS

Preoperative T staging using CECT enables the initial assessment of PNI status in GBC patients. A combination of gender and gallbladder neck/cystic duct invasion may effectively predict PNI in GBC, particularly in cT3-4 GBC.

Risk factors and survival prediction model establishment for prognosis in patients with radical resection of gallbladder cancer

BACKGROUND

Gallbladder cancer (GBC) is the most common malignant tumor of the biliary system, and is often undetected until advanced stages, making curative surgery unfeasible for many patients. Curative surgery remains the only option for long-term survival. Accurate postsurgical prognosis is crucial for effective treatment planning. tumor-node-metastasis staging, which focuses on tumor infiltration, lymph node metastasis, and distant metastasis, limits the accuracy of prognosis. Nomograms offer a more comprehensive and personalized approach by visually analyzing a broader range of prognostic factors, enhancing the precision of treatment planning for patients with GBC.

AIM

To identify risk factors and develop a predictive model for GBC prognosis.

METHODS

A retrospective study analyzed the clinical and pathological data of 93 patients who underwent radical surgery for GBC at Peking University People's Hospital from January 2015 to December 2020. Kaplan-Meier analysis was used to calculate the 1-, 2- and 3-year survival rates. The log-rank test was used to evaluate factors impacting prognosis, with survival curves plotted for significant variables. Single-factor analysis revealed statistically significant differences, and multivariate Cox regression identified independent prognostic factors. A nomogram was developed and validated with receiver operating characteristic curves and calibration curves.

RESULTS

Among 93 patients who underwent radical surgery for GBC, 30 patients survived, accounting for 32.26% of the sample, with a median survival time of 38 months. The 1-year, 2-year, and 3-year survival rates were 83.87%, 68.82%, and 53.57%, respectively. Univariate analysis revealed that carbohydrate antigen 19-9 expression, T stage, lymph node metastasis, histological differentiation, surgical margins, and invasion of the liver, extrahepatic bile duct, nerves, and vessels (P ≤ 0.001) significantly impacted patient prognosis after curative surgery. Multivariate Cox regression identified lymph node metastasis (P = 0.03), histological differentiation (P < 0.05), nerve invasion (P = 0.036), and extrahepatic bile duct invasion (P = 0.014) as independent risk factors. A nomogram model with a concordance index of 0.838 was developed. Internal validation confirmed the model's consistency in predicting the 1-year, 2-year, and 3-year survival rates.

CONCLUSION

Lymph node metastasis, tumor differentiation, extrahepatic bile duct invasion, and perineural invasion are independent risk factors. A nomogram based on these factors can be used to personalize and improve treatment strategies.

Risk Factors and Prognostic Factors in GBC

Background: Gallbladder cancer (GBC) is a rare entity with a poor prognosis, usually discovered late due to nonspecific symptoms; therefore, over the last years, attention has been focused on identifying the risk factors for developing this malignancy in order to provide an early diagnosis, as well as new prognostic factors in order to modulate the long-term evolution of such cases. The aim of this review is to discuss both major risk factors and prognostic factors in GBC for a better understanding and integration of relevant and currently available information. Methods: A literature search was performed using Cochrane Library, PubMed, Google Scholar, Elsevier, and Web of Science; studies published after the year of 2000, in English, were reviewed. Results: Over time, risk factors associated with the development of GBC have been identified, which outline the profile of patients with this disease. The most important prognostic factors in GBC remain TNM staging, safety margin, and R0 status, along with perineural invasion and lymphovascular invasion. Both the technique and experience of the surgeons and a pathological examination that ensures final staging are particularly important and increase the chances of survival of the patients. Conclusions: improvements in surgical techniques and pathological analyses might provide better and more consistent guidance for medical staff in the management of patients with GBC.

High intramuscular adipose tissue content associated with prognosis and postoperative complications of cancers

Sarcopenia has been considered an adverse prognostic factor in cancer patients. Intramuscular adipose tissue content, as a new marker of sarcopenia, can effectively reflect skeletal muscle quality. The aim of this study was performed to evaluate the association between high intramuscular adipose tissue content (IMAC) and survival outcomes and postoperative complications in cancer patients. Specific databases, including the Web of Science, Embase and Web of Science, were systematically searched to identify relevant articles evaluating the prognostic value of IMAC in cancer patients. Hazard ratios (HRs) or odds ratios (ORs) with 95% confidence intervals (CIs) were utilized for comprehensive analysis. All data analyses were performed using STATA 12.0 software. A total of 25 studies from 24 articles including 5663 patients were enrolled in the study. Meta-analysis showed that high IMAC was associated with unfavourable overall survival (OS) (HR: 2.21, 95% CI: 1.70-2.86, P < 0.001), relapse-free survival (RFS) (HR: 1.51, 95% CI: 1.30-1.75, P < 0.001) and disease-specific survival (DSS) (HR: 1.64, 95% CI: 1.19-2.28, P = 0.003). Subgroup analysis revealed that high IMAC remained an adverse prognostic factor when stratified by different country, treatment methods, cancer type or analysis type. High IMAC had better predictive value for gallbladder carcinoma (GBC) (HR: 3.50, 95% CI: 1.98-6.17, P < 0.001), hepatocellular carcinoma (HCC) (HR: 1.84, 95% CI: 1.45-2.33, P < 0.001), pancreatic cancer (PC) (HR: 2.11, 95% CI: 1.67-2.66, P < 0.001) and colorectal cancer (CRC) (HR: 2.54, 95% CI: 1.27-5.10, P = 0.009). High IMAC was also identified as a significant risk factor for postoperative complications (OR: 2.05, 95% CI: 1.22-3.46, P = 0.007). High IMAC was associated with an adverse prognosis and an increased risk of postoperative complications in cancer patients. IMAC may be a good indicator of sarcopenia.

Unraveling the Mysteries of Perineural Invasion in Benign and Malignant Conditions

Perineural invasion (PNI) is defined as the dissemination of neoplastic cells within the perineural space. PNI can be a strong indicator of malignancy and is linked to poor prognosis and adverse outcomes in various malignant neoplasms; nevertheless, it can also be seen in benign pathologic conditions. In this review article, we discuss various signaling pathways and neurotrophic factors implicated in the development and progression of PNI. We also describe the methodology, benefits, and limitations of different in vitro, ex vivo, and in vivo models of PNI. The spectrum of presentation for PNI can range from diffuse spread within large nerves ("named" nerves) all the way through localized spread into unnamed microscopic nerves. Therefore, the clinical significance of PNI is related to its extent rather than its mere presence or absence. In this article, we discuss the guidelines for the identification and quantification of PNI in different malignant neoplasms based on the College of American Pathologists (CAP) and World Health Organization (WHO) recommendations. We also describe benign pathologic conditions and neoplasms demonstrating PNI and potential mimics of PNI. Finally, we explore avenues for the future development of targeted therapy options via modulation of signaling pathways involved in PNI.

Lymph node metastatic status could predict the prognosis of intracholecystic papillary neoplasm of gallbladder

Intracholecystic papillary neoplasm (ICPN) is a non-invasive epithelial tumor that presents as a grossly identifiable mass arising in the mucosa and protruding into the lumen. ICPN is associated with invasive carcinoma. There are few studies on the clinicopathological features of ICPN, including that with invasive carcinoma. We evaluated the clinicopathological characteristics of 42 ICPNs and 41 conventional gallbladder adenocarcinomas (cGBAs). Subserosa or deeper (≥ss) invasion was significantly lower in ICPN (61.9%) than that in cGBA (90.2%) (P = 0.004). Cox regression analysis revealed that lymph node metastasis (hazard ratio [HR] [95% confidence interval (CI)]: 2.610 [1.131, 6.024], P = 0.025) and positive margin (HR [95% CI]: 5.143 [2.113, 12.516], P < 0.001), but not ≥ss invasion (HR [95% CI]: 1.541 [0.479, 4.959], P = 0.469), were independent prognostic factors. In addition, there was a significant interaction between histological type and lymph node metastasis (HR [95% CI]: 0.191 [0.042, 0.983], P = 0.033). In cGBA, the presence or absence of lymph node metastasis did not affect prognosis; however, ICPN without lymph node metastasis had better prognosis. Therefore, the histological classification of ICPN and cGBA and the pathological evaluation of lymph node metastasis in ICPN are crucial for determining prognosis.

Perineural Invasion and Spread in Common Abdominopelvic Diseases: Imaging Diagnosis and Clinical Significance

Malignancies and other diseases may spread by multiple pathways, including direct extension, hematogenous spread, or via lymphatic vessels. A less-well-understood route is the peripheral nervous system, which is known as perineural spread (PNS). In addition to accounting for pain and other neurologic symptoms, PNS affects both disease prognosis and management. Although PNS is commonly discussed in relation to head and neck tumors, there is emerging data regarding PNS in abdominopelvic malignancies and other conditions such as endometriosis. Due to improved contrast and spatial resolution, perineural invasion, a finding heretofore diagnosed only at pathologic examination, can be detected at CT, MRI, and PET/CT. PNS most commonly manifests as abnormal soft-tissue attenuation extending along neural structures, and diagnosis of it is aided by optimizing imaging parameters, understanding pertinent anatomy, and becoming familiar with the typical neural pathways of spread that largely depend on the disease type and location. In the abdomen, the celiac plexus is a central structure that innervates the major abdominal organs and is the principal route of PNS in patients with pancreatic and biliary carcinomas. In the pelvis, the lumbosacral plexus and inferior hypogastric plexus are the central structures and principal routes of PNS in patients with pelvic malignancies. Although the imaging findings of PNS may be subtle, a radiologic diagnosis can have a substantial effect on patient care. Knowledge of anatomy and known routes of PNS and optimizing imaging parameters is of utmost importance in providing key information for prognosis and treatment planning. © RSNA, 2023 Supplemental material and the slide presentation from the RSNA Annual Meeting are available for this article. Quiz questions for this article are available through the Online Learning Center.

Association of CT Findings With Perineural Invasion in Gallbladder Cancer: Preliminary Assessment

Perineural invasion (PNI) indicates a worse prognosis for patients with gallbladder cancer (GBC). This preliminary retrospective study included 19 patients with GBC who under-went contrast-enhanced CT in the 4 weeks before undergoing surgical resection. GBC showed PNI on pathologic assessment in eight of 19 patients. On CT, wall thickening morphology had sensitivity of 75.0% and specificity of 81.8% for PNI; soft-tissue stranding around the celiac plexus had sensitivity of 62.5% and specificity of 100.0% for PNI.

Preoperative skeletal muscle fat infiltration is a strong predictor of poorer survival in gallbladder cancer underwent surgery

BACKGROUND & AIMS

Recently, a decrease in skeletal muscle, termed sarcopenia, has been reported to be associated with poorer survival of patients in several types of cancer. However, few studies have investigated the association between sarcopenia and the survival of patients with gallbladder cancer.

METHODS

A total of 88 patients undergoing curative resection for advanced gallbladder cancer were included in this study. The quality of skeletal muscle was assessed by the intramuscular adipose tissue content (IMAC), and the quantity of skeletal muscle was assessed by the psoas muscle index (PMI), measured on preoperative computed tomography. The optimum cutoff values for IMAC and PMI for predicting the overall survival in each sex were determined using a minimum p value approach. Clinicopathological factors, IMAC and PMI were retrospectively analyzed to identify the predictors of overall survival (OS).

RESULTS

The cutoff values for IMAC were -0.3 in males and 0.04 in females. The numbers of patients with low IMAC and high IMAC were 42 and 46, respectively. The cutoff values for PMI were 7.3 cm²/m² in males and 5.0 cm²/m² in females. The numbers of patients with low PMI and high PMI were 22 and 66, respectively. A multivariate analysis revealed that pT stage (pT3/4, hazard ratio [HR] = 6.72, p = 0.004), high IMAC (HR = 4.12, p < 0.001), Bile duct infiltration (present, HR = 2.82, p = 0.046), high age (≥72 years old, HR = 2.64, p = 0.010), major hepatectomy (performed, HR = 2.50, p = 0.031) and pN1/2 (HR = 2.17, p = 0.010) as independent prognostic factors.

CONCLUSION

IMAC was independent prognostic factor for resected advanced gallbladder cancer, so the quality of skeletal muscle more strongly predicted survival than the quantity of skeletal muscle.

The clinical outcomes of extended resections in patients with IV stage gallbladder cancers: A retrospective study from a large tertiary center

Background and aim

The role of extended resections in patients with clinical stage IV gallbladder cancer (GBC) remains unclear. This study retrospectively analyzed the clinical outcomes of patients who underwent extended resections for IV GBC.

Methods

Patients who were diagnosed with IV stage GBCs and underwent extended resections in Eastern Hepatobiliary Surgery Hospital, Shanghai, China, were retrospectively included in our study. Extended resection was defined as a major hepatectomy (resection of ≥3 liver segments), a pancreatoduodenectomy, or both. The clinical outcomes (baseline characteristics, preoperative variables, intraoperative variables, pathological outcomes, and follow-up data) were obtained and analyzed. The factors associated with major postoperative complications and long-term survival were analyzed by logistic regression analyses.

Results

From January 2011 to June 2017, 74 patients were included in our study. There were 33 (44.6%) males and the median age was 62.5 years (interquartile range [IQR], 56.0-67.0 years). According to pathological specimens, the median tumor size was 7cm (IQR, 6-8cm), 73(98.6%) of them received R0 resection and 72 (97.2%) of them were IV A stage GBC. Three perioperative deaths (5.4%) occurred, and major postoperative complications occurred for 15 patients (20.3%). Among them, 61 patients (82.4%) experienced recurrence and 17 patients (23.0%) were still alive after a median follow-up period of 52 months. The disease free survival time was 9 months (95% confidence interval [CI], 7.8-10.2 months) and the overall survival was 18.0 months (95% CI, 15.2-20.8 months). Longer hospital stay days [odds ratio, (OR)=1.979, 95%CI:1.038-1.193, P=0.003), initial symptoms with abdominal pain (OR=21.489, 95%CI=1.22-37.57, P=0.036), more blood transfusion volume during hospitalization (OR=1.036, 95%CI:1.021-1.058, P=0.005), and intraoperative hemorrhage (OR=18.56, 95%C:3.54-47.65, P=0.001) were independently associated with postoperative complications. Moreover, locally recurrence (OR=1.65, 95%CI:1.17-1.96, P=0.015), and more adjuvant chemotherapy cycles (OR=1.46, 95%CI:1.13-1.76, P=0.026) were independently associated with long-term survival.

Conclusion

Our retrospective study identified that extended resections can be safely and efficaciously performed on stage IV GBC patients in selected cases and performed by experienced surgeons.

Nerve Density and Neuronal Biomarkers in Cancer

Simple Summary

Researchers have shown that tumor biomarkers and increased nerve density are important clinical tools for determining cancer prognosis and developing effective treatments. The aims of our review were to synthesize these findings by detailing the histology of peripheral nerves, discuss the use of various neuronal biomarkers in cancer, and assess the impact of increased nerve density on tumorigenesis. This review demonstrates that specific neuronal markers may have an important role in tumorigenesis and may serve as diagnostic and prognostic factors for various cancers. Moreover, increased nerve density may be associated with worse prognosis in different cancers, and cancer therapies that decrease nerve density may offer benefit to patients.

Abstract

Certain histologic characteristics of neurons, novel neuronal biomarkers, and nerve density are emerging as important diagnostic and prognostic tools in several cancers. The tumor microenvironment has long been known to promote tumor development via promoting angiogenesis and cellular proliferation, but new evidence has shown that neural proliferation and invasion in the tumor microenvironment may also enable tumor growth. Specific neuronal components in peripheral nerves and their localization in certain tumor sites have been identified and associated with tumor aggressiveness. In addition, dense neural innervation has been shown to promote tumorigenesis. In this review, we will summarize the histological components of a nerve, explore the neuronal biomarkers found in tumor sites, and discuss clinical correlates between tumor neurobiology and patient prognosis.

Triple cancer of gallbladder, common bile duct and papilla of Vater: Report of a case and review of literature

INTRODUCTION AND IMPORTANCE

Synchronous malignancies of gallbladder and biliary tree are together rare entity whose pathogenesis is yet unknown. We report the case of a triple synchronous cancer of 3 distinct location: gallbladder, common bile duct (CBD) and papilla of Vater.

CASE PRESENTATION

An 84-years-old woman, was admitted to our Hospital with clinics features of obstructive jaundice. Dilatation of the biliary tree and CBD without evidence of gallstones was seen at US. CT scan confirmed distal CBD obstruction. An endo-US showed a nodule of the head of pancreas infiltrating the lower CBD. Finally, hepatic-MRI displayed a gallbladder malignancy with invasion of CBD. Preoperative staging showed 3 diagnostic suspicions: carcinoma of CBD on CT, pancreatic carcinoma on endo-US and malignancy of gallbladder on MRI. A cephalic duodenopancreatectomy and radical gallbladder resection was performed. Final pathology revealed 3 distinct location of moderately differentiated adenocarcinomas: Gallbladder, CBD and Vater's papilla. Microscopic examination didn't detect any direct continuity between the 3 tumors. Metastases were identified in the pancreaticoduodenal, peri-hepatic and peri-gastric lymph nodes.

CLINICAL DISCUSSION

Literature displayed 22 cases of synchronous malignancies of gallbladder and CBD and 1 case of triple cancer with associated Vater's papilla carcinoma. In most of these cases, an association with an anomalous pancreatic-bile duct junction was reported. Although the real incidence remain unknown, it was reported to occur in 5-10% of CBD cancers.

CONCLUSION

Suspicion of such combination of cancer should be remembered, especially when preoperative investigations don't allow a precise localization of tumor in the biliary tree.

Pyloric adenomatous carcinoma of the gallbladder following laparoscopic cholecystectomy: A case report

INTRODUCTION

Adenoma and intra-adenoma carcinoma of the gallbladder are relatively rare diseases, and the World Health Organization classification reports a frequency of 0.3% for gallbladder adenomas. Precise preoperative diagnosis of gallbladder cancer, especially in the early stages, is challenging. Herein, we report a case of pyloric adenomatous carcinoma of the gallbladder, diagnosed by laparoscopic cholecystectomy and pathology, along with a literature review. This case was reported in accordance with the SCARE 2020 Guideline (Ref).

PRESENTATION OF CASE

A 62-year-old woman was diagnosed with a 4-mm polypoid lesion in the gallbladder during a medical examination. The patient was followed-up by ultrasonography (US) once a year and was referred to our department because of an increase in size. Carcinoembryonic antigen and carbohydrate antigen 19-9 levels were within normal limits. Abdominal ultrasonography revealed a pedunculated polypoid lesion in the body of the gallbladder measuring 8 mm. Computed tomography demonstrated that the whole tumor was enhanced in the early phase without significant lymph node enlargement. Magnetic resonance cholangiopancreatography demonstrated a type Ip polypoid lesion located in the body of the gallbladder without pancreaticobiliary junctional abnormalities. Endoscopic ultrasound detected a superficial nodular-type Ip polypoid lesion in the gallbladder body with a parenchyma-like internal echogenic pattern.

DISCUSSION

Based on these findings, the patient was diagnosed with gallbladder adenoma, and laparoscopic cholecystectomy was performed. Histopathological examination revealed the tumor was a papillary growth of atypical high columnar epithelial cells. The final diagnosis was pyloric adenoma with high-grade dysplasia and intra-adenoma carcinoma. The patient is currently undergoing outpatient follow-up without recurrence for 1 year.

CONCLUSION

Early gallbladder carcinoma with adenoma should be considered in patients with small gallbladder polypoid lesions. Considering the surgical stress of cholecystectomy and the malignant potential of gallbladder cancer, preceding surgery would be acceptable.

The Efficacy of S-1 as Adjuvant Chemotherapy for Resected Biliary Tract Carcinoma: A Propensity Score-Matching Analysis

Even though S-1 is a widely used chemotherapeutic agent, there is no evidence for its use in an adjuvant setting for biliary tract carcinoma (BTC). Patients who underwent surgical treatment for BTC between August 2007 and December 2018 were selected. Propensity score matching was performed between patients who received S-1 as adjuvant chemotherapy (S-1 group) and those who underwent surgical treatment alone (observation group). Of 170 eligible patients, 38 patients were selected in each group after propensity score matching. Among those in the matched cohort, both the median recurrence-free survival (RFS) and overall survival (OS) in the S-1 group were significantly longer than those in the observation group (RFS, 61.2 vs. 13.1 months, p = 0.033; OS, not available vs. 28.2 months, p = 0.003). A multivariate analysis of the OS revealed that perineural invasion and adjuvant S-1 chemotherapy were independent prognostic factors. According to a subgroup analysis of the OS, the S-1 group showed significantly better prognoses than the observation group among patients with perineural invasion (p < 0.001). S-1 adjuvant chemotherapy might improve the prognosis of BTC, especially in patients with perineural invasion.

Nerves in the Tumor Microenvironment: Origin and Effects

Studies have reported the vital role of nerves in tumorigenesis and cancer progression. Nerves infiltrate the tumor microenvironment thereby enhancing cancer growth and metastasis. Perineural invasion, a process by which cancer cells invade the surrounding nerves, provides an alternative route for metastasis and generation of tumor-related pain. Moreover, central and sympathetic nervous system dysfunctions and psychological stress-induced hormone network disorders may influence the malignant progression of cancer through multiple mechanisms. This reciprocal interaction between nerves and cancer cells provides novel insights into the cellular and molecular bases of tumorigenesis. In addition, they point to the potential utility of anti-neurogenic therapies. This review describes the evolving cross-talk between nerves and cancer cells, thus uncovers potential therapeutic targets for cancer.

Causes of misdiagnosis and missed diagnosis and therapeutic and preventive strategies for unexpected gallbladder carcinoma

Laparoscopic cholecystectomy (LC) has been widely used in the treatment of gallbladder diseases. Since the indications for operation are constantly expanding, the intraoperative or postoperative incidence of unexpected gallbladder carcinoma (UGC) is gradually increasing. The incidence of UGC in LC and open cholecystectomy is 2.09% and 0.91%, respectively. Because gallbladder carcinoma is often accompanied by gallstones or inflammation and lacks specific clinical manifestations, imaging features, and specific serum tumor markers, the preoperative diagnostic rate of gallbladder carcinoma is only 30%, and 30% of cases of gallbladder carcinoma are diagnosed intraoperatively or postoperatively. Pathological T stage, lymph node metastasis, and gallbladder rupture are independent risk factors for the prognosis of patients with UGC. Preoperative imaging combined with serological tumor markers, intraoperative careful exploration, and rapid pathological examination are important measures to reduce the misdiagnosis and missed diagnosis of UGC. For patients with benign gallbladder diseases with a high potential of canceration, performing cholecystectomy in time and strictly grasping the indications for preserving gallbladder for benign gallbladder diseases are important preventive measures to reduce the incidence of UGC.

Surgical treatment of gallbladder cancer: An eight-year experience in a single center

BACKGROUND

Gallbladder cancer (GBC) is the most common biliary malignancy and has the worst prognosis, but aggressive surgeries [e.g., resection of the extrahepatic bile duct (EHBD), major hepatectomy and lymph node (LN) dissection] may improve long-term survival. GBC may be suspected preoperatively, identified intraoperatively, or discovered incidentally on histopathology.

AIM

To present our data together with a discussion of the therapeutic strategies for GBC.

METHODS

We retrospectively investigated nineteen GBC patients who underwent surgical treatment.

RESULTS

Nearly all symptomatic patients had poor outcomes, while suspicious or incidental GBCs at early stages showed excellent outcomes without the need for two-stage surgery. Lymph nodes around the cystic duct were reliable sentinel nodes in suspicious/incidental GBCs. Intentional LN dissection and EHBD resection prevented metastases or recurrence in early-stage GBCs but not in advanced GBCs with metastatic LNs or invasion of the nerve plexus. All patients with positive surgical margins (e.g., the biliary cut surface) showed poor outcomes. Hepatectomies were performed in sixteen patients, nearly all of which were minor hepatectomies. Metastases were observed in the left-sided liver but not in the caudate lobe. We may need to reconsider the indications for major hepatectomy, minimizing its use except when it is required to accomplish negative bile duct margins. Only a few patients received neoadjuvant or adjuvant chemoradiation. There were significant differences in overall and disease-free survival between patients with stages ≤ IIB and ≥ IIIA disease. The median overall survival and disease-free survival were 1.66 and 0.79 years, respectively.

CONCLUSION

Outcomes for GBC patients remain unacceptable, and improved therapeutic strategies, including neoadjuvant chemotherapy, optimal surgery and adjuvant chemotherapy, should be considered for patients with advanced GBCs.

Extended Resections for Advanced Gallbladder Cancer: Results from a Nationwide Cohort Study

Background

Extended resections (i.e., major hepatectomy and/or pancreatoduodenectomy) are rarely performed for gallbladder cancer (GBC) because outcomes remain inconclusive. Data regarding extended resections from Western centers are sparse. This Dutch, multicenter cohort study analyzed the outcomes of patients who underwent extended resections for locally advanced GBC.

Methods

Patients with GBC who underwent extended resection with curative intent between January 2000 and September 2018 were identified from the Netherlands Cancer Registry. Extended resection was defined as a major hepatectomy (resection of ≥ 3 liver segments), a pancreatoduodenectomy, or both. Treatment and survival data were obtained. Postoperative morbidity, mortality, survival, and characteristics of short- and long-term survivors were assessed.

Results

The study included 33 patients. For 16 of the patients, R0 resection margins were achieved. Major postoperative complications (Clavien Dindo ≥ 3A) occurred for 19 patients, and 4 patients experienced postoperative mortality within 90 days. Recurrence occurred for 24 patients. The median overall survival (OS) was 12.8 months (95% confidence interval, 6.5–19.0 months). A 2-year survival period was achieved for 10 patients (30%) and a 5-year survival period for 5 patients (15%). Common bile duct, liver, perineural and perivascular invasion and jaundice were associated with reduced survival. All three recurrence-free patients had R0 resection margins and no liver invasion.

Conclusion

The median OS after extended resections for advanced GBC was 12.8 months in this cohort. Although postoperative morbidity and mortality were significant, long-term survival (≥ 2 years) was achieved in a subset of patients. Therefore, GBC requiring major surgery does not preclude long-term survival, and a subgroup of patients benefit from surgery.

New method for the assessment of perineural invasion from perihilar cholangiocarcinoma

PURPOSE

Perineural invasion (PN) is often found in perihilar cholangiocarcinoma. New procedure was developed to assess PN around the right hepatic artery (RHA) using dual-energy computed tomography (DECT).

METHODS

Thirty patients with perihilar cholangiocarcinoma who underwent DECT before biliary drainage were retrospectively reviewed. Mask images, i.e., the periarterial layer (PAL) around the RHA and superior mesenteric artery (SMA), were made from late arterial phase DECT. The mean CT number of the PAL was measured.

RESULTS

Twenty patients with PN around the RHA were classified into the PN (+) group. The remaining 10 patients without PN and other 26 patients with other diseases that are never accompanied with PN were classified into the PN (-) group. The PAL ratio (the CT number of the PAL around the RHA relative to that around the SMA) was calculated. Both the mean CT number of the PAL around the RHA and the PAL ratio were significantly higher in the PN (+) group than in the PN (-) group. According to an ROC analysis, the predictive ability of the PAL ratio was superior. Using the cutoff value of the PAL ratio 1.009, a diagnosis of PN around the RHA was made with approximately 75% accuracy.

CONCLUSIONS

Assessment with CT number of the PAL reconstructed from DECT images is an easy and objective method to diagnose PN.

Long-term outcomes of incidental gallbladder carcinoma without additional resection: A single institution experiment

Incidental gallbladder carcinoma (IGC), defined as unexpected malignancy identified in the surgical gallbladder specimen of a cholecystectomy performed for a benign diagnosis, can be difficult to suspect preoperatively. Furthermore, there are valid clinical reasons to defer reoperation for additional resection, particularly in elderly patients. The present study aimed to determine the long-term outcomes and prognostic factors associated with recurrence in patients with IGC. The medical records of 678 patients who underwent cholecystectomy at Toyooka Hospital between September 2011 and November 2017 were reviewed. The cases identified to be IGC were retrospectively analyzed to determine patient and histopathological characteristics, surgical details, long-term outcomes and factors associated with cancer recurrence. A total of 22 patients were diagnosed with gallbladder carcinoma following cholecystectomy by histopathological examination, and 12 of these were identified to be IGC. The median age was 80 years (range 70-89 years). Although 6 of the 12 patients with IGC had stage pT2 or pT3 tumors, only 1 patient underwent additional resection. Recurrence occurred in 3 of the 8 patients who did not undergo additional resection and were available for long-term follow-up. Recurrence was not associated with the extent of tumor invasion but may be associated with other histopathological findings, preoperative treatment history and risk factors for recurrence. Furthermore, long-term survival was observed in patients with pT2 and pT3 tumors who did not undergo additional resection. Recurrence was not associated with the extent of tumor invasion but may be associated with other histopathological findings, preoperative treatment history, and risk factors for recurrence. Furthermore, long-term survival was observed in patients with pT2 and pT3 tumors who did not undergo additional resection. Even if it is a progressive IGC case, appropriate preoperative treatment or cholecystectomy without persistence of the carcinoma cell, based on a preoperative image evaluation and a postoperative histopathological examination, may greatly influence the long-term prognosis of IGC.

RNA Sequencing Revealed Signals of Evolution From Gallbladder Stone to Gallbladder Carcinoma

Gallbladder stone is a major risk factor for gallbladder carcinoma (GBC), while there is still a controversy whether period of follow-up since newly diagnoses of asymptomatic gallstones increases the risk of GBC. In this study, 10 GBC patients and 30 patients with gallstones were admitted to our hospital. Patients with gallstones were divided into 3 groups according to the follow-up time, involving 10 patients with follow-up period of 1–3 years (GS3 group), 10 patients with follow-up period of 5–10 years (GS5 group), and 10 patients with follow-up period of more than 10 years (GS10 group). Tumor and para-tumor tissues of GBC patients, and gallbladder tissues of gallstone patients were collected. RNA sequencing was performed on the 50 samples. Besides, 1,704 differentially expressed genes (DEGs) were identified in tumors compared with para-tumor tissues of 10 GBC patients, which were enriched into some well-known cancer-related pathways, such as PI3K-Akt, mitogen-activated protein kinase (MAPK), Ras, and Wnt signaling pathways, and the most significant pathway was neuroactive ligand-receptor interaction. Patients with gallstones with periods of follow-up equal to 1–3 and > 10 years showed to have higher cancer risk than those with 5–10 years. ALPP and GPR87 are potential biomarkers for predicting cancer risk in patients with gallstones. The in vitro results revealed that GPR-87 can promote the proliferation, migration, and invasion of GBC cells. Herein, we explored the relationship between GBC patients and patients with gallstones with different periods of follow-up in transcriptome level.

Clinical impact of celiac ganglia metastasis upon pancreatic ductal adenocarcinoma

BACKGROUND

Pre-operative staging of pancreatic adenocarcinoma guides clinical decision making. Limited data indicate that metastasis to celiac ganglia (CG) correlates with poor prognosis. We investigated feasibility and safety of endoscopic ultrasound fine needle aspiration (EUS-FNA) detection of CG metastasis and its impact upon tumor stage, resectability, and survival in pancreatic ductal adenocarcinoma (PDAC).

PATIENTS

We reviewed our prospectively maintained EUS and cytopathology databases to identify patients with FNA proven CG metastasis in patients with PDAC from 2004 to 2017. Clinical demographics, EUS, CT, MRI, cytopathology, cancer stage, and resectability data were analyzed. Survival of PDAC patients with CG metastasis was compared to the expected survival of PDAC patients of similar stage as reported by the United States National Cancer Database.

RESULTS

Twenty-one patients with PDAC [median age 73 (IQR63-78); 14 (67%) female)], had CG metastasis confirmed by cytopathologic assessment. CG metastasis resulted in tumor upstaging relative to other EUS findings and cross sectional imaging findings in 12 (57%) and 15 (71%) patients, and converted cancers from resectable to unresectable relative to EUS and cross sectional imaging in 7 (37%) and 7 (37%) patients, respectively. In patients with PDAC, the survival of patients with CG metastasis was not significantly different from the overall survival (hazard ratio 0.71; 95% confidence interval 0.44, 1.13; p = 0.15).

CONCLUSIONS

EUS-FNA may safely identify CG metastases. While CG metastasis upstaged and altered the resectability status among this cohort of patients with PDAC, the survival data with regard to PDAC suggest that this may be misguided.

Upregulation of RET induces perineurial invasion of pancreatic adenocarcinoma

Tumor spread along nerves, a phenomenon known as perineurial invasion, is common in various cancers including pancreatic ductal adenocarcinoma (PDAC). Neural invasion is associated with poor outcome, yet its mechanism remains unclear. Using the transgenic Pdx-1-Cre/KrasG12D /p53R172H (KPC) mouse model, we investigated the mechanism of neural invasion in PDAC. To detect tissue-specific factors that influence neural invasion by cancer cells, we characterized the perineurial microenvironment using a series of bone marrow transplantation (BMT) experiments in transgenic mice expressing single mutations in the Cx3cr1, GDNF and CCR2 genes. Immunolabeling of tumors in KPC mice of different ages and analysis of human cancer specimens revealed that RET expression is upregulated during PDAC tumorigenesis. BMT experiments revealed that BM-derived macrophages expressing the RET ligand GDNF are highly abundant around nerves invaded by cancer. Inhibition of perineurial macrophage recruitment, using the CSF-1R antagonist GW2580 or BMT from CCR2-deficient donors, reduced perineurial invasion. Deletion of GDNF expression by perineurial macrophages, or inhibition of RET with shRNA or a small-molecule inhibitor, reduced perineurial invasion in KPC mice with PDAC. Taken together, our findings show that RET is upregulated during pancreas tumorigenesis and its activation induces cancer perineurial invasion. Trafficking of BM-derived macrophages to the perineurial microenvironment and secretion of GDNF are essential for pancreatic cancer neural spread.

Indications for major hepatectomy and combined procedures for advanced gallbladder cancer

Background

The clinical impact of major hepatectomy for advanced gallbladder cancer is currently unclear.

Methods

Patients who underwent resection for stage II, III or IV gallbladder cancer were enrolled. The surgical outcomes of patients who underwent major hepatectomy were compared with those of patients treated with minor hepatectomy and those with unresectable gallbladder cancer. The clinical impact of major hepatectomy and combined advanced procedures such as portal vein resection or pancreatoduodenectomy for advanced gallbladder cancer were evaluated.

Results

A total of 96 patients were enrolled; 29 patients underwent major and 67 had minor hepatectomy. The overall morbidity rate was higher in the major hepatectomy group (55 versus 27 per cent; P = 0·022). There were no deaths after major hepatectomy. Overall survival was better in the major hepatectomy group than in the group of 15 patients with unresectable disease (median survival 17·7 versus 11·4 months; P = 0·003). In a subgroup analysis of the major hepatectomy group, liver metastasis (P = 0·038) and hepatic arterial invasion (P = 0·017) were independently associated with overall survival. Overall survival in patients with liver metastasis (P = 0·572) or hepatic arterial invasion (P = 0·776) was comparable with that in the unresectable group. However, overall survival among patients with lymph node metastasis (P = 0·062) or following portal vein resection (P = 0·054) or pancreatoduodenectomy (P = 0·011) was better than in the unresectable group.

Conclusion

Major hepatectomy combined with portal vein resection or pancreatoduodenectomy, if necessary, may be considered in the treatment of advanced gallbladder cancer, especially in selected patients without liver metastasis or hepatic arterial invasion.

Report of a case with gallbladder carcinoma: P53 expression of the peritumor epithelium might predict biliary tract recurrence

INTRODUCTION

The over-expression of P53 protein in gallbladder carcinoma is a biomarker correlating with a poor survival. However, the significance of P53 expression in peritumor tissues is unknown. We experienced a case of gallbladder carcinoma where the operative specimen showed over-expression of P53 on the peritumor epithelium, and early recurrence developed at the biliary tract.

PRESENTATION OF CASE

A 74-year-old female patient was referred to our hospital due to wall thickening of the gallbladder on ultrasonography. Radiographic examinations revealed wall thickening at the fundus of gallbladder and no abnormalities of the biliary tract or surrounding lymph nodes. We performed open cholecystectomy and lymph node dissection without extrahepatic bile duct resection, as a frozen section of the surgical stump of the cystic duct was cancer-free. However, a pathological examination revealed over-expression of P53 protein in the epithelium of the peritumor to the cystic duct, which were diagnosed as normal on hematoxylin eosin staining. The patient developed bile duct metastases, two and half years after the operation. She underwent endoscopic stenting for the obstruction of bile duct with no additional therapy, and died 6 months later.

DISCUSSION AND CONCLUSION

The immunohistochemical staining of the GB wall or surgical stump for a surgical specimen of GBC may be crucial to predict the bile duct recurrence.

Report of a case with T1a gallbladder poorly differentiated adenocarcinoma, solid type, which developed into lymph node metastases

We experienced a case with gallbladder carcinoma growing limited to the mucosa (T1a), which developed massive lymphatic vessel spread and lymph node metastases.

A 72-year-old man was referred to our hospital for the swelling of his gallbladder during a routine ultrasound sonography checkup. We diagnosed the patient with gallbladder carcinoma with lymph node metastasis according to the radiographic findings and performed the open cholecystectomy and lymph node dissection. A histological examination showed poorly differentiated adenocarcinoma, solid type, and the tumor was limited to the mucosa. The number of lymphatic vessels was increased in the tumor and peritumor areas, and cancer cells were observed in the lymphatic vessels, which were detected via D2-40 immunohistochemistry. A careful histological examination and follow-up is required for T1a gallbladder carcinoma.

Confinement to the intrapancreatic bile duct is independently associated with a better prognosis in extrahepatic cholangiocarcinoma

BACKGROUND

Actual differences of long term outcome of extrahepatic cholangiocarcinoma according to the location of the tumor have not yet been studied. The aim of this study was to evaluate the prognosis and optimal surgical procedure for middle (BD) cancer.

METHODS

Among 109 patients with carcinoma of the extrahepatic BD underwent surgical resection, curative resection of extrahepatic BD cancer was performed in 90 patients. They were classified into three groups according to the location of tumors: DISTAL (n = 32), tumor was confined to the intrapancreatic bile duct; MID (n = 20), tumor was located between below the confluence of the hepatic duct bifurcation and suprapancreatic portion of the BD; and DIFFUSE (n = 38), tumor was located diffusely.

RESULTS

Tumor involving the middle BD (MID or DIFFUSE) had a higher rate of perineural invasion as compared to the DISTAL group. The overall and disease-free survival rate for the MID or DIFFUSE group was significantly worse than that of DISTAL. In the MID/DIFFUSE group, there was no significant difference of survival according to the type of the operation (pancreaticoduodenectomy or segmental BD resection). The multivariate analysis showed that tumor involving middle BD (MID or DIFFUSE group) and node metastasis were independently poor prognostic factors for the disease free and overall survival.

CONCLUSION

Extrahepatic cholangiocarcinoma involving the extrapancreatic BD has a worse prognosis than those confined to the intrapancreatic BD. In patients with tumors confined to the middle BD, BD resection can be considered as an alternative surgical procedure to pancreaticoduodenectomy, if an R0 resection can be accomplished.

Combined extrahepatic bile duct resection for locally advanced gallbladder carcinoma: does it work?

BACKGROUND

Prophylactic combined extrahepatic bile duct resection remains controversial for locally advanced gallbladder carcinoma without extrahepatic bile duct invasion. The aim of this study is to resolve this issue and establish an appropriate surgery for locally advanced gallbladder carcinoma.

METHODS

A total of 52 patients underwent surgical resection combined with extrahepatic bile duct resection for locally advanced gallbladder carcinoma without extrahepatic bile duct invasion, and their medical records were retrospectively reviewed for microvessel invasion (MVI), including lymphatic, venous, and/or perineural invasions, around the extrahepatic bile duct.

RESULTS

Of the 52 patients, 8 (15 %) had MVI around the extrahepatic bile duct. All of the 8 patients had Stage IV disease. According to a survival analysis of the 50 patients who tolerated surgery, MVIs around the extrahepatic bile duct and distant metastasis were identified as independent prognostic factors. Survival for patients with MVI around the extrahepatic bile duct was dismal, with a lack of 2-year survivors.

CONCLUSIONS

MVI around the extrahepatic bile duct is a sign of extremely locally advanced gallbladder carcinoma; therefore, prophylactic combined bile duct resection has no survival impact for patients without extrahepatic bile duct invasion.

Hepatectomy of segment 4b and 5 with extrahepatic bile duct resection for pT2 gallbladder carcinoma is valid: a single-institution result

The results of surgical treatment for T2 gallbladder carcinoma are equivocal, while the precise preoperative TNM staging and localization of gallbladder carcinoma are difficult. The aim of this study was to report the validity of segment 4b and 5 (S4b+5) hepatectomy with extrahepatic bile duct resection for these tumors. We reviewed 30 patients with pT2 gallbladder cancer who underwent S4b+5 hepatectomy with extrahepatic bile duct resection. The median number of lymph nodes retrieved in the S4b+5 hepatectomy group was 11 (0-23) nodes, and lymph node metastasis was observed in 9 of 30 (30%) cases. Although all surgical margins were macroscopically negative, 4 of the 30 patients (13%) had pathologically positive margins. The overall survival rate of patients was 85.1% at 5 years. Of the 30 patients with S4b+5 hepatectomy, surgical margin alone was analyzed as a prognostic factor in univariate and multivariate analysis. The survival rate was comparable between the tumor on the hepatic side and peritoneal side (P = 0.856). Nine patients with additional S4b+5 hepatectomy after simple cholecystectomy because of incidental diagnosis of gallbladder cancer also had comparable survival compared to the remaining 21 patients with simultaneous S4b+5 hepatectomy (P = 0.624). S4b+5 hepatectomy with extrahepatic bile duct resection could be good treatment modality for T2 gallbladder cancers because precise preoperative diagnosis of tumor depth, location, and lymph node metastasis for these tumors is difficult.

Surgical resection of solid gallbladder adenocarcinoma presenting as a large mass: report of a case

This report describes a case of a patient with a large solid gallbladder adenocarcinoma that was completely resected through aggressive surgery. The patient was a 57-year-old woman who had been diagnosed with advanced gallbladder cancer, had no indications for surgical resection and was scheduled to undergo systemic chemotherapy. She presented to our hospital for a second opinion. At the time of assessment, her tumor was large but was well-localized and had not invaded into the surrounding tissues, indicating that surgical resection was a reasonable option. Subsequently, the tumor was completely extracted via right hepatectomy with en bloc resection of the caudate lobe and extrahepatic bile duct. Histopathologically, the tumor was a solid adenocarcinoma. Although there are relatively few reports in the literature regarding solid gallbladder adenocarcinoma, well-localized growth appears to be a characteristic feature. On the basis of a tumor’s progression behavior, aggressive surgical treatment might be indicated even when the tumor has grown to a considerable size.

Portal vein arterialization: a salvage procedure for a totally de-arterialized liver. The Paul Brousse Hospital experience

BACKGROUND

Portal vein arterialization (PVA) has been used as a salvage inflow technique when hepatic artery (HA) reconstruction is deemed impossible in liver transplantation (LT) or hepatopancreatobiliary (HPB) surgery. Outcomes and the management of possible complications have not been well described.

METHODS

The present study analysed outcomes in 16 patients who underwent PVA during the period from February 2005 to January 2011 for HA thrombosis post-LT (n = 7) or after liver resection (n = 1), during curative resection for locally advanced HPB cancers (requiring HA interruption) (n = 7) and for HA resection without reconstruction (n = 1). In addition, a literature review was conducted.

RESULTS

Nine patients were women. The median age of the patients was 58 years (range: 30-72 years). Recovery of intrahepatic arterial signals and PVA shunt patency were documented using Doppler ultrasound until the last follow-up (or until shunt thrombosis in some cases). Of five postoperative deaths, two occurred as a result of haemorrhagic shock, one as a result of liver ischaemia and one as a result of sepsis. The fifth patient died at home of unknown cause. Three patients (19%) had major bleeding related to portal hypertension (PHT). Of these, two underwent re-exploration and one underwent successful shunt embolization to control the bleeding. Four patients (25%) had early shunt thrombosis, two of whom underwent a second PVA. After a median follow-up of 13 months (range: 1-60 months), 10 patients (63%) remained alive with normal liver function and one submitted to retransplantation.

CONCLUSIONS

Portal vein arterialization results in acceptable rates of survival in relation to spontaneous outcomes in patients with completely de-arterialized livers. The management of complications (especially PHT) after the procedure is challenging. Portal vein arterialization may represent a salvage option or a bridge to liver retransplantation and thus may make curative resection in locally advanced HPB cancers with vascular involvement feasible.

Pathology report assessment of incidental gallbladder carcinoma diagnosed from cholecystectomy specimens: results of a French multicentre survey

AIMS

To assess the accuracy of pathology reports on gallbladder specimens from patients operated on for incidental gallbladder carcinoma.

METHODS

Demographic data, details on pathological reports including gross and microscopic features section were recorded in 100 selected patients with incidental gallbladder carcinoma diagnosed from 2004 to 2007.

RESULTS

Pathology reports had a conventional format in 93% of cases, without any standardization. Turnaround time ranged from 1 to 35 days. Frozen sections were performed in 20% of cases. The reports failed to give information on prognostic histological factors: exact tumour site (missing in 55% of cases), depth of tumour infiltration within the gallbladder wall (missing in 10%), surgical margins (missing in 40% for the cystic duct margin), tumour differentiation (missing in 28%), vascular invasion (missing in 52%) and perineural invasion (missing in 51%). Lymph node status could be assessed in 44% of cases. Distances between the tumour and the cystic duct and circumferential margins were not specified in 68% and 84% of cases. Only 29% of the reports clearly stated the pTNM stage in the conclusion section. The pT stage with margin status and tumour site was only mentioned in 30% of the reports.

CONCLUSION

Pathology reports on gallbladder carcinoma from participating centres frequently lacked important information on key prognostic histological factors.

Perineural invasion in extrahepatic cholangiocarcinoma: prognostic impact and treatment strategies

BACKGROUND

The significance of perineural invasion in extrahepatic cholangiocarcinoma has not been fully elucidated. This study aims to determine the prognostic impact of and optimal treatment strategy for perineural invasion in patients with extrahepatic cholangiocarcinoma.

METHODS

Medical records of 133 patients with extrahepatic cholangiocarcinoma who underwent curative resection were reviewed retrospectively. Ninety-eight patients had perineural invasion and 35 patients did not. Univariate and multivariate survival analyses were performed to clarify the prognostic impact of and optimal treatment strategy for perineural invasion.

RESULTS

Only tumor differentiation (P=0.024) was independently associated with perineural invasion in the multivariate logistic regression model. Multivariate survival analysis revealed that perineural invasion (P=0.002), resection margin status(P=0.016), and International Union Against Cancer (UICC) pT factor (P=0.015) were independent prognostic factors of overall survival. Overall 5-year survival rates for patients with and without perineural invasion were 28 and 74 %, respectively. Among 98 patients with perineural invasion, the use of adjuvant chemotherapy (P=0.003), lymph node status (P=0.015), resection margin status (P=0.008), and UICC pT factor (P=0.016) were independently associated with overall survival by multivariate analysis. Overall 5-year survival rates for patients with perineural invasion who did and did not receive adjuvant chemotherapy were 33 and 21 %, respectively (P=0.023).

CONCLUSIONS

Perineural invasion is a potent prognostic factor in extrahepatic cholangiocarcinoma. Adjuvant chemotherapy may improve the overall survival of patients with perineural invasion.

Clinicopathological features of long-term survivors for advanced biliary tract cancer and impact of the number of lymph nodes involved

BACKGROUND & AIM

To investigate the characteristics of long-term survivors after surgery for advanced biliary tract cancer (BTC), especially those with local invasion and/or lymph node involvement.

METHODS

We analyzed the features of long-term survivors using a prospectively collected database and verified the results using recent patients' data which have been well-described, especially in relation to lymph node dissection and metastasis. We used classification by the Japanese Society of Biliary Surgery (JSBS).

RESULTS

Among 170 patients with advanced BTC (Stage III or IV in JSBS), 25 (10 bile duct cancer, 9 gall bladder cancer, and 6 cancer of the papilla of Vater) survived for more than 5 years. Twenty-four patients had undergone fCurA/B (R0) surgery in these 25 patients. In comparison with the patients who did not survive for 5 years, the long-term survivors had fewer metastatic lymph nodes, that is, up to three (p = 0.0028). In regard to the impact of lymph node metastasis, the prognostic factor was the number of lymph nodes (3-year overall survival, 0 or 1: 68.1% vs >2: 40.0%, p = 0.0304).

CONCLUSION

For obtaining long-term survival, curative resection would be necessary in patients with no more than one lymph node metastasis.

Prognostic factors for gallbladder cancer in the laparoscopy era

PURPOSE

Hepatobiliary surgery has changed dramatically in recent decades with the advent of laparoscopic techniques. The aim of this retrospective study was to compare survival rates according to stages, adjusting for important prognostic factors.

METHODS

A retrospective study of a 17-year period from January 1994 to April 2011 was carried out. The cases studied were divided into two time period cohorts, those treated in the first 9-years (n = 109) and those treated in the last 7-years (n = 109).

RESULTS

An operation with curative intent was performed on 218 patients. The 5-year survival rates according to the depth of invasion were 86% (T1), 56% (T2), 45% (T3), and 5% (T4). The number of cases of incidental gallbladder cancer found during 3,919 laparoscopic cholecystectomies was 96 (2.4%). Incidental gallbladder cancer revealed a better survival rate (P = 0.003). Iatrogenic bile spillage was found in 20 perforations of the gallbladder during laparoscopic cholecystectomies, 16 preoperative percutaneous transhepatic gallbladder drainages and 16 percutaneous transhepatic biliary drainages; only percutaneous transhepatic biliary drainage patients showed a significantly lower survival rate than patients without iatrogenic bile spillage (P < 0.034). Chemoradiation appeared to improve overall survival (P < 0.001). Multivariate analysis also revealed that time period, type of surgery, surgical margin, lymphovascular invasion, lymph node involvement, and chemoradiation therapy had significant effects.

CONCLUSION

This study found that the prognosis of gallbladder cancer is still determined by the stage at presentation due to the aggressive biology of this tumor. Early diagnosis, radical resection and appropriate adjuvant therapy can increase overall survival.

Invasion of the hepatic artery is a crucial predictor of poor outcomes in gallbladder carcinoma

BACKGROUND

In the present study we undertook a retrospective analysis of gallbladder carcinoma to assess whether histologically determined hepatic artery (HA) invasion and portal vein (PV) invasion can be considered prognostic factors.

METHODS

Seventy-one patients who had undergone radical resection for gallbladder carcinoma between 1995 and 2008 at University of Tsukuba were selected from the database for analysis. Patients who required extended surgery for para-aortic lymph node metastasis were also included. Correlation between invasion of the HA and the PV and prognosis and other clinicopathologic factors were analyzed.

RESULTS

There were two postoperative deaths among the 71 patients. Pathological invasion of the HA was confirmed in 16 (22.5%) cases and PV invasion was confirmed in 15 patients. Patients with invasion of the HA had a significantly poorer prognosis than those without HA invasion (P < 0.0001). Additionally, in univariate analysis, gender (male), positive para-aortic lymph node metastasis, PV invasion, and HA invasion were identified as significant poor prognostic factors. In multivariate analysis, only HA invasion was an independent prognostic factor (Odds Ratio 0.323; P = 0.029).

CONCLUSIONS

Invasion of the HA is a crucial prognostic factor in patients with gallbladder carcinoma.

T-category reflects the histopathologic characteristics of gallbladder cancer

AIMS

Gallbladder (GB) cancer is a relatively uncommon gastrointestinal malignancy and is known to often result in unfavorable outcomes. Recent advances in aggressive surgical resection have improved the overall survival rate of patients with GB cancer. We aimed to evaluate the outcomes and prognostic factors of GB cancer following a surgical resection with curative intent.

METHODS

Between March 2001 and March 2009, 89 patients with GB cancer underwent surgical resection with curative intent at the National Cancer Center of Korea. We then conducted a retrospective analysis of clinicopathologic data.

RESULTS

Nineteen patients underwent simple cholecystectomy and 70 patients underwent extended cholecystectomy. Tumor-free resection margins were obtained in 84 cases. The 1-, 3- and 5-year disease-specific survival rates in the 89 patients were 85.8%, 68.0% and 64.1%, respectively. By multivariate analysis, only the T-category was significant (p < 0.001). The T-category showed a close correlation with all of the other histopathologic factors which were significant in univariate analysis.

CONCLUSION

The T-category of GB cancer represents not only the depth of the primary tumor but also the aggressiveness of its histopathologic nature.

Prognostic impact of vascular endothelial growth factor-A expression in resected gallbladder carcinoma

The purpose of this study was to evaluate the value of vascular endothelial growth factor-A (VEGF-A) expression and other confirmed prognostic factors in predicting clinical outcomes after the resection of gallbladder carcinoma (GBC). Between January 1999 and January 2006, a total of 84 consecutive and non-selected patients who underwent resection for GBC were retrospectively reviewed. Of the 84 patients studied, 45 cases (53.6%) exhibited high expression of VEGF-A and were placed into the high expression group. The 14 cases (16.7%) that showed no VEGF expression and the 25 cases (29.7%) that had lower VEGF-A levels were pooled into the low expression group (46.4%). There was a relationship between VEGF-A status and pM stage (P = 0.027) as well as histologic differentiation (P < 0.001). In univariate analysis by log-rank test, ECOG performance status, CA 19-9, pN stage, pM stage, histologic differentiation, and VEGF-A expression were significant prognostic factors (P = 0.015, 0.001, 0.020, <0.001, 0.040, and <0.001, respectively). Multivariate analysis revealed that pN status and VEGF-A expression maintained independent prognostic influence on overall survival (P < 0.001 and P = 0.013, respectively). VEGF-A expression has a positive correlation with pM stage and histologic differentiation. pN status and VEGF-A expression were independent prognostic factors of overall survival in patients with resected GBC.

Prognostic factors of patients with advanced gallbladder carcinoma following aggressive surgical resection

BACKGROUND

The prognosis for patients with advanced gallbladder carcinoma is dismal despite aggressive surgical resection. The aim of this study is to determine useful prognostic factors for patients with gallbladder carcinoma following aggressive surgical resection.

METHODS

Medical records of 62 patients with gallbladder carcinoma who underwent surgical resection were retrospectively reviewed. Univariate and multivariate models were used to analyze the effect of clinicopathological factors on long-term survival.

RESULTS

According to the UICC staging system, ten (16%), 11 (18%), eight (13%), 16 (25%), nine (15%), and eight patients (13%) were diagnosed with stages I, II, IIIA, IIIB, IVA, and IVB disease, respectively. Partial hepatectomy and pancreatoduodenectomy were performed for 43 (69%) and 11 (18%) patients, respectively. Overall survival rates of all 62 and 41 patients with UICC stages III and IV disease were 71% and 56% at 1 year, 48% and 23% at 3 years, and 48% and 23% at 5 years, respectively (median survival time, 15.8 and 12.7 months, respectively). Multivariate analysis revealed that independent prognostic factors included tumor differentiation (p = 0.006), hepatic invasion (p = 0.002), lymph node metastasis (p = 0.009), and surgical margin status (p = 0.002) for all patients, and adjuvant chemotherapy (p = 0.005), tumor differentiation (p = 0.008), hepatic invasion (p = 0.001), and surgical margin status (p = 0.022) for patients with UICC stages III and IV disease.

CONCLUSIONS

R0 resection and adjuvant chemotherapy are significant prognostic factors in advanced gallbladder carcinoma and should be performed to improve survival.

Incidentally-discovered gallbladder cancer: When, why and which reoperation?

Cancer of the gallbladder, a rare entity with a poor prognosis, is often discovered incidentally during or after cholecystectomy. It tends to disseminate early via lymphatic, peritoneal, endobiliary, and hematogenous pathways. Diagnosis is made intra-operatively in only a quarter of cases, by examination of the opened cholecystectomy specimen in the operating room by the surgeon; this procedure should be routine. For incidentally-discovered cancers, survival was 28% at five years. Prognostic factors include age, TNM stage, gallbladder perforation during cholecystectomy and less-than-optimal resection at re-operation. Whether the laparoscopic route for the initial cholecystectomy has an impact on survival remains a subject of debate. R0 surgery is the only potentially curative treatment: simple cholecystectomy with clear margins is adequate resection for stage T1a tumors; extended cholecystectomy with lymphadenectomy and possibly resection of the bile duct is required for more advanced stages. After curative resection, neo-adjuvant or adjuvant chemotherapy and radiotherapy have not, so far, proven effective. Improvement of surgical practices (systematic review of cholecystectomy specimens in the OR, prevention of gallbladder perforation with bile spillage during surgery, early re-intervention for optimal resection) could improve the prognosis of these cancers.

The severity of neural invasion is a crucial prognostic factor in rectal cancer independent of neoadjuvant radiochemotherapy

OBJECTIVE

To provide a comprehensive characterization of neural invasion (NI) in rectal adenocarcinoma (RC), to establish a novel NI-severity scoring system, and to assess the prognostic value of NI with emphasis on its localization and severity.

BACKGROUND

The literature merely contains small-scale studies with limited histopathological characterization of NI in RC.

METHODS

Neural invasion was thoroughly characterized in 296 patients with locally advanced uT3-RC (139 with primary resection and 157 with neoadjuvant radiochemotherapy [nRCTx]). To identify the precise localization of NI, we investigated the main tumor, peritumoral area, adjacent normal tissue, and all lymph nodes. To classify the clinical impact of NI, an NI severity score was established and related to patient prognosis.

RESULTS

Neural invasion was detected in 32% of patients with primary resection and in 19% (P = 0.010) receiving nRCTx. The major location of NI was found in the peritumoral area. The prevalence of NI in the main tumor within the primary resection group was 6%, whereas it was absent in the nRCTx group (P = 0.002). Increasing NI severity, but not NI localization, was associated with a significantly poorer survival and increased local recurrence rate in both groups. Multivariate analysis (including TNM-stage, grading, and Carcinoembryonic antigen (CEA)) revealed NI prevalence and severity as independent prognostic factors.

CONCLUSIONS

Neural invasion in RC has a heterogeneous appearance in regard to its localization and its severity. nRCTx seems to have a suppressive effect on NI. Neural invasion severity might be applied as a novel tool to estimate accurately patient's prognosis and thus should be considered in pathology reports.

Gender-Specific Prognostic Markers of Patients with Gallbladder Cancer after Surgical Resection

The aim of this study was to elucidate gender-specific markers for postresectional long-term survival of gallbladder cancer (GBC) based on a cohort of Chinese patients. Clinicopathological records of 81 patients (27 males and 54 females) after surgical resection for GBC were reviewed retrospectively. The influence of each variable on survival was determined using the Kaplan-Meier method and log-rank test. For females, Cox regression analysis was also adopted. Univariate analysis showed that the absence of lymph node and distant metastases, differentiation grade, and curative resection were associated with prolonged survival for all males, whereas tumor size, differentiation grade, and the presence of lymph node metastases influenced the overall or disease-free survival of patients after curative resection (all P < 0.05). On the other hand, Nevin stage was an independent marker for both overall survival for all females and overall and disease-free survival for female patients who underwent curative resection. Additionally, resection type and differentiation grade were of independent prognostic significance for different subgroups of females (all P < 0.05). Our data suggested that tumor-related factors affect prognosis of both male and female patients with GBC after resection. Of these factors, tumor differentiation status might be more significant for males, but Nevin stage had a stronger predictive potential for females.

Preoperative inflammation is a prognostic factor for gallbladder carcinoma

BACKGROUND

Inflammation frequently accompanies gallbladder carcinoma (GBC), but its impact on outcome is unclear. The present study investigated the impact of concomitant inflammation on survival of patients with GBC.

METHODS

All patients undergoing surgery for GBC between October 2003 and May 2009 were identified retrospectively from a prospectively collected database. Patients were classified according to whether preoperative inflammation was present (65 patients) or not (23).

RESULTS

A total of 88 patients were enrolled. There were no differences in sex, mean age, tumour node metastasis (TNM) stage and radicality of resection between the two groups. The overall 3-year survival rate was lower in patients with preoperative inflammation than in those without (33 versus 73 per cent; P = 0·001). In univariable analysis, preoperative inflammation, T, N and M category, TNM stage, radicality of surgery and tumour differentiation were significant prognostic factors. The presence of preoperative inflammation (hazard ratio (HR) 2·38, 95 per cent confidence interval 1·04 to 5·43), lymph node metastases (HR 5·23, 1·05 to 26·09) and R1 or R2 resection (HR 3·77, 1·47 to 9·72) were independent prognostic factors for poor survival.

CONCLUSION

The presence of preoperative inflammation is an independent prognostic factor for poor survival in patients with GBC.

Adenocarcinoma of the prostate involving the lumbosacral plexus: MRI evidence to support direct perineural spread

BACKGROUND

Prostate adenocarcinoma, which may recur despite aggressive treatment, has the potential to spread to the lumbosacral plexus. This intraneural involvement is not widely known and is thought to be from direct perineural spread. We hypothesized that high-resolution imaging could provide supportive evidence for this mechanism.

METHODS

The clinical data and imaging studies (magnetic resonance imaging, MRI, and positron emission tomography/computed tomography, PET/CT) of patients evaluated at our institution between 2004 and 2009 for lumbosacral plexopathy due to intraneural prostate carcinoma were retrospectively reviewed.

RESULTS

Four patients presenting with painful lumbosacral plexopathy were found to have intraneural lumbosacral prostate adenocarcinoma. Two patients had involvement of the lumbosacral plexus ipsilateral to the lobe of the prostate most involved with adenocarcinoma at prostatectomy. High-resolution MRI and PET/CT studies revealed similar findings: abnormal soft tissue signal was followed from the prostate (n = 1) or prostatic bed (n = 3) area along the expected course of the pelvic plexus to the level of the sciatic notch, where it involved the sacral spinal nerves and sciatic nerve. Imaging findings were consistent with neoplastic infiltration, which was confirmed at biopsy in three patients.

CONCLUSIONS

The potential for prostate adenocarcinoma to spread to the lumbosacral plexus has, to our knowledge, not been readily appreciated. Because the imaging findings are often subtle, we believe that intraneural lumbosacral plexus involvement may not be uncommon. This study, with the use of high-resolution MRI and PET/CT studies, supports the direct perineural spread of prostate adenocarcinoma via the pelvic plexus to the lumbosacral plexus. This mechanism could also explain cases of leptomeningeal and/or dural-based prostate metastases.

Surgical management of infrahilar/suprapancreatic cholangiocarcinoma: an analysis of the surgical procedures, surgical margins, and survivals of 77 patients

BACKGROUND

Optical surgical management of infrahilar/suprapancreatic cholangiocarcinoma remains controversial.

METHODS

Between 1988 and 2006, 77 patients with infrahilar/suprapancreatic cholangiocarcinoma underwent curative surgical resections following our intention-to-treat strategy. The clinicopathological factors affecting survival were evaluated using univariate and multivariate analyses with regard to the surgical procedures and surgical margins.

RESULTS

The surgical procedure included extrahepatic bile duct resection alone (EHBD; n = 17), major hepatectomy combined with extrahepatic bile duct resection (MHx; n = 26), pancreaticoduodenectomy (PD; n = 28), and MHx and concomitant PD (HPD; n = 6). Performance of MHx and/or PD in addition to EHBD increased surgical morbidity (p = 0.001). Among patients undergoing the four surgical procedures (EHBD, MHx, PD, and HPD), no significant difference was found in the incidence of positive overall surgical margins (53%, 65%, 46%, and 67%, p = 0.51) or long-term survivals (median survival time, 51, 27, 41, and 22 months, p = 0.60). A multivariate analysis revealed that perineural invasion (95% confidence interval, 1.1-12.3, p = 0.009), nodal metastasis (1.6-6.8, p = 0.001), and blood transfusion (1.1-3.9, p = 0.02) were independent predictors of a poor outcome. Perineural invasion was associated with positive radial margins (p = 0.045) and submucosal ductal infiltration (p = 0.03).

CONCLUSION

Perineural invasion, rather than the type of surgical procedure, had a significant impact on surgical curability and survival of patients with infrahilar/suprapancreatic cholangiocarcinoma treated according to our intention-to-treat strategy.

Adjuvant gemcitabine plus S-1 chemotherapy improves survival after aggressive surgical resection for advanced biliary carcinoma

OBJECTIVE

The aim of this study was to evaluate the efficacy of adjuvant gemcitabine plus S-1 chemotherapy after aggressive surgical resection for advanced biliary carcinoma.

SUMMARY BACKGROUND DATA

No effective adjuvant therapy for advanced biliary carcinoma has been reported although its prognosis is extremely poor.

METHODS

Medical records were reviewed for 103 patients with International Union Against Cancer (UICC) stage II biliary carcinoma who underwent aggressive surgical resection. About 50 patients received 10 cycles of adjuvant gemcitabine plus S-1 chemotherapy and 53 patients did not. Clinicopathological factors and patient survival were compared between the 2 groups using univariate and multivariate analysis. A cycle of chemotherapy consisted of intravenous gemcitabine 700 mg/m(2) on day 1 and oral S-1 50 mg/m(2) for 7 consecutive days, followed by a 1-week break from chemotherapy.

RESULTS

Patient demographics, tumor characteristics, and surgical procedures did not differ between the 2 groups. Aggressive surgical procedures including major hepatectomy or pancreatoduodenectomy were performed for 94 of 103 patients. In the chemotherapy group, 37 patients (74%) were given the full number of 10 cycles. The use of postoperative adjuvant chemotherapy (P < 0.001) and surgical margin status (P = 0.003) were independently associated with long-term survival by multivariate analysis. Five-year survival rates of patients who did or did not receive postoperative adjuvant chemotherapy were 57% and 24%, respectively (P < 0.001). Toxicity during chemotherapy was mild.

CONCLUSIONS

Adjuvant gemcitabine plus S-1 chemotherapy may be one of several factors contributing to improved outcomes after aggressive surgical resection of advanced biliary carcinoma in recent years.

Indication for postoperative adjuvant therapy in biliary carcinoma based on analysis of recurrence and survival after surgical resection

Postoperative adjuvant therapy is mandatory for biliary carcinoma because of its unfavorable prognosis. The aim of this study was to evaluate the indication for postoperative adjuvant therapy in biliary carcinoma. The charts of 139 consecutive patients with biliary carcinoma (37 ampullary carcinomas, 36 distal carcinomas, 38 carcinomas of the gallbladder, and 28 hilar cholangiocarcinomas) who underwent surgical resection were retrospectively reviewed. Recurrence rates and survival rates after surgery were analyzed. Of the 139 carcinomas, the recurrence rates of International Union Against Cancer (UICC) stages IA, IB, IIA, IIB, and III cancers were 9%, 20%, 60%, 83%, and 100%, respectively. The recurrence rates of UICC stages II and III cancers were significantly higher than that of UICC stage I cancer (82% vs 13%, P < 0.001). The 5-year survival rates for patients with UICC stages IA, IB, IIA, IIB, and III cancers were 85%, 75%, 36%, 20%, and 0%, respectively. The 5-year survival rates for UICC stages II and III cancers were significantly lower than that for UICC stage I cancer (21% vs 82%, P < 0.001). Postoperative adjuvant therapy should be given to patients with UICC stages II and III biliary carcinomas because of their high rate of recurrence and the poor prognosis.

Safety of combined resection of the middle hepatic artery in right hemihepatectomy for hilar biliary malignancy

BACKGROUND/PURPOSE

In patients with hilar biliary malignancies, preservation of the middle hepatic artery (MHA, segment IV artery) where it runs close to the tumor in the hepatic hilum may lead to resection with positive margins. This retrospective study assessed the safety of combined resection of the MHA with right hemihepatectomy, caudate lobectomy, and bile duct resection for hilar biliary malignancies.

METHODS

Of 61 patients with hilar biliary malignancies who underwent right hemihepatectomy, we classified the branching patterns of the MHA according to the origins and courses in the hilum. The MHA was resected without reconstruction in 16 patients in whom the artery ran close to the tumor. We compared the perioperative outcomes in these patients with those of patients who did not undergo resection of the artery.

RESULTS

Anatomically, the MHA ran on the right side of the umbilical portion of the portal vein in 40 (66%) patients. Perioperative data for the patients who underwent combined resection were similar to those in whom the MAH was preserved. There were no postoperative complications that could be directly related to the arterial resection.

CONCLUSIONS

Combined resection of the MHA during right hemihepatectomy for hilar biliary malignancies has a safe perioperative course.