Gallbladder Cancer Involving the Extrahepatic Bile Duct

Preoperative MRI-based nomogram to predict survival after curative resection in patients with gallbladder cancer: a retrospective multicenter analysis

PURPOSE

To use preoperative MRI data to construct a nomogram to predict survival in patients who have undergone R0 resection for gallbladder cancer.

METHODS

The present retrospective study included 143 patients (M:F, 76:67; 67.15 years) with gallbladder cancer who underwent preoperative MRI and subsequent R0 resection between 2013 and 2021 at two tertiary institutions. Clinical and radiological features were analyzed using univariate and multivariate Cox regression analysis to identify independent prognostic factors. Based on the multivariate analysis, we developed an MRI-based nomogram for determining prognoses after curative resections of gallbladder cancer. We also obtained calibration curves for 1-,3-, and 5-year survival probabilities.

RESULTS

The multivariate model consisted of the following independent predictors of poor overall survival (OS), which were used for constructing the nomogram: age (years; hazard ratio [HR] = 1.04; 95% confidence interval [CI], 1.04-1.07; p = 0.033); tumor size (cm; HR = 1.40; 95% CI, 1.09-1.79; p = 0.008); bile duct invasion (HR = 3.54; 95% CI, 1.66-7.58; p = 0.001); regional lymph node metastasis (HR = 2.47; 95% CI, 1.10-5.57; p = 0.029); and hepatic artery invasion (HR = 2.66; 95% CI, 1.04-6.83; p = 0.042). The nomogram showed good probabilities of survival on the calibration curves, and the concordance index of the model for predicting overall survival (OS) was 0.779.

CONCLUSION

Preoperative MRI findings could be used to determine the prognosis of gallbladder cancer, and the MRI-based nomogram accurately predicted OS in patients with gallbladder cancer who underwent curative resection.

Preoperative CT findings for prediction of resectability in patients with gallbladder cancer

OBJECTIVES

To predict residual tumor (R) classification in patients with a surgery for gallbladder (GB) cancer, using preoperative CT.

METHODS

One hundred seventy-three patients with GB cancer who underwent CT and subsequent surgery were included. Two radiologists assessed CT findings, including tumor morphology, location, T stage, adjacent organ invasion, hepatic artery (HA) invasion, portal vein invasion, lymph node metastasis, metastasis, resectability, gallstone, and combined cholecystitis. The R classification was categorized as no residual tumor (R0) and residual tumor (R1 or R2). We analyzed the correlation between CT findings and R classification. We also followed up the patients as long as five years and analyzed the relationship between the R classification and the overall survival (OS).

RESULTS

There were 134 patients with R0 and 39 patients with R1/R2. On multivariable analysis, liver invasion (Exp(B) = 3.19, p = 0.010), bile duct invasion (Exp(B) = 3.69, p = 0.031), and HA invasion (Exp(B) = 3.74, p = 0.039) were independent, significant predictors for residual tumor. When two of these three criteria were combined, the accuracy for predicting a positive resection margin was 83.38% with a specificity of 93.28%. The OS and the median patient survival time differed significantly according to the resection margin, i.e., 56.0% and 134.4 months in the R0 resection and 5.1% and 10.8 months in the R1/R2 resection group (p < 0.001).

CONCLUSIONS

Preoperative CT findings could aid in planning surgery and determining the resectability using the high-risk findings of residual tumor, including liver invasion, bile duct invasion, and HA invasion.

KEY POINTS

• Liver invasion, bile duct invasion, and HA invasion were significant preoperative CT predictors for residual tumor in GB cancer. • HA invasion showed the highest OR on multivariate analysis and the highest predictor point on a nomogram for predicting a positive resection margin. • Association of two factors can predict positive resection margin with an accuracy of 83.38% and a specificity of 93.28%.

Routine extra-hepatic bile duct resection in gallbladder cancer patients without bile duct infiltration: A systematic review

AIM

The optimal treatment for advanced gallbladder cancer, in particular T2 stage cancer, is unclear. The use of "radical cholecystectomy" or more extended procedures with extra-hepatic bile duct resection are matter of debate. Due to the lack of consensus regarding the oncological significance of routine extra-hepatic bile duct (EBD) resection for gallbladder carcinoma, we decided to perform a systematic review investigating the real benefit of this procedure focusing on the primary outcomes of overall survival and disease-free survival.

METHODS

A systematic literature search was performed using PubMed, EMBASE, Scopus and the Cochrane Library Central according to the PRISMA statement guidelines for conducting and reporting systematic reviews. Multiple primary and secondary outcomes were analyzed.

RESULTS

The selected articles included 424 patients who underwent routine EBD resection without bile duct infiltration. Only two papers discussed the number of dissected lymph nodes during EBD resection for gallbladder carcinoma. Four of the seven included papers reported on tumor involvement in lymph nodes at rates ranging between 39% and 83%. All of the studies included in this systematic review reported on results of overall survival. In general, 5-years OS rate of the EBD-resected patients was not significantly different than that of the EBD-preservation group, while the mobility was significantly higher in the EBD resection group.

CONCLUSIONS

Routine EBD resection in gallbladder cancer patients without bile duct infiltration is not associated with improved overall survival, improved lymph-node harvesting or with minor recurrence rate, but it is associated with higher morbidity rates.