Heterogeneity of management practices surrounding operable gallbladder cancer - results of the OMEGA-S international HPB surgical survey

BACKGROUND

Gallbladder cancer (GBC) is an aggressive, uncommon malignancy, with variation in operative approaches adopted across centres and few large-scale studies to guide practice. We aimed to identify the extent of heterogeneity in GBC internationally to better inform the need for future multicentre studies.

METHODS

A 34-question online survey was disseminated to members of the European-African Hepatopancreatobiliary Association (EAHPBA), American Hepatopancreatobiliary Association (AHPBA) and Asia-Pacific Hepatopancreatobiliary Association (A-PHPBA) regarding practices around diagnostic workup, operative approach, utilization of neoadjuvant and adjuvant therapies and surveillance strategies.

RESULTS

Two hundred and three surgeons responded from 51 countries. High liver resection volume units (>50 resections/year) organised HPB multidisciplinary team discussion of GBCs more commonly than those with low volumes (p < 0.0001). Management practices exhibited areas of heterogeneity, particularly around operative extent. Contrary to consensus guidelines, anatomical liver resections were favoured over non-anatomical resections for T3 tumours and above, lymphadenectomy extent was lower than recommended, and a minority of respondents still routinely excised the common bile duct or port sites.

CONCLUSION

Our findings suggest some similarities in the management of GBC internationally, but also specific areas of practice which differed from published guidelines. Transcontinental collaborative studies on GBC are necessary to establish evidence-based practice to minimise variation and optimise outcomes.

[Primary cholangiocarcinoma associated with Caroli disease]

A 68 years old male presented with right hypochondrium abdominal pain and jaundice with no other clinical finding. CAT Scan and Ultrasonography showed right lobe bile duct dilatation. Magnetic Resonance Cholangiopancreatography gave an outstanding vision of a restricted right lobe bile duct dilatation associated to choledocholithiasis. A right hepatectomy and bile duct exploration were performed. The histopathological study disclosed a Caroli disease associated to a primary cholangiocarcinoma. Caroli disease is a congenital disorder characterized by intrahepatic cystic bile duct dilatation with a high risk association with cholangiocarcinoma.

Intraoperative chemohyperthermic peritoneal perfusion as an adjuvant to gastric cancer: final results of a randomized controlled study

BACKGROUND/AIMS

Although the most frequent cause of death after curative resection of advanced gastric cancer is peritoneal recurrence, there was no effective therapy for the prevention of peritoneal recurrence. This randomized trial sought to determine whether intraoperative chemohyperthermic peritoneal perfusion could eliminate microscopic residual disease and thereby improve survival of patients with advanced gastric cancer.

METHODOLOGY

One-hundred and thirty-nine patients with T2-4 gastric cancer underwent curative gastrectomy with extended lymphadenectomy. These patients were randomly allocated into the following three groups. Patients in the CHPP group received surgery + chemohyperthermic peritoneal perfusion, and those in the CNPP group underwent surgery + chemonormothermic peritoneal perfusion. The third group was surgery alone group. In the CHPP and CNPP groups, peritoneal cavity was perfused with 6-8 liters of heated saline at, respectively, 42-43 degrees C and 37 degrees C with 30 mg of mitomycin C and 300 mg of cisplatin by a extracorporeal circulation machine.

RESULTS

Major operative complication occurred in 19% (9/48), 14% (6/44) and 19% (9/47) of the CHPP, CNPP and surgery alone group, respectively. Complication which uniquely developed after chemohyperthermic peritoneal perfusion was bowel perforation. Mortality rates of each group were 4% (2/48), 0% (0/44) and 4% (2/47) in the CHPP, CNPP and surgery alone group, respectively. Overall 5-year survival rates of CHPP, CNPP and surgery alone groups were 61%, 43% and 42%, respectively. In a subset analysis, patients with gastric cancer having serosal invasion or lymph node metastasis have shown a statistically significant improvement in survival when treated with chemohyperthermic peritoneal perfusion. However, chemonormothermic peritoneal perfusion had no survival benefit. By analyzing with Cox proportional hazard model, chemohyperthermic peritoneal perfusion emerged as an independent prognostic factor for good survival. Surgery alone had three-fold higher risk of death than chemohyperthermic peritoneal perfusion.

CONCLUSIONS

Chemohyperthermic peritoneal perfusion had an efficiency for the prophylaxis of recurrence after curative resection of advanced gastric cancer, and is indicated for patients with tumor infiltrating beyond serosal layer and node positive tumor.

[Incipient gallbladder carcinoma. Clinical and pathological study and prognosis in 196 cases]

BACKGROUND

There is little information about the behavior of early gallbladder carcinoma.

AIM

To report the clinical and pathological features of 196 patients with early gallbladder carcinoma.

MATERIAL AND METHODS

All patients with gallbladder cancer diagnosed between 1988 and 1997 were reviewed. In 703 of 829 patients, there was information about clinical features and follow up, and were included in this study. All gallbladders were subjected to a complete mapping. When neoplastic cells involved only the mucosa or muscular layer, the tumors were considered as early.

RESULTS

One hundred ninety six patients had an early carcinoma (161 women, aged 57.5 years and 35 male, aged 63.4 years). One hundred twenty eight tumors were located in the mucosa and 68 in the muscular layer. Patients with tumors involving the mucosa were younger than those with tumors involving the muscular layer. All tumors were adenocarcinomas, 66% were well differentiated and 32% moderately differentiated. Tumors were not visible macroscopically in 132 cases. Five and 10 years survival was 92%. Subjects of less than 40 years old had a 100% survival at 5 years. A hepatic and lymph node resection was done in 12 patients with tumors infiltrating the muscular layer but in only one, the tumor infiltrated the liver. No difference in survival was observed when a simple cholecystectomy or radical surgery was done.

CONCLUSIONS

Nearly 25% of gallbladder carcinomas can be classified as early and its diagnosis requires a directed study. Simple cholecystectomy is curative for this type of gallbladder cancer.

[Findings in surgical reinterventions for cancer of the gallbladder in patients with and without preoperative chemotherapy and radiotherapy]

BACKGROUND

The usefulness of surgery in the treatment of gallbladder cancer has not been clearly established. The benefits of chemo and radiotherapy are similarly dubious.

AIM

To report the pathological findings in patients subjected to surgical reinterventions for gallbladder cancer.

PATIENTS AND METHODS

We report 54 patients with gallbladder cancer that were subjected to a second surgical intervention for resection of liver segments IVb and V and lymph nodes corresponding to the liver hilar, portal, peripancreatic, celiac artery and periaortic territories. Thirteen of these patients were subjected to preoperative chemo-radiotherapy (4500 Gy and 5-fluouracil 500 mg/m2).

RESULTS

Lymph node metastases were found in 25 and 38%, and liver metastases in 25 and 28% of patients with or without chemo-radiotherapy respectively. The most frequent pathological findings attributed to radiation in the liver were fatty infiltration in 75% of cases, vascular transformation in 83% of cases and minimal periportal lymphocyte infiltration in 40% of cases. Lymph nodes were atrophic in 67% of cases and had foci of cortical necrosis in 46% of cases. Three cases had regional lymph node and liver metastases. Most tumor cells were viable.

CONCLUSIONS

No differences in the number of lymph node or liver metastases were observed between patients with and without chemo-radiotherapy. No effect of the treatment on residual tumor was observed either.

[CD44 (HCAM) expression in subserous gallbladder carcinoma]

BACKGROUND

HCAM or CD44 is a multifunctional cell adhesion molecule, related to cell-cell, cell-extracellular matrix interactions and involved in tumor invasion.

AIM

To study the importance of CD44 expression in subserous gallbladder carcinoma.

MATERIAL AND METHODS

One hundred five samples (93 female) of subserous gallbladder carcinoma and 33 non tumoral gallbladder were studied. CD44 was stained using the streptavidine-biotin technique, using human anti CD44 antibodies. Eighty subjects with carcinoma were followed for a period up to 105 months.

RESULTS

Mean age of patients was 62.6 years old, all tumors were adenocarcinoma, all were silent and 13% were well differentiated. CD44 was expressed in all controls and in 91%, the expression was normal. In 57% of cancer samples, CD44 expression was abnormal, in 50% it was less expressed and in 24%, it was not expressed. No differences in CD44 expression was observed between mucosa from control samples and mucosa adjacent to the tumor or superficial or deep tumoral areas. Global five years survival was 40%. No significant differences in survival were observed in those tumors with a lower of absent CD44 expression. Six patients with a higher expression died before 18 months of follow up.

CONCLUSIONS

Nearly 50% of subserous gallbladder carcinomas show an abnormal CD44 expression.

[P53 gene mutation in gallbladder cancer]

BACKGROUND

Gallbladder cancer frequency and mortality renders it one of the most important neoplastic diseases in Chile. P53 tumor suppressor gene has been studied in most types of cancer, but there is scarce information about it in gallbladder cancer.

AIM

To study the frequency of P53 gene mutation in gallbladder cancer in the ninth region of Chile.

MATERIAL AND METHODS

In 25 pathological samples of gallbladder cancer, the direct amplification and sequencing of p53 gene exons 5,6,7,8-8 was possible.

RESULTS

Seventeen punctual mutations were observed in 13 cases (52%). There were 10 transitions, 5 transversions, one insertion (codon 194) and one deletion (codon 186). Eight cases had mutations in exon 5, six had mutations in exon 6, two had mutations in exon 7 and one had mutations in exons 8-9. In 14 of 25 cases, gene p53 protein was positive. When immunohistochemical expression of gene p53 protein was positive in more than 20% of cells, there was a high correlation between genetic alterations and immunohistochemical expression of the protein, with a specificity, sensitivity, positive and negative predictive values over 80%.

CONCLUSIONS

P53 gene mutation is observed in a high proportion of gallbladder cancers at it can be accurately detected with conventional immunohistochemical techniques. The importance of this gene in the genesis of this carcinoma should be determined studying preneoplastic lesions and early carcinomas.

Gallbladder cancer, management of early tumors

In spite of the fatal course associated with patients with gallbladder cancer, there is a subgroup of them in whom prognosis could be improved. Although early gallbladder cancer is considered a tumor with invasion of the mucosa or the muscular layer, in this manuscript we analyze those with invasion confined to the gallbladder. Pre-operative diagnosis of these patients is rare with cholecystectomy specimen histologic analysis being the most common way of detecting these tumors. The level of wall invasion represents a useful and practical way of dividing the patients according to their prognosis and treatment. Mucosal and muscular invasion tumors could be cured by simple cholecystectomy. Among patients with a tumor confined to the gallbladder, those with subserosal infiltration represent the largest group. Residual tumor after cholecystectomy is a common fact in these patients, thus a more aggressive procedure than simple cholecystectomy should be performed. Generally, extended cholecystectomy is the preferred approach for dealing with these patients. Unfortunately, in spite of the employment of extended and potentially curative surgery, prognosis is still poor and additional therapeutic procedures are needed. Finally, when tumors compromise the serosal layer, 5-year survival is poor irrespective of the type of therapy. However, well-selected cases deserve to undergo aggressive treatment.

Gallbladder cancer in a high risk area: morphological features and spread patterns

BACKGROUND/AIMS

Gallbladder carcinoma is one of the most frequent malignant tumors in Chile. The aim of this paper is to show our experiences in gallbladder carcinoma.

METHODOLOGY

Six-hundred-sixty-nine cases of gallbladder carcinoma were included in this prospective study; 557 females (83.5%) and 112 males (16.5%). In 466 cases (70%), diagnosis was carried out in the cholecystectomy sample, 45 cases were partial cholecystectomies and 158 cases were metastases of gallbladder carcinoma.

RESULTS

Ninety-eight per cent of the cases were adenocarcinomas, and in 85% of the cases gallstones were observed. Thirty-seven per cent of the primary tumors were macroscopically inapparent. One-hundred-thirty-one cases (29%) were early carcinomas and 323 cases (71%) were advanced carcinomas. A relationship between differentiation grade and infiltration level (p=0.0001) was observed. Lymph-node metastasis was found in 18.5%, 4.5% and 3.3% in the first, second and third lymph-node barriers respectively. Muscular tumors presented no lymph-node metastasis, while in serosal tumors lymph node metastasis reached 62% (p=0.04). Hepatic tumor infiltration was observed in 11%, 19% and 38% of muscular, subserosal and serosal tumors.

CONCLUSIONS

The high frequency of inapparent carcinomas, gallstones and inflammatory changes of the vesicular wall are elements that make the pre-operative diagnosis of gallbladder carcinoma difficult. Differentiation grade and infiltration level are the most reliable prognostic factors in gallbladder carcinoma. Lymph-node metastasis or liver tumor infiltration are infrequent in early gallbladder carcinoma.

Preoperative chemoradiotherapy in the treatment of gallbladder cancer

Gallbladder cancer is generally associated with a poor prognosis, with local recurrence being the main pattern of failure. In an attempt to improve on the present status of management, we evaluated a prospective Phase II study involving preoperative 5-fluorouracil and radiation. Among 27 eligible patients with a potentially resectable gallbladder cancer detected after cholecystectomy, 18 were treated with preoperative radiation (4500 cGy; 180 cGy/fraction, 5 days/week) concurrent with a continuous infusion of 5-fluorouracil (350 mg/m2/day, days 1-5 and 21-25). Toxicity included leukopenia (8 patients) and thrombocytopenia (7 patients). Delay in surgery due to hematological toxicity was seen in 6 patients. Of the 18 patients, 15 underwent a reoperation. Resection was performed in 13 (86%). Pathologic findings after reoperation revealed residual tumor in both liver and lymph nodes in 3 patients. At a median follow-up of 24 months, 7 patients are alive. Among the patients who died after curative resection, local recurrence was demonstrated in only 1. This is the first report concerning preoperative chemoradiation in gallbladder cancer. To assess its effect on survival, a prospective randomized trial will be necessary.

[Advances in the diagnosis and treatment of pancreatic carcinoma]

Pancreatic carcinoma has a dismal prognosis. In the last years, great efforts have been made to improve diagnosis and preoperative staging of potentially curable carcinomas. Actually, the diagnosis of fairly small tumours is possible. Chemoradiation therapy protocols prior to pancreatectomy, aiming to improve survival, are currently being held. This therapy allows radiation to be distributed into well oxygenated cells before surgical devascularization. This procedure can be done with acceptable morbidity and mortality rates. In selected cases of irresectable carcinoma, surgical palliation allows a better quality of life. Pancreatoduodenal resection, along with other traditional oncological therapies, will continue to be the therapy of choice for patients with carcinoma of the head of the pancreas, without local or regional metastases. However, an intensive search for new therapeutic strategies, specially in the field of molecular biology, is being carried out.

Choledochoduodenostomy for common bile duct stones

Among the techniques for dealing with common bile stones, choledochoduodenostomy (CDS) represents a useful alternative. This operation is indicated mainly in patients with recurrent stones, giant stones, or concomitant common bile stricture and duct stones. At the present time most of the patients undergoing CDS have been already undergone endoscopic retrograde cholangiography or ultrasonography to study the common bile duct and the cause of symptoms. The common bile duct diameter is of paramount importance when determining the feasibility of performing a CDS, the critical size being 1.2 cm. The most common operation is a side-to-side anastomosis employing absorbable sutures. Stomal patency is the most important factor for preventing classic complications such as cholangitis and sump syndrome. These complications are rare, being observed in only 5% of the patients. Long-term results of the operation show that it is a safe procedure that should be considered a good option in selected patients with choledocholithiasis.

[Tumor invasion in gallbladder cancer. Importance of blood vascular tumor infiltration diagnosis]

BACKGROUND

The infiltration of venous blood vessels in gallbladder carcinoma and its importance as a prognostic factor has not been well studied. Victoria blue stain has been used to identify vascular involvement in gastric and thyroidal carcinomas.

AIM

To assess blood vessel infiltration using Victoria blue stain in gallbladder carcinomas.

MATERIAL AND METHODS

One hundred forty eight samples of gallbladder carcinomas, coming from 24 men and 123 women aged 60.4 +/- 12.2 years old, were studied. They were stained with Victoria blue stain to quantify blood vessel invasion.

RESULTS

Twenty nine percent of tumors had blood vessel infiltration, 61% had lymph vessel and 20% had perineural infiltration. Lymph vessel or perineural involvement was found in 81% and 31% of those tumors with blood vessel infiltration, respectively. Perineural infiltration was associated with lymph or vascular involvement in 93 and 40% of tumors, respectively. None of the early carcinomas had blood vessel infiltration, whereas 33% of advanced tumors had this type of infiltration (p < 0.001). No differences in vascular infiltration were observed according to the differentiation of the tumor.

CONCLUSIONS

Blood vessel infiltration was observed only in advanced gallbladder carcinomas and was tightly related to the degree of gallbladder wall infiltration. The presence of perineural infiltration was the best marker of lymph or blood vessel infiltration.

p53 tumour suppressor gene protein expression in early and advanced gallbladder carcinoma

AIMS

Gallbladder carcinoma is one of the most frequent malignant tumours occurring in Chile and the mortality rate in both sexes ranks among one of the highest in the world. Mutation of p53 tumour suppressor gene has been demonstrated in many tumours. Our aim was to determine protein expression of p53 gene in early and advanced gallbladder carcinoma.

METHODS AND RESULTS

Protein expression of gene p53 was studied by immunohistochemical means in 191 gallbladder carcinomas (157 primary tumours, 34 metastases) and 25 controls. In 86 out of 191 cases (45%), protein expression of gene p53 was observed. Differences related to sex, age, or race were not observed. All gallbladder controls were negative. Twenty-five per cent of well-differentiated tumours were p53 positive, while moderate or poorly differentiated carcinomas reached 50% (P = 0.04). p53 expression was observed in 23.5% of early carcinomas and in 48.2% of advanced carcinomas (P = 0.01). No differences between primary tumours and metastasis were demonstrated.

CONCLUSIONS

Protein expression of p53 tumour suppressor gene is observed in 45% of gallbladder carcinomas. The absence of expression in controls and in normal mucosa adjacent to tumours suggests its utility in differentiating atypical gallbladder epithelia from neoplastic lesions.

DNA ploidy pattern and tumor suppressor gene p53 expression in gallbladder carcinoma

The relationship between p53 gene expression and DNA content in advanced gallbladder carcinoma was studied. Fifty-three cases of advanced gallbladder carcinoma (45 primary tumors and 8 metastases) were analyzed, p53 protein expression was determined by immunohistochemistry, DNA content was measured by cytophotometric techniques. Study subjects included 45 (85%) female and 8 male patients, with an overall mean age of 58.6 years. Positive staining for p53 protein was observed in 27 (51%) cases. In subserosal tumors, the expression was significantly less than that in tumors that reached the serosa (P = 0.01). Twenty-nine (55%) cases were diploid and 24 were aneuploid. Sixty-seven % of primary tumors were diploid, whereas 87% of metastases showed an aneuploid DNA content. Both diploid and aneuploid tumors were positive for the p53 protein in the same proportion, and p53 was also expressed equally in both primary and secondary tumors. In advanced gallbladder carcinoma, the expression of the p53 gene was earlier than the accumulation of abnormal quantities of chromosomal DNA in the tumor cells. The determination of these events as markers in preneoplastic lesions is warranted in gallbladder carcinogenesis.

[Pancreas divisium as a cause of chronic pancreatitis. Clinical case]

We report a 6 years old girl with chronic pancreatitis, presenting as recurring bouts of abdominal pain and hyperamylasemia, secondary to a lack of communication between the main papilla and pancreatic duct (pancreas divisium). The diagnosis was made during an intraoperative pancreatography and treatment consisted in a sphincteroplasty of the secondary papilla.

[Gallbladder cancer: a review]

In Chile, gallbladder cancer is the tumor with the highest mortality rates among women. Cholelithiasis is the most common associated factor and the reduction in cholecystectomy rates could be an important factor in the incidence of gallbladder cancer. Unfortunately, the disease is diagnosed late and the study of the surgical piece is the main form of early recognition. The degree of gallbladder wall infiltration by the tumor is the simplest and best staging method that has prognostic value. Gallbladder fat must be considered as a separate tissue, since its biological behavior differs from that of the subserous. The treatment of these tumors is based in their dissemination modality that is mainly local and regional. Surgical resection and radiotherapy are potentially effective. However the detection of high risk patients that should be subjected to cholecystectomy should be the better therapeutic alternative.

[CAA 19-9 and carcinoembryonic antigen in gallbladder cancer]

The aim of this work was to assess the diagnostic yield of serum tumoral markers, Ca 19-9 and carcinoembryonic antigen, in patients with gallbladder cancer. We studied 54 patients of whom 33 had gallbladder cancer and in 21 the tumor was removed previously and were presently free of disease. Twenty one patients with cholelithiasis were used as controls. Ca 19-9 was over 37 U/ml in 22 (65%) patients with cancer, in two patients free of disease and in two controls. The sensitivity and specificity of Ca 19-9 was 0.66 and 0.90 respectively. Carcinoembryonic antigen was over 2.5 ng/ml in 25 patients with cancer (56%) and its sensitivity and specificity was 0.75 and 0.71 respectively. Using a cutoff point of 4 ng/ml, these figures were 0.51 and 0.9 respectively. The better predictive capacity was given by a Ca 19-9 over 37 U/ml or a carcinoembryonic antigen over 4 ng/ml. It is concluded that, although the sensitivity and specificity of these markers was adequate in this work, one must bear in mind that studied patients had advanced tumors.

[Hereditary chronic pancreatitis. Report of a case]

Childhood hereditary pancreatitis is a rare entity of uncertain etiology, characterized by recurrent episodes of acute pancreatitis, abdominal pain and other unspecific symptoms. Among several therapeutic alternatives, pancreatojejunostomy is presently the treatment of choice. We report a 17 years old male with chronic hereditary pancreatitis that was treated with pancreatojejunostomy drainage.

[Gallbladder cancer. Case-control study]

Gallbladder cancer is the principal oncological cause of death in chilean women and cholelithiasis is a well recognized risk factor. Aiming to unravel other risk factors for gallbladder cancer, we compared 50 patients subjected to cholecystectomy in whom a gallbladder cancer was found with 50 age and sex matched operated controls without cancer. Subjects were clinically assessed and interrogated about demographic, obstetrical features and feeding features. Multiples and early pregnancies were factors significantly associated to the development of gallbladder cancer. Twenty subjects (44%) with cancer knew that they had cholelithiasis and 41 patients in each group were symptomatic. It is concluded that pregnancy may be a risk factor for gallbladder cancer probably due to the lithogenic effect of its hormonal changes. Also, early cholecystectomy in symptomatic individuals may be an effective preventive measure.

[Gallbladder cancer in the IX Region of Chile. Impact of the anatomopathological study of 474 cases]

We studied prospectively 474 cases (83% female with a female:male ratio of 5:1) of gallbladder carcinoma diagnosed in a period of 7 years. Twenty two percent of patients were younger than 50 years old. Ninety percent of tumors were adenocarcinomas. In 1987, 45% of cases were diagnosed in metastases compared to 1993, when only 10% of tumors were diagnosed in such histological material. Thirty four percent of tumors were not macroscopically identified; all these inapparent tumors were advanced in 1987, whereas 53% were incipient in 1993. Moreover, inapparent tumors had a significantly lower degree of gallbladder wall infiltration and higher degree of differentiation. Well differentiated tumors had a lesser degree of wall infiltration. It is concluded that the careful histopathological study of gallbladder cancer has allowed a thorough knowledge of the natural history and clinical presentation of gallbladder carcinoma.

[Laparoscopic cholecystectomy makes difficult the analysis of gallbladder mucosa. Morphometric study]

Laparoscopic gallbladder surgery damages gallbladder mucosa, impeding an adequate histological examination. We studied gallbladder samples coming from 56 conventional and 44 laparoscopic cholecystectomies performed in patients with chronic cholecystitis without signs of acute inflammation. The length of each examined sample and the length of the portion where superficial epithelia was not found was measured. No differences in sample length was found between both types of cholecystectomy. However; the segment with superficial mucosa was significantly shorter in the samples coming from laparoscopic surgery. Seventeen samples did not contain mucosa at all and 14 of these (82%) came from laparoscopic procedures. Eighty six percent of samples coming from laparoscopic surgery were considered inadequate for histological study compared to 36% of samples coming from conventional cholecystectomy. It is concluded that laparoscopic cholecystectomy hampers the study of gallbladder mucosa and may have an impact on the diagnosis of neoplastic gallbladder lesions.

[Gallbladder carcinoma: expression of the c-myc and ras-p-21 oncogene products]

The expression of c-myc and p-ras-21 oncogenes was studied using an immunohistochemical method with monoclonal antibodies in 126 samples of gallbladder carcinoma (103 primary tumors and 23 metastatic lesions). Twenty five gallbladder samples without tumor evidence were used as controls. C-myc oncoprotein was positive in one control sample and p-ras-21 oncoprotein was negative in all. Among primary carcinomas c-myc was positive in 9 (9%) and p-ras-21 in 4 (4%); among metastatic carcinomas c-myc was positive in 6 (26%, p = 0.03 vs primary carcinoma) and p-ras-21 in 11 (48%, p < 0.001 vs primary carcinoma). There was a non significant association between c-myc and p-ras-21 expression and degree of histological differentiation and level of tumoral infiltration. It is concluded that c-myc and p-ras-21 oncoprotein expression is observed in less than 10% of primary gallbladder carcinomas and that this expression is significantly higher in metastatic carcinomas. This may reflect an activation or overexpression of these oncogenes in metastatic cells.

[Determination of DNA content using cytophotometry in nuclear suspension conserved for prolonged periods (preliminary study)]

The variations in cytophotometric determination of DNA content were studied in a concentrated suspension of nuclei stored for prolonged periods. These came from normal and tumoral cells of an uterine leiomyosarcoma, fixed in formalin and included in paraffin. DNA was measured in normal and tumoral cells at days 0, 1, 7, 11, 19, 27 and 33. No significant variations in DNA measurement were observed. In a same day, there was an uniform DNA content, ploidy pattern and DNA index and an aneuploid pattern was diagnosed in all histograms. These results suggest that nuclear suspensions can be conserved for long periods and used for DNA content determination, allowing the access of remote places to these techniques.

[Mutagen extraction from bile of patients with inflammatory biliary pathology: Ames test using blue rayon]

Gallbladder carcinoma is frequent in Chile. The aim of this study was to report the mutagenicity of whole human bile, using the Ames/Salmonella microsome assay with Salmonella typhimurium TA98. The bile of 19 patients, aged 23 to 64 years old, subjected to cholecystectomy was examined, and mutagen activity was found in 13 (72%). Mutagens were extracted using blue rayon and three dilutions for the eluted material from blue rayon were used (50, 100 and 200 ul). The best result was obtained using 200 ul. In some cases, the amount of revertive colonies was very high (over 5 times the control value). We propose that the bile from these patients possibly contains mutagenic substances with frame shift mutagenic activity and that these substances may be related to gallbladder carcinoma. Our results have addressed the importance of bile studies to elucidate the pathogenesis of gallbladder carcinoma.

[Stomach and gallbladder cancer. Analysis of cell cycle phases by means of flow cytometry]

The characteristics of the different phases of cell cycle were analyzed in paraffin embedded samples of gall bladder cancer (n = 96) and gastric cancer (n = 40). Computational programs that included Dean, Kosugi and manual methods were used. No differences in variation coefficients were observed between tumors with normal or aneuploid ADN content, with any of the employed methods. Histograms with variation coefficients over 10% were not considered. No differences were observed between the two forms of analysis of Kosugi's method; however there were differences between the manual method and Kosugi's and Dean's methods. The percentage of cells in G0/G1 phase varied between 74.1 and 81.5% according to the employed method. The obtained percentages with Kosugi's method with normal distribution were significantly lower in all the studied groups. These percentages fluctuated between 79.7 and 94.4% in tumors with normal ADN content and between 60.3 and 80.4% in tumors with abnormal ADN content. The proportion of cells in phase G2/M was lower and in phase S lower and more homogeneous among diploid compared to aneuploid tumors. These differences were observed only in primary tumors and not in metastases.

[Epithelial lesions associated with gallbladder carcinoma. A methodical study of 32 cases]

Using mapping techniques, 32 consecutive gallbladder carcinomas diagnosed in our department were studied. The defined lesions were dysplasia, carcinoma in situ and superficial spreading carcinoma. A total of 2257 lesions were recorded from 1072 inclusions. All the defined lesions were present in about 10% of all sections. However, if each case is considered separately, dysplasia was present in 81.3% of cases, carcinoma in situ in 65.6% of cases and superficial spreading carcinoma in 68.8% of cases. An isolated focus of atypical epithelium without anatomic relation with the main tumor was demonstrated in only 3 cases and a close relation between invasive carcinoma and dysplastic lesions was observed in the remainder. Infiltration of Rokistansky-Aschoff sinuses was observed in 40% of cases. We were not able to demonstrate, on histological basis, differences between superficial spreading carcinoma and carcinoma in situ. We conclude that atypical lesions of the gallbladder are not frequently seen and that their presence must prompt the search of a carcinomatous lesion by means of serial sections of all the histological sample.

[Immunohistochemical demonstration of pepsinogens I and II in the gallbladder]

The immunohistochemical expression of pepsinogen I (PI) and pepsinogen II (PII) was studied in 103 gallbladder carcinomas, 25 non tumoral gallbladder lesions and 23 gallbladder cancer metastases. PI was positive in 6% of carcinomas and only in 2% of non tumoral contiguous mucosa. PII was positive in 46% of carcinomas and 43% of controls. Metastases were negative for both enzymes. Pyloric gland metaplasia of non tumoral mucosa adjacent to the tumor expressed PII in 68.9% and PI in 3.4% of cases. The same lesion in non tumoral gallbladders was positive for PII in 66.6% of cases, and no case expressed PI. There was no relationship between PI expression and the histological degree of differentiation. Only tumors with serosal or subserosal involvement were positive for PI. PII had a higher expression in early or well differentiated tumors. Tumors with pyloric gland metaplasia in the contiguous non tumoral mucosa expressed PII more frequently. Our results, based on the expression of PI and PII, suggest a relationship between the presence of pyloric gland metaplasia and some types of gallbladder cancer.

[Gallbladder cancer: immunohistochemical expression of CA-19-9, epithelial membrane antigen, dupan-2 and carcinoembryonic antigen]

The immunohistochemical expression of CA19-9, epithelial membrane antigen (EMA), and carcinoembryonic antigen (CEA) was studied in 103 tissue samples of gallbladder cancer and 25 samples of non tumoral gallbladder lesions. CA19-9 and EMA were positive in over 90% of cancers and non tumoral lesions. Dupan-2 expression was observed in 100% of non tumoral lesions and 78% of cancers. CEA expression was observed in 12% of non tumoral lesions and 89% of cancers. The magnitude of immunohistochemical staining was moderate or intense for all antibodies, except Dupan-2. No differences were observed in the location of positive staining in superficial or deep parts of the tumor. In these lesions the positive staining was cytoplasmatic with a granular and irregular pattern; on the contrary, in the non tumoral lesions, staining was seen in the apical parts of the cell. Calculated sensitivity, specificity and positive predictive value for CEA was 89%, 88% and 96% respectively. If future studies disclose a good correlation between serological and immunohistochemical detection of this antigen, its determination would be potentially useful in clinical grounds.

[Characteristics of gastric cancer in the IX region of Chile]

The results of a prospective protocol for the management of patients with gastric cancer applied from May 1988 to June 1991 are reported. 123 patients were operated on and a resection performed in 55%. Only 14 patients had incipient tumor and 44 had "curative" surgery. There was a preponderance of non differentiated tumors located high in the stomach. Endoscopy and biopsy were performed in cases with positive diagnosis in 91 and 93%, respectively. The overall actuarial survival rate was 37% at 38 months, rising to 50% for patients undergoing resection and to 82% in patients with "curative" resection.

Gallbladder cancer in Chile. A report on 54 potentially resectable tumors

Fifty-four patients with potentially resectable gallbladder tumors, chosen from 205 cases diagnosed at the Pathologic Unit of the authors' institution, were included in a prospective protocol of management. Of the potentially resectable tumors, only four were indicated before cholecystectomy (7.4%). Inconspicuous tumors were frequently observed, explaining in part the poor results of ultrasonogram for diagnosis. Poorly differentiated tumors were related to a greater rate of metastasis and shorter survival. Likewise, younger patients were associated with a worse prognosis. Patients with tumor confined to the mucosal layer were followed-up only during their postoperative courses. Patients with tumor involvement of the subserosa or muscular layer were offered treatment of a second operation, which included a lymphadenectomy and a liver wedge resection. For patients with serosal involvement, a more aggressive approach was proposed. Metastatic lymph node involvement was found in 9 of the 25 (36%) patients in whom dissection was performed. However, tumor invasion of the liver was seen in 10 of the 24 (41.6%) patients who underwent a liver resection. Patients who had a curative resection had a significantly longer survival in comparison with those who had a palliative resection or simple cholecystectomy.

Gallbladder cancer in Chile. A report on 54 potentially resectable tumors

Fifty-four patients with potentially resectable gallbladder tumors, chosen from 205 cases diagnosed at the Pathologic Unit of the authors' institution, were included in a prospective protocol of management. Of the potentially resectable tumors, only four were indicated before cholecystectomy (7.4%). Inconspicuous tumors were frequently observed, explaining in part the poor results of ultrasonogram for diagnosis. Poorly differentiated tumors were related to a greater rate of metastasis and shorter survival. Likewise, younger patients were associated with a worse prognosis. Patients with tumor confined to the mucosal layer were followed-up only during their postoperative courses. Patients with tumor involvement of the subserosa or muscular layer were offered treatment of a second operation, which included a lymphadenectomy and a liver wedge resection. For patients with serosal involvement, a more aggressive approach was proposed. Metastatic lymph node involvement was found in 9 of the 25 (36%) patients in whom dissection was performed. However, tumor invasion of the liver was seen in 10 of the 24 (41.6%) patients who underwent a liver resection. Patients who had a curative resection had a significantly longer survival in comparison with those who had a palliative resection or simple cholecystectomy.

[Gastric cancer: epidermal growth factor and epidermal growth factor receptor]

In 19 patients with advanced gastric cancer the expression of epidermal growth factor receptor and epidermal growth factor (EGF) were studied using immunohistochemical techniques. There were 12 males and the mean age of the group was 54.8 years. Most cases belonged in Borrmann's types III or IV. Tumoral cells were positive for EGF receptor in 9 patients (47%), with a strong reaction in 6. Thirteen of 18 subjects were positive for EGF. The reaction for EGF receptor was positive in 20% of 12 patients with intestinal type tumors and in 67% of 7 patients with diffuse tumors. Reaction for EGF was positive in 80% of intestinal type tumors and 64% of diffuse tumors. Simultaneous positive reactions for both antigens was observed in 5 of 18 patients, all with diffuse type tumors. Signet ring cell tumors showed less positivity than less differentiated ones. Thus, the expression of EGF and EGF receptor was higher in our patients with advanced gastric cancer than reported elsewhere.

[Lithiasis of gallbladder in the IX region. Study of the autopsies in a zone with a high proportion of Mapuche population]

The frequency of gallbladder stones in he IXth Region of Chile with a large indigenous population, was studied in forensic necropsies from 1980 to 1989. Among 2,505 autopsies, 85% were males and 15% females. At least 1 "mapuche" surname occurred in 27% of cases. Stones were found in 34% of females and 12.7% of males. No differences were found between "mapuche" and non mapuche cases. Cholecystectomy had been performed in 2.3% of males and 9.1% of males. These results do not differ from those reported from other regions in Chile.

Experience in the surgical treatment of 331 patients with pulmonary hydatidosis

Echinococcus disease is prevalent in Chile, with a rate of occurrence of 8.2 per 100,000. During a 15-year-period (1970 to 1985) we operated on 331 patients for pulmonary hydatidosis. Chest roentgenography was the main method of diagnosis. Among the total of 508 surgical procedures performed, pulmonary cystectomy was the most common (61.4%), whereas pulmonary resection was used in 31.4% of patients. The arc 5 test was used to confirm the diagnosis. Results were positive in 85% of the patients in whom it was done. There were 12.9% immediate postoperative complications in 12.9%, with late complications occurring in 4.10% and an overall mortality rate of 4.21%. These data suggest that hydatid cyst is still a common disease in our country, causing an important number of hospital admissions and a high percentage of complications.

[Inapparent cancer of the gallbladder]

Gallbladder cancer is the most common cancer in the Chilean female population. A prospective histological mapping of cholecystectomy pieces allowed the detection of 37 tumors not evident to the surgeon. Tumoral invasion engaged the mucous membrane in 7, the muscular layer in 8, the subserous layer in 12, the serous membrane in 5 and the surrounding adipose tissue of the gallbladder in 5 cases. 18 pts were reoperated on for resective oncological surgery. In 5 of these cases the ganglia, and in 6 the hepatic tissue behind the gallbladder were involved. Actuarial survival at 38 months was 48% (10 pts have died by the time of this publication). The prognosis of the disease was directly related to histological differentiation and to the degree of tumoral invasion. Gallbladder cancer has a poor prognosis even if the surgeon has no suspicion of the disease and a simple cholecystectomy is by no means a healing therapy.

[Nucleolus organizer regions and ploidy pattern of DNA in stomach neoplasms]

We studied 20 gastric adenocarcinoma to determine DNA ploidy pattern by flow cytometry and nucleolar organizer regions by the colloidal silver method. There were 12 diffuse and 8 intestinal type lesions. 11 tumors were classified as diploid and 9 as aneuploid. No correlation was observed between DNA ploidy pattern and mean number of nucleolar organizer regions. The histologic type was significantly related to the number of nucleolar organizer regions (p < 0.01). Poorly differentiated lesions had significantly less nucleolar organizer regions than intestinal type lesions. Lesions with ring cells (n = 6) had similar number of nucleolar organizer regions than poorly differentiated lesions.

[Advanced stomach neoplasms: expression of the fixation index of bromodeoxyuridine in vivo]

We studied fixation of bromodeoxyuridine by immunohistochemistry in 17 patients with advanced gastric cancer. Macroscopically, they corresponded to Borman's types III (n = 10), IV (5) I (1) and unclassified (1). 11 patients had a diffuse lesion, 5 an intestinal type lesion and 1 an epidermoid carcinoma. Positive reactions were observed in 27.7% of cells (95% CL 10-48%). No difference was observed in positivity of superficial (29%) or deep areas of the tumor (27%). Greater fixation rates were observed in patients under 50 years, of age compared to older patients. The percentage of positive reactive cells was not related to macroscopic or histologic tumor type. Greater fixation rates were observed in this series compared to those previously reported, suggesting greater proliferation rates in these patients.

[Stomach neoplasms in the IX Region of Chile: comparison of the anatomo-pathological study of lymph node emptying in 2 periods]

Complete resection of lymph nodes may help achieve a cure in patients with gastric cancer. In this paper we evaluate the yield of a careful search for lymph nodes in fresh tissue obtained immediately after resection. A mean of 42.5 nodes per gastric piece was obtained, which is significantly higher than that previously reported with examination of fixed tissue. The yield was higher for all node groups except the left para-cardial one.

Pancreatojejunostomy

Pancreatoduodenectomy is a complex procedure associated with considerable mortality and morbidity. Pancreatojejunostomy is probably the main cause of morbidity, and controversy concerning the best type of reconstruction still exists. In this report the technique of pancreatojejunostomy is demonstrated. An end-to-side pancreatojejunostomy is performed on all patients. For patients with a pancreatic duct of less than 4 mm in diameter, the top of the pancreatic duct is inserted into a stab-wound of jejunum. It is secured with a purse-string suture. Furthermore, two layers of reinforcement are done. By using this technique, an end-to-side anastomosis was done on patients with soft glands and small ducts. In patients with a pancreatic duct greater than 4 mm, a three-layer anastomosis is done between pancreas and jejunum. This is a technique that allows the performance of an end-to-side anastomosis regardless of the pancreas consistency or pancreatic duct diameter.

[Association of gallbladder and Vater's ampulla neoplasms. Report of a case]

A 54 year old female was operated on for ampullary carcinoma diagnosed by retrograde cholangiography. Histologic study of the gallbladder resected at operation revealed another carcinoma at that location. Pancreato-duodenectomy plus a double segmental resection of liver was performed. The patient remains in good condition 11 months after operation.

[Gallbladder cancer: anatomic and anatomo-pathologic considerations]

Gallbladder cancer is a common neoplasia in Chile. Subclinical forms constitute 30 to 50% of all cases and poorly differentiated lesions are more common in Chile than elsewhere. Traditional grading of this neoplasia according to the degree of wall infiltration neglects important aspects such as the discontinuity of the muscular layer, heterogeneity of the subserosa, microinvasion of the mucosa and Rokitansky-Aschoff sinuses. All of these factors may influence prognosis. Surgical biopsy of liver and lymph nodes in cases without infiltration of the mucosa has revealed up to 60% rate of hepatic infiltration and a somewhat lower on for lymph nodes. We have designed a study that will evaluate the importance of all these factors in the prognosis of gallbladder cancer in our institution.

[Neoplasms of Vater's papilla: study of nucleolar organizer regions]

We analyzed the number and aspect of nucleolar organizer regions in 11 specimens from ampullary carcinoma, by means of silver colloidal staining. The number of regions was higher than that found in intestinal villi but similar to that in cripti. The size of the regions was larger than any of those mentioned above. These elements may contribute to evaluate endoscopic samples in the diagnosis of ampullary lesions.

Operative findings in patients with early forms of gallbladder cancer

Of 52 patients diagnosed as having gallbladder cancer in a 2-year period, 15 had no evidence of serosal involvement. Four of these 15 patients had tumour confined to the mucosa and did not undergo reoperation while 11 patients underwent lymph node dissection and hepatic wedge resection at a second operation. The correct diagnosis was suspected before the first operation in only one of 11 patients undergoing reoperation; the tumour was found microscopically in seven patients. Of the 11 patients who underwent reoperation, five had lymph node involvement, and three of these patients had both liver and lymphatic involvement. Our results underline the difficulty of establishing the diagnosis of gallbladder cancer before operation and the lack of major morbidity and mortality suggests that there may be value in reoperating on patients found to have gallbladder carcinoma without serosal involvement. Further follow-up is required to assess the long-term value of this approach.

[The pathological findings in patients reoperated on for gallbladder cancer]

We reviewed the pathological data from 20 patients who were reoperated on for gallbladder cancer. Diagnosis was made in all from the histological analysis of the removed gallbladder. Mean age was 54. Tumor infiltration extended to the muscular layer in 6, to the subserosa in 9 and to the serosa in 5 patients. At surgery, local hepatic resection and lymph node dissection were performed. Tumoral involvement was limited to the liver in 2 patient, to lymph nodes in 3 and extended to both in the remaining. The first lymph node barrier was involved in 40%, the second in 15% and the tumor extended to the third barrier in 10%. These data suggest that hepatic and lymph node involvement occur early in gallbladder cancer and explain the poor prognosis of this malignancy.

[Study and application of the DNA pattern in oncology]

Abnormalities of DNA content are commonly observed in malignant tumors. Clinically relevant information may be obtained given the ease with which DNA pattern can be studied. Flux cytometry and photocytometry are the methods commonly used and both measure the emission of fluorescence after staining the nucleus. ADN pattern has been found to be related to prognosis in many tumors. Also, precancerous lesions and tumor heterogeneity can be analyzed by this technique.