SARS COV-2 Pandemic. Chilean Air Force experience in the air transport of critical ill patients. The first 100 cases

Objective

Methods

Results

Conclusions

Gallbladder cancer who is really cured?

BACKGROUND

Although gallbladder cancer (GBCA) is characterized by a dismal prognosis, there is a proportion of patients who are cured. The aim of this study was to analyze the profile of these patients.

METHODS

A database was queried for patients who underwent curative resection with a follow-up of at least 5 years. Patients were prospectively treated and registered by the same surgical team. A multivariate regression analysis was used to identify factors associated with long-term survival.

RESULTS

From 1988 to 2013, 461 patients were evaluated and 112 who underwent resection were analyzed. Among the patients, five year survival was 57% while lymph node and liver compromise were the only independent factors associated with survival. On the other hand, the elapsed time between the cholecystectomy and the resection, the differentiation grade and the level of wall invasion did not have an independent effect on the prognosis.

CONCLUSION

Despite its poor prognosis, a subset of patients can be cured of GBCA. R0 resection of patients without lymph and liver infiltration are key to GBCA survival.

A systematic review of the effectiveness of adjuvant therapy for patients with gallbladder cancer

BACKGROUND

Equipoise exists regarding the benefit of adjuvant therapy (AT) in patients with gallbladder cancer (GBC). The aim of this study was to critically review the available evidence for the effectiveness of AT in patients with GBC following surgery with curative intent.

METHODS

A systematic review was performed. Relevant studies were identified from Trip Database, BIREME-BVS, SciELO, Cochrane Central Register, WoS, MEDLINE, EMBASE and SCOPUS. Adjuvant therapies considered included chemotherapy, chemoradiotherapy, and radiotherapy. The primary outcome was overall survival (OS). Subgorup analysis of patients with positive lymph node disease (PLND), positive surgical margin (PSM), or advanced stage (AS) were performed.

RESULTS

748 related articles were identified; 27 met the selection criteria (3 systematic reviews and 24 observational studies). Evidence provided was moderate, poor and very poor for chemotherapy, chemoradiotherapy, and radiotherapy. Existing evidence is not robust, but suggests certain benefits with AT in improving OS, especially in patients with PLND, PSM and AS.

CONCLUSION

Results do not provide strong evidence that AT is effective in patients who undergo resection for GBC. Subgroups of PLND and PSM may have a survival advantage. Future studies with appropriate internal validity and adequate number of patients are required to better answer this question.

Inactivation of tumor suppressor gene pten in early and advanced gallbladder cancer

Background

PTEN is a tumor suppressor gene that regulates the PTEN/PI3k/AKT/mTOR pathway, which is frequently altered in human cancers including gallbladder cancer (GBC). To determine the frequency of PTEN expression in GBC and to establish its relation to clinical and morphological parameters and survival in GBC.

Methods

The immunohistochemical expression of PTEN was studied in 108 GBC. All the cases included areas of non-tumor mucosa adjacent to the tumor.

Results

The group was comprised of 108 patients, 91 women (84.3 %) and 17 men (15.7 %) with an average age of 65.2 years (SD ± 12.3 years). Thirty-five cases (33 %) were early carcinomas (EC) and the remaining 73 (67 %) were advanced cases (AC). All the internal controls were positive (moderate or intense in 96.3 %). Only in three AC (4.1 %) was there a complete absence of PTEN immunohistochemical expression. There were no significant differences in relation between PTEN expression and tumor infiltration or degree of differentiation. The three patients with PTEN inactivation died before 10 months; however, the other patients with AC had a survival of 53 % at 10 months.

Discussion

Loss of PTEN expression was observed in 4.1 % of the advanced GBC. All the patients with this alteration died before 10 months. PTEN inactivation could be a rare event, but with a poor prognosis in advanced GBC.

Gallbladder cancer in Chile: Pathologic characteristics of survival and prognostic factors: analysis of 1,366 cases

OBJECTIVES

To explore gallbladder cancer (GBC), the second leading cause of cancer-related death in women in Chile.

METHODS

Analysis of macroscopic and microscopic variables, morphometry, and survival in 1,366 patients with GBC.

RESULTS

Patients comprised 1,138 women and 228 men; diagnoses included 213 (15.6%) cases of mucosal carcinoma, 132 (9.7%) cases of muscular carcinoma, 316 (23.1%) cases of subserosal carcinoma, 382 (28.0%) cases of serosal carcinoma, and 323 (23.6%) cases beyond the serosa. Women older than 55 years with a gallbladder length greater than 9.5 cm had a five-times-greater relative risk of cancer. Those with a gallbladder wall thickness less than 7 mm had a better 5-year survival rate than those with a gallbladder wall thickness greater than 10 mm (P = .0001). Patients who had cholesterolosis of the gallbladder had 9.2 times less probability of having cancer. The infiltration level of the gallbladder wall was the most important independent prognostic factor (P < .001), followed by differentiation and lymphatic involvement (P < .001 and P = .05, respectively). Vascular infiltration had a mortality rate of 100%.

CONCLUSIONS

Morphologic features are strongly associated with the prognosis of GBC and must be taken into consideration when supplementary treatment is recommended.

[Quality of DNA from archival pathological samples of gallbladder cancer]

BACKGROUND

The quality of the archival samples stored at pathology services could be a limiting factor for molecular biology studies.

AIM

To determine the quality of DNA extracted from gallbladder cancer samples at different institutions.

MATERIAL AND METHODS

One hundred ninety four samples coming from five medical centers in Chile, were analyzed. DNA extraction was quantified determining genomic DNA concentration. The integrity of DNA was determined by polymerase chain reaction amplification of different length fragments of a constitutive gene (β-globin products of 110, 268 and 501 base pairs).

RESULTS

The mean DNA concentration obtained in 194 gallbladder cancer samples was 48 ± 43.1 ng/µl. In 22% of samples, no amplification was achieved despite obtaining a mean DNA concentration of 58.3 ng/ul. In 81, 67 and 22% of samples, a DNA amplification of at least 110, 268 or 501 base pairs was obtained, respectively. No differences in DNA concentration according to the source of the samples were demonstrated. However, there were marked differences in DNA integrity among participating centers. Samples from public hospitals were of lower quality than those from private clinics.

CONCLUSIONS

Despite some limitations, in 80% of cases, the integrity of DNA in archival samples from pathology services in our country would allow the use of molecular biology techniques.

[HER2 gene amplification and overexpression in advanced gastric cancer]

BACKGROUND

Overexpression/amplification of the HER2 gene in advanced gastric cancer is a predictor of response to adjuvant therapy with monoclonal antibodies.

AIM

To determine the frequency of HER2 gene overexpression and amplification in advanced gastric cancer.

MATERIAL AND METHODS

One hundred nine advanced gastric cancer biopsy specimens, from 76 men and 33 women aged 67 ± 14 and 62 ± 12 years respectively, were selected. Three histological patterns (diffuse, intestinal and mixed) were recognized. Automated immunohistochemistry was performed with monoclonal c-erbB-2 (NCL-356) Novocastra. Fluorescent in situ hybridization (FISH) for HER2 was performed in positive cases.

RESULTS

In 39% of cases, immunohistochemical staining was negative. It was 1+, 2+ and 3+ positive in 15, 36 and 11% of cases, respectively. It was positive in 16% and 3% of intestinal type and mixed carcinomas, respectively. It was negative in all diffuse carcinomas. FISH was performed in 39 (2 +) cases and in 11 (3 +) cases. The gene amplification was positive in two (2 +) and 11 (3 +) cases (11.9%). The overall concordance between immunohistochemical staining and in situ hybridization was 85%.

CONCLUSIONS

In advanced gastric cancer, HER2 gene overexpression or amplification was observed in 11% and 12% of cases, respectively.

Overexpression of the HER2/neu Gene: A New Therapeutic Possibility for Patients With Advanced Gallbladder Cancer

BACKGROUND

The HER2/neu gene is a proto-oncogene that can predict the response to treatment with trastuzumab, pertuzumab, and lapatinib. This study was conducted to determine the frequency of HER2/neu overexpression and to identify a subgroup of patients with gallbladder cancer who would benefit from targeted therapy.

METHODS

Patients with gallbladder cancer (n = 187; 165 women and 22 men) with a recorded follow-up of at least 5 years were included, along with control subjects (n = 75). An automated immunohistochemical technique was used with an anti-ErbB2 antibody. Scoring was conducted according to the CAP/ASCO (College of American Pathologists/American Society of Clinical Oncology) criteria for breast cancer.

RESULTS

Overexpression of HER2/neu was observed in 12.8% of the cases. Of those, 0% were mucosal, 14.3% muscular, 12.8% subserosal, and 10.6% serosal. In 20% of the cases, equivocal staining was observed. Overexpression was more frequent in the advanced cancers and in the better differentiated tumors (13.8% and 17.4%, respectively), but the difference was nonsignificant. The patients with overexpression of HER2/neu had a worse overall survival, when compared with those who had no expression at 5 years (34% vs. 41%).

CONCLUSION

This is the single largest study of HER2/neu expression in gallbladder cancer to use commonly accepted scoring criteria. The results indicate that HER2/neu overexpression occurred in 14% of the advanced gallbladder cancer cases. This subgroup may benefit from inhibitors of the HER2/neu pathway.

Gastric leak after sleeve gastrectomy: analysis of its management

BACKGROUND

Bariatric surgery is increasingly being performed and sleeve gastrectomy (SG) has proved to be effective and safe. Among its complications, leaks are the most serious and life threatening.

METHODS

The focus of the study is nine patients who underwent a SG and developed a gastric leak after surgery. Our data were obtained from the clinical charts of the patients and through interviews with the surgeon who performed the index surgery.

RESULTS

Eight patients underwent SG at outside institutions while one was operated at Clinica Alemana. Three patients developed symptoms within 5 days after surgery, while the rest were diagnosed after 10 days from the surgery. A CT scan was the method used to confirm the diagnosis in all patients. The three patients who had a leak detected during the immediate postoperative period underwent laparoscopic reoperation. Among the rest of the patients, percutaneous drainage was employed in one patient as the primary procedure while the other underwent surgical drainage. An esophageal endoluminal stent was employed in four patients. The leak closed in all patients with the healing time ranging from 21 to 240 days.

CONCLUSIONS

Diagnosis of a leak after a SG required a greater index of suspicion in order to perform an early diagnosis. Sepsis control and nutritional support are the cornerstones of this treatment. Evolution is characterized by longer periods of time that are necessary in order to wait until the leak closes. Management must be tailored to each patient.

ERCC1 (excision repair cross-complementing 1) expression in pT2 gallbladder cancer is a prognostic factor

Gallbladder cancer (GBC) is the main cause of death by malignant tumour in women in Chile. There is no information regarding the role of excision repair cross-complementing group 1 (ERCC1) in GBC. Our aim is to determine the expression and significance of ERCC1 as a prognostic factor in GBC. Tissue microarrays were prepared using 200 surgically resected GBCs and 50 non-malignant gallbladders as controls. In 190 cases, ERCC1 was determined by immunohistochemistry. The correlation between ERCC1 expression and GBC pathological characteristics and patient survival were analysed. Ninety-five percent of the non-malignant gallbladder epithelia showed intense and diffuse ERCC1 expression. GBC cases showed ERCC1 expression in the tumour cells in 100/190 (53%) cases. The best differentiated tumours showed significantly greater expression than the less differentiated (p<0.05). Patients with ERCC1-positive status with subserosal carcinomas (pT2) had significantly better survival than ERCC1-negative patients at 20 and 60 months of follow-up (p=0.005), and the probability of dying was 6 times lower for ERCC1-positive than for ERCC1-negative patients. Our preliminary results show that chole-cystectomised patients with GBC in stage pT2 and with ERCC1 expression have significantly better survival than patients at the same stage that did not present ERCC1 expression.

[Association between cholesterolosis and gallbladder cancer]

BACKGROUND

Cholesterolosis is frequently observed in cholecystectomies performed for lithiasis or chronic cholecystitis.

AIM

To determine the degree of association between cholesterolosis and gallbladder cancer.

MATERIAL AND METHODS

In a prospective study of gallbladder cancer, all gallbladders obtained during cholecystectomies were processed for pathological study, following a special protocol. As part of this study, 23,304 surgical samples obtained between 1993 and 2002 were studied, looking for a relationship between cholesterolosis and chronic cholecystitis, adenomas, dysplasia and gallbladder cancer.

RESULTS

Seventy nine percent of patients were women. Cholesterolosis was observed in 3123 cases (13.4%). Cholesterolosis was more common in women (14.2%) than in men (10.2%9) (p < 0.001). In the same period, 29 patients were diagnosed with adenomas (0.12%), 179 cases with dysplasia not associated with gallbladder cancer (0.8%) and 739 gallbladder cancer (3.2%). The frequency of cholesterolosis was 13.8% in chronic cholecystitis, 13.7% in adenomas, 12.1% in dysplasias and 1.35% in patients with gallbladder cancer (p < 0.01). Of the thirteen cases with gallbladder cancer and cholesterolosis, 10 were early gallbladder carcinomas. Patients with cholesterolosis were 9.2 times less likely td have cancer than those who did not have cholesterolosis.

CONCLUSIONS

Cholesterolosis has a strong negative association with gallbladder cancer.

[Cystic tumors of the pancreas]

Cystic tumors of the pancreas are diagnosed with increasing frequency. The main problems associated with their diagnosis are to determine if they are benign or malignant and to decide their surgical excision or clinical follow-up, since these tumors can be benign, potentially malignant or malignant. Imaging techniques such as CT scan, magnetic resonance and endoscopic ultrasonography are the key procedures that must be performed before adopting a final therapeutic decision. However, 10% of cystic lesions are unable to be categorized even after thorough imaging evaluation. We analyze the characteristics of the more common cystic pancreatic lesions and the means to recognize them.

Gallstones and gallbladder cancer-volume and weight of gallstones are associated with gallbladder cancer: a case-control study

BACKGROUND

Gallstones are considered the most important risk factor for gallbladder cancer.

AIM

To identify differences in the number, weight, volume, and density of gallstones associated with chronic cholecystitis (CC), gallbladder dysplasia (GD), and gallbladder cancer (GBC).

METHODS

A total of 125 cases were selected, of which 93 had gallstones associated with GBC and 31 had gallstones associated with GD. The controls were those with CC, matched by sex and age. The number, weight, volume, and density of these gallstones were examined in order to determine differences and relative cancer risk.

RESULTS

Number: Multiple gallstones were present in over 76% of cases (GBC and GD) and controls (P = ns). The average number of multiple stones was 21 in GBC versus 14 in controls (P < 0.01). Weight: The average weight of the gallstones was 9.6 g in GBC versus 6.0 g in controls (P = 0.0004). The average weight in multiple stones over 10 g had strong association with GBC (P = 0.0006). Volume: The average volume was 11.7 and 6.48 ml in GBC and controls (P = 0.0002). Average volumes of 6, 8, and 10 ml had a relative cancer risk of 5, 7, and 11 times, respectively. Size: No differences were shown between GBC, GD, and controls.

CONCLUSIONS

The volume of gallstones associated with other risk factors of GBC may be helpful in prioritizing cholecystectomies in symptomatic patients.

Preneoplastic lesions in gallbladder cancer

BACKGROUND

Gallbladder cancer is an uncommon disease except in countries like Chile and areas of India and Japan. The knowledge regarding the etiology and mechanisms through which this neoplasia is developed is significantly less compared to other malignant tumors.

RESULTS

The epithelial lesions involved in gallbladder carcinogenesis are dysplasia and adenomas that represent two biologically distinct carcinogenetic models. Dysplasia progresses to carcinoma in situ (CIS) and subsequently becomes invasive. Over 80% of invasive gallbladder cancers present areas adjacent to the CIS and epithelial dysplasia. Other authors have demonstrated adenomatous areas in carcinomas, or malignant transformation in an adenoma. The low incidence of gallbladder adenomas (0.14% of cholecystectomies) and the presence of adenomatous remnants in the neighboring mucosa to early carcinomas in less than 3% of the cases suggest the limited importance of this carcinogenic pathway. Epithelial dysplasia which is not associated with gallbladder cancer is observed in approximately 1% of cholecystectomies for symptomatic lithiasis. Metaplasia, dysplasia, and CIS are present in the mucosa adjacent to the cancer in 66%, 81.3%, and 69%, respectively. The average ages of patients with dysplasia not associated to cancer (51.9 years), early carcinomas (56.8 years), and advanced carcinomas (62.9 years) demonstrate a gradient which suggests the progression of these lesions.

CONCLUSIONS

From the morphological point of view, the dysplasia-carcinoma sequence is the most plausible carcinogenic pathway for gallbladder cancer, a process which would require a period of approximately 10 years.

Gallbladder cancer: an analysis of a series of 139 patients with invasion restricted to the subserosal layer

The goal was to study our experience in the management of a series of patients with a potentially curative subserosal gallbladder cancer who were prospectively treated by the authors. Between April 1988 and July 2004, 139 patients were enrolled in our prospective database. Of the above, 120 were operated on with an open procedure and the rest with laparoscopic surgery. In only eight patients was the diagnosis suspected before the cholecystectomy. The majority of tumors were adenocarcinoma. Six patients had an epidermoid tumor, and one had a carcinosarcoma. Of the patients, 74 underwent reoperation, while in 55 (70.2%) it was possible to perform an extended cholecystectomy with a curative aim. Operative mortality was 0%, and operative morbidity was 16%. Lymph node metastases were found in 10 (18.8%), while in 7 (13.2%) the liver was involved. The overall survival rate was 67.7%, while in those who underwent resection, the survival rate was 77%. Through the use of a multivariate analysis, the presence of lymph node metastasis was found to be an independent factor with respect to prognosis. The feasibility of performing an extended cholecystectomy in patients with gallbladder cancer and invasion of the subserosal layer allows for a good survival rate. The presence of lymph node metastases represents the main poor prognosis factor, and some type of adjuvant therapy should be studied in this particular group.

Chemoradiotherapy in gallbladder cancer

Gallbladder cancer (GC) is considered a rare disease associated with a poor prognosis. Unfortunately, the low number of cases makes the performance of trials addressing the role of adjuvant, neoadjuvant, and/or palliative therapy difficult. For a long time, the majority of trials were 5-fluorouracil (5 FU)-based, and results were uniformly poor. Since the introduction of Gemcitabine, response rates of approximately 30% have been observed through the use of this drug and new approaches have been tested. In this sense, drugs such as Cisplatin and Capecitabine have been employed concurrently with gemcitabine and/or radiation. Since a recurrence pattern is both distant and local, chernoradiation seems a logical option to deal with the disease. However, at the present time, the lack of valid and scientific evidence means that most of the recommendations originate from trials dealing with other tumors, such as pancreas cancer and biliary tract cancer (BTC). The aforementioned treatment alternatives warrant further evaluation focusing on GC.

[Frequency of K-ras mutation in biliary and pancreatic tumors]

BACKGROUND

The ras gene family (H-ras, N-ras and K-ras) are oncogenes that mutate frequently in human cancer, specially in tumors of the biliary tract and pancreas.

AIM

To determine the frequency of K-ras gene codon 12 mutation in pancreatic and biliary tumors.

MATERIAL AND METHODS

Samples of 35 gallbladder, 15 ampulla of Vater, 10 biliary tract and 9 pancreatic tumors, were analyzed. The tumor tissue was microdissected from paraffin embedded biopsies. The mutation was detected by a combination of polymerase chain reaction (PCR) and restriction fragment length polymorphism (RFLP).

RESULTS

Overall, 46% of samples had K-ras gene mutations. Mutation frequency was 80, 56, 50 and 29% for ampulla of Vater, pancreatic, biliary tract and gallbladder tumors, respectively. When compared with the rest, gallbladder tumors had a significantly lower frequency of the mutation. Median survival for biliary tract tumors was 6 months, compared with 65 months for gallbladder tumors (p <0.05).

CONCLUSIONS

Gallbladder carcinoma had the lower frequency of K-ras mutation, when compared with pancreatic, biliary tract and ampulla of Vater tumors.

Aspectos quirúrgicos del cáncer de vesícula biliar

There is controversy in some aspects of the surgical treatment of non-mucosal gallbladder carcinoma. An accurate staging based on T (wall) involvement is crucial, otherwise understanding may yield falsely pessimistic results. The decision about the type of resection to be performed should be based on patient status (age, performance, comorbidities, etc) and tumor characteristics (histological type, vascular, neural or lymphatic spread, cell differentiation, tumor involvement of surgical margins in cystic duct, etc). For muscular (T1b) involvement, there is a great controversy about performing a simple cholecystectomy or en-block radical resection. For T2 there is consensus that an en-block radical surgery including liver resection (IVb - V) and lymphonodal clearance should be performed, since this approach has a great impact in survival. The role of surgical excision for tumors with serosal or liver involvement is controversial, due to the poor survival of these patients. However we have observed a 13% actuarial survival at 5 years, in this subset of patients.

[Neoadjuvant chemoradiotherapy in gallbladder cancer]

BACKGROUND

Gallbladder cancer is generally associated with a poor prognosis, being local recurrence the main pattern of failure.

AIM

To evaluate neoadjuvant chemoradiation as a means to improve the prognosis in gallbladder cancer.

PATIENTS AND METHODS

Twenty three gallbladder cancer patients were prospectively treated between June 1993 and September 1999 in the Temuco Regional Hospital. Eighteen (82%) patients had subserosal infiltration, while three (13%) had serosal and two (9%) adipose tissue infiltration. Chemotherapy was done with 5-fluorouracil in continuous infusion during 5 days at day 1 and 28 of treatment. Radiotherapy consisted in a total dose of 4500 cGy, divided in 25 sessions. Patients' survival was compared with a series of 19 patients not subjected to chemoradiation, formerly treated at the institution.

RESULTS

Twenty patients had hematological problems secondary to the therapy. Leucopenia and thrombocytopenia were the most common toxic effects and eight had leucopenia under 2.0 x 10(3) during the treatment course. Chemoradiation delayed surgical treatment in eight patients. After the chemoradiation protocol, seven patients were excluded from surgical treatment and 14 patients underwent resection. Three of the latter (11%) had liver involvement and four (14%) had lymph node involvement. Among the patients who underwent resection, five are still alive with a follow up of 43.8 months. Treated patients had a worst actuarial survival than subjects not treated with chemoradiation.

CONCLUSIONS

In this series of patients chemoradiation had no positive effect and a potentially detrimental effect in patients with gallbladder cancer.

[Detection of bone marrow micrometastases in patients with gallbladder cancer]

BACKGROUND

There is a very strong documented correlation between the appearance of cancer cells in blood and occurrence of metastasis in gastrointestinal cancer.

AIM

To determine MUC1, CK19, CK20 and CEA mRNA expression in bone marrow of patients with gallbladder cancer and evaluate its clinical significance.

MATERIAL AND METHODS

Sixty eight samples were analyzed, 38 bone marrow samples of gallbladder cancer patients, 20 healthy donors, and 10 frozen samples of gallbladder cancer. Nested reverse transcriptase-polymerase chain reaction (nested RT-PCR) was used to analyze mRNA expression.

RESULTS

All frozen tumors were positive for CEA, CK19, and MUC1 mRNA and 70% were positive for CK20. Seventeen of 20 donor samples were positive for MUC1 and only one sample from donors was positive for both CK20 and CK19 mRNA. Among the 38 blood and bone marrow samples of gallbladder cancer patients, the expression of MUC1, CK19, CK20, and CEA, mRNA was 60.5% (23/38), 31.6% (12/38), 7.9% (3/38), and 7.9% (3/38), respectively. Disregarding the MUC1 results. 37% (14/38), 13% (5/38) and 5% (2/38) were positive for one, two and three markers respectively. Not significant differences were found in survival with a follow up to 12 months.

CONCLUSION

Our results indicate that the molecular detection of tumor cells in bone marrow in patients with gallbladder carcinoma is technically possible, being CEA, CK19 and CK20 gene expression the best markers. The MUC1 gene expression marker was highly unspecific and it should not been considered. The detection of bone marrow micrometastasis might be helpful in prognosis and the selection of clinical treatment but a larger series with a longer follow-up should be studied.

[Inactivation of CDKN2A gene (p16) in gallbladder carcinoma]

BACKGROUND

The CDKN2A gene encodes a cyclin dependent kinase inhibitor, p16, which promotes cell cycle arrest. Methylation of the promoter region transcriptionally inactivates the gene.

AIM

To study the relationship between methylation status of the prometer region of p16 gene, the immunohistochemical expression of p16 and clinical and morphological features of gallbladder carcinoma.

MATERIAL AND METHODS

We analyzed the methylation status of the promoter region of the CDKN2A gene in gallbladder adenocarcinomas using methylation specific PCR (MSP). We also used microsatellite markers near the CDKN2A gene to detect allelic imbalance (AI) and examined the tumors by immunohistochemistry (IHC) for p16 expression.

RESULTS

Of 38 gallbladder adenocarcinomas analyzed by IHC, 11 cases (29%) were negative for p16 protein. Nine (24%) had methylation of the promoter region of the CDKN2A gene. Twenty nine cases were negative for methylation, but four (14%) of these 29 exhibited AI at one or more of the microsatellite markers. CDKN2A promoter methylation was not associated with microsatellite instability (MSI-H).

CONCLUSIONS

The inactivation of CDKN2A by methylation and/or deletion might play an important role in gallbladder carcinogenesis.

[Management of gallbladder cancer with invasion of the muscular layer]

BACKGROUND

Gallbladder cancer is the leading cause of death of cancer among women in Chile. Detection of early forms of the disease during the pathological study of the cholecystectomy specimen is common. The management of these cases, specially those with invasion of the muscular layer is under discussion.

AIM

To analyze the clinical features of patients with gallbladder cancer and muscular layer invasion and their prognosis after a simple cholecystectomy.

PATIENTS AND METHODS

We studied a series of 46 patients with gallbladder cancer and invasion of the muscular layer. In the majority of cases diagnosis was performed at the moment of specimen study. Eleven patients underwent reoperation. Of these, ten underwent lymphadenectomy and liver resection while one patient underwent resection of the cystic duct stump.

RESULTS

During follow up, five patients died as a consequence of gallbladder cancer. Overall survival was 78%, with no differences between patients subjected or not a new operation.

CONCLUSIONS

Gallbladder cancer with muscular infiltration has a good prognosis, independent of the type of therapy.

[K-ras gene mutation in gallbladder carcinoma]

BACKGROUND

Different K-ras mutation frequencies in gallbladder cancer have been reported.

AIM

To study the frequency of K-ras gene mutations in advanced gallbladder carcinoma not associated to anomalous junction of pancreatic-biliary duct (AJPBD).

MATERIAL AND METHODS

33 formalin fixed paraffin embedded samples of gallbladder carcinoma (30 women, age range 32-86 years) were selected. Pancreatic cancer tissue with K-ras mutations was used as control. DNA was extracted from the histological section by mean of microdissection and K-ras mutations in codon 12 were detected by polymerase chain reaction and restriction fragment length polymorphism (RFLP), using previously reported technique.

RESULTS

Most cases were poorly differentiated adenocarcinomas. K-ras mutation was detected in 10 cases (30%) samples. No differences in K-ras mutation frequency between subserous and serous tumors were detected and no relation between histological features and the mutation was observed.

CONCLUSIONS

K-ras mutation in codon 12 is present in 30% in our advanced gallbladder carcinomas. The study of K-ras mutation in preneoplastic lesions and early carcinonmas will be important to determine the role of this gene in the gallbladder carcinogenesis in Chile.

[DNA content and survival in subserous gallbladder carcinoma]

BACKGROUND

The clinical and morphological characterization of the subserous gallbladder carcinomas is controversial.

AIM

To study the prognostic importance of DNA content of subserous gallbladder carcinoma.

MATERIAL AND METHODS

We studied 104 females aged 60+/-12 years old and 16 men aged 70+/-13 years old. In all of them diagnosis was established after mapping of cholecystectomy sample and had a complete clinical follow up. DNA content was measured by flow cytometry.

RESULTS

All tumors were adenocarcinoma, and only 16% were well differentiated. Aneuploidy was observed in 29 cases (26%) with DNA index fluctuating between 1.1 and 1.8. Lymphatic vessel tumor involvement was present in 16 of 22 cases with aneuploidy and in 22 of 46 diploid tumors (p=0.05). Eighty nine percent of aneuploid tumors were detected macroscopically and 11% were unapparent. Five years survival was non significantly better among patients with diploid tumors than in patients with aneuploid tumors (45 and 28%, respectively, p=0.2). The histological differentiation was the only variable significantly associated with survival.

CONCLUSIONS

Aneuploidy is present in 26% of subserous gallbladder carcinoma. It is not related with any of the morphological or clinical variables studied in this series of patients.

[Clinicopathological features of gallbladder polyps and adenomas]

BACKGROUND

Chile has a high frequency of gallbladder cancer. Polyps are common lesions of gallbladder mucosa but there is little information about their morphological features.

AIM

To report the clinical and pathological features of 219 gallbladder polyps.

MATERIAL AND METHODS

Cholecystectomites samples in which a polypoid lesion was diagnosed microscopically. In all cases, complete clinical information and digitalized images of the complete surgical specimens was reviewed.

RESULTS

In a period of 10 years, 21,412 gall-bladders were processed. Among these, 884 carcinomas were diagnosed and in 219 cases (1%) a polyp was found. One hundred and eighty three patients were females (mean age 49.3 years) and 36 males (mean age 53.4 years). The preoperative diagnosis of gallbladder polyp wars done only in 26 cases (12%). Eighty five percent of polyps were non-neoplastic (metaplastic in 32%, cholesterol in 29%, hyperplastic in 22% and inflammatory in 2%). The remaining 15% were adenomas. Seventy five percent of non-neoplastic polyps were located in the proximal half of the gallbladder and 88% of adenomas in the distal half. Ninety five percent of non-neoplastic polyps measured less than 10 mm. Among adenomas, 47% measured less than 5 mm and 28% more than 10 mm. Smaller polyps were of cholesterol and larger polyps were adenomas. Eight adenomas were associated with an adenocarcinoma, two had less than 5 mm length. Mean age of patients with adenomas associated to cancer was higher than patients with pure adenomas (64.6 and 44.3 years respectively, p > 0.001).

CONCLUSIONS

There are size and location differences between non neoplastic polyps and adenomas. Adenomas associated to cancer may measure less than 5 mm. Therefore the polyp size criteria to decide surgical behavior in symptomatic gallstone patients may be misleading.

[Subserous gallbladder carcinoma: expression of cadherine-catenine complex]

BACKGROUND

Subserous gallbladder carcinoma is difficult to diagnose and treat. There are no tissue markers with prognostic value in this type of tumor.

AIM

To study the immunohistochemical expression of E-cadherin alpha and beta catenin in subserous gallbladder carcinoma.

PATIENTS AND METHODS

One hundred seventeen subjects (103 women and 14 men aged 62 and 69 years as a mean, respectively), were studied. Thirty five gallbladder samples without evidence of cancer were used as controls. Expression of markers was studied with standard immunohistochemical techniques for formalin fixed and paraffin embedded tissue.

RESULTS

Ninety seven percent of tumors were adenocarcinoma. A lower or absent expression of E-cadherin, alpha catenin and beta catenin was observed in 26, 33 and 29% of tumors, respectively. Actuarial five years survival was 37%. No association between macroscopic features of the tumor and survival was observed. Well differentiated tumors had a 73% survival, whereas less differentiated tumors had a 30% survival. Tumors with a normal expression of the markers had a slightly better survival, although not significant (p = 0.06).

CONCLUSIONS

Approximately 30% of subserous gallbladder carcinoma have an abnormal expression of E-cadherin, alpha catenin and beta catenin. This abnormal expression has no relationship with prognosis and is probably secondary to the aberrant genic expression of the tumor.

[Is gallbladder cancer a disease with bad prognosis?]

Gallbladder cancer is frequent in Chile, but it is not uniformly mortal. The diagnosis is usually made after a cholecystectomy, indicated for a symptomatic cholelithiasis. Global survival of gallbladder cancer can be as high as 40% at five years. In 69% of women of less than 30 years old, the tumor is detected in early stages. In these cases, cholecystectomy is the curative procedure, with a 90% survival at five years. According to our experience, cholecystectomies should be performed between 40 and 50 years of age in men and between 30 and 40 years in women. The prognostic factors that should be considered are symptoms associated to lithiasis, age, parity, obesity, size of stones and the size of the gallbladder. If the tumor is detected in early stages, the survival is good. The natural history of the disease would change significantly if all women with symptomatic stones were operated.

[Morphological prognostic elements in gallbladder cancer]

BACKGROUND

The exact survival rates and prognostic factors of gallbladder cancer are still incompletely known.

AIM

To report the actuarial survival of patients with gallbladder cancer.

MATERIAL AND METHODS

Six hundred thirty seven women, aged 59 years old as a mean and 108 men, aged 64 years old as a mean, with gallbladder cancer are reported. Patients were followed for up to 150 months.

RESULTS

Two hundred twenty four patients had an early and 521 had an advanced carcinoma. Overall survival was 38% at ten years. Sex or ethnic origin did not influence survival. Early tumors had a 92% survival at 10 years whereas the survival of advanced tumors was 16% at 5 years. Subserous tumors had a 5 years survival of 32% whereas serous tumors had a 5 years survival of 11%. Well-differentiated advanced tumors had a significantly better survival than moderately or poorly differentiated tumors. Vascular or lymphatic infiltration was also associated to a lower survival. All patients with advanced tumors and vascular infiltration died before 5 years.

CONCLUSIONS

Tumor infiltration and differentiation degree were the most important prognostic independent factors in gallbladder cancer.