Outcome of radical surgery for carcinoma of the gallbladder according to the tumor node metastasis and Japanese Society of Biliary Surgery stages

Primary carcinoma of the gallbladder is a progressive, lethal disease. Survival of patients with this neoplasm depends strictly on lymph node involvement and depth of tumor invasion. The aim of the study was to evaluate the results of our surgical series according to the tumor node metastasis and Japanese Society of Biliary Surgery classification systems. A retrospective analysis of our 15-year experience was performed. Of the 79 patients with gallbladder carcinoma observed at our institution between 1984 and 2001, a radical resection was carried out in 20 patients. Patients with stage I-II disease represent a minority of the cases of gallbladder carcinoma; the disease is localized in these patients, and surgical treatment provides the opportunity for good survival. Survival rates for patients with stage III-IV disease demonstrates that radical extended surgery offers the only chance for a relatively prolonged survival.     

不同术式对Ⅳ期胆囊癌生存状况比较分析

目的探究不同外科手术对于Ⅳ期胆囊癌患者的治疗效果和对生存状况的影响。方法回顾性分析2011年1月至2012年1月接受手术治疗的142例Ⅳ期胆囊癌患者资料,其中38例接受扩大根治术的患者为A组,27例接受胆囊全切术的患者为B组,31例接受姑息切除术的患者为C组,46例接受胆道内外引流术的患者为D组。对所有患者进行为期3年的术后随访,采用SPSS19.0软件进行统计学分析,比较4组患者治疗后1年、2年、3年生存率、中位生存时间。各组中位生存时间结果比较采用t检验,计数资料比较用χ~2检验,生存率比较用Kaplan-Meier检验,P0.05为差异具有统计学意义。结果对于Ⅳa期胆囊癌患者,A组患者生存状况更优,其1年生存率为63.2%、2年生存率为34.2%、3年生存率为10.5%,中位生存时间为(18.7±2.9)个月。A组1年生存率与B组差异不大,但2、3年生存率以及中位生存时间较B组更长。A、B组的1年、2年、3年生存率均高于C、D组;且中位生存时间也较高,A、B组与C、D组相比差异具有统计学意义(t=2.215,P=0.036)。对于Ⅳb期患者,4组患者1年、2年、3年生存率无统计学差异,但A组患者较其他3组患者中位生存时间更长。A组1年生存率21.1%、2年生存率10.5%、3年生存率2.6%,中位生存时间(11.3±3.4)个月。4组患者中位生存时间比较差异具有统计学意义(t=2.189,P=0.036)。结论对于Ⅳa期胆囊癌患者扩大根治术以及胆囊全切术比其他手术方式效果更优,尤其是扩大根治术能够更好的提高Ⅳa期患者生存状况。对于Ⅳb期胆囊癌患者采用扩大根治术则可以提高患者的中位生存时间,因此临床上对于Ⅳ期胆囊癌患者可以采用扩大根治术为主要外科治疗方式。     

Aggressive surgical approach for stage IV gallbladder carcinoma based on Japanese Society of Biliary Surgery classification

BACKGROUND/PURPOSE: The role of aggressive surgery for stage IV gallbladder carcinoma remains controversial. Survival and prognostic factors were analyzed in patients with stage IV disease, based on the Japanese Society of Biliary Surgery (JSBS) classification, to identify the group of patients who could benefit from radical surgery. METHODS: A retrospective analysis was done of 79 patients with JSBS stage IV gallbladder carcinoma who had undergone surgical resection with curative intent at our institution. The standard procedures were anatomical S4a + S5 subsegmentectomy (n = 29) with extrahepatic bile duct resection and extended lymphadectomy, but when right Glisson's sheath and/or the hepatic hilum were involved, right extended hepatectomy (n = 34) or right trisegmentectomy (n = 3) was selected. To achieve a tumor-free margin combined pancreaticoduodenectomy was performed in 12 patients, and major vascular resection in 17 patients. RESULTS: In the patients with stage IV gallbladder carcinoma, the curative resection rate was 65.8% and the hospital mortality rate was 11.4%. The postoperative 5-year survival rate following curative resection was 13.7%. Univariate analysis indicated that curability, hepatoduodenal ligament invasion, nodal involvement, and vascular resection were significant prognostic factors. Neither hepatic invasion nor liver metastasis was a significant factor. CONCLUSIONS: Aggressive surgical resection should be considered even in stage IV patients when hepatoduodenal ligament invasion and nodal involvement are absent or limited. Acceptable survival may be expected among such patients only when curative resection is achieved.     

Factors influencing postoperative hospital mortality and long-term survival after radical resection for stage IV gallbladder carcinoma

Factors influencing postoperative hospital mortality and long-term survival after radical resection of stage IV gallbladder carcinoma remain unclear. The objective of this study was to identify characteristics of patients who are good candidates in terms of surgical risk and long-term survival for radical resection of stage IV gallbladder carcinoma. A retrospective study was made of attempted surgical cure in 72 patients with stage IV gallbladder carcinoma. There were 14 postoperative hospital deaths (19%). Eleven (19%) of the 58 patients discharged from hospital survived for more than 3 years. Multivariate analysis indicated male gender, extended right hepatic lobectomy in a cholestatic liver, and portal vein resection as independent risk factors that correlated with hospital death. Distant metastasis was the sole independent factor that related negatively with long-term survival by multivariate analysis. Subset analysis was performed with combinations of the four independent factors obtained by multivariate analyses. The hospital mortality rate and the 3-year survival rate in the 44 patients without portal vein involvement were 9% and 28%, respectively, and were 3% and 27%, for the 31 women in this group. The highest 3-year survival rate (39%) was observed in the 26 patients without distant metastasis and portal vein involvement, despite a hospital mortality rate of 12%. Better patient selection may improve the outcome of radical surgery for stage IV gallbladder carcinoma. These data may be useful in designing future trials of the surgical treatment of advanced gallbladder carcinoma.     

Indications and results of radical treatment of gallbladder carcinoma

Extended cholecystectomy is the only chance of a cure for patients with locally advanced cancer of the gallbladder. The aim of the study was to evaluate the short- and long-term results of surgical treatment and to define the prognostic factors associated with better survival. We conducted a retrospective study in 81 patients with gallbladder cancer admitted to our surgical department from 1985 to 1999. Radical surgery was performed on 39 patients. The type of surgical treatment was based on the TNM stage of the disease: all but stage I patients underwent extended cholecystectomy (resection of segment IVa-V, N1-2 lymph-node dissection). The mortality and morbidity rates were 5.1% and 28.2%, respectively. In the patients undergoing curative resection, the 5-year survival was 31.5% (75% in T1 patients, 57.1% in T2, 25.9% in T3 and 0% in T4. Long-term survival of patients with T1-2 tumours was significantly better than that of T3 (P = 0.02) or T4 patients (P = 0.0003); 53.6% of N0 patients were still alive at 5 years as against only 14.5% of N+ patients (P = 0.06). Depth of infiltration is an important prognostic factor. The presence of lymph-node metastases should not be a contraindication to surgery since long-term survival is possible.     

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

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

Surgical treatment for advanced gallbladder cancer: indications and limitations

We have aggressively performed extensive surgery including major liver resection for advanced gallbladder cancer since 1979. The 5-year survival rates for stage IVa and IVb patients after curative resection were 19% and 6%, respectively. Seven patients in the stage IVa group (n = 69) and one in stage IVb (n = 16) have survived for more than 5 years. The hospital mortality rate including all deaths within and over 30 days of curative operation for stage IV gallbladder cancer was 19%. Although radical resection is the only treatment of choice for advanced gallbladder cancer to obtain long-term survival, there are serious problems in extensive surgery. The most important issue is reduction of the hospital mortality rate. Elucidation of the clinical and molecular characteristics leading to potential long-term survival and development of new strategies for the treatment of recurrent tumors are also important issues.     

Surgical treatment of patients with T2 gallbladder carcinoma invading the subserosal layer

BACKGROUND: Because T2 carcinoma of the gallbladder that invades perimuscular connective tissue without extension beyond serosa or into the liver has a hope for longterm survival, we attempted to clarify significant prognostic factors with respect to tumor- and surgery-related variables. STUDY DESIGN: Of 65 patients with gallbladder carcinoma who had undergone surgical resection from 1983 to 1999, 28 had T2 carcinoma histologically proved. The significance of variables for survival was examined by the Kaplan-Meier method and log-rank test followed by multivariate analyses using Cox's proportional hazard model. RESULTS: There were 17 patients with stage II carcinoma (T2 N0 M0), 6 with stage III (T2 N1 M0), and 5 with stage IVB. Lymph node metastasis was present in 11 patients (39%) and it reached to the peripancreatic head region (N2) in 5 of them. Lymphatic, venous, and perineural invasions were found in 68%, 57%, and 43%, respectively. With respect to tumor factors, the absence of perineural invasion (Odds ratio [OR] 16.77, 95% confidence interval [CI] 2.17-129.94, p = 0.0069), absence of lymph node metastasis (OR 15.00, 95% CI 2.08-108.33, p = 0.0073), and stage II (II versus III and IVB, OR 15.00, 95% CI 2.08-108.33, p = 0.0073) were significant factors related to good postoperative survival in the multivariate analysis. Surgical procedure (radical resection versus cholecystectomy, OR 4.31, 95% CI 1.34-13.82, p = 0.0142) and surgical margin (OR 7.41, 95% CI 2.19-25.13, p = 0.0013) were significant factors in the univariate analysis. Cancer-free surgical margins provided a significantly better survival (5-year survival rate, 62%); none with cancer-positive surgical margins survived for more than 27 months. In the multivariate analysis, surgical procedure was significant (OR 25.49, 95% CI 1.62-400.72, p = 0.021). Radical surgery, including extended cholecystectomy (resection of the gallbladder together with the gallbladder bed of the liver) and anatomic resection of liver segment 5 and of the lower part of segment 4, gave a significantly better 5-year survival rate than cholecystectomy (59% versus 17%). The 5-year survival rate after radical resection in patients with stage II was 75%; that in patients with stage III and IVB was 33%. CONCLUSIONS: Results suggest that radical surgery is the treatment of choice for patients with T2 carcinoma of the gallbladder. The presence of lymph node metastasis, perineural invasion, or both suggests the necessity of additional treatment after radical surgery.     

Prognostic factors and long-term results after surgery for gallbladder carcinoma: a retrospective study of 127 patients

BACKGROUND: The surgical management of gallbladder cancer is controversial, especially as to the indications for reoperation, extended resection, and aggressive treatment in advanced tumor stages. METHODS: Records and follow-ups of 127 patients with gallbladder carcinoma who underwent surgery between 1980 and 1997 were examined according to the pTNM and Nevin staging systems. Factors predictive for survival were obtained from histopathologic staging and surgical procedures. RESULTS: Surgery for gallbladder cancer was associated with an overall 5-year survival rate of 6.6%. Curative resection was possible in 35.5% of cases, which resulted in 5-year survival rates of 20%. Noncurative surgery revealed poor prognosis, with median survival time limited to 3.2 months, independently of macroscopic or microscopic tumor residues. None of the latter patients survived longer than 24 months. Surgery of stage I/II cancer showed a 5-year survival rate of 64.5%. In stage III/IV tumors, resectability was only 20.4%. However, curative surgery in advanced stages significantly increased median survival from 3.2 to 19.4 months. CONCLUSIONS: Only complete tumor resection can provide long-term survival, even in advanced stages. Because negative surgical margins and UICC stage are the strongest predictors for survival, reoperation is required with all incidental findings above the T1b stage.     

胆囊癌不同手术方式的疗效分析

目的 探讨胆囊癌不同手术方式的疗效.方法 回顾性分析2000年1月至2009年10月四川大学华西医院收治的81例胆囊癌患者的临床资料,分析胆囊癌患者采用不同治疗方式的疗效,肿瘤不同浸润深度与淋巴结转移的关系.采用Kaplan-Meier法进行生存分析,生存率比较采用Log-rank法.结果 Ⅰ、Ⅱ、Ⅲ、Ⅳ期胆囊癌患者中...     

Is there a Role for Radical Surgery in Advanced Gallbladder Carcinoma?

Forty-four patients with advanced gallbladder carcinoma (18 with stage pT₃ and 26 with stage pT₄ of the Union Internacional Contra la Cancrum classification) were aggressively managed by extended heptatic resection in 33 patients, bile duct resection in 28, pancreaticoduodenectomy in seven, gastrointestinal resection in eleven and portal vein resection and reconstruction in seven. Adjacent organ involvement was classified as follows: type I, hepatic involvement with or without gastrointestinal invasion (Ia, Ib); type II, bile duct involvement with or without gastrointestinal invasion (IIa, IIb); type III, hepatic and bile duct involvement with or without gastrointestinal invasion (IIIa, IIIb); type IV, gastrointestinal involvement without hepatic or bile duct invasion. Fourteen of 15 patients with type I tumours had a curative resection compared with seven of 26 with type III lesions (P< 0.0001). The surgical mortality rate was two of 15 patients with type I tumours, seven of 26 with type III tumours and nine of 44 for the whole group. The long-term survival rate after curative resection was four and two of 23 at 3 and 5 years respectively, significantly better than two and none of 21 at I and 2 years after non-curative resection (P<0.01). The survival rate after curative resection for patients with type I tumours was four and two of 14 at 3 and 5 years respectively, significantly better than for other types (P<0.05). This classification of advanced gallbladder carcinoma according to involvement of adjacent organs might be helpful in planning surgery for this condition; in particular, type I tumours should be treated by a radical surgical procedure to achieve a favourable outcome.     

Surgical Outcomes and Prognostic Factors for T2 Gallbladder Cancer Following Surgical Resection

Background

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

Methods

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

Results

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

Conclusions

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

Laparoscopic resection for rectal cancer: Outcomes in 194 patients and review of the literature

Background There are few reports on laparoscopic rectum resection demonstrating its feasibility and efficacy in patients with rectal cancer. Most patient series are small, and results must be considered preliminary and medium-term. Our large prospective conducted study aimed to assess the effectiveness of a totally laparoscopic resection for rectum carcinoma with emphasis on perioperative and long-term oncological outcomes.Methods Between November 1992 and July 2003, 194 unselected patients were resected laparoscopically for rectal carcinoma. Patients with locally advanced rectum carcinoma (uT3/uT4) and no evidence of distant metastases were candidates for neoadjuvant chemoradiation. Adjuvant treatment was administered to patients with UICC stage II/III disease. All patients were followed up prospectively to evaluate complications and late outcomes. Survival probability analysis was performed using the Kaplan-Meier method. Study selection was made by Medline search using the following key words: rectal cancer, rectal neoplasms, laparoscopy, and resection. Single case reports and abstracts were excluded. When surgical series were reported more than once, only the most recent reports were considered and listed.Results The most common procedures were low anterior resection with total mesorectum excision in 65.5% of patients and high anterior resection in 25.3%. Average operative time was 174 min. Average number of lymph nodes removed was 25.4 and length of specimen resected was 27.6 cm. Resection was curative in 145 patients and palliative in 49 cases. UICC tumor stages were as follows: stage I: 25.2%, stage II: 27.3%, stage III: 30.4%, and stage IV: 17%. Intraoperative complications were <1% for lesions of the ureter, urinary bladder, and deferent duct. Conversion to conventional surgery was necessary in two cases (1%). The most common postoperative complication was anastomotic leakage in 13.5% of patients. There was no postoperative mortality. Follow-up evaluation ranged from 1 to 128 months with a mean of 46.1 months. The most common late complication was incisional hernia in 3.6% of patients. Port-site metastases occurred in one patient (0.5%). Tumor recurrence developed in 23 of the 145 curative resected patients (11.7% distant metastases and 4.1% local recurrence). Overall local recurrence rate was 6.7% (4.1% after curative resection and 14.3% after palliative resection). Overall survival rate was 90.6% at 1 year, 74.5% at 3 years, and 66.3% at 5 years. Overall 5-year survival rate was 76.9% after curative resection and 31.8% after palliative resection. Cancer-related survival rate was 94% at 1 year, 82.4% at 3 years, and 78.9% at 5 years. At 5 years it was 87.7% after curative resection and 48.5% after palliative resection. At 5 years, the survival rate was 100% for stage I, 94.4% for stage II, 66.6% for stage III, and 44.6% for stage IV.Conclusions Our results and the literature review clearly demonstrate that laparoscopic resection for rectal cancer is not associated with higher morbidity and mortality. Established oncological and surgical principles are respected and long-term outcomes are at least as good as those after open surgery.Presented by T. Benhidjeb at the 12^th International Congress of the European Association for Endoscopic Surgery (E.A.E.S.), Barcelona, Spain, June 2004     

An aggressive surgical approach leads to improved survival in patients with gallbladder cancer: a 12-year study at a North American Center

OBJECTIVE: To determine if an aggressive surgical approach, with an increase in R0 resections, has resulted in improved survival for patients with gallbladder cancer. SUMMARY BACKGROUND DATA: Many physicians express a relatively nihilistic approach to the treatment of gallbladder cancer; consensus among surgeons regarding the indications for a radical surgical approach has not been reached. METHODS: A retrospective review of all patients with gallbladder cancer admitted during the past 12 years was conducted. Ninety-nine patients were identified. Cases treated during the 12-year period 1990 to 2002 were divided into 2 time-period (TP) cohorts, those treated in the first 6 years (TP1, N = 35) and those treated in the last 6 years (TP2, N = 64). RESULTS: Disease stratification by stage and other demographic features were similar in the 2 time periods. An operation with curative intent was performed on 38 patients. Nine (26%) R0 resections were performed in TP1 and 24 (38%) in TP2. The number of liver resections, as well as the frequency of extrahepatic biliary resections, was greater in TP2 (P < 0.04). In both time periods, an R0 resection was associated with improved survival (P < 0.02 TP1, P < 0.0001 TP2). Overall survival of all patients in TP2 was significantly greater than in TP1 (P < 0.03), with a median survival of 9 months in TP1 and 17 months in TP2. The median 5-year survival in TP1 was 7%, and 35% in TP2. The surgical mortality rate for the entire cohort was 2%, with a 49% morbidity rate. CONCLUSIONS: A margin-negative, R0 resection leads to improved survival in patients with gallbladder cancer.     

Surgical treatment of complicated diverticular disease of the colon

The present study analyzes the results obtained by the AA with the different types of surgery adopted in the treatment of the complicated diverticulosis of the colon, highlighting, on the basis of data available in literature, the possible treatments in the different clinical settings. A retrospective study analyzing type of complication, the surgical technique adopted, Hinchey stage, mortality and morbidity rates and average hospital stay correlated with the kind of intervention has been carried out on 83 surgical interventions performed between 1984 and 1988. The results show that 43 R.A.P. (R.A.P. = primitive anastomosis resection) (32 cases at the I-II stage and 11 cases at the III-IV stage), 27 Hartmann (11 at the I-II and 16 at the III-IV), 9 colostomies (2 at the I-II and 7 at the III-IV), 2 esteriorizations and 2 simple drains have been carried out on a total of 44 intestinal perforations, 16 recurrent diverticulitis, 13 intestinal occlusions, 2 fistulae, 5 abscesses and 3 hemorrhages. The total mortality rate amounts to 10.6%; the morbidity rate of the R.A.P. interventions to 14.4 (I-II stage-related morbidity = 15.6%, III-IV stage = 63.6%), Hartmann's to 9.6% and that of the colostomies to 3.6%. Furthermore, in this work, we have considered the cases of riconversation after Hartmann interventions (9 cases): in the second operations the mortality and morbility rate amounts to 0 and the hospital stay to 9 days. The AA analyze on the surgical technique adopted in the different cases and the of choice criteria. According to the data obtained and to current literature, it results that the primitive anastomosis resection represents the first choice intervention at the I-II stage, although, in selected cases, it can be carried out also at the III-IV stage. Hartmann surgery confirms its effectiveness while simple colostomy is no longer accepted in literature.     

Influence of tumour differentiation on survival after resection for rectal cancer in a series of 1296 patients

The influence of differentiation grade on tumour staging, local recurrence and long term survival prospects has been evaluated in a series of patients managed by resection for rectal cancer. Differentiation was known in 1095 of 1296 patients. Well-differentiated tumours were over-represented among Dukes' stage A cases and poorly differentiated among those with disseminated disease (P less than 0.001). Local recurrence was twice as common (31%) after curative resection of poorly differentiated tumours than of well (14%) or moderately (17%) differentiated. Five year cancer specific survival rates after resection (curative and palliative combined) of tumours of good, average or poor differentiation were 68%, 59% and 33%, respectively. After potentially curative resection, survival was also significantly worse in patients with poorly differentiated tumours (P less than 0.001); 5 year survival rates of patients with tumours of good, average or poor differentiation were 75%, 71% and 51%, respectively. Survival prospects beyond 5 years in patients with Dukes' stage A tumours were significantly reduced when the tumour was poorly differentiated; 5 and 10 year survival rates were 76% and 40%, respectively. However, patients with Dukes' stage C tumours of poor differentiation had an identical 5 and 10 year cancer specific survival, 26%. Patients with mucoid type tumours had worse survival prospects than those with non-mucoid type (P less than 0.02).     

A Curative Resection Improves the Postoperative Survival Rate Even in Patients with Advanced Gallbladder Carcinoma

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

原发性胆囊癌96例回顾性分析

目的 探讨原发性胆囊癌的不同治疗方式、不同病理分期及分化程度对预后的影响.方法 对1994年12月至2003年12月间连续收治的96例原发性胆囊癌病例的临床病理特点、不同的治疗方式及其随访结果进行生存分析. 结果 96例中手术治疗61例,非手术治疗及放弃治疗者35例.获得随访77例(80%).Nevin Ⅰ～Ⅲ期患者的预后明显好于NevinⅣ～Ⅴ期患者.R0及R1切除术的3年生存率分别为80%及20%,R2切除术患者平均生存期为5.2个月,未行切除的患者平均生存期为2.5个月. 结论早期诊断、R0手术是胆囊癌患者长期存活的关键,病理分期对胆囊癌的预后有重要影响.     

The role of surgery in the treatment of adrenocortical carcinoma

The authors evaluate the role of surgery in the treatment of primary adrenocortical cancer. They describe a case-report of a "giant" surrenalic cancer in a young woman affected by chronic hepatitis B related, submitted to "en bloc" surgical resection, locoregional lumphectomy and omolateral nefropexy. The adjuvant post-operative therapy consisted in six cicles of chemioterapy with Mitotane (op'DDD) at conventional dose. Postoperative course was unevenful and the patient was discharged after four days. Postoperative adjuvant therapy was well tolerated and after one year the patient is disease free. In Italy adrenocortical cancer represents about the 10% of adrenal neoplasms and causes a mortality--cancer related--about of 0.1% among all cancers. The incidence of relapse is about 25% after "en bloc" resection with 5 years survival of 54% in stage I-II, 21.4% in stage III, 6.5% in stage IV, respectively. The age < 40 years a functional activity of the mass, stage and resecability of neoplasm represent the most important prognostic factors. The use of mitotane in the postoperative adjuvant therapy is still controversry with variable results. Surgery represents the treatment of choice in case of primary adrenocortical cancer and is well indicated also for patients with advanced stage and recurrent loco-regional disease.     

Long-term survivors after resection of carcinoma of the head of the pancreas: significance of histologically curative resection

Background/Purpose The prognosis of patients with pancreatic cancer is said to have not been improved markedly by any procedures in the past 20 years. Since 1973, we have gradually extended the area of dissection when performing curative resection for pancreatic cancer to improve the resection rate and prognosis. Nineteen patients have survived for 3 years or more, and the 5-year survival rates of patients with cancer of the head of the pancreas were 23.9% for macroscopically curative resection and 34.3% for histologically curative resection.Methods We histologically observed surgical specimens, cut into 3- to 5-mm sections and compared the histologic characteristics of the 19 patients who survived for 3 years or more with those of 41 patients who died of cancer within 3 years (excluding 6 operative and hospital deaths), in order to find the conditions required for long-term survival.Results The following conditions were associated with long-term survival: (1) tumor diameter 3cm or less; (2) either absence of lymph node metastasis or metastasis limited to the n₁ group; (3) degree of invasion of the anterior pancreatic capsule of zero (s0); and (4) either no retropancreatic invasion (rp0) or exposed retropancreatic invasion (rpe) with no cancer invasion of dissected peripancreatic tissue ew(–).Conclusions At present, because the rpe rate is more than 70%, resection of the pancreas, including the superior mesenteric vein and the retropancreatic fusion fascia, is essential for a curative resection, because the retropancreatic tissue between the back of the pancreas and this fascia is anatomically considered to be in the position of the subserosal tissue in the gallbladder or stomach. Combined resection of the superior mesenteric artery may further improve the results of resection for pancreatic cancer, from the anatomical viewpoint.