Incidental gallbladder carcinoma

Carcinoma detected at histological examination of the gallbladder is defined as incidental. It is a fairly rare event, but the increase in the number of cholecystectomies performed has led to a rise in detection of incidental gallbladder carcinoma. Histologically, in most cases, these are pT1 and pT2 carcinomas. Up until the 'nineties it was believed that these carcinomas could be adequately treated by simple cholecystectomy, whereas today the treatment of choice entails a second operation. This study constitutes a review of 20 years' experience. The database consists of 3012 cholecystectomies. Survival data are calculated in relation to the evolution of surgical treatment, thus making it possible to correlate tumour staging, patient survival and surgical therapy. The incidence of IGC was about 0.66% (20 cases). The survival rates of patients operated on by extended cholecystectomy, compared with those achieved previously with simple cholecystectomy, have risen from 92% to 100% at 1 year and from 26% to 66% at 5 years, respectively. The contributions made by literature reports since the 'nineties have prompted hepatobiliary surgeons to modify their attitudes towards incidental gallbladder carcinoma. Detection of previously unrecognised microinfiltrations of the serosa and of neoplastic involvement of distant lymph-node stations has led to the introduction of the concept of extended cholecystectomy. Comparison between our historical survival curve of patients treated with simple cholecystectomy and the distinctly better curve of those treated with a radical second operation accounts for the evolution of surgical treatment over the past two decades.     

原发性胆囊癌

目的探讨胆囊癌的早期诊断及各种手术对其预后的影响。方法对５６例胆囊癌患者的致病因素进行分析。结果按照Ｎｅｖｉｎ分期Ⅰ期５例,Ⅱ期７例,Ⅲ期１０例,Ⅳ期１３例,Ⅴ期１０例。行各类切除性手术３２例（５７１％）,剖腹探查取活检１３例（２３２％）,非手术行放疗或化疗１１例（１９７％）。各类切除性手术的１,３,５年生存率分别为５６３％（１８／３２）,２８１％（９／３２）,１２５％（４／３２）,探查活检的１３例及非手术治疗的１１例均在明确诊断后５个月内死亡。结论早期诊断和及时行根治性手术是改善胆囊癌预后的关键     

Porcelain gallbladder is not associated with gallbladder carcinoma

The surgical management of porcelain gallbladder is based on studies performed in 1931 and 1962, which indicated a correlation between porcelain gallbladder and carcinoma. We sought to evaluate the characteristics of patients with porcelain gallbladder and the risk for gallbladder carcinoma. The medical records of 10,741 cholecystectomies performed between 1955 and 1998 were reviewed and recorded. The pathology slides were evaluated for evidence of calcification and gallbladder carcinoma. Fifteen (0.14%) of 10,741 specimens were porcelain gallbladders. Ten patients (67%) had symptoms suggestive of biliary colic or cholecystitis. Five (33%) were asymptomatic and diagnosed incidentally. All specimens demonstrated chronic cholecystitis and partial calcification of the gallbladder wall. Nine (60%) had cholelithiasis. None had gallbladder carcinoma by recent review of pathologic material. During this same period 88 (0.82%) patients had gallbladder carcinoma, none of which showed calcification of the wall. This report represents the largest modern review of porcelain gallbladders. No carcinoma was identified among patients with porcelain gallbladder. In addition no patient with gallbladder carcinoma had calcified gallbladder. With a better understanding of the natural history of the porcelain gallbladder the current management of these patients may change.     

Advanced gallbladder carcinoma with biliobiliary fistula, resected by hepatopancreatoduodenectomy, in an aged patient

We report a 78-year-old man with a gallbladder carcinoma and biliobiliary fistula, diagnosed by percutaneous transhepatic cholangioscopic biopsy through the fistula. The impacted stones in the common hepatic duct were crushed, and then selective cholangiography under percutaneous transhepatic cholangioscopy (PTCS) revealed a biliobiliary fistula. Cholangioscopic biopsy tissues taken from the gallbladder revealed adenocarcinoma, but biopsies taken from the fistula revealed no evidence of malignancy. Further investigations indicated that the gallbladder carcinoma involved the duodenum and the distal common bile duct. A hepatopancreatoduodenectomy, including both an extended right hepatic lobectomy with resection of the caudate lobe and a pancreatoduodenectomy, was performed. Despite the patient's advanced age, he made an unremarkable postoperative recovery and was able to enjoy an active social life for 8 months after the surgery. We discuss biliobiliary fistula associated with gallbladder carcinomas and the use of hepatopancreatoduodenectomy for advanced biliary cancer in aged patients. Received: October 12, 2000 / Accepted: March 12, 2001     

Subclinical gallbladder carcinoma.

Clinicopathologic features of 31 patients with subclinical gallbladder carcinoma were reviewed in an attempt to determine the parameters for a course of therapy. Subclinical gallbladder carcinoma was defined as a gallbladder carcinoma that was first diagnosed microscopically by surgical pathologists. Of 31 patients, there were 26 women and 5 men, ranging in age from 54 to 84 years (mean age: 68 years). All 31 patients had undergone cholecystectomy for presumed benign gallbladder conditions. The 31 gallbladder carcinomas consisted of 6 carcinomas limited to the mucosa or the muscle coat (m or pm) and 25 carcinomas extending into the subserosal layer with surgical margins free of malignant cells in 14 (ss ew [-]) and affected by malignant cells in 11 (ss ew [+]). Cumulative 1-year, 3-year, and 5-year survival rates of six patients with m or pm carcinoma were 100% (p less than 0.001, versus ss ew [+] at 1 year), 100% (p less than 0.05, versus ss ew [-] at 3 years), and 100% (p less than 0.05, versus ss ew [-] at 5 years) compared with 91% (p less than 0.01, versus ss ew [+] at 1 year), 65%, and 65% of 14 with ss ew (-) carcinoma and 43%, 0%, and 0% of 11 with ss ew (+) carcinoma. Thirteen of the 31 patients died of local recurrence and/or liver metastasis. Univariate logrank analysis of 10 prognostic factors showed that depth of invasion, venous invasion, and surgical margin were prognostic factors. Multivariate Cox-regression analysis of these three profound factors demonstrated that surgical margin and depth of invasion were independent variables. These results showed that m or pm subclinical gallbladder carcinoma does not necessarily require an additional operation, whereas ss ew (-) and ss ew (+) carcinomas necessitate additional resection and adjuvant treatment.     

术后意外胆囊癌

目的探讨术后意外胆囊癌的处理对策。方法对78例术后胆囊癌进行回顾性临床病理分析，并就临床分期和预后与非意外胆囊癌组进行比较。结果78例术后意外胆囊癌，术前诊断以各类急、慢性胆囊炎、胆囊结石和胆囊息肉为主。77例行单纯胆囊切除术，1例行胆囊造瘘术。按UICC标准进行TNM分期，0期9例，Ⅰ期27例，Ⅱ期31例，Ⅲ期11例，无ⅣA和ⅣB期病例；意外胆囊癌组的肿瘤分期与非意外组相比，差异有统计学意义（P〈0．0001）。意外胆囊癌组的预后也明显好于非意外组（P〈0．01）。结论手术医师应提高对胆囊癌的警惕性。术中常规剖视胆囊，对可疑病变行冰冻切片检查。对T2～T4期的术后意外胆囊癌应宜再次剖腹做根治性手术，以改善预后。     

Chemotherapy in gallbladder carcinoma

Gallbladder cancer is an aggressive tumor. Its incidence varies according to geography. Surgery is the standard treatment for localized stage but there is no standard treatment in metastatic or locally advanced disease. Because of the rarity of bile tract cancer (BTC) and gallblader carcinoma (GBC), most studies have grouped all BTC and GBC together, and there are very few GBC-specific studies. In addition, there is a paucity of randomized controlled studies in this disease with small numbers of patients and inclusion bias. One randomized trial ABC-02?was well conducted and showed a survival benefit in favor of gemcitabine (GEM)+cisplatin (CDDP), which can be regarded as the standard in locally advanced BTC. Adjuvant therapy after surgical resection is not validated. Understanding the molecular mechanisms of carcinogenesis of GBC has opened the way for the use of targeted therapies. This new treatment would improve survival and quality of life of our patients.     

Unsuspected carcinoma of the gallbladder

Laparoscopic cholecystectomy is the treatment of choice for gallstones. A formal contraindication is gallbladder cancer. However, in a great number of cases, this is a previously unsuspected intraoperative finding, and sometimes its first appearance is in acute cholecystitis. We present the case of 67-year-old woman, which presented an unsuspected carcinoma of the gallbladder that developed abdominal wall implants at the umbilical and left hypocondrium site. The success of LC favors the observation of cases similar to that described in this article. Surgeons who operate using laparoscopic techniques should bear this possibility in mind and practice an extemporaneous biopsy at the slightest suspicion of malignancy, and, if it is confirmed, the operation should be continued as an open one.     

胆囊癌发生相关危险因素的探讨

目的 探索胆囊癌发生的相关危险因素,为防治胆囊癌提供理论依据.方法 回顾性分析2000年1月至2010年12月北京协和医院收治的153例胆囊癌患者(胆囊癌组)的临床病理资料,并抽取同期收治的300例胆囊结石患者(胆囊结石组)和300例非胆道疾病的成年患者(对照组)作为对照进行1:2病例对照研究.计数资料采用x2检验,对相关危险因素先进行单因素分析,采用x2检验,筛选出有统计学意义的可疑危险因素,再用多因素Logistic回归方程进行分析.结果 胆囊癌组与对照组患者比较,年龄、胆囊结石病史、绝经年龄、累积行经时间、生育与否及生育次数是胆囊癌的危险因素,差异有统计学意义(x2=58.22,180.14,9.59,24.30,18.66,15.17,P＜0.05);年龄、胆囊结石病史、累积行经时间及生育次数是胆囊癌的独立危险因素(x2=55.76,180.95,24.30,8.54,P＜0.05);进一步分析发现,有胆囊结石的患者罹患胆囊癌的危险性是无相关病史患者的34倍( OR =34.22).绝经年龄越晚(51～55岁)、累积行经时间越长(≥30年)、生育次数较多(3次)的女性患胆囊癌的可能性越大(OR=3.96,9.68,3.51).胆囊癌组胆囊结石患者与胆囊结石组患者比较,年龄、胆囊结石病程、累积行经时间及生育次数是胆囊癌的危险因素(x2=70.66,16.66,11.59,4.69,P＜0.05);年龄、胆囊结石病程及累积行经时间是患胆囊癌的独立危险因素(x2=64.29,8.82,5.58,P＜0.05);进一步分析发现,罹患胆囊癌危险性随着年龄升高而增大,胆囊癌发生的危险性随着结石病程延长而升高.对于女性患者,累积行经时间≥30年也会增加罹患胆囊癌的危险因素.结论 年龄、胆囊结石病史、胆囊结石病程、累积行经时间及生育次数可能是胆囊癌发病的危险因素.对于年龄≥60岁、胆囊结石病程≥3年的患者应切除胆囊,以降低胆囊癌的发病率;女性患者有以上表现者应高度重视,及时诊断和治疗.     

Radical surgery for gallbladder carcinoma

The aims of the study were to evaluate the adequacy of the surgical treatment and results of curative extended resections for gallbladder cancer. To this end we carried out a retrospective analysis of 59 patients operated on at our institution from 1983 to 2000. Nineteen patients received a curative resection with a radical intent (4 stage I-II patients and 15 stage III-IV patients, according to the AJCC classification). Kaplan-Meyer survival was 100% after one year and 66.6% after five years for stage I-II patients; 44.4% after one year and 0% after 5 years for stage III patients; 75.0% after one year and 0% after 5 years for stage IV patients. Our analysis confirms the poor prognosis of gallbladder carcinoma. In stage I-II patients surgical treatment offers a good chance of survival. In stage III-IV patients surgery affords good palliation. "Curative" extended resection is, however, a safe surgical procedure and offers a real possibility of enhancing survival.     

Adenosquamous carcinoma of the gallbladder

Between 1976 and 1987, 49 patients with cancer of the gallbladder were treated. In three specimens, histologic characteristics of adenosquamous carcinoma were detected, namely blasts deriving from both squamous and glandular epithelium. These carcinomas, relatively rare, are usually found in the gastrointestinal tract, the thyroid, the breast and the female genital apparatus.     

早期胆囊癌的外科处理

胆囊癌的手术切除率和5年生存率均极低,对胆囊癌的诊治存在诸多争议.2010年新制定的AJCC第7版胆囊癌TNM分期改动较大,反复较多,体现了目前对胆囊癌诊治的困惑.肿瘤浸润深度(T)是影响胆囊癌预后的最重要因素[1].相对早期的T1、T2期胆囊癌,淋巴结转移率低,手术疗效较好[2].     

Primary carcinoma of the gallbladder

Primary carcinoma of the gallbladder, while infrequent, is the most representative among the malignant neoplasms of the biliary tract. The diagnosis of carcinoma of the gallbladder was made in 22 out of 1252 operations performed for gallbladder disease (1.8%) since January 1980 through June 1988: only in 9% of the subjects a malignant tumor of the gallbladder was suspected preoperatively. In 21 cases the carcinoma was associated with chronic lithiasic cholecystitis. The 22 cases were assessed according to the classification proposed by Nevin. The operations performed were: 4 routine cholecystectomies (stages I and II) 4 cholecystectomies with lymphadenectomy (stages I and II); 4 cholecystectomies with lymphadenectomy and liver wedge resection of the bed of the gallbladder (stages II, III, IV, V); 7 explorative laparotomies and 3 gastrojejunal anastomoses (stage V). A complete follow-up was available for each of the 22 subjects: cumulative survival rates were calculated according to Kaplan-Meyer. The overall 5-year cumulative survival rate after operation was 19% for the whole group, whereas it reached 76% for the subgroup of 9 patients classified in stages I and II. This analysis reinforces the statement that surgical therapy can achieve excellent results if brought about before cancer overwhelms the muscular layer of the gallbladder wall. Thus, as the preoperative diagnosis of gallbladder carcinoma is extremely difficult and uncertain, any delay in performing cholecystectomy seems to be unwise in all those cases of chronic benign disease of the gallbladder (whether lithiasic in nature or not) that are suspected to be a major risk factor for cancer degeneration because of their frequent association with the carcinoma of the gallbladder.     

胆囊癌的综合治疗

原发性胆囊癌是胆道系统中占首位的恶性肿瘤,预后差,5年存活率低,仅为5%~13%,手术切除是治愈胆囊癌的最有效方法,胆囊癌外科手术方式的选择主要取决于病人的一般情况、肿瘤局部病变情况和胆囊癌的分期,目前早期胆囊癌Nevin I期行单纯胆囊切除术,II~V期胆囊癌多需扩大切除范围包括肝脏、胆囊床切除,以及清扫包括胆囊三角淋巴结及周围的区域淋巴结,化疗、放疗均能有效延长病人生存期。