Unsuspected gallbladder cancer diagnosed during or after laparoscopic cholecystectomy

BACKGROUND: The long-term prognosis of laparoscopic cholecystectomy (LC) for patients with unsuspected gallbladder carcinoma (GBC) remains unclear. We investigated retrospectively the role of examination of frozen sections and the prognosis of patients with unsuspected GBC detected during or after LC. METHODS: LC was performed on 1,793 consecutive patients. If a suspicious lesion was found, intraoperative frozen section examination was performed. RESULTS: Of all these patients, 38 (2.1%) were histopathologically diagnosed as having a GBC during (28) or after LC (10). The tumor stages of the 28 diagnosed during LC were: pT1a (17), pT1b (2), pT2 (8), and pT3 (1). The sensitivity and specificity of intraoperative frozen section examination were 90 and 100%, respectively. On the other hand, those 10 cases diagnosed after LC had pT1a (1) and pT2 (9) tumors. Survival rates were not significantly affected by whether the patient was diagnosed with GBC during or after LC. CONCLUSIONS: The survival with unsuspected GBC was related to stage and it was confirmed that a carefully performed LC is adequate treatment for Stage 1A and B cancer. The LC procedure does not adversely affect the prognosis of unsuspected GBC, regardless of whether it is detected during or after LC.     

腹腔镜胆囊切除意外胆囊癌的临床分析

目的 总结腹腔镜胆囊切除术中(laparoscopic cholecystectomy,LC)意外胆囊癌(unsuspected gallbladder carcinoma,UGC)的治疗经验,探讨其应对策略.方法 回顾性分析我院8000例LC术中及术后诊断为UGC的16例临床资料.结果 所有16例胆囊癌病例中,在LC术中诊断7例,LC术后诊断有9例,其中Nevin Ⅰ期2例、Ⅱ期6例、Ⅲ期7例、Ⅳ期1例.患者的5年存活率Nevin Ⅰ期为100%,Ⅱ期的5年存活率为66.7%,Ⅲ期和Ⅳ期未有5年存活者.结论 UGC患者的存活与肿瘤分期相关,Nevin Ⅰ期胆囊癌,行LC即可.LC术中怀疑有胆囊癌应及时行冰冻病理检查,对于确诊Nevin Ⅰ期以外的UGC应该尽早开腹行胆囊癌根治术.     

Laparoscopic cholecystectomy and gallbladder cancer

Heightened awareness of the possible presence of gallbladder cancer (GBC) and the knowledge of appropriate management are important for surgeons practising laparoscopic cholecystectomy (LC). Long-term effects of initial LC versus open cholecystectomy (OC) on the prognosis of patients with GBC remain undefined. Patients who are suspected to have GBC should not undergo LC, since it is advantageous to perform the en-bloc radical surgery at the initial operation. Since preoperative diagnosis of early GBC is difficult, preventive measures, such as preventing bile spillage and bagging the gallbladder should be applied for every LC. Many port-site recurrences (PSR) have been reported after LC, but the incidence of wound recurrence is not higher than after OC. No radical procedure is required after postoperative diagnosis of incidental pT1a GBC. It is unclear if patients with pT1b GBC require extended cholecystectomy. In pT2 GBC, patients should have radical surgery (atypical or segmental liver resection and lymphadenectomy). In advanced GBC (pT3 and pT4), radical surgery can cure only a small subset of patients, if any. Additional port-site excision is recommended, but the effectiveness of such measure is debated.     

Incidental finding of gallbladder carcinoma detected during or after laparoscopic cholecystectomy.

AIM: Carcinoma of the gallbladder is a rare neoplasm with a dismal prognosis. With the increase of cholecystectomies due to the wide acceptance of laparoscopic cholecystectomy, the incidental diagnosis of gallbladder carcinoma is more frequent. We report our experience with gallbladder cancer diagnosed during or after the performance of laparoscopic cholecystectomy. METHODS: We evaluated 11 patients with gallbladder cancer out of 5539 patients who underwent laparoscopic cholecystectomy. Patient clinical and demographic characteristics were reviewed. RESULTS: Intraoperatively in 297 patients there was the suspicion of adenocarcinoma and frozen sections were performed. In four of them the diagnosis of adenocarcinoma was confirmed. In two of them the procedure was converted to open with gallbladder liver bed resection and regional lymph node dissection while the other two were considered inoperable. Of the remaining 5242 patients, seven were diagnosed postoperatively at the pathologic examination. Of these, five patients refused to undergo a repeat operation. We did not observe port site metastasis in any of our patients. Survival was low and ranged from 3-14 months. CONCLUSION: Gallbladder cancer runs a short course, with a poor prognosis. The use of a meticulous laparoscopic technique seems to be important for the diagnosis and the avoidance of early complications of the disease.     

Laparoscopic cholecystectomy and unsuspected gallbladder cancer.

Gallbladder cancer is a relatively uncommon malignancy. Its presentation is similar to that of gallstone disease and sometimes with non-specific symptoms. Laparoscopic cholecystectomy has become the method of choice for removing the gallbladder in most benign conditions. Occasionally, unsuspected gallbladder carcinoma is encountered in association with laparoscopic cholecystectomy. Overall gallbladder cancers have a poor prognosis, despite surgery or adjuvant therapies. However, in selected cases, a favourable outcome can be expected and the less favourable predicted outcome can be improved. Management of patients with gallbladder cancer in different situations is discussed: gallbladder cancer noted post-operatively on final pathology, gallbladder cancer noted after removal of the gallbladder and opening of the specimen at the time of surgery, difficulty encountered at the time of dissection and resultant suspicion of gallbladder cancer, and diagnosis of extensive disease at initial placement of the laparoscope. Copyright Harcourt Publishers Limited.     

Adjuvant radiotherapy improves long-term survival after resection for gallbladder cancer A population-based cohort study

BackgroundData supporting routine use of adjuvant radiotherapy (RT) compared to without RT (noRT) for gallbladder cancer (GBC) is unclear. This study aimed to determine whether RT improves long-term survival following resection for GBC.MethodsPatients receiving resection for GBC followed by RT from 2004 to 2016 were identified from the National Cancer Database (NCDB). Patients with survival <6 months were excluded to account for immortal time bias. Propensity score matching (PSM) and Cox regression was performed to account for selection bias and analyze impact of RT on overall survival.ResultsOf 7514 (77%) noRT and 2261 (23%) RT, 2067 noRT and 2067 RT patients remained after PSM. After matching, RT was associated with improved survival (median: 26.2 vs 21.5 months, p < 0.001), which remained after multivariable adjustment (HR: 0.82, CI_95%: 0.76–0.89, p < 0.001). On multivariable interaction analyses, this benefit persisted irrespective of nodal status: N0 (HR: 0.84, CI_95%: 0.77–0.93), N1 (HR: 0.77, CI_95%: 0.68–0.88), N2/N3 (HR: 0.56, CI_95%: 0.35–0.91), margin status: R0 (HR: 0.85, CI_95%: 0.78–0.93), R1 (HR: 0.78, CI_95%: 0.68–0.88) and use of adjuvant chemotherapy (AC) (HR: 0.67, CI_95%: 0.57–0.79). Benefit with RT were also seen in patients with T2 - T4 disease and in patients undergoing simple and extended cholecystectomy.ConclusionRT following resection was associated with improved survival in this study, even in margin-negative and node-negative disease. These findings may suggest addition of RT into multimodality therapy for GBC.     

Laparoscopic cholecystectomy for treatment of unexpected early-stage gallbladder cancer

BACKGROUND AND OBJECTIVES: Laparoscopic cholecystectomy (LC) may result in the incidental diagnosis of early stage (T1 and T2) gallbladder cancer. LC is useful for T1 patients, however, its role in T2 patients remains controversial. We sought to determine the effect of initial LC on patient outcome in early-stage gallbladder cancer. METHODS: Twenty-nine patients with T1 or T2 disease were reviewed retrospectively to assess preoperative diagnosis, intraoperative findings, and outcomes. RESULTS: Diagnoses included gallbladder stones (5), gallstones with polyps (5), and gallbladder polyps (19). Malignancy was suspected in 15 patients (14 polyp lesions and 1 gallbladder stone with wall thickening). After frozen sections, two T2 patients were immediately treated with radical operation owing to positive margins. Of 14 patients diagnosed by pathology, 4 T2 patients with positive margins underwent a second radical operation. Five-year survival rate was 100% and 49.6 % (T1 and T2 patients). No mortality or recurrence was detected in T1 patients (mean follow-up, 45.8 months; range, 6-98 months). Three T2 patients died, and one T2 patient relapsed after LC. No port site metastasis was detected. CONCLUSIONS: LC for T1a and T1b gallbladder cancer needs no additional treatment, however, radical operation for T2 patients is recommended, regardless of the margin condition.     

Laparoscopic bile duct resection with lymph node dissection for gallbladder cancer diagnosed after laparoscopic cholecystectomy

IntroductionLaparoscopic reoperation of postoperatively diagnosed gallbladder cancer is a technically challenging procedure due to inflammatory adhesion or fibrosis around the hepatoduodenal ligament and gallbladder bed [1,2]. Here we describe a technique for laparoscopic bile duct resection with lymph node dissection in a patient with cystic duct cancer diagnosed after laparoscopic cholecystectomy.VideoA 73-year-old woman presented with postoperatively diagnosed gallbladder cancer. She underwent laparoscopic cholecystectomy to treat symptomatic gallbladder stones at another hospital, 2 months earlier. Postoperative pathology revealed a 0.9 × 0.7 cm, T2 lesion of adenosquamous carcinoma located at the cystic duct. The cystic duct margin showed high-grade dysplasia. We planned to perform laparoscopic bile duct resection with lymph node dissection. After adhesiolysis to expose the hepatoduodenal ligament, the lymph nodes were dissected around the retropancreatic area, hepatoduodenal ligament, and common hepatic artery in an en bloc fashion. Combined segmental resection of the bile duct, including the fibrotic scar around the cystic duct stump, was completed with negative resection margins. Retrocolic choledochojejunostomy and side-to-side jejunojejunostomy were then performed intracorporeally.ResultsThe operation time was 195 minutes and the estimated intraoperative blood loss was minimal. The postoperative pathologic report revealed no residual tumor tissue and negative resection margins. Lymph node metastasis was found in one of eight retrieved lymph nodes. The patient was discharged on postoperative day 4 with no postoperative complications.Conclusion.Laparoscopic radical surgery involving bile duct resection and lymph node dissection can be safely performed in patients with postoperatively diagnosed gallbladder cancer.     

Adjuvant hormone therapy after radiation or surgery for localized or locally advanced prostate cancer

Opinion statement Prostate cancer is being diagnosed at an earlier age and earlier disease stage than previously and increasing numbers of relatively young men are receiving potentially curative radical prostatectomy or radiotherapy for early prostate cancer. Although many of these men have an excellent outcome, a significant proportion subsequently experience disease recurrence or cancer-related death. Men with unfavorable tumor characteristics at the time of radical prostatectomy or radiotherapy are particularly at high risk of experiencing disease recurrence. One strategy to improve outcome for these men is adjuvant hormone therapy (hormone therapy administered immediately after therapy of primary curative intent). Surgical castration (bilateral orchiectomy), medical castration using the luteinizing hormone-releasing hormone (LHRH) agonist goserelin, and antiandrogen monotherapy have been investigated as adjuvant hormone therapy to radical prostatectomy and radiotherapy, and each therapy has demonstrated clinical benefits because of a significant improvement in disease-free survival. Furthermore, data are available to indicate that adjuvant hormone therapy achieved by goserelin or bilateral orchiectomy improves overall survival, particularly in men at high risk of progression. Because the effects of LHRH agonists are reversible, they provide a more acceptable method of adjuvant therapy compared to bilateral orchiectomy, particularly in the adjuvant setting, and are preferred by patients. However, the adverse effects on quality of life, in particular on sexual interest and function and bone mineral density, may limit the use of LHRH agonists in some patients. However, these parameters are maintained with nonsteroidal antiandrogens. The first data from the Early Prostate Cancer program indicate that adjuvant bicalutamide 150 mg is associated with a significant improvement in progression-free survival after radical prostatectomy or radiotherapy. Gynecomastia and breast pain are the most common side effects associated with bicalutamide therapy. Medical or surgical castration in combination with an antiandrogen (combined androgen blockade) is another option for use as an adjuvant hormone therapy. However, no study has reported on the use of combined androgen blockade in this setting. Adjuvant hormone therapy provides clinicians with another treatment option for patients with early prostate cancer and unfavorable tumor characteristics.     

乳腺癌根治术或改良根治术后辅助性放疗

近年来关于影响乳腺癌术后辅助性放疗预后及效果的因素逐渐成为研究热点,乳腺癌的不同分期、不同亚型、激素水平以及患者的身体质量指数等均与其密切相关.此外,从三维适形放疗到螺旋断层放疗,放疗技术的发展也有了质的突破,使得疾病的治疗更加精确化、合理化.     

Unsuspected gallbladder carcinoma discovered during or after cholecystectomy: focus on appropriate radical re-resection according to the T-stage

Background

The long-term survival of patients with unsuspected gallbladder carcinoma (UGC) and the role of radical re-resection for this disease remain unclear.

Methods

A retrospective study was carried out on 38 UGC patients. The time-to-event data were demonstrated by Kaplan–Meier curves. Comparing survival curves of two groups using the log-rank test.

Results

The overall incidence of UGC in patients underwent cholecystectomy in our hospital was 0.18 % (25 of 14,073). Distribution according to actual pT-stage (the UICC) was: pT1a: n = 3; pT1b: n = 11; pT2: n = 4; pT3: n = 12; pT4: n = 8. The preoperative diagnosis included a high rate of acute biliary tract inflammation (24 of 38, 63.2 %). Compared with other gallbladder carcinoma patients, UGC group had significantly higher proportion of early stages (pT1) (36.8 %, 14 of 38 cases) (p < 0.01), and better prognosis. The comparison of radical re-resection versus simple cholecystectomy showed a significant benefit in overall survival for the pT3 group (22.0 ± 5.48 vs. 5.0 ± 0.9 months; p = 0.02). There are median survival differences between the two subgroups of patients with pT1b tumors whether received re-resection or not. Median survival was 62.0 months and 24.0 ± 8.5 months, respectively, though the differences are not statistically significant (p = 0.131).

Conclusion

Radical re-resection is strongly recommended for patients with pT1b-stage cancer. The reoperation should be performed as soon as possible, preferably within 10 days after the initial operation.     

Adjuvant chemotherapy after surgery in advanced gastric cancer

Two hundred and fifty-four patients with advanced gastric cancer underwent radical surgery and ftorafur (FT) or 5-fluorouracil (5-FU) was orally administered as the adjuvant chemotherapy (ACT). Recurrence after ACT were analyzed by the quantification method II. As a result, it was found that: 1) ACT over 2 years could lower the recurrence rate, and careful follow-up is still necessary up to 4 years, and 2) after the remission induction therapy with mitomycin C and/or 5-FU and cytarabine, 12 mg/kg/day of FT for the first year and 8 mg for the second year are advisable.     

Retrobulbar metastasis from gallbladder carcinoma after laparoscopic cholecystectomy. A case report

Extra-abdominal metastases from gallbladder cancer are very rare; the sites outside the abdomen most frequently affected are the skin, bone and central nervous system. In the literature, only one case of orbital metastasis from gallbladder cancer has been reported, in a patient previously treated by open cholecystectomy. We report the case of a 53-year-old woman who underwent a laparoscopic cholecystectomy for symptomatic gallbladder stones. Postoperative histological examination revealed an unsuspected gallbladder adenocarcinoma. One month later she came to our observation after having developed diplopia and ophthalmic pain due to an orbital metastasis. We decided not to perform a surgical second look because of the already rapid dissemination of the malignant tumor. The few cases of uncommon gallbladder cancer metastases after laparoscopic cholecystectomy described in the literature are discussed, as well as the possible role of laparoscopy in the dissemination and localized seeding of malignant cells.     

Late development of umbilical metastasis after laparoscopic cholecystectomy for a gallbladder carcinoma

A periumbilical mass developed 47 months after laparoscopic cholecystectomy. Pathologic examination of this mass showed features of moderately differentiated papillary adenocarcinoma, similar to that identified within the previously removed early stage (pT1b) gallbladder carcinoma. The cause of this at the laparoscope port is unclear. after laparoscopic cholecystectomy for gallbladder carcinoma has not been reported previously. We reported a case with late periumbilical tumor seeding at the navel trocar insertion site in a 65-year-old female. A review of the preventative information of tumor recurrence and management is discussed. The use of gasless laparoscopy, slow desufflation, trocar site washout, wound protector and specimen bags are recommended.     

腹腔镜胆囊切除术治疗早期胆囊癌患者的临床观察

目的探讨胆囊癌早期患者采用腹腔镜胆囊切除术治疗的临床效果。方法选取2013年5月至2017年3月间西安医学院附属宝鸡医院收治的59例胆囊癌早期患者,按采用的手术方法不同分为观察组和对照组,其中,采用腹腔镜胆囊切除术治疗的30例患者纳入观察组,采用胆囊癌根治术治疗的29例患者纳入对照组。比较两组患者凝血功能变化、术后并发症情况、1年生存率及复发率。结果术前,两组患者活化部分凝血活酶时间(APTT)和D-二聚体水平比较,差异无统计学意义(P> 0. 05);术后24h,观察组APTT较对照组短,D-二聚体水平较对照组高,差异均有统计学意义(均P <0. 05)。观察组并发症发生率为6. 7%(2/30),低于对照组的31. 0%(9/29),差异有统计学意义(P <0. 05)。随访1年,观察组患者1年生存率为86. 7%,对照组患者1年生存率为93. 1%,两组患者生存率比较,差异无统计学意义(P> 0. 05)。随访1年,观察组复发率10. 0%(3/30),对照组为6. 9%(2/29),两组患者复发率比较,差异无统计学意义(P> 0. 05)。结论胆囊癌早期患者采用腹腔镜胆囊切除术治疗能降低并发症发生率,且不影响预后,但术后血栓发生风险高,围术期需给予防范性措施。