Guidelines for the management of biliary tract and ampullary carcinomas: surgical treatment

The only curative treatment in biliary tract cancer is surgical treatment. Therefore, the suitability of curative resection should be investigated in the first place. In the presence of metastasis to the liver, lung, peritoneum, or distant lymph nodes, curative resection is not suitable. No definite consensus has been reached on local extension factors and curability. Measures of hepatic functional reserve in the jaundiced liver include future liver remnant volume and the indocyanine green (ICG) clearance test. Preoperative portal vein embolization may be considered in patients in whom right hepatectomy or more, or hepatectomy with a resection rate exceeding 50%–60% is planned. Postoperative complications and surgery-related mortality may be reduced with the use of portal vein embolization. Although hepatectomy and/or pancreaticoduodenectomy are preferable for the curative resection of bile duct cancer, extrahepatic bile duct resection alone is also considered in patients for whom it is judged that curative resection would be achieved after a strict diagnosis of its local extension. Also, combined caudate lobe resection is recommended for hilar cholangiocarcinoma. Because the prognosis of patients treated with combined portal vein resection is significantly better than that of unresected patients, combined portal vein resection may be carried out. Prognostic factors after resection for bile duct cancer include positive surgical margins, especially in the ductal stump; lymph node metastasis; perineural invasion; and combined vascular resection due to portal vein and/or hepatic artery invasion. For patients with suspected gallbladder cancer, laparoscopic cholecystectomy is not recommended, and open cholecystectomy should be performed as a rule. When gallbladder cancer invading the subserosal layer or deeper has been detected after simple cholecystectomy, additional resection should be considered. Prognostic factors after resection for gallbladder cancer include the depth of mural invasion; lymph node metastasis; extramural extension, especially into the hepatoduodenal ligament; perineural invasion; and the degree of curability. Pancreaticoduodenectomy is indicated for ampullary carcinoma, and limited operation is also indicated for carcinoma in adenoma. The prognostic factors after resection for ampullary carcinoma include lymph node metastasis, pancreatic invasion, and perineural invasion.     

Need and extension of lymph node dissection in gallbladder carcinoma

Gallbladder carcinomas have the propensity to metastasize early, commonly into locoregional lymph nodes. For gallbladder carcinomas with infiltration of at least the muscularis (pT1b) or subserosa (pT2), surgical therapy with a curative intent always includes a locoregional lymphadenectomy besides cholecystectomy and an anatomical or atypical liver resection. In incidentally discovered gallbladder carcinomas, such a locoregional lymphadenectomy should be performed depending on the age of the patient and on tumor extension. However, this only is helpful with respect to prognosis, if the metastases are limited to the hepatoduodenal ligament or to the posterosuperior pancreaticoduodenal nodes. For gallbladder carcinomas with metastases into more distal lymph nodes, especially in paraaortal nodes, lymphadenectomy only rarely impacts long-term survival. An extended lymphadenectomy that includes resection of the bile duct and/or pancreatic head is associated with an increased rate of morbidity and mortality, therefore not being of proven advantage in terms of prognosis.     

Laparoscopic Cholecystectomy: Its Effect on the Prognosis of Patients with Gallbladder Cancer

Numerous reports suggest more recurrences and a worse prognosis after laparoscopic cholecystectomy (LC) than after open cholecystectomy (OC). The objective of this study was to compare the survival rate of patients undergoing a laparoscopic procedure versus those undergoing an open operation. A series of 24 patients with gallbladder cancer detected after LC were compared with 40 consecutive patients with gallbladder cancer detected after OC. Patients were matched by wall invasion, age, and whether they underwent a reoperation or only cholecystectomy. The series included 2 patients with in situ tumors, 2 with mucosal tumors, 1 with muscular invasion, 13 with subserosal invasion, and 6 with serosal invasion. Recurrences were observed in 4 of the 10 patients with subserosal compromise who underwent reoperation. In contrast, in the OC group of 26 patients with subserosal invasion, 20 of whom were reoperated, only 2 had a recurrence. Of the six patients with serosal infiltration, three in the LC underwent reoperation, all of whom had recurrences that precluded resection. Of the 12 patients in the OC group who presented with serosal invasion, 6 were reoperated and 4 had a recurrence. Overall survival curves did not show differences when patients were compared according to the type of procedure performed. Similarly, the analysis of patients according to the level of wall invasion indicated that there was no significant difference in survival. Although multiple reports have shown a worse prognosis for patients with gallbladder cancer undergoing LC, this study did not show a significant survival difference between the two methods. Although there is a higher but insignificant recurrence rate among the patients who underwent LC, this is not translated into survival.     

Aggressive surgery for stage IV gallbladder carcinoma; what are the contraindications?

Background/Purpose Advanced gallbladder carcinoma with paraaortic lymph node metastasis or distant metastasis is normally considered a contraindication for surgery. Our latest analyses suggest otherwise. Methods Records of 166 patients who underwent surgery for stage IV gallbladder carcinoma were reviewed retrospectively. Predictors of hospital mortality and long-term survival were analyzed. Long-term survival in patients with paraaortic lymph node metastasis and/or distant metastasis was also determined. Results Fifteen patients were 5-year survivors, with a 5-year survival rate of 12% among the 166 patients investigated. Overall hospital mortality was 14%. Male sex and portal vein resection were independent predictors of hospital mortality. Multivariate analysis of long-term survival failed to identify independent predictors. Patients with distant metastasis were divided into two groups based on whether or not the metastases were distant from the liver. Patients with paraaortic lymph node metastasis who underwent curative resection or who had isolated liver metastasis survived longer than those with other distant metastasis or those with unresectable advanced cancer. Conclusions Patients with advanced gallbladder carcinoma can benefit from surgical resection even when paraaortic lymph node metastasis and/or liver metastasis are present. However, surgical indications in advanced disease should be determined on an individual basis, based on clinical status.     

三种术式治疗Ⅱ期胆囊癌的疗效及并发症情况比较

目的探讨三种术式治疗Ⅱ期胆囊癌的疗效及并发症情况。 方法回顾性分析2007年1月至2014年12月156例Ⅱ期胆囊癌患者资料,根据治疗方式分为A、B、C三组,每组52例,A组给予腹腔镜下胆囊切除术、淋巴结清扫术和射频消融治疗,B组给予开腹胆囊切除术、淋巴结清扫术和射频消融治疗,C组给予开腹胆囊切除术、淋巴结清扫术和肝脏部分切除术治疗。观察各组患者治疗效果和并发症差异。采用SPSS24.0统计学软件分析,术中术后各个指标比较采用F检验;治疗有效率、术后1～3年生存率复发率及并发症发生率、术后并发症发生率等采用χ²检验,P<0.05差异有统计学意义。 结果A组患者手术时间、术中出血量、术后住院时间及术后并发症发生率最低(P<0.05),但三组患者术后有效率、术后1～3年生存率及术后3年复发率差异均无统计学意义(P>0.05)。 结论腹腔镜下胆囊切除术联合淋巴结清扫术和射频消融治疗Ⅱ期胆囊癌具有显著疗效。     

pT2期胆囊癌的手术治疗及预后

目的：探讨pT2期胆囊癌的治疗与预后。方法：15例pT2期胆囊癌病例入选,对比分析存活率和手术相关的4个预后因素,包括手术方式、手术中是否有胆汁溢出,手术切缘是否残留肿瘤、淋巴结是否转移。结果：全组单纯胆囊切除术8例,胆囊癌根治术7例;胆汁溢出发生3例,手术切缘肿瘤残留3例,淋巴结转移5例。多因素分析表明手术切缘是否残留肿瘤、手术方式、胆汁溢出及淋巴结是否转移是影响预后的独立因素;Log-rank检验表明生存率与手术切缘是否阴性、手术方式、胆汁溢出及淋巴结是否转移有相关性。结论：对于pT2期胆囊癌患者,如果患者无淋巴结转移,术中无胆汁溢出,手术切缘肿瘤无残留,行根治性胆囊癌手术可达到较好效果。     

浸润深度局限在胆囊壁内的T1和T2期胆囊癌的预后分析

目的 探讨不同治疗方式对浸润深度局限于胆囊壁内的T1、T2期胆囊癌预后的影响。方法 对浸润深度局限于胆囊壁内的45例T1和12期胆囊癌患者的预后进行回顾分析。结果 Cox多因素分析显示肿瘤浸润深度（T）、胆囊癌根治术以及术后化疗是影响预后的三个独立的因素。在未用化疗的情况下T1a期、T1b期和T2期胆囊癌在单纯胆囊切除术后的5年生存率分别为100％、67％和0,T1b期与T2期两组生存差异有统计学意义。在未用化疗的情况下T2期胆囊癌在单纯胆囊切除和胆囊癌根治术后的5年生存率分别为0和63％。T2期胆囊癌在单纯胆囊切除术后使用化疗与未用化疗的生存差异有统计学意义。结论 T1期胆囊癌预后明显优于12期胆囊癌。T1a期和T1b期胆囊癌在单纯胆囊切除术后即可获得比较满意的5年生存率。胆囊癌根治术和化疗均可以改善T2期胆囊癌的预后。     

Immunohistochemically demonstrated lymph node micrometastasis and prognosis in patients with gallbladder carcinoma

OBJECTIVE: To investigate whether immunohistochemically demonstrated lymph node micrometastasis has a survival impact in patients with advanced gallbladder carcinoma (pT2-4 tumors). SUMMARY BACKGROUND DATA: The clinical significance of immunohistochemically detected lymph node micrometastasis recently has been evaluated in various tumors. However, few reports have addressed this issue with regard to gallbladder carcinoma. METHODS: A total of 1476 lymph nodes from 67 patients with gallbladder carcinoma (pN0, n = 40; pN1, n = 27) who underwent curative resection were immunostained with monoclonal antibody against cytokeratins 8 and 18. The results were correlated with clinical and pathologic features and with patient survival. RESULTS: Lymph node micrometastases were detected immunohistochemically in 23 (34.3%) of the 67 patients and in 37 (2.5%) of the 1476 nodes examined. Of the 37 nodal micrometastases, 21 (56.8%) were single-cell events, and the remaining 16 were clusters. Five micrometastases were detected in the paraaortic nodes. Clinicopathologic features showed no significant associations with the presence of lymph node micrometastases. Survival was worse in the 27 patients with pN1 disease than in the 40 with pN0 disease (5-year survival; 22.2% vs. 52.6%, P = 0.0038). Similarly, survival was worse in the 23 patients with micrometastasis than in the 44 without micrometastasis (5-year survival; 17.4% vs. 52.7%, P = 0.0027). Twenty-eight patients without any lymph node involvement had the best prognosis, whereas survival for the 11 patients with both types of metastasis was dismal. The grade of micrometastasis (single-cell or cluster) had no effect on survival. The Cox proportional hazard model identified perineural invasion, lymph node micrometastasis, and microscopic venous invasion as significant independent prognostic factors. CONCLUSIONS: Lymph node micrometastasis has a significant survival impact in patients with pN0 or pN1 gallbladder carcinoma who underwent macroscopically curative resection. Extensive lymph node sectioning with keratin immunostaining is recommended for accurate prognostic evaluation for patients with gallbladder carcinoma.     

Appraisal of surgical resection of gallbladder carcinoma with special reference to hepatic resection

Carcinoma of the gallbladder a gastrointestinal malignancy with an extraordinarily poor prognosis. However, aggressive surgery, with special reference to hepatic resection, may improve survival. To prove this, we performed a retrospective analysis over an 18-year period to investigate the experience of a center that began employing liver resection in patients with gallbladder cancer in 1978. The analysis was based on patients' documentation and regular follow-up to January 1996. The standard procedures were extended cholecystectomy (cholecystectomy with lymphadenectomy and wedge hepatic resection), anatomic segmentectomy of segments IVa and V, and extended hepatectomy. Significance was assessed by the log-rank test. Thirty-nine patients were resected, curatively in 41% (n = 22; group I) and palliatively in 31% (n = 17; group 2). In 28% (n = 15; group 3) a palliative or no operation was performed. Only curatively resected patients were analyzed and followed up to January 1996. No patients in group 1 died postoperatively. The actuarial 5-year survival rate of the patients with curative resection was 55%. Four patients had stage I, two had stage II, four had stage III, and two had stage IV disease according to TNM-classification. Six of the 16 patients without lymph node metastasis survived more than 5 years. A significant difference in long-term survival was recognised between stage II and stage IV patients and between stage (pT1a)- and (look table 1b) (pT1b)-patients (P < 0.01). Diagnostic efforts should focus on detecting early stages I and II gallbladder cancer. In advanced cases, aggressive surgery, particularly with hepatic resection, is the method of choice and is successful even in patients 70 years and older. Received for publication on July 31, 1997; accepted on April 1, 1998     

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.     

Patterns of Failure and Determinants of Outcomes Following Radical Re-resection for Incidental Gallbladder Cancer

Background

Better appreciation of the course and factors that influence incidental gallbladder cancer is needed to develop treatment strategies aimed at improved outcomes. The purpose of this study was to determine pattern of disease recurrence and influencing factors in patients undergoing radical re-resection for incidental gallbladder cancer.

Methods

Patients undergoing radical re-resection from February 2003 to May 2010 were analyzed. Influence of variables (lymph node ratio, ASA grade, gender, adjuvant treatment, time interval between cholecystectomy and radical re-resection (in months), and TNM stage) on disease-free survival was assessed.

Results

Of 163 patients, 127 (92 female and 35 male patients; median age 50 years) underwent successful radical re-resection. Median duration between two surgeries was 2 months (range 1–10). Twenty-five percent of patients with pT1b disease had lymph node metastases. Two-year disease-free survival rate was 79.6 % (median follow-up, 16 months). On follow-up, 18 of 24 patients developed recurrences at distant sites. Lymph node metastasis was the single variable significantly influencing disease-free survival. Adjusting for disease stage when analyzing time interval between cholecystectomy and radical re-resection on a continuous scale as a prognostic factor for recurrence revealed no significant impact of increasing interval between surgeries (hazard ratio 1.12; 95 % confidence interval 0.95–1.34; p = 0.17).

Conclusions

The most important predictor of disease recurrence is lymph node metastases. In patients who undergo curative radical re-resection for incidental gallbladder cancer, recurrent disease is more likely to occur at distant sites. Patients with pT1b disease should be offered radical re-resection with a radical lymphadenectomy. It is not the delay in revision surgery but TNM stage that influences outcomes in incidental gallbladder cancer.     

Indications for pancreatoduodenectomy in patients undergoing lymphadenectomy for advanced gallbladder carcinoma

Background/Purpose Carcinoma of the gallbladder shows diverse patterns of spread. The most appropriate surgical procedures according to the depth and extent of the spread of the tumor are still controversial.Methods We investigated this surgical problem clinicopathologically, especially regarding the indications for pancreatoduodenectomy (PD), by retrospectively reviewing the clinical records of 216 patients who were surgically treated for advanced gallbladder carcinoma. Detailed studies of resected specimens, in our department, showed that preservation of the pancreas head carried an increased risk of residual microscopic metastases in small peripancreatic lymphatic nodes and ducts. Some patients with curative operations had shown recurrence in lymph nodes around the head of the pancreas within a few years after PD. Therefore, we performed hepatopancreatoduodenectomy (HPD) in 93 patients, some of whom underwent the HPD as a prophylactic dissection of peripancreatic lymph nodes and some of whom underwent the HPD as a curative resection due to invasion to the peripancreatic lymph nodes, duodenum, and pancreas, observed macroscopically. The surgical outcome after PD was compared with that obtained after other curative resections (non-HPD).Results In patients with microscopically negative lymph node metastasis without hepatoduodenal ligament invasion, PD was not necessary for a complete resection of lymphatic metastases around the pancreas head. The 5-year survival rate of these patients who had HPD was not significantly higher than that for non-HPD resections with curative intent (73% vs 63%), and lymphatic recurrence was not marked. On the other hand, in patients with positive lymph node metastases without hepatoduodenal ligament invasion, PD was necessary for a complete resection. The 5-year survival rate after HPD in these patients was significantly improved compared to that after non-HPD resections with curative intent (87% vs 17%), because lymphatic recurrence was reduced (0% vs 80%).Conclusions In advanced carcinomas with positive hepatoduodenal ligament invasion, although the basic operative strategy, which inevitably includes right lobectomy, should be curative, PD should not be performed for prophylactic lymphatic resection, because local recurrence in the hepatoduodenal ligament cannot be controlled by PD, and the 5-year survival rate of curative HPD was only 4% (non-HPD resection with curative intent, 18%); moreover, frequent, lethal, major postoperative complications (hepatic failure) occurred after combined right lobectomy.     

Gallbladder carcinoma and surgical treatment

Gallbladder carcinoma shows an unusual geographic and demographic distribution. It is relatively uncommon in Europe, but more frequent in Israel, Chile, Bolivia and in Southwestern Native Americans in the United States. Chronic cholecystitis, choledochal cysts, high body mass index, female gender, age, nicotine and industrial exposure to carcinogens are associated risk factors. The frequency of gallbladder cancer in all operations of the biliary tract is about 1-3%, reflecting the commonest biliary tract malignancy. Preoperative imaging, including ultrasound and computed tomography (CT), may reveal signs indicative of the presence of malignancy. However, most patients are not diagnosed prior to surgical intervention. Survival depends on the ability to achieve a curative resection, including hepatectomy and lymph node dissection in patients with local extended tumour according to the stage of the disease. Overall, the curative resection rates for gallbladder carcinoma range from 10% to 30%. Regional and para-aortic lymphadenectomy provides no survival benefit for patients with para-aortic disease, which has a negative influence on prognosis equivalent to that of distant metastases. A survival benefit is seen only in selected patients with metastases limited to the regional nodes. Taking a sample biopsy of the para-aortic nodes before starting surgery is recommended because these nodes are involved more frequently than expected. For those patients with unresectable cancer, palliative surgical, endoscopic or radiological bypass procedures can improve quality of life. Other approaches to the management of advanced tumours include systemic chemotherapy or combined chemo-radiotherapy and need further evaluation. Early-stage tumours are often discovered as an incidental finding during (laparoscopic) cholecystectomy or on histological examination of the gallbladder, mostly necessitating relaparotomy and extensive resection. In the following, management of patients with gallbladder cancer at different stages and situations is discussed.     

Prognostic Significance of Level and Number of Lymph Node Metastases in Patients with Gastric Cancer

BACKGROUND: To present data that provide some insight into the appropriateness of a nodal grouping category and its relation to survival in patients with gastric cancer. METHODS: We reviewed data of 777 patients with advanced gastric cancer who had undergone curative gastrectomy to investigate the prognostic significance of level and number of lymph node metastases. RESULTS: The prognosis of patients with gastric cancer was well correlated with the level and number of lymph node metastases. Multivariate analysis indicated that the level and number of lymph node metastases were independent prognostic indicators. Moreover, the number of lymph node metastases was an independent prognostic factor in N1, N2, and N3 patients. The most statistically significant difference in disease-specific survival was observed at a threshold of 11 lymph node metastases, yielding a chi2 value of 42.88, a hazard ratio of 2.523, at a 95% confidence interval of 1.913, 3.329 (P < .0001) by Cox proportional hazard model. On the basis of this result, patients were divided into two groups as follows: marked lymph node metastasis group (number of positive nodes > or =11) and slight lymph node metastasis group (number of positive nodes < or =10). The prognosis of patients with marked lymph node metastasis was statistically significantly worse than that with slight lymph node metastasis in N1, N2, and N3 patients. CONCLUSIONS: Both level and number were indispensable for evaluating lymph node metastasis. Therefore, addition of the number of positive nodes to the N category defined by the Japanese Classification of Gastric Carcinoma may be a useful strategy in the N staging classification in gastric cancer.     

Mediastinal Metastases in Bronchogenic Carcinoma: Influence of Postoperative Irradiation,Cell Type,and Location

A 17-year experience with 136 patients with bronchogenic carcinoma and mediastinal metastases is reported. Six died postoperatively. Postoperative mediastinal irradiation was given to 110 patients surviving curative resection who had evidence of tumor spreading to the mediastinal lymph nodes. The remaining 20 patients did not receive radiation therapy.Of the 136 patients, 29 (21.3%) lived 5 years free from disease and 9 survived 10 or more years. Of the 110 patients who survived operation and underwent irradiation, 29 (26.4%) survived 5 years. None of the 20 patients not receiving radiation therapy lived 5 years. Of the patients who underwent irradiation, 18 of the 50 patients with squamous cell carcinoma survived 5 years, while only 7 of 55 with adenocarcinoma survived 5 years.We do not believe that the discovery of mediastinal lymph node involvement in bronchogenic carcinoma is a contraindication to pulmonary resection. As in our previous reports, histological cell type has proved to be an important indicator of absolute survival. Patients with squamous cell carcinoma had an absolute 5-year survival of 33.9%, while the patients with adenocarcinoma had an absolute survival of 12.3%.The level of lymph node metastasis has an influence on prognosis as well. Patients with subcarinal lymph node metastases had a lower survival than patients with superior mediastinal involvement.     

Predictors for Patterns of Failure after Pancreaticoduodenectomy in Ampullary Cancer

Background Ampullary cancer has the best prognosis in periampullary malignancy but unpredicted early recurrence after resection is frequent. The current study tried to find the predictors for recurrence to be used as determinative for postoperative adjuvant therapy. Methods Information was collected from patients who underwent pancreaticoduodenectomy with regional lymphadenectomy for ampullary cancer in high-volume hospitals between January 1989 and April 2005. Recurrence patterns and survival rates were calculated and predictors were identified. Results A total of 135 eligible patients were included. The 30-day operative mortality was 3%. Median followup for relapse-free patients was 52 months. Disease recurred in 57 (42%) patients, including 31 liver metastases, 26 locoregional recurrences, 9 peritoneal carcinomatoses, 7 bone metastases, and 6 other sites. Pancreatic invasion (P = 0.04) and tumor size (P = 0.05) were the predictors for locoregional recurrence, while lymph node metastasis was the sole predictor for liver metastasis (P = 0.01). The 5-year disease-specific survival rate was 45.7%; 77.7% for stage I, 28.5% for stage II, and 16.5% for stage III; and 63.7% for node-negative versus 19.1% for node-positive patients. Pancreatic invasion and lymph node involvement were both predictors for survival of patients with ampullary cancer. Conclusion Pancreaticoduodenectomy with regional lymphadenectomy is adequate for early-stage ampullary cancer but a dismal outcome can be predicted in patients with lymph node metastasis and pancreatic invasion. Lymph node metastasis and pancreatic invasion can be used to guide individualized, risk-oriented adjuvant therapy.     

The Impact of Lymph Node Metastases on Survival in Extremity Soft Tissue Sarcomas

Background The impact of lymph node metastases on survival in extremity soft tissue sarcomas has been studied for a long time with controversial results. The purpose of this study was to compare survival of patients with initial lymph node metastases with those having lymph node or distant metastases or both after initial curative surgery. Methods Patients treated between 1995 and 2000 for extremity soft tissue sarcoma were retrospectively studied in four groups: those with metastatic regional lymph nodes at the time of diagnosis, those with only regional lymph node recurrences, those with only distant metastatic relapses, and those with both regional lymph node recurrences and distant metastatic relapses, all of the last three groups after initial curative surgery. The impact of timing of lymph node metastases on disease-free and overall survival was evaluated. Results A total of 110 patients (73 men) with a median age of 45 years were eligible for the study. Three-year disease-free survival was significantly longer in patients with initial regional lymph node metastases than in patients with only lymph node recurrences after curative surgery (p = 0.04) and patients with initial (p = 0.0002) and recurrent (p = 0.0004) regional lymph node metastases had longer disease-free survival than patients with distant metastases. Overall survival difference between patients with initial regional lymph node metastases and patients with only lymph node recurrences after curative surgery was significant at 5 years (p = 0.01). Conclusions It is logical to separate patients with initial lymph node metastases from those with distant metastases in staging and to treat patients with initial lymph node metastases with radical surgical interventions if complete tumor resection seems feasible.     

Gender-specific prognostic markers of patients with gallbladder cancer after surgical resection

The aim of this study was to elucidate gender-specific markers for postresectional long-term survival of gallbladder cancer (GBC) based on a cohort of Chinese patients. Clinicopathological records of 81 patients (27 males and 54 females) after surgical resection for GBC were reviewed retrospectively. The influence of each variable on survival was determined using the Kaplan-Meier method and log-rank test. For females, Cox regression analysis was also adopted. Univariate analysis showed that the absence of lymph node and distant metastases, differentiation grade, and curative resection were associated with prolonged survival for all males, whereas tumor size, differentiation grade, and the presence of lymph node metastases influenced the overall or disease-free survival of patients after curative resection (all P < 0.05). On the other hand, Nevin stage was an independent marker for both overall survival for all females and overall and disease-free survival for female patients who underwent curative resection. Additionally, resection type and differentiation grade were of independent prognostic significance for different subgroups of females (all P < 0.05). Our data suggested that tumor-related factors affect prognosis of both male and female patients with GBC after resection. Of these factors, tumor differentiation status might be more significant for males, but Nevin stage had a stronger predictive potential for females.     

Risk Factors Influencing Recurrence, Patterns of Recurrence, and the Efficacy of Adjuvant Therapy After Radical Resection for Gallbladder Carcinoma

Backgrounds

Gallbladder carcinoma (GBC) is an aggressive neoplasm, and resection is the only curative modality. Recurrence frequently occurs after the curative resection of advanced GBC. Adjuvant treatment, particularly radiotherapy, is recommended and is used without any evidence of a beneficial effect. The aim of this study was to characterize patterns of recurrence and to identify the factors that influence recurrence and the efficacy of adjuvant therapy after the curative resection of GBC.

Methods

The records of patients that underwent surgical resection with curative intent for gallbladder carcinoma from October 1994 and August 2007 were retrospectively reviewed. Recurrence patterns, times to recurrence, and survival rates were analyzed. Sites of recurrence were identified retrospectively and categorized as locoregional or distant.

Results

One hundred sixty-six patients underwent surgical resection with curative intent for gallbladder adenocarcinoma. The 5-year recurrence rates of stages IA, IB, IIA, and IIB patients were 0%, 24.3%, 44.9%, and 58.3%, retrospectively. Positivity for lymph node metastases was found to have predictive significance for disease-free survival (p?=?0.009). Regional lymph node recurrence (27.7%) was observed most frequently. There was no significant disease-free survival rates between the no adjuvant therapy and the adjuvant therapy groups.

Conclusions

The regional lymph nodes and the liver were found to be the most common sites of recurrence after curative resection. Lymph node metastases were identified as an independent predictor of tumor recurrence by multivariate analysis. Based on the disease-free survivals observed in this study, the authors find it would be difficult to advocate the routine use of adjuvant radiotherapy and/or chemotherapy     

Primary cancers of the gallbladder. Apropos of a homogeneous series of 75 cases

Seventy-five cases of primary carcinoma of the gallbladder are reviewed retrospectively under observation of a fifteen year period, representing 2.4 per cent of the number of biliary tract surgery performed during the same period. The majority of the patients presented with advanced disease with extension and metastases to the liver (56%) and to the adjacent organs (53.3%) and to the lymph nodes along the common bile duct (21.3%). Eleven patients had localized disease at the time of the operation; they were treated with cholecystectomy. Eight patients had clinically inapparent carcinoma at the time of the cholecystectomy; the diagnosis being established post-operatively by histologic examination of the excised gallbladder. There were no five years survivors in this second group of patients, but five of them are one year survival (62.5%) and one is still alive three years and six months after surgery. The remaining patients with inapparent carcinoma died within three years of the time of the operation. The present report emphasize the poor prognosis associated with carcinoma of the gallbladder and the presence of gallstones. Carcinoma of the gallbladder in our experience has proved curable only when accidentally discovered at cholecystectomy for presumed benign biliary tract disease. This fact plus the frequent and serious non neoplastic complications of neglected gallstones are strong indications for early elective cholecystectomy and extended resection may improve the survival rate.