Evaluation of Surgical Procedures for T2 Gallbladder Cancer in Terms of Recurrence and Prognosis

Abstract

Summary: T2 (tumor invades perimuscular connective tissue; no extension beyond serosa or into liver) gallbladder cancer has generally been treated by S4aS5 subsegmentectomy (S4aS5 HR). We investigated the therapeutic effect of full-thickness cholecystectomy (FC) and gallbladder bed resection (GBR), in terms of tumor location and resection margin (distance from the tumor). At our department we employ the following protocol to determine the extent of resection needed to achieve R0 status: (1) A tumor located in the gallbladder fundus (Gf) or body (Gb) and only on the free peritoneal side was classified as P-type, for which full-thickness cholecystectomy and regional lymph node dissection were performed. (2) A tumor located in Gf or Gb and in contact with the liver bed was classified as H-type, for which gallbladder bed resection and regional lymph node dissection were performed. (3) A tumor located in the gallbladder neck (Gn) was classified as N-type, for which gallbladder bed resection, bile duct resection, and regional lymph node dissection were performed.Twenty-two patients admitted to our department between January 2000 and December 2014 with pT2gallblad-der cancers were included in our study. Surgical procedures performed were compared with those specified in our protocol, and patients in whom the extent of resection was greater than that specified in our strategy were evaluated clinicopathologically and in terms of recurrence and the prognosis.Six (27.2%), 7 (31.8%), and 9 (40.9%) patients underwent limited, standard, and extended surgery, respectively. Ten (66.7%) of 15 patients with tumors close to the liver bed underwent cholecystectomy or extended surgery, 7 (85.7%) of 8 patients with tumors close to the bile duct underwent bile duct resection, and 16 (72.7%) of 22 patients underwent regional lymph node dissection.Recurrence at the bile duct resection margin, para-aortic lymph node metastasis, and hepatic metastasis occurred in 2, 1, and 3 patients, respectively. The 3-year survival rates (for patients including those dying of noncancer causes) were 50, 100, and 75% after limited, standard, and extended surgery, respectively.There was a significant difference in the survival rate of patients who underwent standard or extended surgery (P=0.0273).Favorable results were obtained in T2 gallbladder cancer patients without performing S4aS5 subsegmentectomy. Depending on the tumor location, neither full-thickness cholecystectomy nor gallbladder bed resection appeared to pose problems regarding recurrence or prognosis.In conclusion, surgical treatment based on our protocol, which aims to achieve the condition of R0, may result in a sufficient therapeutic effect.

Impact of surgical strategies on the survival of gallbladder cancer patients: analysis of 715 cases

“…1b). Plenty of studies have indicated that the performance of radical resection might be the best choice for GBC management at clinical stage II [14,17,[22][23][24][25]. In our study, we also found that radical resection should be the only Fig.…”

“…Since liver resection has been verified to have a poor survival outcome, with a 13~18% in-hospital mortality, [12,13], the effect of radical surgery for GBC patients at advanced stages with poor conditions is quite limited. Kawahara et al also have reported an effective surgical strategy for extent of resection in GBC at T2 stage, which is based on the gallbladder location of tumor [14].…”

Importance of Gross Type in Patients With T2 Gallbladder Cancer

“…Many GBCAs are diagnosed after simple cholecystectomy because the laparoscopic approach had become the golden standard treatment modality for gallbladder diseases. Current guidelines and studies recommend re-operation in incidental T2 GBCA because of residual cancer and survival bene t. 4,9,[15][16][17] However, real clinical situations are much different from guidelines. In many studies, reoperation rate or liver resection rate are lower than those that we expected.…”

Improvement in the diagnosis and treatment of T2 gallbladder carcinoma is pivotal to improvement in the overall prognosis for this disease

“…However, Sternby et al contended that those studies constituted a low level of evidence because they involved a limited number of cases, they were exclusively retrospective observational studies and case reports, and they did not discuss the impact that lesions on the peritoneal or hepatic side of the gallbladder had on prognosis. In March 2017, Kawahara et al (5) published a retrospective study of 22 patients who underwent surgery for T2 GBC. The authors performed different surgical procedures based on the location of the lesion: full-thickness cholecystectomy (FC) + local lymph node dissection if a lesion of the gallbladder fundus or corpus is on the peritoneal side of the gallbladder (P-type) [author's note: this is T2a] ; gallbladder bed resection (GBR) + local lymph node dissection if the lesion is on the hepatic side of the gallbladder (H type) [author's note: this is T2b]; GBR + extrahepatic bile duct resection + local lymph node dissection if the lesion is on the cystic duct (N type).…”

“…(3) stones larger than 2 cm; (4) fully filled stones; (5) gallbladder wall calcification, porcelain gallbladder, with a malignancy rate as high as 50%; (6) thickening of the gallbladder wall; (7) atrophic gallbladder; (8) gallbladder adenoma or stones with gallbladder polypoid lesions; (9) gallbladder polyps larger than 1 cm; (10) preoperative MRCP suggesting an abnormality in the juncture of the bile and pancreatic ducts; (11) Mirizzi syndrome; (12) previous gallbladder ostomy (27); and (13) in China, patients who have undergone gallbladder-preserving micro-blasting lithotripsy should also be included.…”