Is Carcinoma of the Gallbladder a Curable Lesion?

Abstract

Carcinoma of the gallbladder is an uncommon, but not rare tumor that is associated with a 5% five-year survival rate after resection and this rate has not appreciably improved over the last decades in most series. Nevin et al.(20) however have reported that favorably staged gallbladder cancers (according to histologic grade and depth of invasion) have a relatively good prognosis. They quoted an overall five-year survival of 21% in 66 patients. Most of the surviving patients (11) were in the favorably staged category: Stage I (intramucosal cancer) and Stage II (invasion of mucosa and muscularis). The remaining few were in Stage III (invasion of all layers), Stage IV (cystic node metastases), or Stage V (extension of metastases to the liver or distant sites). Our data has been analyzed to determine whether microstaging of the primary cancer will select out a subgroup with a favorable prognosis, and whether there are survival benefits according to the type of surgical resection. A clinical and pathologic review was done of 100 patients treated at the University of Virginia Hospital from 1930 to 1978. There were 77 women and 23 men, with an average age of 65 years (range 21-89). Gallstones were described in 78% of the patients. Surgical procedures included cholecystectomy alone (23 patients), cholecystectomy with biliary drainage (17 patients), cholecystectomy and resection of the hepatic bed (8 patients), and exploration with biopsy or bypass (44 patients). Autopsy only was done in eight patients. There were only three long-term survivors (6 years, 11 years, and 24 years). Median survival was six months with cholecystectomy alone, five months with cholecystectomy and bypass, 14 months after partial liver resection, and 2.0 months after laparotomy/bypass/biopsy. The five-year survival rate was 5% after cholecystectomy alone or with bypass, and 13% (1/8) after cholecystectomy and partial liver resection (p = 0.07). Microstaging of the primary cancers showed no prognostically favorable subgroup. Of 46 patients with microstaged lesions, only 13% were in the very favorable Stage I and II groups (only one of six survived), 46% were Stage III (1/21 survived), and the remaining 41% were in the highly unfavorable Stage IV and V groups (1/19 survived). Most patients showed progression of disease either primarily or secondarily that was locoregional (liver and nodes). Although longterm survival may accompany cholecystectomy alone for a favorable early-staged cancer, this is still uncommon. There may be theoretical, although not proven, merit for resection of the hepatic bed and regional node dissection in the selected patient, possibly complimented by adjuvant therapy. Future advances in chemotherapy and radiation will be needed to augment the current poor cure rate of this disease.

Routes of Hepatic Metastasis of Gallbladder Carcinoma

“…N a k a m u r a et al 1 1 a n d Miyazaki et al 1 2 h a v e achieved better survival rates from extensive hepatectomy in cases with direct hepatic invasion than in previously reported cases, in which hepatic wedge resection had been performed. 8 ' 9 According to our study findings, in which the distance between the margin of direct hepatic invasion and hepatic metastasis had no correlation with the extent of direct hepatic invasion, occult localized hepatic metastasis around the gallbladder bed may not be removed by hepatic wedge resection for advanced gallbladder cancer. In view of this possibility, substantial hepatectomy, such as resection of S4a and S5, resection of S4a, S5, and S6, or extended right hepatectomy might be a better choice in cases with direct hepatic invasion but not necessarily in cases with involvement of the hepatoduodenal ligament.…”

“…One reason for the poor outcome might be excessively limited hepatic resection; wedge resection of the gallbladder bed is the most popular procedure. 8,9 Some surgeons have reported that more extensive hepatectomy such as extended right hepatic lobectomy offers a better prognosis. 10_12 We propose, in agreement with the findings of other investigations about hepatic metastasis from colorectal cancer, 13 ' 14 that hepatic recurrence after resection for advanced gallbladder carcinoma is due, at least in part, 11 metastatic lesions were located within the portal tracts or accompanied by invasion into the portal tracts.…”

Significance of Subserosal Lesions and Results of Extended Cholecystectomy in the Treatment of Primary Carcinoma of the Gallbladder

“…The most logical surgical approach to carcinoma of the gallbladder, therefore, is cholecystectomy, wedge resec tion of the underlying liver, and skeletonization of the hepatoduodenal ligament [19], However, the choice of operative procedures also depends on the depth of inva sion. At surgery, any suspicious lesion should be exam ined by frozen section.…”

Carcinoma of the gallbladder

“…In the University of Virginia series [16], of 100 reported pa-tients 92 were explored, and in 44 of these only biopsy with or without bypass was possible. From the remaining 48 who underwent resection, 40 had a cholecystectomy with or without common duct drainage, and 8 had cholecystectomy with partial liver resection.…”