Purpose: Patients with advanced gallbladder cancer often required extended surgical procedure. In addition to the surgical treatment, the relationships between various clinopathological factors and the outcomes remain controversial. The aim of this study is to evaluate the factors influencing the surgical outcome in patients with T3-4 gallbladder cancer.
Methods
Patients and data collection
This study work was performed retrospectively in six medical institution at Daegu-Kyungpook area. Data from 135 patients who underwent surgical treatment for postoperatively confirmed T3 and T4 gallbladder between January 2000 and December were collected. Factors influencing the prognosis of locally advanced gallbladder cancer after resection were analyzed by univariate and multivariate analysis.
Indications for surgery
In patients with advanced gallbladder cancer without involvement of the liver or minimal infiltration into the liver, wedge resection of the gallbladder bed/segment IVb/V resection and regional / extend lymph node (LN) dissection was planned. When the massive invasion of the liver was diagnosed, major hepatectomy was indicated. If the tumors involved extrahepatic bile duct or aggressive regional lymph node metastasis around the bile duct was found, bile duct resection was added. Hepatopancreaticoduodenectomy was considered in patients with the following conditions: (1) lower bile duct involvement, (2) pancreatic infiltration, (3) duodenal infiltration, and (4) aggressive retropancreatic lymph node metastasis. Palliative surgical interventions were performed when enbloc tumor removal cannot be achieved because of distant metastases, peritoneal seeding, positive para-aortal lymph nodes, or wide tumor invasion, or body conditions cannot afford aggressive surgery or patients refused. For the palliative surgery, biliary tract drainage was performed once jaundice or biliary tract invasion occurred.
Statistical analysis
Results were analyzed using the Statitical Package for the Social Sciences for Windows version 23.0. Associations among variables were analyzed by using the chi-square test of Fisher’s exact test. Survival analysis were performed using the Kaplan-Meier method, log-rank test, and Cox-regression.
Results
The patients comprised of 59 men and 76 women, aged 38 to 84 years (median age 69 years). Gallstones were present in 26 patients (19.3%). 123 patients received extended cholecystectomyv and R0 resection was achieved in 107 patients (87.0%). Of 123 patients who performed extended cholecystectomy, combined extrahepatic bile duct resection were performed in 50 patients (40.7%) and 109 patients (88.6%) received systemic lymphadenectomy. The 1-, 3-, and 5-year overall survival rate for extended cholecystectomy patients were 63.6%, 40.5%, and 24.7%. The 1-, 3-, and disease specific 5-year survival rate for extended cholecystectomy patients were 76.4%, 54.2%, and 42.5%. According to the 7th edition AJCC TNM staging system, T stage of the primary tumors were pT3 in 109 patients (88.6%) and pT4 in 14 patients (11.4%). The disease specific 5-year survival rate for patients with T3 and T4 disease was 44.9% and 18.0%, respectively. The disease specific 5-year survival rate for patients with N0, N1, and N2 disease was 56.5%, 36.9% and 0%, respectively. According to the nodal status, 45(36.6%) patients were pN0, 57 patients (46.3%) were pN1, and 7 patients (5.7%) were pN2. The disease specific 5-years survival rate in N0, N1, and N2 were 56.5%, 36.9%, and 0%. Although there was no difference according to whether hepatectomy or extrahepatic bile duct resection was performed, the survival rate was significantly improved when systemic lymphadenectomy was performed.
Conclusion: The prognosis of patients with locally advanced gallbladder cancer is poor. Extended resection is not always beneficial in locally advanced cancer. However, long-term survival can be expected in some cases. To improve long term prognosis for the patients with locally advanced cancer, surgeon should try to performed extended resection.