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RESULTS OF RADICAL SURGERY FOR CARCINOMA OF GALLBLADDER
DR CHEUNG YUE SUN
Department of Surgery
Prince of Wales Hospital
The Chinese University of Hong Kong
Overview
• Introduction
• Staging System – AJCC
• Treatment of T1 lesion
• French Surgical Association Survey
• PWH Experience
• Literature Review
Introduction• CA Gallbladder is rare but fatal
– 3-15 per 100,000– Median survival < 6 months– Overall 5-year survival < 5%
• F:M = 2-6 : 1• Incidence increases with age• Mean age = 65• 75-90% are adenocarcinoma• Association between CA GB & gallstones
– 70-90% patients had gallstones– 1% of patients with cholecystectomy
Barakat. Cancer 2006; 106:434-40Bilimoria. Diseases of the Gallbladder and Bile Ducts
Staging – AJCC TNM Staging Tis Carcinoma-in-situ
T1 Lamina propria / muscleT2 perimuscular connective tissue, not be
yond serosaT3 perforated serosa / direct invade liver /
one adjacent organsT4 main portal vein / hepatic a / multiple e
xtrahepatic organs
N0 No regional LN
N1 Regional LN met
M0 No distant Met
M1 Distant met
AJCC Cancer Staging Manual. 6th Ed 2002
Stage GroupingStage 0 Tis N0 M0Stage IA T1 N0 M0Stage IB T2 N0 M0Stage IIA T3 N0 M0Stage IIB T1-T3 N1 M0Stage III T4 Any N M0Stage IV Any T Any N M1
Treatment for T1 lesion• Median survival after Cholecystectomy was compa
rable to radical resection: 95 months– Overall 10-year survival 87%
• Lymphatic vessel invasion and LN metastasis is rare
• T1 lesion was local disease amenable to cholecystectomy
Wakai BJS 2001; 88: 675-8
Past Experience for Advanced Tumor
• French Surgical Association Survey 1980-1989 - 73 institutions in France, Europe
• 724 patients histological proven CA GB• 85% tumor invaded beyond serosa (T3/T4)
– 90% died at 1 year• 23% underwent curative operations• Overall 30-day operative mortality 22%• 5-yr survival
– T1 / T2 : 20-28%– T3 / T4 : 0
Cubertafond Ann. Surg. 1994 219; 275-80
Can radical surgery give better results?
10-year Experience of PWH
• 1995 – 2004• 34 patients of CA GB underwent operation• Pathology reports, case notes and computer recor
ds were reviewed• Median Age = 65 (37 to 86)• M:F = 16:18• 5 patients diagnosed after cholecystectomy• Pathology
– Adenocarcinoma 27– Papillary Adenocarcinoma 4– Mucinous Adenocarcinoma 1– Unknown 2
Treatment Group
• Curative Surgery (44%)– Cholecystectomy– Segment 4b/5 resection*– Porta-hepatis LN dissection– Extrahepatic bile-duct resection (3)
• Palliative Surgery (31%)– Palliative cholecystectomy / by-pass
• Diagnostic Laparotomy / Laparoscopy (21%)
* Rt hepetectomy - 1, Ext Rt Hepatectomy - 1
Staging by Traeatment Group
Curative Surgery: n= 15 (44%)• Tcis 1• T1 N0 1• T2 Nx 1• T2 N0 4• T2 N1 1• T3 Nx 3• T3 N0 3• T3 N1 1
Palliative Surgery: n=12 (35%)
• T2 4• T3 5• T4 2• M1 1
Diagnostic Lap : n=7 (21%)• T4 N1 2• M1 5
Mortality and Morbidity• Mortality (9%)
– AMI– Liver Failure– Pneumonia
• Morbidity (12%)– Wound infection– Pneumonia– Chylous ascites– Subhepatic collection
Curative vs PalliativeMortality = 2:1
Morbidity = 4:0
Survival
• Overall Median Survival: 23 months– Max: 127 months
• Curative: 39 months
• Palliative: 5 months
• Diagnostic: 3.5 months
• 8 patients in the curative group still alive
Survival Functions
Survival (months)
140120100806040200-20
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1.0
.8
.6
.4
.2
0.0
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Treatment Intent
Diagnostic
Diagnostic-censored
Palliative
Palliative-censored
Curative
Curative-censored
Log Rank p=0.0002
Stratification for T2 / T3
Survival Functions
T_STAGE = 2
Survival (months)
140120100806040200
Cu
m S
urv
iva
l
1.2
1.0
.8
.6
.4
.2
0.0
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Treatment Intent
Palliative
Palliative-censored
Curative
Curative-censored
Survival Functions
T_STAGE = 3
Survival (months)
3020100
Cu
m S
urv
iva
l
1.2
1.0
.8
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.4
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0.0
-.2
Treatment Intent
Palliative
Palliative-censored
Curative
Curative-censored
Other LiteraturePatient
No.Age Operative Procedure T – Staging
Mortality / Morbidity
Median Survival (months)
5-yr Survival
Fong 2000
410 65
Cholecystectomy S4b,5 Resection LN Dissection+- bile duct resection
1 2(2)
4% / 29%
NS 5.4 4%
2 64(37)
NC 8 3%3 137(36)
4 207(27) C 26 ^ 38%
Suzuki 2004
20 63.5
CholecystectomyS4b,5 ResectionLN Dissection+- bile duct resection
pT2 0 / 16% 64 77%
Sasaki 2006
65 64.3
CholecystectomyS4b,5 ResectionLN Dissection+- PD +- bile duct resection
1 15
3.1% / 29.2%
-
40% (overall)pN0 76.2%pN1 30.0%pN2 45.8%
pM1 0%
2 24
3 20
4 6
Summary
• Radical Surgery -– Cholecystectomy – Segment 4b/5 liver resection– Regional LN dissection
• Provides better survival for locally advanced CA GB
• Significant morbidity and mortality
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