RESULTS OF RADICAL SURGERY FOR CARCINOMA OF GALLBLADDER DR CHEUNG YUE SUN Department of Surgery Prince of Wales Hospital The Chinese University of Hong.

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)

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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)

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Treatment Intent

Palliative

Palliative-censored

Curative

Curative-censored

Survival Functions

T_STAGE = 3

Survival (months)

3020100

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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

THANK YOU