Gallbladder cancer is a rare but often lethal malignancy. Even with advances in diagnosis and treatment of gallbladder cancer, long-term survival remains dismal. Only a minority of patients are candidates for resection at the time of diagnosis. Nonetheless, our results showed that selected patients have a favorable outcome after curative surgery. The 5-year survival rate in 40% of the patients who were able to undergo complete resection was 60.3%.
Gallbladder cancer affects women more commonly than men in all populations, with some series reporting the prevalence three to five times higher for females.1,9 The highest frequency occurs in women of over 65 years with a long history of gallstones. In this series, the female-to-male ratio was 1:1, and the median age was 59 years, which was younger than the previously reported.
In previously reported series of patients with gallbladder cancer, the resection rates range from 17% to 47%, and the 5-year survival rates after complete resection vary from 18% to 58%.2,3,8–14 Gallbladder cancer warrants extended resection only if potentially curative (RO) resection is feasible. In patients treated with curative intent, the success of complete resection depended on T-stage, which is in accordance with other reports.2,3,10,15
For Tis and T1a tumors (mucosa), it is generally agreed that simple cholecystectomy is an adequate treatment,1–7,16,17 while for Tlb tumors, a more aggressive surgical approach is required. Tlb tumors are associated with lymph node metastases in 15% of cases, whereas T1a tumors are associated with lymph node metastases in only 2.5% of cases. In this series, lymph node metastasis was absent and the 5-year survival rate was 100% in the 5 patients who had Tis or T1 tumors. Radical resection is certainly warranted and recommended in patients with T2 tumors. The reported incidence of lymph node metastasis in T2 tumor cases is 17.4%—61.9%.7,18 In this series, the incidence of lymph node metastasis was 29.2%. The median survival time of 18 T2 patients with negative surgical margins and curative lymph node dissection was 103.5 months, whereas that of 7 T2 patients with positive surgical margins or noncurative lymph node dissection who died from this disease was within 2 years. The outcome of surgery for patients with T3 and T4 is poorly independent of the high rate of lymph node metastasis and non-curative surgery.1,2,19 Recently, extended resection or pancreaticoduodenectomy has been advocated for advanced gallbladder carcinoma and, in some series, has increased the 5-year survival rate to 15%-63% (T3) and 7%-25% (T4).1,17 In our study, pancreatoduodenectomy was performed in 2 patients with direct involvement of the head of the pancreas, but the outcomes were disappointing: one died 13 days postoperatively from pulmonary failure and the other died 6 months postoperatively from liver metastasis. Lymph node metastasis is common,18 and in our surgical series the rate of lymph node metastasis was 58.8% in T3 tumor cases and 85.4% in T4 tumor cases. In our patients with T3 or T4 gallbladder carcinomas, the survival was significantly better after curative resection than after resection for other reasons.
In conclusion, the limitation of this study included retrospective data analysis and some patients followed up for less than 5 years. However, gallbladder carcinoma is an aggressive disease with a poor prognosis. Our study suggests that AJCC stage and type of surgery are strong predictors of survival. To increase the possibility of long-term survival, aggressive resection should be pursued in all patients. Complete or RO resection (negative margins and nodal dissection one level past microscopically involved lymph nodes) clearly improves the survival. Adjuvant therapy use is clearly associated with improved survival in patients with loco-regional disease, especially in patients surgically treated with non-curative intent. So more effective adjuvant therapies and new drugs are needed to improve the overall survival.
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