Long-term outcomes of surgical resection for T1b gallbladder cancer: an institutional evaluation

Abstract

Background: There is no comprehensive agreement concerning the overall performance of radical resection for T1b gallbladder cancer (GBC). This research focused on addressing whether T1b GBC may spread loco-regionally and whether radical resection is necessary.

Methods: A retrospective analysis was conducted of 1032 patients with GBC who underwent surgical resection at our centre and its affiliated institutions between January 1982 and December 2018. A total of 47 patients with T1b GBC, 29 (62%) of whom underwent simple cholecystectomy and 18 (38%) of whom underwent radical resection with regional lymph node dissection, were enrolled in the study.

Results: GBC was diagnosed pre-operatively in 16 patients (34%), whereas 31 patients (66%) had incidental GBC. There was no blood venous or perineural invasion in any patient on histology evaluation, except for lymphatic vessel invasion in a single patient. There were no metastases in any analysed lymph nodes. The open surgical approach was more prevalent among the 18 patients who underwent radical resection (open in all 18 patients) than among the 29 patients who underwent simple cholecystectomy (open in 21; laparoscopic in 8) (P = 0.017). The cumulative 10- and 20-year overall survival rates were 65 and 25%, respectively. The outcome following simple cholecystectomy (10-year overall survival rate of 66%) was akin to that following radical resection (64%, P = 0.618). The cumulative 10- and 20-year disease-specific survival rates were 93 and 93%, respectively. The outcome following simple cholecystectomy (10-year disease-specific survival rate of 100%) was equivalent to that following radical resection (that of 86%, P = 0.151). While age (> 70 years, hazard ratio 5.285, P = 0.003) and gender (female, hazard ratio 0.272, P = 0.007) had a strong effect on patient overall survival, surgical procedure (simple cholecystectomy vs. radical resection) and surgical approach (open vs. laparoscopic) did not.

Conclusions: Most T1b GBCs represent local disease. As pre-operative diagnosis, including tumour penetration of T1b GBC, is difficult, the decision of radical resection is justified. Additional radical resection is not required following simple cholecystectomy provided that the penetration depth is restricted towards the muscular layer and that surgical margins are uninvolved.

Keywords: Gallbladder neoplasms; Prognosis; Surgery; Treatment outcome.

Fig. 1

Precise pathological examination and macroscopic appearance of early-stage gallbladder cancer. The resected gallbladder specimen was sliced at 5 mm intervals, and precise pathological examinations were performed by mapping cancer lesions to reduce the possibility of pathological under-staging. a Protruding type, sessile tumour plus superficial elevated type. b Superficial elevated plus flat type. Red and yellow lines indicate the area of the tumour invading the lamina propria and muscular layer, respectively

Fig. 2

Kaplan-Meier estimates of overall survival in 47 patients with T1b gallbladder cancer. a The median overall survival time was 158 months with cumulative 5-, 10-, 15-, and 20-year overall survival rates of 81, 65, 48, and 25%, respectively. b The median overall survival time in patients undergoing simple cholecystectomy was 154 months with cumulative 5-, 10-, 15-, and 20-year survival rates of 84, 66, 40, and 24%, whereas the median overall survival time in patients undergoing radical resection was 182 months with cumulative 5-, 10-, 15-, and 20-survival rates of 78, 64, 64, and 32%, respectively (P = 0.618)

Fig. 3

Kaplan-Meier estimates of disease-specific survival in 47 patients with T1b gallbladder cancer. a The median disease-specific survival time was not reached with cumulative 5-, 10-, 15-, and 20-year disease-specific survival rates of 97, 93, 93, and 93%, respectively. b The median disease-specific survival time in patients undergoing simple cholecystectomy was not reached with cumulative 5-, 10-, 15-, and 20-year disease-specific survival rates of 100, 100, 100, and 100%, whereas the median disease-specific survival time in patients undergoing radical resection was not reached with cumulative 5-, 10-, 15-, and 20-year disease-specific survival rates of 94, 86, 86, and 86%, respectively (P = 0.151)