Indications for curative resection of advanced gallbladder cancer with hepatoduodenal ligament invasion.
OBJECTIVE
Hepatoduodenal ligament invasion (HLI) is an inhibiting factor for the curative resection of advanced gallbladder cancer. The aim of this study was to clarify the indications for surgical resection in patients with advanced gallbladder cancer with and without HLI by analyzing outcomes.


METHODS
The subjects were 58 patients with advanced gallbladder cancer who underwent aggressive resection, and 20 nonresected patients diagnosed as haring HLI. The presence of stromal cancerous infiltration at six sites in the hepatoduodenal ligament was investigated. The extent of cancer spread was classified into two grades by the number of sites where cancer cells detected: low grade, one or two invasion sites; high grade, three or more sites.


RESULTS
Pancreatoduodenectomy, vascular reconstruction, and extensive hepatectomy were frequently performed in the patients with HLI. The cumulative 5-year-survival rate of the HLI patients was 10.9%, significantly worse than that of the resected patients without HLI (46.6%; P < 0.01). Patients with paraaortic lymph node metastasis died within 1 year. The cumulative 5-year-survival rate after curative resection was 38.1%, significantly better than that after noncurative resection (0%; P < 0.05). The survival was significantly worse in patients with high-grade invasion than in these with low-grade invasion (P < 0.05), being equivalent to that in the nonresection patients. Of four factors, operative curability, hepatic lobectomy, HLI grade, and paraaortic lymph node metastasis, the HLI grade and hepatic lobectomy were considered to be significant prognostic factors by Cox's multivariate analysis (backward stepwise method).


CONCLUSIONS
Aggressive surgical resection for curative purposes should be limited to patients with low-grade HLI and metastasis-negative paraaortic lymph nodes.
Endo
I
I
Second Department of Surgery, Yokohama City University School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan.
Shimada
H
H
Fujii
Y
Y
Sugita
M
M
Masunari
H
H
Miura
Y
Y
Tanaka
K
K
Misuta
K
K
Sekido
H
H
Togo
S
S
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D004386:Duodenum / Q000473:pathology; D005260:Female; D005706:Gallbladder Neoplasms / Q000401:mortality / Q000473:pathology* / Q000601:surgery*; D006498:Hepatectomy; D006801:Humans; D008022:Ligaments / Q000473:pathology*; D008099:Liver / Q000473:pathology; D008207:Lymphatic Metastasis; D008297:Male; D008875:Middle Aged; D009361:Neoplasm Invasiveness; D009367:Neoplasm Staging; D016577:Pancreaticoduodenectomy; D016016:Proportional Hazards Models; D016019:Survival Analysis; D016896:Treatment Outcome