title: Strategies for surgical treatment of gallbladder carcinoma based on information available before resection.
abstract: OBJECTIVE
  Precise preoperative staging for gallbladder carcinoma is difficult, despite recent advances in hepatobiliary imaging. However, the most accurate preoperative staging may be possible by integrating preoperative key data.
  
  
  OBJECTIVE
  To establish useful strategies for the surgical treatment of gallbladder cancer based on information available before resection.
  
  
  METHODS
  Retrospective review.
  
  
  METHODS
  University hospital and tertiary referral cancer center.
  
  
  METHODS
  From January 1, 1978, through March 31, 2001, 152 patients with gallbladder cancer underwent surgical resection with curative intent. Preoperative diagnoses of the T factor (image-T) and N factor (image-N) in the TNM classification were determined by evaluating all findings of diagnostic imaging, including ultrasonography, enhanced computed tomography, endoscopic ultrasonography, and angiography. The distribution of lymph node metastasis and prognostic factors were also analyzed.
  
  
  RESULTS
  The overall diagnostic accuracy for image-T was 52.6% (95% confidence interval, 44.7%-60.6%) and was lower in patients with pT1 and pT2 disease (37.2% and 33.9%, respectively). However, image-T was a significant predictor of lymph node metastasis and patient outcome. Preoperative staging for N was more difficult, with only 24.5% (95% confidence interval, 12.4%-36.5%) of the node-positive patients being correctly diagnosed. An analysis of harvested lymph nodes showed that the cystic, pericholedochal, and posterosuperior peripancreatic nodes were the most prevalent sites of metastasis, and these were considered key nodes for the lymphatic spread of gallbladder cancer. By combining data on image-T and positivity of these key nodes, more accurate TNM staging was possible. Although an extended lymph node dissection provided significantly better survival in patients with pN2 disease, there was no survival advantage to more radical operations, including bile duct resection or pancreaticoduodenectomy.
  
  
  CONCLUSIONS
  Although precise preoperative TNM staging for gallbladder carcinoma was difficult, the most accurate staging before resection was possible by integrating image-T classification and data from the intraoperative histopathologic examination of key lymph nodes. Based on this staging, we propose algorithms for the surgical treatment of gallbladder carcinoma.
authors.affiliation: Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, University of Tokyo, Japan. KUKUDO-2SU@h.u-tokyo.ac.jp
authors.forename: Norihiro
authors.initials: N
authors.lastname: Kokudo
authors.forename: Masatoshi
authors.initials: M
authors.lastname: Makuuchi
authors.forename: Takeshi
authors.initials: T
authors.lastname: Natori
authors.forename: Yoshihiro
authors.initials: Y
authors.lastname: Sakamoto
authors.forename: Junji
authors.initials: J
authors.lastname: Yamamoto
authors.forename: Makoto
authors.initials: M
authors.lastname: Seki
authors.forename: Tamaki
authors.initials: T
authors.lastname: Noie
authors.forename: Yasuhiko
authors.initials: Y
authors.lastname: Sugawara
authors.forename: Hiroshi
authors.initials: H
authors.lastname: Imamura
authors.forename: Shingo
authors.initials: S
authors.lastname: Asahara
authors.forename: Takaaki
authors.initials: T
authors.lastname: Ikari
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000465:Algorithms; D003952:Diagnostic Imaging; D005260:Female; D005706:Gallbladder Neoplasms / Q000175:diagnosis* / Q000473:pathology / Q000601:surgery*; D006801:Humans; D008207:Lymphatic Metastasis / Q000175:diagnosis; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D011237:Predictive Value of Tests; D011379:Prognosis; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D016019:Survival Analysis; D016896:Treatment Outcome