Strategies for surgical treatment of gallbladder carcinoma based on information available before resection.
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.
Kokudo
Norihiro
N
Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, University of Tokyo, Japan. KUKUDO-2SU@h.u-tokyo.ac.jp
Makuuchi
Masatoshi
M
Natori
Takeshi
T
Sakamoto
Yoshihiro
Y
Yamamoto
Junji
J
Seki
Makoto
M
Noie
Tamaki
T
Sugawara
Yasuhiko
Y
Imamura
Hiroshi
H
Asahara
Shingo
S
Ikari
Takaaki
T
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