A Novel Pathology-Based Preoperative Risk Score to Predict Locoregional Residual and Distant Disease and Survival for Incidental Gallbladder Cancer: A 10-Institution Study from the U.S. Extrahepatic Biliary Malignancy Consortium.
BACKGROUND
This study was designed to develop a more robust predictive model, beyond T-stage alone, for incidental gallbladder cancer (IGBC) for discovering locoregional residual (LRD) and distant disease (DD) at reoperation, and estimating overall survival (OS). T-stage alone is currently used to guide treatment for incidental gallbladder cancer. Residual disease at re-resection is the most important factor in predicting outcomes.


METHODS
All patients with IGBC who underwent reoperation at 10 institutions from 2000 to 2015 were included. Routine pathology data from initial cholecystectomy was utilized to create the gallbladder cancer predictive risk score (GBRS).


RESULTS
Of 449 patients with gallbladder cancer, 262 (58 %) were incidentally discovered and underwent reoperation. Advanced T-stage, grade, and presence of lymphovascular (LVI) and perineural (PNI) invasion were all associated with increased rates of DD and LRD and decreased OS. Each pathologic characteristic was assigned a value (T1a: 0, T1b: 1, T2: 2, T3/4: 3; well-diff: 1, mod-diff: 2, poor-diff: 3; LVI-neg: 1, LVI-pos: 2; PNI-neg: 1, PNI-pos: 2), which added to a total GBRS score from 3 to 10. The scores were separated into three risk-groups (low: 3-4, intermediate: 5-7, high: 8-10). Each progressive GBRS group was associated with an increased incidence LRD and DD at the time of re-resection and reduced OS.


CONCLUSIONS
By accounting for subtle pathologic variations within each T-stage, this novel predictive risk-score better stratifies patients with incidentally discovered gallbladder cancer. Compared with T-stage alone, it more accurately identifies patients at risk for locoregional-residual and distant disease and predicts long-term survival as it redistributes T1b, T2, and T3 disease across separate risk-groups based on additional biologic features. This score may help to optimize treatment strategy for patients with incidentally discovered gallbladder cancer.
Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, 30322, USA.
Cecilia G
CG
Ethun
Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, 30322, USA.
Lauren M
LM
Postlewait
Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, 30322, USA.
Nina
N
Le
Division of Surgical Oncology, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA.
Timothy M
TM
Pawlik
Division of Surgical Oncology, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA.
Stefan
S
Buettner
Department of Surgery, Stanford University Medical Center, Stanford, CA, USA.
George
G
Poultsides
Department of Surgery, Stanford University Medical Center, Stanford, CA, USA.
Thuy
T
Tran
Division of Surgical Oncology, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.
Kamran
K
Idrees
Division of Surgical Oncology, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.
Chelsea A
CA
Isom
Department of Surgery, Washington University School of Medicine, St Louis, MO, USA.
Ryan C
RC
Fields
Department of Surgery, Washington University School of Medicine, St Louis, MO, USA.
Linda X
LX
Jin
Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
Sharon M
SM
Weber
Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
Ahmed
A
Salem
Division of Surgical Oncology, Department of Surgery, University of Louisville, Louisville, KY, USA.
Robert C G
RC
Martin
Division of Surgical Oncology, Department of Surgery, University of Louisville, Louisville, KY, USA.
Charles
C
Scoggins
Department of Surgery, Wake Forest University, Winston-Salem, NC, USA.
Perry
P
Shen
Department of Surgery, Wake Forest University, Winston-Salem, NC, USA.
Harveshp D
HD
Mogal
Division of Surgical Oncology, Department of Surgery, The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA.
Carl
C
Schmidt
Division of Surgical Oncology, Department of Surgery, The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA.
Eliza
E
Beal
Department of Surgery, New York University, New York, NY, USA.
Ioannis
I
Hatzaras
Department of Surgery, New York University, New York, NY, USA.
Rivfka
R
Shenoy
Division of Surgical Oncology, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.|Division of Surgical Oncology, Department of Surgery, University of Miami, Miami, FL, USA.
Nipun
N
Merchant
Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, 30322, USA.
Kenneth
K
Cardona
Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, 30322, USA. smaithe@emory.edu.
Shishir K
SK
Maithel
D000368:Aged; D001808:Blood Vessels / Q000473:pathology; D002763:Cholecystectomy; D005706:Gallbladder Neoplasms / Q000473:pathology* / Q000601:surgery*; D006801:Humans; D033162:Incidental Findings; D042601:Lymphatic Vessels / Q000473:pathology; D008875:Middle Aged; D060787:Neoplasm Grading; D009361:Neoplasm Invasiveness; D009362:Neoplasm Metastasis; D009367:Neoplasm Staging; D018365:Neoplasm, Residual; D010525:Peripheral Nerves / Q000473:pathology; D011237:Predictive Value of Tests; D012086:Reoperation; D018570:Risk Assessment / Q000379:methods; D015996:Survival Rate; D014481:United States