1. RESULTS OF RADICAL SURGERY FOR CARCINOMA OF GALLBLADDER DR CHEUNG YUE SUN Department of Surgery Prince of Wales Hospital The Chinese University of Hong Kong

2. Overview Introduction Staging System – AJCC Treatment of T1 lesion French Surgical Association Survey PWH Experience Literature Review

3. Introduction CA Gallbladder is rare but fatal –3-15 per 100,000 –Median survival < 6 months –Overall 5-year survival < 5% F:M = 2-6 : 1 Incidence increases with age Mean age = 65 75-90% are adenocarcinoma Association between CA GB & gallstones –70-90% patients had gallstones –1% of patients with cholecystectomy Barakat. Cancer 2006; 106:434-40 Bilimoria. Diseases of the Gallbladder and Bile Ducts

4. Staging – AJCC TNM Staging TisCarcinoma-in-situ T1Lamina propria / muscle T2perimuscular connective tissue, not beyond serosa T3perforated serosa / direct invade liver / one adjacent organs T4main portal vein / hepatic a / multiple extrahepatic organs N0No regional LN N1Regional LN met M0No distant Met M1Distant met AJCC Cancer Staging Manual. 6th Ed 2002 Stage Grouping Stage 0TisN0M0 Stage IAT1N0M0 Stage IBT2N0M0 Stage IIAT3N0M0 Stage IIBT1-T3N1M0 Stage IIIT4Any NM0 Stage IVAny TAny NM1

5. Treatment for T1 lesion Median survival after Cholecystectomy was comparable to radical resection: 95 months –Overall 10-year survival 87% Lymphatic vessel invasion and LN metastasis is rare T1 lesion was local disease amenable to cholecystectomy Wakai BJS 2001; 88: 675-8

6. Past Experience for Advanced Tumor French Surgical Association Survey 1980-1989 - 73 institutions in France, Europe 724 patients histological proven CA GB 85% tumor invaded beyond serosa (T3/T4) –90% died at 1 year 23% underwent curative operations Overall 30-day operative mortality 22% 5-yr survival –T1 / T2 : 20-28% –T3 / T4 : 0 Cubertafond Ann. Surg. 1994 219; 275-80

7. Can radical surgery give better results?

8. 10-year Experience of PWH 1995 – 2004 34 patients of CA GB underwent operation Pathology reports, case notes and computer records were reviewed Median Age = 65 (37 to 86) M:F = 16:18 5 patients diagnosed after cholecystectomy Pathology –Adenocarcinoma 27 –Papillary Adenocarcinoma 4 –Mucinous Adenocarcinoma 1 –Unknown 2

9. Treatment Group Curative Surgery (44%) –Cholecystectomy –Segment 4b/5 resection* –Porta-hepatis LN dissection –Extrahepatic bile-duct resection (3) Palliative Surgery (31%) –Palliative cholecystectomy / by-pass Diagnostic Laparotomy / Laparoscopy (21%) * Rt hepetectomy - 1, Ext Rt Hepatectomy - 1

11. Staging by Traeatment Group Curative Surgery: n= 15 (44%) Tcis1 T1 N01 T2 Nx1 T2 N04 T2 N11 T3 Nx3 T3 N03 T3 N11 Palliative Surgery: n=12 (35%) T24 T35 T42 M11 Diagnostic Lap : n=7 (21%) T4 N12 M15

12. Mortality and Morbidity Mortality (9%) –AMI –Liver Failure –Pneumonia Morbidity (12%) –Wound infection –Pneumonia –Chylous ascites –Subhepatic collection Curative vs Palliative Mortality = 2:1 Morbidity = 4:0

13. Survival Overall Median Survival: 23 months –Max: 127 months Curative:39 months Palliative:5 months Diagnostic:3.5 months 8 patients in the curative group still alive

14. Log Rank p=0.0002

15. Stratification for T2 / T3

16. Other Literature Patient No. AgeOperative ProcedureT – Staging Mortality / Morbidity Median Survival (months) 5-yr Survival Fong 2000 41065 Cholecystectomy S4b,5 Resection LN Dissection +- bile duct resection 12(2) 4% / 29% NS5.44% 264(37) NC83% 3137(36) 4207(27)C26 ^38% Suzuki 2004 2063.5 Cholecystectomy S4b,5 Resection LN Dissection +- bile duct resection pT20 / 16% 6477% Sasaki 2006 6564.3 Cholecystectomy S4b,5 Resection LN Dissection +- PD +- bile duct resection 115 3.1% / 29.2% - 40% (overall) pN0 76.2% pN1 30.0% pN2 45.8% pM1 0% 224 320 46

17. Summary Radical Surgery - –Cholecystectomy –Segment 4b/5 liver resection –Regional LN dissection Provides better survival for locally advanced CA GB Significant morbidity and mortality

18. THANK YOU