A. M. Blakely1, P. Wong1, P. Chu2, S. G. Warner1, G. Singh1, Y. Fong1, L. G. Melstrom1 1City Of Hope National Medical Center,Department Of Surgery,Duarte, CA, USA 2City Of Hope National Medical Center,Department Of Pathology,Duarte, CA, USA
Introduction: Gallbladder adenocarcinoma is often incidentally identified on pathology following cholecystectomy for presumed benign indications. Intra-operative gallbladder rupture risks peritoneal seeding of disease. We hypothesized that bile spillage would be a negative prognostic factor after index cholecystectomy in patients with gallbladder adenocarcinoma.
Methods: A retrospective chart review of all patients treated at a cancer center from 2009 to 2017 with histologically confirmed gallbladder adenocarcinoma was performed. Operative and pathology reports were compared. Patient, disease, and treatment factors were analyzed in terms of disease recurrence and overall survival.
Results: Of 79 patients with gallbladder adenocarcinoma, 66 (84%) had both operative and pathologic reports available. Median patient age was 68 years (range 33 to 95), and 71.2% were female. Tumor stage was T1 for 7 (11%), T2 for 25 (38%), and T3 for 35 (53%). Node stage was N0 for 22 (33%), N1+ for 26 (39%), and Nx for 18 (27%). Hepatobiliary operations performed included cholecystectomy (CCY) alone (n=34, 59%), CCY and combined or interval partial hepatectomy (n=27, 36%), and CCY with common bile duct resection (n=5, 5%). Operations were performed with palliative intent for advanced disease in 10 patients (15%). Full-thickness rupture was significantly more likely to be documented in pathology reports (n= 20 of 66, 30%) than in operative reports (n=15 of 66, 23%; p<0.0001). Median recurrence-free survival was 11 months (interquartile range [IQR] 5 to 28); median overall survival was 16 months (IQR 10 to 31). Seven patients with T1 or T2 lesions had peritoneal recurrence, of whom 4 (57%) had pathology-confirmed rupture. Subset Cox proportional hazards regression of N0 and Nx patients analyzing patient age, grade, tumor stage, and pathology-confirmed rupture was performed (Table 1), finding that only rupture was associated with overall survival at 5 years (hazards ratio 3.5, 95% confidence interval 1.1-12.1, p=0.037).
Conclusion: Surgical resection of gallbladder adenocarcinoma patients with node-negative disease limited to the gallbladder represents an opportunity for long-term survival. Rupture of the gallbladder wall during cholecystectomy risks seeding of the abdominal cavity, therefore upstaging disease and potentially diminishing overall survival. Explicit documentation of intra-operative spillage is critical as it may have implications for outcomes as well as for consideration of up-front systemic therapy prior to definitive resection.
