A report in the May issue of Archives of Surgery, one of the JAMA/Archives journals has revealed that even though the overall prognosis for gallbladder cancer appears to be improving, many patients still have incurable disease and poor survival rates.
An estimated 9,520 new cases of gallbladder or bile duct cancer were diagnosed in the United States in 2008, and approximately 3,340 of these patients will die of their disease, according to background information in the article. The disease affects women more frequently than men and surgical removal of diseased portions of the organ (resection) is the only curative treatment. However, many patients present to the clinician with advanced-stage disease and are not candidates for this procedure. "Gallbladder cancer is characterized by locally aggressive behavior, with early spread to regional lymph nodes and distant dissemination," the authors write. "In addition, it recurs rapidly even after presumed curative resection."
AdvertisementIoannis T. Konstantinidis, M.D., of Massachusetts General Hospital and Harvard Medical School, Boston, and colleagues identified 402 patients with gallbladder cancer at one university-affiliated tertiary care center between 1962 and 2008. Of these, 260 underwent surgical exploration at the same institution and were included in the data analysis. They were diagnosed during three periods: period A (1962 to 1979, 83 patients), period B (1980 to 1997, 105 patients) and period C (1998 to 2008, 72 patients).
Overall median (midpoint) survival improved from 3.5 months in period A to 6.5 months in period B and 12 months in period C. "The stage of disease at presentation affected the survival in all time periods (stage I, median survival not reached; stage II, 10.3 months; stage III, 4.7 months and stage IV, four months)," the authors write. "The survival of patients who presented with advanced-stage disease and who underwent palliative [treating symptoms only] procedures remained poor in all periods (A, 1.9 months; B, 3.9 months; and C, 3.6 months)."
Of the 260 cancer patients who had surgery to explore the extent of their disease, 151 (58.1 percent) underwent resection. Unresectable disease was found in eight patients and became less common over time (44.4 percent in periods A and B, 17.3 percent in period C).
Between January 1994 and March 2008, 6,881 laparoscopic cholecystectomies (procedures to remove gallstones) were performed at the same facility; 17 cases of gallbladder cancer were discovered incidentally during these procedures. "When gallbladder cancer is found incidentally during or after a cholecystectomy, aggressive resection should be performed either during the present operation or during a second operation," the authors write. "In our series, 56 percent of patients who underwent re-exploration [a second surgery] were found to have residual disease. Patients underwent re-exploration at a median of 41 days, similar to other series. Increased T stage at cholecystectomy correlated with a higher frequency of residual disease."
"Patients with gallbladder cancer continue to have a poor prognosis because many of the patients present with advanced disease," the authors write. "Earlier detection coupled with an aggressive surgical approach leads to better outcomes. A better understanding of the molecular pathways contributing to the development of gallbladder cancer is needed to develop improved adjuvant therapies to increase overall survival."