Is Carcinoma of the Gallbladder a Curable Lesion?

Carcinoma of the gallbladder is an uncommon, but not rare tumor that is associated with a 5% five-year survival rate after resection and this rate has not appreciably improved over the last decades in most series. Nevin et al.(20) however have reported that favorably staged gallbladder cancers (according to histologic grade and depth of invasion) have a relatively good prognosis. They quoted an overall five-year survival of 21% in 66 patients. Most of the surviving patients (11) were in the favorably staged category: Stage I (intramucosal cancer) and Stage II (invasion of mucosa and muscularis). The remaining few were in Stage III (invasion of all layers), Stage IV (cystic node metastases), or Stage V (extension of metastases to the liver or distant sites). Our data has been analyzed to determine whether microstaging of the primary cancer will select out a subgroup with a favorable prognosis, and whether there are survival benefits according to the type of surgical resection. A clinical and pathologic review was done of 100 patients treated at the University of Virginia Hospital from 1930 to 1978. There were 77 women and 23 men, with an average age of 65 years (range 21-89). Gallstones were described in 78% of the patients. Surgical procedures included cholecystectomy alone (23 patients), cholecystectomy with biliary drainage (17 patients), cholecystectomy and resection of the hepatic bed (8 patients), and exploration with biopsy or bypass (44 patients). Autopsy only was done in eight patients. There were only three long-term survivors (6 years, 11 years, and 24 years). Median survival was six months with cholecystectomy alone, five months with cholecystectomy and bypass, 14 months after partial liver resection, and 2.0 months after laparotomy/bypass/biopsy. The five-year survival rate was 5% after cholecystectomy alone or with bypass, and 13% (1/8) after cholecystectomy and partial liver resection (p = 0.07). Microstaging of the primary cancers showed no prognostically favorable subgroup. Of 46 patients with microstaged lesions, only 13% were in the very favorable Stage I and II groups (only one of six survived), 46% were Stage III (1/21 survived), and the remaining 41% were in the highly unfavorable Stage IV and V groups (1/19 survived). Most patients showed progression of disease either primarily or secondarily that was locoregional (liver and nodes). Although longterm survival may accompany cholecystectomy alone for a favorable early-staged cancer, this is still uncommon. There may be theoretical, although not proven, merit for resection of the hepatic bed and regional node dissection in the selected patient, possibly complimented by adjuvant therapy. Future advances in chemotherapy and radiation will be needed to augment the current poor cure rate of this disease.