Surgical treatment of patients with T2 gallbladder carcinoma invading the subserosal layer

BACKGROUND: Because T2 carcinoma of the gallbladder that invades perimuscular connectiv e tissue without extension beyond serosa or into the liver has a hope for l ongterm survival, we attempted to clarify significant prognostic factors wi th respect to tumor- and surgery-related variables. STUDY DESIGN: Of 65 patients with gallbladder carcinoma who had undergone surgical resect ion from 1983 to 1999, 28 had T2 carcinoma histologically proved. The signi ficance of variables for survival was examined by the Kaplan-Meier method a nd log-rank test followed by multivariate analyses using Cox's proportional hazard model. RESULTS: There were 17 patients with stage II carcinoma (T2 N0 M0), 6 with stage III (T2 N1 M0), and 5 with stage IVB. Lymph node metastasis was present in 11 patients (39%) and ir reached to the peripancreatic head region (N2) in 5 o f them. Lymphatic, venous, and perineural invasions were found in 68%, 57%, and 43%, respectively. With respect to tumor factors, the absence of perin eural invasion (Odds ratio [OR] 16.77, 95% confidence interval [CI] 2.17-12 9.94, p = 0.0069), absence of lymph node metastasis (OR 15.00, 95% CI 2.08- 108.33, p = 0.0073), and stage IT (II versus III and IVB, OR 15.00, 95% CT 2.08-108.33, p = 0.0073) were significant factors related to good postopera tive survival in the multivariate analysis. Surgical procedure (radical res ection versus cholecystectomy, OR 4.31, 95% CT 1.34-13.82, p = 0.0142) and surgical margin (OR 7.41, 95% CI 2.19-25.13, p = 0.0013) were significant f actors in the univariate analysis. Cancer-free surgical margins provided a significantly better survival (5-year survival rate, 62%); none with cancer -positive surgical margins survived for more than 27 months. In the multiva riate analysis, surgical procedure was significant (OR 25.49, 95% CI 1.62-4 00.72, p = 0.021). Radical surgery, including extended cholecystectomy (res ection of the gallbladder together with the gallbladder bed of the liver) a nd anatomic resection of liver segment 5 and of the lower part of segment 4 , gave a significantly better 5-year survival rate than cholecystectomy (59 % versus 17%). The 5-year survival rate after radical resection in patients with stage II was 75%; that in patients with stage III and IVB was 33%. CONCLUSIONS: Results suggest that radical surgery is the treatment of choice for patient s with T2 carcinoma of the gallbladder. The presence of lymph node metastas is, perineural invasion, or both suggests the necessity of additional treat ment after radical surgery. (J Am Coll Surg 2001;192:600-607. (C) 2001 by t he American College of Surgeons).