Surgical management of gallbladder cancer: Simple versus extended cholecystectomy and the role of adjuvant therapy
Gyulnara G. Kasumova, Omidreza Tabatabaie, Mark P. Callery, Andrea Bullock, Ayotunde B. Fadayomi, Sing Chau Ng, Robert Fisher, Jennifer F. Tseng
Beth Israel Deaconess Medical Center, Boston, MA
Objective: Since many are discovered incidentally at laparoscopic cholecystectomy, we sought to assess if adjuvant therapy could provide outcomes comparable to extended cholecystectomy.
Design: Retrospective review.
Setting: National Cancer Data Base 2004-2013
Participants: Patients with pT2/T3 gallbladder adenocarcinoma who underwent resection.
Interventions: Adjuvant therapy was defined as chemotherapy, with or without radiotherapy, within 90 days of surgery.
Outcome: Baseline characteristics compared by chi-square. Kaplan-Meier method used to compare overall survival. One-to-one propensity score matching for the receipt of adjuvant therapy was used to account for confounders.
Results: 5,891 patients were identified, of whom 28.4% (1674) received adjuvant therapy. The majority, 88.9% (5239), had a simple cholecystectomy. Patients who received adjuvant therapy versus surgery alone were more likely to: be younger (age ≤66; 50.8% vs. 24.5%), have private insurance (37.4% vs. 20.5%), have no comorbidities (69.9% vs. 62.0%), have pT3 disease (54.1% vs. 39.4%), positive lymph nodes (39.4% vs. 21.9%), have positive resection margins 40.8% vs. 34.1%), and have extended cholecystectomy (15.4% vs. 9.3%) (all p-values<0.0001). Median overall survival was longer for all patients undergoing radical versus simple surgery (15.8 vs. 13.1 months; p=0.0477). However, median survival was significantly longer for radical surgery with adjuvant therapy (21.7 months) than cholecystectomy with adjuvant (15.6 months), which was significantly longer than either simple (12.2 months) or extended cholecystectomy (10.4 months) alone (all log-rank p≤0.01). After propensity score matching, there were no differences in baseline or tumor characteristics and results of survival analyses remained robust.
Conclusions: Adjuvant therapy prolongs short term survival after resection of T2/T3 tumors. Cholecystectomy with adjuvant therapy is superior to extended resection alone in the short term and may serve as a potential alternative to re-resection in select individuals.
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