New trends in diagnosis and management of gallbladder carcinoma

Gallbladder(GB)carcinoma,although relatively rare,is the most common biliary tree cholangiocarcinoma with aggressiveness and poor prognosis.It is closely associated with cholelithiasis and long-standing large(>3 cm)gallstones in up to 90%of cases.The other main predisposing factors for GB carcinoma include molecular factors such as mutated genes,GB wall calcification(porcelain)or mainly mucosal microcalcifications,and GB polyps≥1 cm in size.Diagnosis is made by ultrasound,computed tomography(CT),and,more precisely,magnetic resonance imaging(MRI).Preoperative staging is of great importance in decisionmaking regarding therapeutic management.Preoperative staging is based on MRI findings,the leading technique for liver metastasis imaging,enhanced three-phase CT angiography,or magnetic resonance angiography for major vessel assessment.It is also necessary to use positron emission tomography(PET)-CT or ^(18)F-FDG PET-MRI to more accurately detect metastases and any other occult deposits with active metabolic uptake.Staging laparoscopy may detect dissemination not otherwise found in 20%-28.6%of cases.Multimodality treatment is needed,including surgical resection,targeted therapy by biological agents according to molecular testing gene mapping,chemotherapy,radiation therapy,and immunotherapy.It is of great importance to understand the updated guidelines and current treatment options.The extent of surgical intervention depends on the disease stage,ranging from simple cholecystectomy(T1a)to extended resections and including extended cholecystectomy(T1b),with wide lymph node resection in every case or IV-V segmentectomy(T2),hepatic trisegmentectomy or major hepatectomy accompanied by hepaticojejunostomy Roux-Y,and adjacent organ resection if necessary(T3).Laparoscopic or robotic surgery shows fewer postoperative complications and equivalent oncological outcomes when compared to open surgery,but much attention must be paid to avoiding injuries.In addition to surgery,novel targeted treatment along with immunotherapy and recent improvements in radiotherapy and chemotherapy(neoadjuvant-adjuvant capecitabine,cisplatin,gemcitabine)have yielded promising results even in inoperable cases calling for palliation(T4).Thus,individualized treatment must be applied.

Current considerations for the surgical management of gallbladder adenomas

Gallbladder adenomas are rare lesions(0.5%)associated with potential malignant transformation,particularly with gallbladder adenomas that are≥1 cm in size.Early detection and management are crucial for preventing lethal carcinoma de-velopment.These polyps can often be distinguished from the more often nonneo-plastic cholesterol pseudopolyps(5%-10%),which are benign.Ultrasonography is the first-line tool for initial diagnosis and follow-up when indicated.The question is whether cholecystectomy is always necessary for all adenomas.The manage-ment of gallbladder adenomas is determined according to the size of the tumor,the growth rate of the tumor,the patient’s symptoms and whether risk factors for malignancy are present.Adenomas≥1 cm in size,an age>50 years and a familial history of gallbladder carcinoma are indications for immediate laparoscopic chole-cystectomy.Otherwise,ultrasound follow-up is indicated.For adenomas 6-9 mm in size,the absence of≥2 mm growth at 6 months,one year,and two years,as well as an adenoma sized<5 mm without existing risk factors indicates that no further surveillance is required.However,it would be preferable to individualize the management in doubtful cases.Novel interventional modalities for preserving the gallbladder need further evaluation,especially to determine the long-term outcomes.

A clinicopathological analysis in unsuspected gallbladder carcinoma: A report of 23 cases

AIM： To study the clinicopathological characteristics of unsuspected gallbladder carcinoma （UGC）. METHODS： We retrospectively studied 23 cases of UGC in Tongji Hospital, and compared their clinicopathological characteristics with 33 cases of preoperatively diagnosed gallbladder carcinoma （PDGC）. RESULTS： The proportion of UGC coexisting with cholecystolithiasis was significantly higher than that of PDGC （x^2 = 13.53, P 〈 0.01）. The infection rate of hepatitis B virus was 21.74% （5/23） in UGC and 30.30% （10/33） in PDGC. Nine （39.13%） of 23 patients with UGC and 8/33 （24.24） PDGC had contact with schistosome pestilent water. The rate of multiple pregnancies was 56.52% （13/23） in the patients with UGC and 42.42% （14/33） in PDGC. The primary location of the UGC was mostly in the neck and body of the gallbladder, and that of the PDGC was often in the body and bottom. The incidence of Nevin stage I and 11 UGC was significantly higher than that of PDGC （x^2 = 4.44, P 〈 0.05 and 2 = 4.96, P 〈 0.05） while that of Nevin stage V UGC was significantly lower than that of PDGC （x^2 = 7.59, P 〈 0.01）. According to the grading of carcinoma, the incidence of well-differentiated UGC was significantly higher than that of PDGC （2 = 4.16, P 〈 0.05）, and that of poorlydifferentiated UGC was significantly lower than that of PDGC （x^2 = 4.48, P 〈 0.05）.CONCLUSION： There are different characteristics between UGC and PDGC, such as in primary location, malignant degree and incidence of coexistence with cholecystolithiasis. Cholecystolithiasis, hepatitis B, schistosome and multiple pregnancies were high risk factors for gallbladder carcinoma.

Cholecystoenteric fistula in a patient with advanced gallbladder cancer: A case report and review of literature

BACKGROUND Cholecystoenteric fistula(CEF)involves the formation of a spontaneous ano-malous tract between the gallbladder and the adjacent gastrointestinal tract.Chronic gallbladder inflammation can lead to tissue necrosis,perforation,and fistulogenesis.The most prevalent cause of CEF is chronic cholelithiasis,which rarely results from malignancy.Because the symptoms and laboratory findings associated with CEF are nonspecific,the condition is often misdiagnosed,pre-senting a challenge to the surgeon when detected intraoperatively.Therefore,a preoperative diagnosis of CEF is crucial.We present the case of a 57-year-old male with advanced gallbladder cancer(GBC)who arrived at the emergency room with persistent vomiting,abdominal pain,and diarrhea.An abdominopelvic computed tomography scan revealed a contracted gallbladder with bubbles in the fundus connected to the second por-tion of the duodenum and transverse colon.We suspected that GBC had invaded the adjacent gastrointestinal tract through a cholecystoduodenal fistula(CDF)or a cholecystocolonic fistula(CCF).He underwent multiple examinations,including esophagogastroduodenoscopy,an upper gastrointestinal series,colo-noscopy,and magnetic resonance cholangiopancreatography;the results of these tests con-firmed a diagnosis of synchronous CDF and CCF.The patient underwent a Roux-en-Y gastrojejunostomy and loop ileostomy to address the severe adhesions that were previously observed to cover the second portion of the duodenum and hepatic flexure of the colon.His symptoms improved with supportive treatment while hospitalized.He initiated oral targeted therapy with lenvatinib for further anticancer treatment.CONCLUSION The combination of imaging and surgery can enhance preoperative diagnosis and alleviate symptoms in patients with GBC complicated by CEF.

Effects of cytoreductive surgery combined with hyperthermic perfusion chemotherapy on prognosis of patients with advanced gallbladder cancer

BACKGROUND Gallbladder cancer(GC)is a common malignant tumor and one of the leading causes of cancer-related death worldwide.It is typically highly invasive,difficult to detect in the early stages,and has poor treatment outcomes,resulting in high mortality rates.The available treatment options for GC are relatively limited.One emerging treatment modality is hyperthermic intraperitoneal chemotherapy(HIPEC).HIPEC involves delivering heated chemotherapy directly into the abdominal cavity.It combines the strategies of surgical tumor resection and localized chemotherapy administration under hyperthermic conditions,aiming to enhance the concentration and effectiveness of drugs within the local tumor site while minimizing systemic toxicity.AIM To determine the effects of cytoreductive surgery(CRS)combined with HIPEC on the short-term prognosis of patients with advanced GC.METHODS Data from 80 patients treated at the Punan Branch of Renji Hospital,Shanghai Jiao Tong University School of Medicine between January 2018 and January 2020 were retrospectively analyzed.The control group comprised 44 patients treated with CRS,and the research group comprised 36 patients treated with CRS combined RESULTS The baseline data of the research and control groups were similar(P>0.05).Six days after surgery,the alanine aminotransferase,aspartate aminotransferase,total bilirubin,and direct bilirubin levels significantly decreased compared to the preoperative levels in both groups(P<0.05).However,the values did not differ between the two groups six days postoperatively(P>0.05).Similarly,the postoperative creatinine and blood urea nitrogen levels were significantly lower than the preoperative levels in both groups(P<0.05),but they did not differ between the groups six days postoperatively(P>0.05).Furthermore,the research group had fewer postoperative adverse reactions than the control group(P=0.027).Finally,a multivariate Cox analysis identified the tumor stage,distant metastasis,and the treatment plan as independent factors affecting prognosis(P<0.05).The three-year survival rate in the study group was higher than that in the control group(P=0.002).CONCLUSION CRS combined with HIPEC lowers the incidence of adverse reactions and improves survival in patients with advanced GC.

Radical lymph node dissection and assessment:Impact on gallbladder cancer prognosis

AIM: To investigate the lymph node metastasis patterns of gallbladder cancer(GBC) and evaluate the optimal categorization of nodal status as a critical prognostic factor.METHODS: From May 1995 to December 2010,a total of 78 consecutive patients with GBC underwent a radical resection at Liaocheng People's Hospital.A radical resection was defined as removing both the primary tumor and the regional lymph nodes of the gallbladder.Demographic,operative and pathologic data were recorded.The lymph nodes retrieved were examined histologically for metastases routinely from each node.The positive lymph node count(PLNC) as well as the total lymph node count(TLNC) was recorded for each patient.Then the metastatic to examined lymph nodes ratio(LNR) was calculated.Disease-specific survival(DSS) and predictors of outcome were analyzed.RESULTS: With a median follow-up time of 26.50 mo(range,2-132 mo),median DSS was 29.00 ± 3.92 mo(5-year survival rate,20.51%).Nodal disease was found in 37 patients(47.44%).DSS of node-negative patients was significantly better than that of nodepositive patients(median DSS,40 mo vs 17 mo,χ2= 14.814,P < 0.001),while there was no significant difference between N1 patients and N2 patients(median DSS,18 mo vs 13 mo,χ2= 0.741,P = 0.389).Optimal TLNC was determined to be four.When node-negative patients were divided according to TLNC,there was no difference in DSS between TLNC < 4 subgroup and TLNC ≥ 4 subgroup(median DSS,37 mo vs 54 mo,χ2 = 0.715,P = 0.398).For node-positive patients,DSS of TLNC < 4 subgroup was worse than that of TLNC ≥ 4 subgroup(median DSS,13 mo vs 21 mo,χ2= 11.035,P < 0.001).Moreover,for node-positive patients,a new cut-off value of six nodes was identified for the number of TLNC that clearly stratified them into 2 separate survival groups(< 6 or ≥ 6,respectively;median DSS,15 mo vs 33 mo,χ2= 11.820,P < 0.001).DSS progressively worsened with increasing PLNC and LNR,but no definite cut-off value could be identified.Multivariate analysis revealed histological grade,tumor node metastasis staging,TNLC and LNR to be independent predictors of DSS.Neither location of positive lymph nodes nor PNLC were identified as an independent variable by multivariate analysis.CONCLUSION: Both TLNC and LNR are strong predictors of outcome after curative resection for GBC.The retrieval and examination of at least 6 nodes can influence staging quality and DSS,especially in nodepositive patients.

Norcantharidin inhibits growth of human gallbladder carcinoma xenografted tumors in nude mice by inducing apoptosis and blocking the cell cycle in vivo

BACKGROUND: Gallbladder carcinoma, a lethal malignant neoplasm with poor prognosis, has dismal results of surgical resection and chemoradiotherapy. We previously reported that norcantharidin (NCTD) is useful against growth, proliferation, and invasion of human gallbladder carcinoma GBC-SD cells in vitro. In this study, we further studied the inhibitory effect of NCTD on the growth of xenografted tumors of human gallbladder carcinoma in nude mice in vivo and the underlying mechanisms. METHODS: The tumor xenograft model of human gallbladder carcinoma in nude mice in vivo was established with subcutaneous GBC-SD cells. The experimental mice were randomly divided into control, 5-FU, NCTD, and NCTD+5-FU groups which were given different treatments. Tumor growth in terms of size, growth curve, and inhibitory rate was evaluated. Cell cycle, apoptosis, and morphological changes of the xenografted tumors were assessed by flow cytometry and light/electron microscopy. The expression of the cell cycle-related proteins cyclin-D1 and p27 as well as the apoptosis-related proteins Bcl-2, Box, and survivin were determined by the streptavidin-biotin complex (SABC) method and RT-PCR. RESULTS: NCTD inhibited the growth of the xenografted tumors in a dose- and time-dependent manner. Tumor volume decreased (5.61+/-0.39 vs. 9.78+/-0.61 cm(3), P=0.000) with an increased tumor inhibitory rate (42.63% vs. 0%, P=0.012) in the NTCD group compared with the control group. The apoptosis rate increased (15.08+/-1.49% vs. 5.49+/-0.59%, P=0.0001) along with a decreased percentage of cells in S phase (43.47+/-2.83% vs. 69.85+/-1.96%, P=0.0001) in the NTCD group compared with the control group. The morphological changes of apoptosis such as nuclear shrinkage, chromatin aggregation, chromosome condensation, and typical apoptosis bodies in the xenografted tumor cells induced by NCTD were observed by light and electron microscopy. The expression of cyclin-D1, Bcl-2 and survivin proteins/mRNAs decreased significantly, with increased expression of p27 and Bax proteins/mRNAs in the NCTD group compared with the control group. CONCLUSION: NCTD inhibits the growth of xenografted tumors of human gallbladder carcinoma in nude mice by inducing apoptosis and blocking the cell cycle in vivo.

Surgical therapy and prognosis of sarcomatoid carcinoma of the gallbladder

BACKGROUND: Sarcomatoid carcinoma of the gallbladder is rare and its characteristics are poorly understood. This study aimed to understand the behavior and prognosis of sarcomatoid carcinoma of the gallbladder as well as its clinical manifestations and survival rate of patients after radical or palliative surgery, and to review the reported data worldwide and our 10 patients. METHODS: From 2004 to 2009, ten patients were pathologically diagnosed with sarcomatoid carcinoma of the gallbladder and underwent operation at our center. These characteristics, clinical presentations, tumor-node-metastasis (TNM) staging, surgical modes, and prognosis were reviewed, retrospectively. We collected the data of 46 patients reported in the English-language literature worldwide and analyzed the survival with ours. The survival rate was estimated using the Kaplan-Meier method, and was compared using the log-rank test. RESULTS: The median age of the 10 patients was 67 years (inter-quartile range 59-74 years), and the size of tumor inter-quartile ranged from 3.1 to 7.9 cm. In this series, 9 patients received radical surgery, and one undewent palliative surgery. There was no surgical mortality, and one patient underwent a second operation because of liver metastasis. The median survival time of the patients was 9 months (inter-quartile range 6-12 months), with 3 patients still being alive until follow-up; however, two patients had tumor recurrence. The data from the 56 patients (10 patients in our series and 46 reported elsewhere) statistically indicated that the median age was 66 years (inter-quartile range 61-74.5 years) and the overall median survival was 5.5 months (inter-quartile range 2.5-10 months). The survival time in the patients undergoing radical surgery (n=42) was significantly longer than that in the patients undergoing palliative surgery (n=14) (P=0.031). CONCLUSIONS: The survival of the patients with sarcomatoid carcinoma of the gallbladder is poor. Some patients may die shortly after the surgery because of recurrence or metastasis. However, radical surgery is still necessary if possible. (Hepatobiliary Pancreat Dis Int 2010; 9: 175-179)

Regional lymphadenectomy for gallbladder cancer: Rational extent, technical details, and patient outcomes

AIM: To define the rational extent of regional lymphadenectomy for gallbladder cancer and to clarify its effect on long-term survival. METHODS: A total of 152 patients with gallbladder cancer who underwent a minimum of "extended" portal lymph node dissection (defined as en bloc removal of the first-and second-echelon nodes) from 1982 to 2010 were retrospectively analyzed. Based on previous studies, regional lymph nodes of the gallbladder were divided into first-echelon nodes (cystic duct or pericholedochal nodes), second-echelon nodes (node groups posterosuperior to the head of the pancreas or around the hepatic vessels), and more distant nodes. RESULTS: Among the 152 patients (total of 3352 lymph nodes retrieved, median of 19 per patient), 79 patients (52%) had 356 positive nodes. Among nodepositive patients, the prevalence of nodal metastasis was highest in the pericholedochal (54%) and cystic duct (38%) nodes, followed by the second-echelon node groups (29% to 19%), while more distant node groups were only rarely (5% or less) involved. Disease-specific survival after R0 resection differed according to the nodal status (P < 0.001): most node-negative patients achieved long-term survival (median, not reached; 5-year survival, 80%), whereas among nodepositive patients, 22 survived for more than 5 years (median, 37 mo; 5-year survival, 43%). CONCLUSION: The rational extent of lymphadenectomy for gallbladder cancer should include the first-and second-echelon nodes. A considerable proportion of node-positive patients benefit from such aggressive lymphadenectomy.

Inhibitory effect of norcantharidin on the growth of human gallbladder carcinoma GBC-SD cells in vitro

BACKGROUND: Gallbladder carcinoma is a lethal malignant neoplasm with dismal surgical results. Unfortunately, the adjuvant therapies for gallbladder carcinoma such as chemotherapy and radiotherapy are also disappointing. We reported that norcantharidin (NCTD), a demethylated form of cantharidin, which is an active ingredient of the Chinese medicine Mylabris, was used against human gallbladder carcinoma GBC-SD cells. In the present study, we further studied the mechanism underlying the inhibitory effect of NCTD on growth of human gallbladder carcinoma GBC-SD cells in vitro. METHODS: Human gallbladder carcinoma GBC-SD cells were grown in cell culture and divided into a NCTD group and a control group. The inhibitory effect of NCTD on growth of GBC-SD cells was investigated by evaluation of proliferation, cell cycle, apoptosis and morphological changes of the cells. Cell proliferation was assessed by tetrazolium-based colorimetric assay. The induction of cell cycle arrest and apoptosis was measured by flow cytometry. The morphological changes of the cells were observed by light- and electron-microscopy. To elucidate the anticancer mechanism of NCTD, expression of the proliferation-related gene proteins PCNA, Ki-67, cyclin-D-1 and p27 and the apoptosis-related gene proteins Bcl-2, Bax and Survivin were determined by the streptavidin-biotin complex method and RT-PCR. RESULTS: NCTD inhibited the proliferation of GBCSD cells in a dose- and time-dependent manner, with an IC50 of 56.18 mu g/ml at 48 hours. The flow cytometric profiles revealed that NCTD (at the IC50 for 48 hours) significantly increased the proportion of cells in G(2)/M phase and significantly decreased the proportion of cells in S phase, with a significantly increased rate of cell apoptosis. After treatment with the 48-hour IC50 dose of NCTD, cell shrinkage, vacuolar cytoplasm, membrane budding, karyorrhexis, karyolysis, chromosome condensation and chromatin aggregation in some GBCSD cells were observed by light-microscopy; decreased microvilli, Golgiosome atrophy, mitochondrial swelling, nuclear shrinkage, chromosome condensation and typical apoptosis bodies were seen by electron-microscopy, and the morphological changes of apoptosis occurred in GBCSD cells. The expression of PCNA, Ki-67 and Bcl-2 proteins decreased significantly; the Pix or relative levels of PCNA mRNA, cyclin-D-1 mRNA, Bcl-2 mRNA and Survivin mRNA decreased significantly, whereas the Pix or relative levels of p27 mRNA and Bax mRNA increased significantly. CONCLUSIONS: NCTD inhibits the growth of human gallbladder carcinoma GBC-SD cells in vitro. Its anticancer mechanism may correlate with inhibition of cell proliferation, arrest of the cell cycle, blockage of DNA synthesis, influence on cell metabolism, induction of cell apoptosis and influence on expression of the proliferation-related genes PCNA, Ki-67, cyclin-D-1 and p27, and the apoptosis-related genes Bcl-2, Bax and Survivin in human gallbladder carcinoma GBC-SD cells.

Effects of radical cholecystectomy on nutritional and immune status in patients with gallbladder carcinoma

INTRODUCTION Carcinoma of the gallbladder is the most commonneoplasm in biliary tract,and its incidence has beenrising in recent years.The rate of correct diagnosisin early gallbladder carcinoma has been raised afterthe wide use of CT,ultrasound scans and frozensection examination.Now radical cholecystectomyis advocated as the best management for patientswith early gallbladder carcinoma.In the

Clinical relationship between MDR1 gene and gallbladder cancer

BACKGROUND: The most common mechanisms of mul- tidrug resistance (MDR) in cancer cells is the expression of an energy-dependent exfflux pump. P-glycoprotein (P-gp) encoded by MDR1 gene and multidrug associated protein (MRP) are well known proteins associated with MDR. In human cancers, the MDR1 gene expression is common in patients with intrinsic and acquired MDR. It is a major therapeutic problem in cancer chemotherapy. Previously we found that the MDR of HCC is related to MRP gene ex- pression and initiates the intrinsic MDR. The aim of this study is to study the expression of MDR1 gene encoding P-gp and MDR1 mRNA in primary gallbladder carcinoma, and analyze its clinical significance. METHODS: Immunohistochemistry (IHC) S-P method and in situ polymerase chain reaction (ISPCR) were used to detect the expression of P-gp and MDR1 mRNA in 53 cases of untreated primary gallbladder carcinoma and 12 ca- ses of cholecystitis (archival paraffin-embedded tissues). RESULTS: The positive expression rates of P-gp and MDR1 mRNA in the 53 cases and 12 cases were 60.38%, 71.69% and 25.00%, 33.33%, respectively. There was a significant difference between the two groups (P<0.05). The positive expression rate of P-gp and MDRlmRNA were 69.44%, 83.33% and 41.18%, 47.06% respectively in tissues in stage of Nevin against Nevin , (P<0.05). In well, moderately differentiated gallbladder carcinoma tissues, their expressions were 79.49%, 69.23% against 50.00%, 35.71% in low, undifferentiated tissues (P<0.05). CONCLUSIONS: MDR to gallbladder carcinoma is closely related to the intrinsic MDR and it provides an important evidence to reverse the MDR by detection of the MDR1gene. Meanwhile, MDR1 gene expression in gallbladder carcinoma is correlated with some biological characteris- tics , takes part in the carcinogenesis of gallbladder tissues, and acts as a valuable biomarker of prognosis.

Genetic changes of p53,K-ras,and microsatellite instability in gallbladder carcinoma in high-incidence areas of Japan and Hungary

AIM： To disclose geographic differences in genetic changes involved in gallbladder carcinogenesis between two distinct high-incidence areas of Japan and Hungary. METHODS： We examined 42 cases of gallbladder carcinoma： 22 Japanese and 20 Hungarian cases, p53 mutations at exons 5 to 8 and K-ras mutations at codon 12 were tested by direct sequencing. Microsatellite instability was determined from fluorescent dye-labeled PCR amplifications of flve-microsatellite markers （BAT-25, BAT-26, D2S123, DSS346, and D17S250）. RESULTS： Mutations of p53 were detected in 11 of 22 Japanese cases and 6 of 18 Hungarian cases （11/22 vs 6/18, P = 0.348）. Transition at CpG sites was found in none of 11 Japanese cases and 2 of 6 Hungarian cases; the difference was marginally significant （0/11 vs 2/6,P = 0.110）. K-ras mutations were detected in only one of the Hungarian cases. Eight of 19 （42.1%） ]apanese cases were MSI-high （presence of novel peaks in more than one of the five loci analyzed）, whereas only 1 of 15 （6.7%） Hungarian cases was MSI-high （P = 0.047）. CONCLUSION： It appears that the p53 mutations and MSI differ in patients with gallbladder carcinoma between two distinct high-incidence areas. Geographic variation might exist in the process of gallbladder carcinogenesis.

Cyclooxygenase-2 promotes angiogenesis by increasing vascular endothelial growth factor and predicts prognosis in gallbladder carcinoma

AIM: To investigate the relationships between the expression of cyclooxygenase-2 (COX-2), vascular endothelial growth factor (VEGF) and the degree of vascularization, clinicopathologic feature, survival time of patients with gallbladder carcinomas. METHODS: Sixty-four gallbladder carcinoma specimens were evaluated for COX-2, VEGF expression by immunohi stochemical methods. Microvessel counts (MVC) were determined using CD34. The relationships between COX-2, VEGF expression, CD34-stained MVC, clinicopathologic features and survival time were analyzed. The correlations between COX-2 and VEGF expression, CD34-stained MVC were also investigated. RESULTS: COX-2, VEGF immunoreactivity were observed in 71.9% (46/64) and 54.7% (35/64) specimens, respectively. The average MVC in 64 cases of gallbladder carcinoma was 57±14 per high power vision field. The status of MVC was closely correlated with Nevin staging, tumor differentiation and lymph node metastasis (P<0.01, 0.002, and 0.003, 0.000, respectively). Increased VEGF expression was significantly correlated with tumor differentiation (poorly and moderately>well differentiated, P<0.05, P = 0.016). Clinical stages had no relation with the expression of VEGF (P>0.05, P = 0.612). There was a positive correlation between COX-2 expression and clinical stages. The positive rate of COX-2 was higher in cases of Nevin stages S4-S5 (81.8%) than in those of Nevin stages S1-S3 (50.0%) with a statistical significance (P0.01, P = 0.009). The expression of COX-2 did not vary with differentiation (P>0.05, P= 0.067). Statistically significant differences were also observed according to lymph node metastasis, COX-2 expression and VEGF expression (P<0.01,0.000, and 0.001, respectively). There was no relation between VEGF, COX-2 expression, MVC and the age and sex of patients. MVC and VEGF positive rate in the COX-2 positive gallbladder carcinoma tissue was higher than that in the COX-2 negative tissue (P<0.05, 0.000, and 0.032, respectively). Patients with VEGF, COX-2 positive tumors had a significantly shorter survival time than those with negative tumors (P<0.05,0.004, 0.01, respectively). CONCLUSION: Augmented tumor neovascularization induced by VEGF may be one of the several effects of COX-2 responsible for poor prognosis of human gallbladder carcinoma. COX-2 inhibitor, either in combination therapy with other agents, or for chemoprevention, may be effective via suppression of angiogenesis in this fatal disease.

Effect of norcantharidin on proliferation and invasion of human gallbladder carcinoma GBC-SD cells

AIM: To investigate the effect of norcantharidin on proliferation and invasion of human gallbladder carcinoma GBC-SD cells in vitro and its anticancer mechanism. METHODS: Human gallbladder carcinoma GBC-SD cells were cultured by cell culture technique. The growth and the invasiveness of GBC-SD cells in vitro were evaluated by the tetrazolium-based colorimetric assay and by the Matrigel experiment and the crossing-river test. Expression of PCNA, Ki-67, MMP2 and TIMP2 proteins of GBC-SD cells was determined by streptavidin-biotin complex method. RESULTS: In vitro norcantharidin inhibited the growth and proliferation of GBC-SD cells in a dose- and time-dependent manner, with the IC50 value of 56.18 μ/mL at 48 h. Norcantharidin began to inhibit the invasion of GBC-SD cells at the concentration of 5 μg/mL, and the invasive action of GBC-SD cells was inhibited completely and their crossing-river time was prolonged significantly at 40 μg/mL. After treatment with norcantharidin, the expression of PCNA, Ki-67, and MMP2 was significantly decreased. With the increase in TIMP2 expression, the MMP2 to TIMP2 ratio was decreased significantly (P<0.05). CONCLUSION: Norcantharidin inhibits the proliferation and growth of human gallbladder carcinoma cells in vitro at relatively low concentrations by inhibiting PCNA and Ki-67 expression. Its anti-invasive activity may be the result of decrease in MMP2 to TIMP2 ratio and reduced cell motility.

Unsuspected Gallbladder Cancer During or After Laparoscopic Cholecystectomy

Objective To summarize the clinical features and outcomes of unsuspected gallbladder carcinoma （HGC） detected during or after laparoscopic cholecystectomy. Methods Medical records of 8005 patients, who underwent laparoscopic cholecystectomy in Peking Hnion Medical College Hospital between June 1993 and June 2011, were reviewed. Patients that pathologically diagnosed as HGC were retrospectively studied in terms of clinical features, preoperative and postoperative diagnosis, surviving period, and complications. Results In the 8005 patients who received laparoscopic cholecystectomy, 36 （0.45%） were diagnosed as LIGC during （25 patients） or after （11 patients） laparoscopic cholecystectomy. The gallbladder cancer was staged as T1 in 16 patients, T2 in 11 patients, and T3 in 9 patients. The 1-, 3-, and 5-year survival rates of all the patients were 88.9% （32/36）, 63.9% （23/36）, and 58.3% （21/36）. The 5-year survival rates in T1 stage, T2 stage, and T3 stage patients were 100%, 75.0%, and 0.0%, respectively. Conclusions The survival rate of HGC is associated with tumor stage, not with operation approaches. Laparoscopic cholecystectomy is appropriate for T 1 patients.

"Extended" radical cholecystectomy for gallbladder cancer:Long-term outcomes, indications and limitations

AIM:To delineate indications and limitations for "ex tended" radical cholecystectomy for gallbladder cancer:a procedure which was instituted in our department in 1982. METHODS:Of 145 patients who underwent a radi cal resection for gallbladder cancer from 1982 through 2006, 52 (36%) had an extended radical cholecystec tomy, which involved en bloc resection of the gallblad der, gallbladder fossa, extrahepatic bile duct, and the regional lymph nodes (first-and second-echelon node groups). A retrospective analysis of the 52 patients was conducted including at least 5 years of follow up. Residual tumor status was judged as no residual tumor (R0) or microscopic/macroscopic residual tumor (R1 2). athological findings were documented according tothe American Joint Committee on Cancer Cancer Stag ing anual (7th edition). RESULTS:he primary t mor as classified as patho-logical T1 (pT1) in 3 patients, pT2 in 36, pT3 in 12, and pT4 in 1. Twenty three patients had lymph node metastases; 11 had a single positive node, 4 had two positive nodes, and 8 had three or more positive nodes. None of the three patients with pT1 tumors had nodal disease, whereas 23 of 49 (47%) with pT2 or more advanced tumors had nodal disease. One patient died during the hospital stay for definitive resection, giv ing an in hospital mortality rate of 2%. Overall survival (OS) after extended radical cholecystectomy was 65% at 5 years and 53% at 10 years in all 52 patients. OS differed according to the p classification ( < 0.001) and the nodal status ( = 0.010). All of 3 patients with pT1 tumors and most (29 of 36) patients with pT2 tu mors survived for more than 5 years. Of 12 patients with pT3 tumors, 8 who had an R1 2 resection, distant metastasis, or extensive extrahepatic organ involve ment died soon after resection. Of the remaining four pT3 patients who had localized hepatic spread through the gallbladder fossa and underwent an R0 resection, 2 survived for more than 5 years and another survived for 4 years and 2 mo. The only patient with pT4 tumor died of disease soon after resection. Among 23 node positive patients, 11 survived for more than 5 years, and of these, 10 had a modest degree of nodal disease (one or two positive nodes). CONCLUSION:Extended radical cholecystectomy is indicated for pT2 tumors and some pT3 tumors with localized hepatic invasion, provided that the regional nodal disease is limited to a modest degree (up to two positive nodes). Extensive pT3 disease, pT4 disease, or marked nodal disease appears to be beyond the scope of this radical procedure.

Metastasis to the gallbladder:A single-center experience of 20 cases in South Korea

AIM： To evaluate the clinicopathologic characteristics of patients with metastases to the gallbladder （MGBs）. METHODS： We performed a single-center retrospective study of 20 patients with MGBs diagnosed pathologically from 1999 to 2007. RESULTS： Among 417 gallbladder （GB） malignancies, 20 （4.8%） were MGBs. The primary malignancies originated from the stomach （n = 8）, colorectum （n = 3）, liver （n = 2）, kidney （n = 2）, skin （n = 2）, extrahepatic bile duct （n = 1）, uterine cervix （n = 1）, and appendix （n = 1）. Twelve patients were diagnosed metachronously, presenting with cholecystitis （n = 4）, abdominal pain （n = 2）, jaundice （n = 1）, weight loss （n = 1）, and serum CA 19-9 elevation （n = 1）; five patients were asymptomatic. The median survival after the diagnosis of MGB was 8.7 mo. On Cox regression analysis, R0 resection was the only factor associated with a prolonged survival [hazard ratio （HR）： 0.01, P = 0.002]; presentation with cholecystitis was associated with poor survival （HR： 463.27, P = 0.006）. CONCLUSION： MGBs accounted for 4.8% of all pathologically diagnosed GB malignancies. The most common origin was the stomach. The median survival of MGI3 was 8.7 mo.

Analysis of p53 and vascular endothelial growth factor expression in human gallbladder carcinoma for the determination of tumor vascularity

AIM： To examine the expression of p53 and vascular endothelial growth factor （VEGF） as well as microvessel count （MVC） and to investigate the role of VEGF as an angiogenic marker and the possible role of p53 in the regulation of angiogenesis in human gallbladder carcinoma. METHODS： Surgically resected specimens of 49 gallbladder carcinomas were studied by immunohistochemical staining for p53 protein, VEGF, and factor VIII-related antigen. VEGF expression and mutant p53 expression were then correlated with Nevin stage, differentiation grade, MVC, and lymph node metastasis. RESULTS： Positive p53 protein and VEGF expressions were found in 61.2% and 63.3% of tumors, respectively. p53 and VEGF staining status was identical in 55.1% of tumors. The Nevin staging of p53- or VEGF-positive tumors was significantly later than that of negative tumors. The MVC in p53- or VEGF-positive tumors was significantly higher than that in negative tumors, and MVC in both p53- and VEGF-negative tumors was significantly lower than that in the other subgroups. CONCLUSION： Our findings suggest that pS3-VEGF pathway can regulate tumor angiogenesis in human gallbladder carcinoma. Combined analysis of p53 and VEGF expression might be useful for predicting the tumor vascularity of gallbladder cancer.

Intraluminal versus infiltrating gallbladder carcinoma:Clinical presentation,ultrasound and computed tomography

AIM： To compare clinical presentation and ultrasound （US） and computed tomography （CT） sensitivity between intraluminal and infiltrating gallbladder carcinoma （GBCA）. METHODS： This retrospective study evaluated 65 cases of GBCA that were categorized morphologically into the intraluminaI-GBCA （n = 37） and infiltrating-GBCA （n = 28） groups. The clinical and laboratory findings, presence of gallstones, gallbladder size, T-staging, nodal status, sensitivity of preoperative US and CT studies, and outcome were compared between the two groups. RESULTS： There were no significant differences between the two groups with respect to female predominance, presence of abdominal pain, serum aminotransferases level, T2-T4 staging, and regional metastatic nodes. Compared with the patients with intraluminaI-GBCA, those with infiltrating-GBCA were significantly older （65.49 ± 1.51 years vs 73.07 ± 1.90 years）, had a higher frequency of jaundice （3/37 patients vs 13/28 patients） and fever （3/37 patients vs 10/28 patients）, higher alkaline phosphatase （119.36 ± 87.80 IU/L vs 220.68 ± 164.84 IU/L） and total bilirubin （1.74 ± 2.87 mg/L vs 3.50 ± 3.51 mg/L） levels, higher frequency of gallstones （12/37 patients vs 22/28 patients）, smaller gallbladder size （length, 7.47± 1.70 cm vs 6.47 ± 1.83 cm; width, 4.21 ± 1.43 cm vs 2.67 ± 0.93 cm）, and greater proportion of patients with 〈 12 mo survival （16/37 patients vs 18/28 patients）. The sensitivity for diagnosing intraluminal- GBCA with and without gallstones was 63.6% and 91.3% by US, and 80% and 100% by CT, respectively. The sensitivity for diagnosing infiltrating-GBCA with and without gallstones was 12.5% and 25% by US, and 71.4% and 75% by c-r, respectively. CONCLUSION： In elderly women exhibiting small gallbladder and gallstones on US, especially those with jaundice, fever, high alkaline phosphatase and bilirubin levels, CT may reveal concurrent infiltrating-GBCA.