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Incidence of Finding Residual Disease for Incidental Gallbladder Carcinoma: Implications for Reresection
Timothy M. Pawlik*1, ANA L. Gleisner1, David a. Kooby4, Todd W. Bauer3, Reid B. Adams3, Lia Assumpcao1, Richard D. Schulick1, Andrea Frilling5, Lorenzo Capussotti2, Michael a. Choti1
1Surgery, Johns Hopkins, Baltimore, MD; 2Surgery, Institute for Research and the Cure of Cancer, Candiolo, Italy; 3Surgery, University of Virginia Medical Center, Charlottesville, VA; 4Surgery, Emory University School of Medicine, Atlanta, GA; 5Surgery, University Hospital Essen, Essen, Germany

Introduction. Reresection for gallbladder carcinoma incidentally discovered after cholecystectomy is routinely advocated. However, the incidence of finding additional disease at the time of reresection remains poorly defined. Such data are important to assess the potential benefit of repeat surgery for incidental gallbladder carcinoma.
Between 1984-2006, 119 patients (pts) underwent reresection at 5 major hepatobiliary centers for gallbladder carcinoma incidentally discovered during cholecystectomy. Data on clinicopathologic factors, operative details, TNM tumor stage, and outcome were collected and analyzed. Data on the incidence and location of residual/additional carcinoma discovered at the time of reresection were also recorded.
Of the 119 pts with gallbladder carcinoma, most patient initially presented with cholelithiasis (85.9%) and underwent laparoscopic cholecystectomy (82%). On pathologic analysis, T-stage was T1 8%, T2 58%, T3 22% and T4 11%. 17 (14%) pts had a positive cystic duct node (N1) and 15 (13%) had a positive cystic duct margin. The median time from cholecystectomy to reresection was 52 days. At the time of reresection, hepatic surgery most often consisted of wedge resection (21%), formal segmentectomy (55%), or right hemihepatectomy (6%). Pts underwent lymphadenectomy (LND) alone (50%) or LND + common bile duct resection (29%). The median number of lymph nodes harvested was 3 and did not differ between LND alone (3) vs LND + common duct resection (4) (P>0.05). Pathology from the reresection specimen noted residual/additional disease in 33% of patients. Specifically, carcinoma was found in the liver bed (21%), lymph nodes (34%), cystic/common bile duct (27%), or peritoneum/liver metastases (20%). Factors associated with finding additional disease included T stage, as well as positive cystic duct margin status (both P<0.05). Of those patients staged as T1, T2 or T3, 0%, 13% and 29%, respectively, had residual disease within the liver. T stage was also associated with the risk of metastasis to locoregional lymph nodes (lymph node metastasis: T1 0%; T2 16%, T3 58%, T4 50%; P<0.05). Cystic duct margin status predicted residual disease in the common bile duct (negative cystic duct, 3% vs positive cystic duct, 33%)(P<0.05).
Aggressive reresection for incidental gallbladder carcinoma is warranted as the majority of pts have residual disease. Although common duct resection does not yield a greater lymph node count, it should be performed at the time of reresection for pts with positive cystic duct margins because one-third will have residual disease in the common bile duct.

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