Trends in the Management and Survival of Surgically Managed Gallbladder Adenocarcinoma: a Population-Based Analysis
Skye C. Mayo*1, Andrew D. Shore3, Christopher L. Wolfgang1, Barish H. Edil1, Kenzo Hirose1, Joseph M. Herman2, Richard D. Schulick1, Michael a. Choti1, Timothy M. Pawlik1
1Surgery, The Johns Hopkins Hospital, Baltimore, MD; 2Radiation Oncology, The Johns Hopkins Hospital, Baltimore, MD; 3Health Policy and Management, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
Introduction: National Comprehensive Cancer Network (NCCN) guidelines recommend hepatic resection and lymphadenectomy (LND) as definitive surgical management for gallbladder adenocarcinoma (GBA). We sought to evaluate compliance with these recommendations and to assess trends in the management and survival of patients (pts) with GBA.Methods: Using the Surveillance, Epidemiology and End Results (SEER) cancer registry, we identified 3566 pts with GBA who underwent surgery from 1973-2005. Data from 1992-2005 (n=2765) were linked with Medicare data to assess trends in clinical management over time. Clinicopathologic data were analyzed and survival was assessed.Results: The proportion of pts with GBA did not change over time (1973-1991, 22%; 1992-1998, 27%; 1999-2002, 27%; 2003-2005, 24%; P=0.17). From 1992-2005, preoperative evaluation included CT (65%), MRI (6%), and PET (2%). Relative utilization of CT, MRI, and cholangiography changed over time (Table). Only 292 (11%) pts underwent hepatic resection (partial hepatectomy: 96%). Hepatic resection increased over time (1992-1998, 8%; 1999-2002, 11%; 2003-2005, 13%; P<0.001). For pts undergoing hepatic resection, a LND was performed in 103 (35%) pts with a significant increase over time (Table). Among pts who had a LND, 45% had nodal metastasis. While 2% of pts received adjuvant chemotherapy, 17% received adjuvant radiation therapy (XRT) (P=0.63). The overall 1-, 3-, and 5-yr survival was 52%, 29%, and 21%. Tumor stage (HR=2.56) was associated with worse survival whereas receipt of XRT (HR=0.78) and LND (HR=0.59) were associated with a decreased risk of death. There was no significant improvement in survival over time (P=0.60).Conclusions: Although the proportion of pts undergoing hepatic resection and LND has increased, compliance with NCCN guidelines for GBA remains poor. Survival of pts with GBA has not improved over time.
Table: Clinical management and operative trends of patients treated for gallbladder adenocarcinoma.
| 1973-1991 (n=791) | 1992-1998 (n=963) | 1999-2002 (n=956) | 2003-2005 (n=846) | |
| Percent of Patients (%) | ||||
| Cholangiogram | -- | 35.6 | 25.2 | 23.2* |
| MRI | -- | 2.1 | 6.9 | 10.6* |
| CT | -- | 59.4 | 60.8 | 72.0* |
| PET | -- | 1.9 | 1.2 | 1.9 |
| Diagnostic laparoscopy | -- | 4.6 | 3.9 | 5.2 |
| Hepatectomy | -- | 8.2 | 10.5 | 13.4* |
| Lymphadenectomy | 27.5 | 25.1 | 30.6 | 34.8* |
| Chemotherapy | -- | 2.5 | 1.0 | 2.4 |
| Radiation Therapy | 13.0 | 15.8 | 15.7 | 14.2 |
*Significant test for trend (P<0.05). MRI = Magnetic resonance imaging; CT = computed tomography; PET = positron emission tomography
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