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Eduardo A. Vega*1,2, Eduardo Vinuela2,3, Marcel P. Sanhueza2,3, Cristian Diaz2,3, Nicolas Jarufe3, Jorge Martinez3, Masuyuki Okuno1, Katharina Joechle1, Yun Shin Chun1, Ching-Wei Tzeng1, Jeffrey E. Lee1, Jean-Nicolas Vauthey1, Claudius Conrad1
1Surgical Oncology, MD Anderson Cancer Center, Houston, TX; 2Surgery, Hospital Sotero del Rio, Santiago, RM, Chile; 3Surgery, Pontificie Universidad Catolica de Chile, Santiago, RM, Chile

BACKGROUND: It is presumed that the non-oncological index cholecystectomy (IC) leading to discovery of incidental gallbladder cancer (IGBC) does not significantly impact survival. This study compares the outcome of non-IGBC vs IGBC to identify patients that may have a negative impact from failure of performing upfront radical cholecystectomy,
METHODS: Clinical and pathologic features of non-IGBC and IGBC patients treated with curative intent at two centers (USA and Chile) during 1999-2016 were compared. Patients with T1 and T4 tumors and preoperative jaundice were excluded. T2 IGBC and non-IGBC were stratified by the presence of hepatic side tumor at IC which has been shown to be a predictor of worse survival (AJCC 8th). Predictors of disease-specific survival (DSS) were analyzed.
RESULTS: The study included 196 patients: 151 (77%) with IGBC and 45 (23%) with non-IGBC. Major liver resection, operative mortality, major complication, N+ status and R1 resection were comparable. DSS rate in IGBC vs non-IGBC was 60% vs 50% at 3 years (p=0.064). Further, 118 (78%) IGBC patients and 18 (48%) non-IGBC patients had T2 disease. Eleven (10%) T2b IGBC and 7 (41.2%) T2b non-IGBC patients had tumor at the hepatic side. T2 and T3 IGBC vs non-IGBC had similar survival (T2: DSS rate at 3 years 63% vs 81%, p=0.730; T3: DSS rate at 3 years 29% vs 46%, p=0120). However, T2b IGBC patients had lower DSS rates than T2b non-IGBC (DSS rate at 3 years, 31% vs 85%; p=0.019). Further, T2b IGBC patients DSS was inferior when the time interval between IC and OER is >60 days. (DSS rate at 3 years, 16% vs 85%; p=0.004). In multivariate analysis of T2 patients, predictive factors for poor DSS are hepatic side tumor in IGBC patients (hazard ratio (HR), 3.2; 95% CI, 1.1-9.4; p=0.032) and N1 status (HR, 2.3; 95% CI, 1.2-4.5; p=0.011).
CONCLUSIONS: Patients with T2b IGBC benefit from single operation even when patients are rendered disease free during a follow up oncologic extended resection. Efforts should be made to identify T2 IGBC preoperatively to refer these patients to centers with expertise in oncologic resection for GB cancer.

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