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EDITORIALS |
From the Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York.
Correspondence: Address correspondence to: Yuman Fong, MD, Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Ave., New York, NY 10021; Fax: 212-639-4031; E-mail: fongy{at}mskcc.org
In the clinical management of gallbladder cancer, the T stage of disease has evolved to be the most useful clinical parameter. This is because the majority of patients with potentially curative disease present after having had a simple cholecystectomy. At that time, the T stage of disease as analyzed pathologically on that initial excision provides enormously important prognostic information that guides further imaging for staging as well as further surgery and adjuvant therapies. The T stage of the tumor is proportional to the likelihood of lymph node metastases and peritoneal dissemination.1,2 Much of our knowledge on the natural history and the outcome from surgical therapy for gallbladder cancer has come from the careful work and analysis by Shirai and his colleagues from Niigata University. The article by Wakai et al.3 in the May issue of the Annals of Surgical Oncology represents yet another important contribution from their group that expands our knowledge of this deadly disease. In this article, the authors present data documenting that patients with T2 gallbladder cancer can be further separated prognostically according to the actual depth of invasion into the subserosa. Those that had less than 2-mm invasion had significantly better outcome than those that had a depth of invasion greater than 2 mm. In addition, they could not find an advantage for an extended cholecystectomy for those patients with less than 2-mm invasion. The importance of this article lies in the observation that the T stage is once again an important prognostic factor. Furthermore, T stage of the disease is a continuous variable even though, for practical reasons, we use it as a discreet variable.
One must, however, caution against extending this biologic observation to clinical practice. In this article, up to 70 histologic sections were performed on each specimen to verify the depth of invasion of these T2 tumors. That is not the kind of histologic analysis that can be obtained at most hospitals. In fact, when patients are referred to a tertiary referral center, oftentimes the original specimens are no longer available and only isolated paraffin sections are available for histologic re-examination. The reader must be reminded that when we perform a simple cholecystectomy, we usually leave the cystic plate behind on the liver. Therefore, the dissection is actually done in a plane that is subserosal on the liver side. If the tumor happens to exist on this side, the likelihood of leaving behind microscopic disease in a T2 gallbladder cancer is fairly high. Any residual disease translates to death in this aggressive tumor.
Furthermore, in this article the major recommendation that cholecystectomy alone is adequate treatment for tumors with less than 2-mm invasion into the subserosa is based on a comparison of 16 patients undergoing radical resection and 8 patients undergoing cholecystectomy. The sample size is too small to instigate a major change in our clinical practice. These patients were not chosen at random and it is likely that most of the patients with node-positive T2 gallbladder cancer were in the groups that had radical resection, thus confounding the results. Therefore, although the results are interesting and important, I feel that at present patients with T2 gallbladder cancer should still be offered a radical resection, including a local excision and regional lymphadenectomy, for the greatest chance of favorable long-term outcome.
Received for publication April 1, 2003. Accepted for publication April 21, 2003.
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