Biology Dictates Prognosis Following Resection of Gallbladder Carcinoma: Sometimes Less is More

In this issue of Annals of Surgical Oncology, D’Angelica and colleagues from the Memorial Sloan–Kettering Cancer Center report data on the importance of extent of resection for gallbladder adenocarcinoma. The analyses reveal that extensive resections for gallbladder cancer are associated with increased morbidity, but not survival. These findings have important implications as some investigators have in the past advocated extended operations that combine major hepatic resection and routine common bile duct resection with reconstructive hepaticojejunostomy to improve longterm survival. Prognosis following surgery for gallbladder adenocarcinoma can vary dramatically, with 5-year survival rates ranging from 10% to 90%. As noted by the authors in their current report, outcome following surgery depends not only on the extent of the curative resection, but more importantly, on the stage of disease. D’Angelica and colleagues reaffirm the basic oncologic tenet that tumor biology—not extent of resection—is the dominate factor that dictates survival. Whether to perform empirically a nonanatomical resection or an anatomical resection for hepatobiliary malignancies of the liver has been controversial. Although some studies have reported that the performance of an anatomical resection improves tumor clearance and outcome, other reports have not demonstrated a benefit for anatomic or ‘‘extended’’ resections. In general, most surgeons have begun to advocate a more parenchymalsparing approach to resection of hepatobiliary tumors that still maintains a negative margin. In support of this, our group previously reported that the extent of hepatectomy for gallbladder carcinoma was not associated with prognosis. D’Angelica similarly noted that patients who underwent a major hepatectomy had a 5-year actuarial survival comparable to those patients who did not undergo major hepatic resection. However, unlike D’Angelica et al., we previously reported that, rather than extent of hepatic resection, surgical margin status was a key determinant of outcome. Specifically, R1/R2 margin status was associated with significantly worse long-term outcome. The failure of the current authors to find margin status to be a significant prognostic factor may be due to the laudatory fact that only nine patients in the series had a positive resection margin. As such, analyses involving margin status may have been underpowered. Regardless, we agree whole-heartedly with our colleagues that rather than dogmatically adhering to an extended versus nonextended surgical resection approach, the surgeon’s goal should be to resect all disease with negative histologic margins. Similar to the extent of hepatic resection, the wholesale adoption of a more extensive approach to the common bile duct may also be unwarranted. While some surgeons have advocated routine resection of the common bile duct at the time of curative resection and portal lymphadenectomy, other investigators have questioned this approach. The study by D’Angelica et al., as well as others, now provide data to show that routine bile duct excision is not necessarily associated with improved overall survival. The notion that resection of the common bile duct may facilitate a more thorough lymphadenectomy also has been questioned. As noted in the D’Angelica report, lymph node counts were similar regardless of whether a common bile duct resection had been performed. It is important to note that, while routine common bile duct resection was not associated with survival or lymph node yield, it was associated with increased morbidity. In fact, D’Angelica et al. noted a 33% incidence of grade 3/4 morbidity in the group of patients who underwent bile duct excision and reconstruction. Citing similar data showing no improvement in long-term survival, as well as the increased risk of Society of Surgical Oncology 2009