1. Is hepatic side tumor in T2 gallbladder cancer need extensive resection compared with peritoneal side tumor? : A multicenter study
Woohyung Lee1, Jae Yool Jang1, Chi-Young Jeong1, Young Hoon Kim2, Young Hoon Roh2, Kwan Woo Kim2, Sung Hwa Kang2, Myung Hee Yoon3, Hyung Il Seo3, Sung-Pil Yun3, Jeong-Ik Park4, Bo-Hyun Jung4, Soon-Chan Hong1
1Department of Surgery, Gyeongsang National University Hospital, Gyeongsang National University, College of Medicine, Republic of Korea
2Department of Surgery, Dong-A University Hospital, Dong-A University, College of Medicine, Busan, Republic of Korea
3Department of Surgery, Gyeongsang National University Hospital, Gyeongsang National University, College of Medicine, Republic of Korea
4Department of Surgery, Inje University Haeundae Paik Hospital, Inje University, College of Medicine, Busan, Republic of Korea

2. Methods Retrospective multicenter study
Gyeongsang National University Hospital
Pusan National University Hostpial
Dong-A University Hostpial
Inje University Haundae Hospital
This study is retrospective study.
The patients who underwent partial liver resection for IHCC
in GNUH from March 2010 to Dec 2012 were enrolled.
And the patients who underwent palliative operation
or diagnosed as T3 T4 or mixed HCC and IHCC were excluded.

3. Methods Jan 2000 - Dec 2015 Inclusion Criteria
1. Pathologically proven T2 gallbladder (GB) adenocarcinoma
2. Additional surgery after simple cholecystectomy
Exclusion Criteria
1. Simple cholecystectomy
2. Incomplete record (tumor site)
3. Adenosquamous, papillary neoplasm,
small cell, squamous cell ca
This study is retrospective study.
The patients who underwent partial liver resection for IHCC
in GNUH from March 2010 to Dec 2012 were enrolled.
And the patients who underwent palliative operation
or diagnosed as T3 T4 or mixed HCC and IHCC were excluded.

4. Patients information N=129 Hepatic side (N= 68) Peritoneal side
GB cancer without liver invasion
(N= 184)
Exclusion
Incomplete record (n=23)
Other pathology (n=11)
R1 resection (n=6)
Simple Cholecystectomy
(n=29)
Cholecystectomy
With LND
(n=20)
Cholecystectomy
With LND & LR
(n=95)
Exclusion
Simple cholecystectomy (n=15)
Additional LND & LR
(n=14)
N=129
Adenosquamous, papillary neoplasm, MCN, small cell ca, squamous cell ca.
Hepatic side
(N= 68)
Peritoneal side
(N= 61)

5. Definition Ann Surg 2015;261:733–739
This study is retrospective study.
The patients who underwent partial liver resection for IHCC
in GNUH from March 2010 to Dec 2012 were enrolled.
And the patients who underwent palliative operation
or diagnosed as T3 T4 or mixed HCC and IHCC were excluded.
Ann Surg 2015;261:733–739

6. Patients Characteristics
Variables
N=129
Age
68.7 ± 9.4
Sex (female, %)
77 (59.7)
BMI (kg/m2)
23.3 ± 3.0
ASA (I/II/III)
9 (6.7) / 95 (73.6) / 25(19.4)
Preoperative Imaging studies
USG (n, %)
74 (57.4)
CT (n, %)
129 (100)
Tumor site
Hepatic side
68 (52.7)
Peritoneal side
61 (47.3)
The median age was 63 years old
Male patients was dominant compared with female
3 patients have Combined hepatitis B
And all pateints were child A
17 patients underwent liver resection only, and 20 patients underwent LND with liver resection
The median hospital stay was 13 days.

7. Results

8. Preoperative data Variables Hepatic side (N=68) Peritoneal side (N=61)
P value
Age
67.1 ± 10.6
70.4 ± 7.4
0.045
Sex (Female)
40 (58.8)
37 (60.7)
0.859
BMI (kg/m2)
23.0 ± 3.0
23.6 ± 3.0
0.279
ASA score (I/II/III)
4/49/15
5/46/10
0.683
Preop imaging study
USG
34 (56.7) CT
68 (100)
61 (100)
CEA (ng/ml)
15.1 ± 58.4
3.6 ± 5.2
0.122
CA 19-9 (U/ml)
75.8 ± 145.1
30.0 ± 52.6
0.024
Total bilirubin
0.8 ± 0.9
0.6 ± 0.3
0.087
AST
31.4 ± 36.0
29.9 ± 39.7
0.819
ALT
28.6 ± 24.7
24.2 ± 16.4
0.243
ALP
187.5 ± 155.2
181.3 ± 98.4
0.786

9. Intraoperative Data 0.527 Wedge resection Variables
Hepatic side (N=68)
Peritoneal side (N=61)
P value
Secondary extended cholecystectomy
6 (7.8)
9 (12.3)
Extent of resection
0.476
Cholecystectomy with LND
9 (13.2)
11 (18.0)
Cholecystectomy with LND & LR
59 (86.8)
50 (82.0)
Extent of LND
0.527
#12
17 (26.6)
12 (21.1)
#8,12,13
47 (73.4)
45 (78.9)
Extent of liver resection
Wedge resection
37 (59.7)
27 (52.9)
0.568
Bisegmentectomy or major LR
25 (40.3)
24 (47.1)
연대에

10. Intraoperative Data 292.7 ± 123.2 268.3 ± 143.7 0.302 560.6 ±435.0
Variables
Hepatic side (N=68)
Peritoneal side (N=61)
P value
OP time (min)
292.7 ± 123.2
268.3 ± 143.7
0.302
EBL (ml)
560.6 ±435.0
475.0 ±368.5
0.259
Frozen biopsy
51 (75.1)
53 (86.9)
0.215
T1a/T1b/T2/T3
1/4/30/1
0/4/34/0
0.778
Intraoperative transfusion
21 (31.3)
8 (13.7)
0.019
Complicated
GB stone
13 (25.0)
15 (28.3)
0.826
In operative data,
Operative time was longer in open group, however no significant.
And surgeon used pringle maneuver more frequently to prevent parenchymal bleeding during resection.
Blood loss was significantly larger in open group .
Otherwise, there was no significant difference in intraoperative Tf and LND

11. Pathologic Data Variables P value Tumor Size(cm) 3.3 ± 1.9 1.9 ± 1.6
Hepatic side (N=68)
Peritoneal side (N=61)
P value
Tumor Size(cm)
3.3 ± 1.9
1.9 ± 1.6
0.195
Gross type
(polypoid /others)
12/56
10/51
1.000
Microvascular invasion
6 (9.7)
8 (13.6)
0.577
Lymphatic invasion
11 (19.6)
14 (25.5)
0.502
Neural invasion
6 (10.0)
Cell differentiation
(WD/MD/PD/UD)
33/22/10/1
33/18/9/0
0.939
N stage (0/1)
47(69.1)/21(30.9)
49(81.7)/11(18.3)
0.126
Retrieved LN
6.5 ± 5.6
6.6 ± 5.8
0.899
Positive LN
0.8 ± 1.8
0.3 ± 1.2
0.111
In pathologic data.
Tumor size was similar,
The proportion of gross type was comparable
And margin status and cell differentiation was similar between 2 groups
Margin positivie
김영일 8개월 만에 node meta
장도업: NO recu

12. Postoperative data Variables P value Postoperative complication
Hepatic side (N=68)
Peritoneal side (N=61)
P value
Postoperative complication
8 (11.9%)
5 (8.2%)
0.566
Biliary leakage
2 (2.9)
0.498
Fluid collection
3 (4.4)
2 (3.3)
1.000
Bleeding
1 (1.5)
1 (1.6)
Wound problem
0.602
Major Complication (≥IIIb)
1 (14.3)
Hospital stay (Days)
13.4 ± 11.04
10.6 ± 5.7
0.074
Adjuvant Tx
25 (41.7)
18 (32.1)
0.338
CTx/RTx/CCRT
10/2/13
8/2/8
0.699
Major complication : postop cerebral infarct으로 ICU care

13. Long term outcome
We compared long term outcome between open and laparoscopic groups

14. Median Survival(Months)
Overall survival
Hepatic vs. Peritoneal side
- Median F/U period: 30.0 ( ) Months
P=0.046
Median Survival(Months)
3-yr OS rate (%)
Hepatic side (68) 98
78.7
Peritoneal side (61)
112
90.5
Median F/U period was 16 months
Median survival was same in 2 groups and
estimated 3 yr OS rate was 81% and 85% in open and lap group, respectively.
There was no significant difference in overall survival between 2 groups.

15. Median disease free survival
Hepatic vs. Peritoneal side liver resection
P=0.037
Median disease free survival
(Months)
3-yr DFS rate (%)
Liver side 70
77.2
Peritoneal side
105
84.9
Disease free survival was evaluated.
Estimated 3 yr DFS rate was 53% and 75% in open and lap group, respectively.
There was no significant difference in disease free survival between 2 groups.
However. Follow up period of laparoscopic group was too short to evaluate exact data.
We have to follow up continuously.

16. Recurrence pattern P value Near resection margin 1 (1.5) 2 (3.3) 0.602
Hepatic side (N=68)
Peritoneal side (N=61)
P value
Near resection margin
1 (1.5)
2 (3.3)
0.602
Intrahepatic
3 (4.4)
1.000
Regional node
Paraaortic LN
Distant meta
7 (10.3)
4 (6.6)
0.538
13 patients experienced recurrence after curative resection
61% patients experienced intrahepatic metastasis.
We compared recurrence pattern according to the operative method. There was no significant difference between 2 groups.
Systemic meta:
T2N1 (1/3) Lap lt lat sectionectomy. Adjuvant CTx, 5개월만에 recur

17. Subgroup analysis
We performed subgroup analysis to exclude bias of lymph node dissection

18. Patients information Liver side (N= 68) Peritoneal side (N= 61) LND
GB cancer without liver invasion
(N= 184)
Exclusion
Incomplete record (n=23)
Other pathology (n=11)
R1 resection (n=6)
Simple Cholecystectomy
(n=29)
Cholecystectomy
With LND
(n=22)
Cholecystectomy
With LND & LR
(n=99)
Exclusion
Simple cholecystectomy (n=15)
Additional LND & LR
(n=14)
Adenosquamous, papillary neoplasm, MCN, small cell ca, squamous cell ca.
Liver side
(N= 68)
Peritoneal side
(N= 61)
LND
(N= 9)
LND c LR
(N= 59)
LND
(N= 11)
LND c LR
(N= 50)

19. Median Survival(Months)
Overall survival
P: LND c LR
P: LND
H: LND c LR
p=0.030
Median Survival(Months)
3-yr OS rate (%)
Peritoneal
LND (n=11)
105
83.3
LND LR (n=50)
113
88.2
Hepatic
LND (n=9) 32
43.8
LND LR (n=59)
103
79.7
H:LND
LND median F/U 27개월 (1-119)
LND LR median F/U 30 (1-129)

20. Patients information Liver side (N= 68) Peritoneal side (N= 61) LND
GB cancer without liver invasion
(N= 184)
Exclusion
Incomplete record (n=23)
Other pathology (n=11)
R1 resection (n=6)
Simple Cholecystectomy
(n=29)
Cholecystectomy
With LND
(n=22)
Cholecystectomy
With LND & LR
(n=99)
Exclusion
Simple cholecystectomy (n=15)
Additional LND & LR
(n=14)
Adenosquamous, papillary neoplasm, MCN, small cell ca, squamous cell ca.
Liver side
(N= 68)
Peritoneal side
(N= 61)
LND
(N= 9)
LND c LR
(N= 59)
LND
(N= 11)
LND c LR
(N= 50)

21. Peritoneal side (LND vs. LND c LR)OS
DFS
p=0.874
p=0.442
Median Survival(Months)
3-yr OS rate (%)
LND (n=11)
105
83.3
LND LR (n=50)
113
88.2
Median Survival(Months)
3-yr DFS rate (%)
LND (n=11) 95
77.9
LND LR (n=50)
106
79.5
LND median F/U 27개월 (1-119)
LND LR median F/U 30 (1-129)

22. Patients information Liver side (N= 68) Peritoneal side (N= 61) LND
GB cancer without liver invasion
(N= 184)
Exclusion
Incomplete record (n=23)
Other pathology (n=11)
R1 resection (n=6)
Simple Cholecystectomy
(n=29)
Cholecystectomy
With LND
(n=22)
Cholecystectomy
With LND & LR
(n=99)
Exclusion
Simple cholecystectomy (n=15)
Additional LND & LR
(n=14)
Adenosquamous, papillary neoplasm, MCN, small cell ca, squamous cell ca.
Liver side
(N= 68)
Peritoneal side
(N= 61)
LND
(N= 9)
LND c LR
(N= 59)
LND
(N= 11)
LND c LR
(N= 50)

23. Hepatic side (LND vs. LND c LR)OS
DFS
20 patients underwent LND dissection, and 17 patients underwent only liver resection
Liver resection group worse 3 yr OS rate compared with LND group,
However there was significant difference between 2 groups.
DFS was similar results with OS
p=0.063
p=0.833
Median Survival(Months)
3-yr OS rate (%)
LND (n=9) 32
43.8
LND LR (n=59)
103
79.7
Median Survival(Months)
3-yr DFS rate (%)
LND (n=9)
29.1
83.3
LND LR (n=59)
70.3
77.1

24. Limitations Retrospective study Small number
Different operative extent among institutions

25. Conclusion
T2 GB cancer showed different oncologic outcomes according to the tumor site.
Peritoneal side tumor showed comparable oncologic outcome regardless of extent of resection.
In hepatic side tumor, radical surgery was related with better oncologic outcome.