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Gall bladder cancer (GBC) is common among the socioeconomically deprived populations of certain geographical regions. Aflatoxin is a genotoxic hepatocarcinogen, which is recognized to have a role in the pathogenesis of hepatocellular carcinoma. However, the role of aflatoxin in the pathogenesis of GBC is largely unknown. We determined serum AFB1‐Lys albumin adduct (AAA) levels as a marker of aflatoxin exposure in the patients with GBC and compared to those without GBC. The relationship of AAA levels to cytogenetic (TP53mutation&HER2/neu amplification) and radiological characteristics of the tumor was assessed. We included GBC cases (n = 51) and non‐GBC controls (n = 100). Mean serum AAA levels were higher in the GBC group (n = 51) than those without GBC (n = 100) (26.1 ± 12.2 vs. 13.1 ± 11.9 ng/mL; p <.001). HER2/neu expression was associated with higher AAA levels compared to those with equivocal or negative expression (43.9 ± 3 vs. 28.6 ± 10 vs. 19.3 ± 7 ng/mL; p <.001). Older age (age >50 years) (odds ratio [OR] = 3.2 [CI: 1.3–8.2]; p =.013), positive Helicobacter pylori serology (OR = 5.1 [CI: 1.4–17.8]; p =.012), presence of GS (OR = 5 [CI: 1.5–16.9]; p =.009) and detectable AAA levels (OR = 6.8 [CI: 1.3–35.7]; p =.024) were independent risk factors for the presence of the GBC among all study subjects. Among patients harboring GS, older age (age >50 years) (OR = 4.5 [CI: 1.3–14.9]; p =.015), female gender (OR = 3.8 [CI: 1.2–12.5]; p =.027), presence of multiple GS (OR = 21.9 [CI: 4.8–100.4]; p <.001) and high serum AAA levels (OR = 5.3 [CI: 1.6–17.3]; p =.006) were independent risk factors for the presence of the GBC. Elderly age >50 years (OR = 2.6 [CI: 1.3–5.2]; p =.010) and frequent peanut consumption (OR = 2.3 [CI: 1.1–4.9]; p =.030) were independent risk factors for high serum AAA levels. The current study has implications for the prevention of GBC through the reduction of dietary aflatoxin exposure. [ABSTRACT FROM AUTHOR]

Radiomics is a method that extracts many features from medical images using various algorithms. Medical nomograms are graphical representations of statistical predictive models that produce a likelihood of a clinical event for a specific individual based on biological and clinical data. The radiomic nomogram was first introduced in 2016 to study the integration of specific radiomic characteristics with clinically significant risk factors for patients with colorectal cancer lymph node metastases. Thereby it gained momentum and made its way into different domains of breast, liver, and head and neck cancer. Deep learning-based radiomics which automatically generates and extracts significant features from the input data using various neural network architectures, along with the generation and usage of nomograms are the latest developments in the application of radiomics for the diagnosis of gall bladder carcinoma. Although radiomics has demonstrated encouraging outcomes in the diagnosis of gall bladder carcinoma, but most of the studies conducted suffer from a lack of external validation cohorts, smaller sample sizes, and paucity of prospective utility in routine clinical settings. [ABSTRACT FROM AUTHOR]

The author outlines his philosophy and practice of management of gall bladder cancer based on his more than three-decade experience at a large tertiary level super-specialty referral hospital attached to a university-status teaching institution at Lucknow in northern India where GBC is very common. [ABSTRACT FROM AUTHOR]

Background: Primary sclerosing cholangitis (PSC) is an idiopathic cholestatic liver disease that may lead to biliary strictures and destruction. It is associated with p-ANCA positivity and inflammatory bowel disease, typically ulcerative colitis. The aim of this study is to investigate the trends of inpatient healthcare utilization and mortality from 2008 to 2017 in the United States. Methods: The Nationwide Inpatient Sample (NIS) was examined to identify adult patients diagnosed with PSC between 2008 and 2017. Data on patient demographics, resource utilization, mortality, and PSC-related complications were collected. STATA version 16.0 was employed to perform forward stepwise multivariate regression analysis, generating adjusted odds ratios for both primary and secondary outcomes. Primary outcomes included the inpatient mortality rate and healthcare resource utilization (length of stay, total charges, and trends over the study period). Secondary outcomes focused on trends in associated comorbidities and malignancies in patients with PSC. Results: The average total charge increased by 32.2% ± 2.12 from USD 61,873 ± 2567 in 2008 to USD 91,262 ± 2961 in 2017. Concurrently, the average length of stay declined from 8.07 ± 0.18 days in 2008 to 7.27 ± 0.13 days in 2017. The APR-DRG severity of illness and risk of death significantly increased (major or extreme) during the study period (2008 to 2017), with severity rising from 73.6% to 82.7% (coefficient: 0.21, 95% CI: 0.13–0.28) and risk of death from 45.3% to 60.9% (coefficient: 0.15, 95% CI: 0.08–0.23). The proportion of patients with HCC increased from 1.3% to 7.9% (coefficient: 2.13, 95% CI: 1.9–2.8). Conversely, the percentage of patients with cholangiocarcinoma (CCA) decreased from 5.1% to 2.8% (coefficient: −0.36, 95% CI: −0.25 to −0.46). Conclusions: There was rising mortality and healthcare resource utilization among patients with PSC from the years 2008 to 2017. These trends were paralleled by increasing rates of decompensated cirrhosis, HCC, and liver transplants. However, the incidence of CCA decreased during this time period. African American patients with PSC had worse inpatient mortality outcomes and healthcare utilization as compared to white patients. Further studies are warranted to investigate a possible causal link amongst these trends. [ABSTRACT FROM AUTHOR]

Abstract Radiomics is a method that extracts many features from medical images using various algorithms. Medical nomograms are graphical representations of statistical predictive models that produce a likelihood of a clinical event for a specific individual based on biological and clinical data. The radiomic nomogram was first introduced in 2016 to study the integration of specific radiomic characteristics with clinically significant risk factors for patients with colorectal cancer lymph node metastases. Thereby it gained momentum and made its way into different domains of breast, liver, and head and neck cancer. Deep learning-based radiomics which automatically generates and extracts significant features from the input data using various neural network architectures, along with the generation and usage of nomograms are the latest developments in the application of radiomics for the diagnosis of gall bladder carcinoma. Although radiomics has demonstrated encouraging outcomes in the diagnosis of gall bladder carcinoma, but most of the studies conducted suffer from a lack of external validation cohorts, smaller sample sizes, and paucity of prospective utility in routine clinical settings.

Background: Robotic surgery has demonstrated outcomes comparable or superior to open and laparoscopic surgeries for extended cholecystectomy.1, 2, 3, 4, 5, 6, 7–8 Despite its advantages, the minimally invasive robotic single-port (SP) system remains underutilized in complex hepatobiliary pancreatic surgery due to instrument limitations and retraction issues.9,10 This study evaluated the feasibility, safety, and effectiveness of the da Vinci SP system in gallbladder cancer surgery. The study was approved by the Ethics Committee of OOO University Hospital (IRB no. DAUH IRB-24-081) and conducted in accordance with the principles of the Declaration of Helsinki. The requirement for informed consent was waived due to the study's retrospective design. Methods: A 62-year-old woman with a diagnosis of gallbladder cancer was referred for surgery. Preoperative computed tomography (CT) scans showed no evidence of metastasis (T2N0). Therefore, a robotic SP extended cholecystectomy was planned. Figure 1 shows a 30-mm SP port and a 1-mm assistant port inserted for the procedure. Due to the absence of an energy device for the liver wedge resection, Maryland bipolar forceps were used, mimicking the Kelly clamp crushing technique. A monopolar cautery hook was used for lymph node resection of stations 7, 8, 12, and 13 (Fig. 2). Results: The total duration of the operation was 226 min, with an estimated blood loss of 200 ml. The CT scan on day 5 showed no abnormalities, and the patient was discharged routinely on day 7 (Fig. 3). The pathologic examination confirmed adenocarcinoma (T2a) with clear resection, and all six lymph nodes tested negative for malignancy. Conclusions: This study underscores the adequacy of robotic surgeries and emphasizes the potential of the da Vinci SP system in hepatobiliary surgery. Despite current challenges related to instrument limitations, the authors are confident that the SP system will evolve into a crucial asset for hepatobiliary surgical practices in the foreseeable future. [ABSTRACT FROM AUTHOR]

Purpose Gallbladder carcinoma (GBC) poses significant challenges in oncology due to its aggressive nature and limited treatment options. The lack of effective biomarkers for early detection and prognosis exacerbates the prognosis for GBC patients. Tumor budding (TB) and tumor infiltrating lymphocytes (TILs) have emerged as potential prognostic indicators in various cancers, reflecting tumor-host immune interactions and tumor aggressiveness. The study of TB and TILs in GBC is particularly important due to the limited literature available. Methods This retrospective observational study aimed to evaluate the association of TB and TILs with clinicopathological parameters in GBC patients. Clinicopathological data were collected from patients with histologically confirmed GBC who underwent surgical resection. The sections were evaluated for TB and TILs using standardized methods. Statistical analysis was performed to assess associations between these parameters and clinicopathological variables. Results Tumor stage and grade showed significant associations with TB and TILs, indicating their potential as prognostic markers. High TB correlated with advanced tumor stage and higher grade, while high TIL infiltration was associated with early tumor stage and lower grade. Additionally, TILs exhibited a significant association with lymphovascular invasion. Interestingly, an inverse association was observed between TB and TILs, highlighting the dynamic interplay between tumor aggressiveness and host immune response. Conclusion TB and TILs hold prognostic significance in GBC, offering insights into its pathogenesis and potential therapeutic targets. Future research exploring the mechanistic underpinnings of tumor-host immune interactions in GBC is crucial for translating these findings into clinical applications and improving outcomes for patients.

Biliary spillage (BS) is a common complication following initial cholecystectomy for gall bladder cancer (GBC). Few studies have explored the importance of BS as a long-term prognostic factor. We perform a meta-analysis of the association between BS and survival in GBC. A systematic literature search was performed in February 2023. Studies evaluating the incidence of BS and its association with long-term outcomes in patients undergoing initial laparoscopic or open cholecystectomy for either incidental or resectable GBC were included. Overall survival (OS), disease-free survival (DFS), and rate of peritoneal carcinomatosis (RPC) were the primary end points. Forest plot analyses were used to calculate the pooled hazard ratios (HRs) of OS, DFS, and RPC. Metaregression was used to evaluate study-level association between BS and perioperative risk factors. Of 181 published articles, 11 met inclusion criteria with a sample size of 1116 patients. The rate of BS ranged between 9% and 67%. On pooled analysis, BS was associated with worse OS (HR = 1.68, 95% confidence interval [CI] = 1.32-2.14), DFS (pooled HR= 2.19, 95% CI = 1.30-3.68), and higher RPC (odds ratio = 9.37, 95% CI = 3.49-25.2). The rate of BS was not associated with higher T stage, lymph node metastasis, higher grade, positive margin status, reresection, or conversion rates. Our meta-analysis shows that BS is a predictor of higher peritoneal recurrence and poor survival in GBC. BS was not associated with tumor characteristics or conversion rates. Further research is needed to identify other potential risk factors for BS and investigate the ideal treatment schedule to improve survival. [ABSTRACT FROM AUTHOR]

Xanthogranulomatous cholecystitis (XGC) is one of the rare variants of chronic cholecystitis which is characterized by inflammation of gall bladder along with infiltration by acute and chronic inflammatory cells. Intramural accumulation of lipid laden macrophages in GB wall is the hallmark of the disease. XGC results in dense adhesion of gall bladder (GB) to surrounding structures, like duodenum, colon, and stomach. The intense GB inflammation results in gall bladder perforation and development of fistulous communication between gall bladder and surrounding structures. This may also lead to formation of inflammatory mass which closely mimic gall bladder malignancy. Often differentiation from carcinoma of GB (Ca GB) on the basis of clinical presentation and even on intra-operative and radiological findings is difficult, and the issue could only be resolved on final Histopathology (HPE). We review presentation and investigation of a patient, discuss our approach in managing dilemma in treating such cases of XGC, and review the literature. [ABSTRACT FROM AUTHOR]

Background: A majority of the patients with gall bladder cancer (GBCa) present at an advanced stage and have poor survival. The aim is to retrospectively study the role of guided FNA in the diagnosis of GBCa in a superspecialty institute and to describe the cytomorphologic spectrum of gall bladder (GB) lesions in the North Indian population. Materials and Methods: All suspected cases of GBCa who underwent guided FNA from the primary GB mass or metastatic liver space-occupying lesion from 2017 to 2019 were included. The aspirate smears were retrieved and analyzed for cytomorphological features independently by two cytopathologists. The neoplastic lesions were classified according to the WHO 2019 classification. Results: Of 489 cases, fine needle aspiration cytology (FNAC) was diagnostic in 463 cases (94.6%), of which 417 (90.1%) were positive for malignancy, 35 (7.5%) were inflammatory, and 11 (2.4%) were inconclusive for malignancy. Adenocarcinoma not otherwise specified (NOS) was the most common type seen in 330 cases (79.1%) and 87 (20.9%) were unusual variants. These included papillary adenocarcinoma (22, 5.2%), mucinous adenocarcinoma (12, 2.8%), signet ring carcinoma (2,0.4%), adenosquamous carcinoma (8, 1.9%), squamous cell carcinoma (10, 2.4%), neuroendocrine neoplasms (7, 1.7%), undifferentiated carcinoma (24, 5.7%) and non-Hodgkin lymphoma (2,0.4%), respectively. Immunohistochemistry on the cell block confirmed the diagnosis wherever possible. Histopathology was discordant in 5 out of 33 cases. Conclusion: Guided FNAC is a sensitive investigation that plays a crucial role in confirming the diagnosis and deciding the further treatment options in advanced-stage GBCa patients. The uncommon variants of GBCa can be reliably categorized on cytology.

Purpose: Gall bladder cancer (GBC) is one of the commonest and deadliest cancers of Northern and Eastern India. The absence of a population-based cancer registry in Uttar Pradesh and Bihar has resulted in a lack of statistical information even though data from several hospital-based registries suggests that incidence rates of GBC may be one of the highest in the world. We present the four-year data on GBC from our tertiary-level multispeciality hospital. Materials & Methods: This is a retrospective and analytical study. All patients of histopathologically proven GBC over four years were included and geographic, demographic and clinical data was collected and presented. Follow up, where available, was used to assess survival at 12 months and factors affecting it. Results: A total of 245 patients with GBC were diagnosed during the study period of which more than two-thirds were women. The majority of cases at our hospital were from the state of Uttar Pradesh with the highest number coming from the Eastern districts closer to the river Ganga and its tributaries. 26.5% of cases were early stage and surgically resectable, 19.6% were locally advanced and unresectable while 53.9% were metastatic at presentation. Age, stage and radical surgery as treatment had a significant association with survival at 12 months. Conclusion: GBC has an extremely high incidence in the Northern plains of India. There is a high suspicion of its association with increasing pollution of the major rivers of the region. Early detection is crucial as definitive surgery is the only curative option with any significant improvement of survival.

Background & Aims: Biliary tract cancer (BTC) is associated with a dismal prognosis, partly because it is typically diagnosed late, highlighting the need for diagnostic biomarkers. The purpose of this project was to identify and validate multiprotein signatures that could differentiate patients with BTC from non-cancer controls. Methods: In this study, we included treatment-naïve patients with BTC, healthy controls, and patients with benign conditions including benign biliary tract disease. Participants were divided into three non-overlapping cohorts: a case-control-based discovery cohort (BTC = 186, controls = 249); a case-control-based validation cohort (validation cohort 1: BTC = 113, controls = 241); and a cohort study-based validation cohort including participants (BTC = 8, controls = 132) referred for diagnostic work-up for suspected cancer (validation cohort 2). Immuno-Oncology (I-O)-related proteins were measured in serum and plasma using a proximity extension assay (Olink Proteomics). Lasso and Ridge regressions were used to generate protein signatures of I-O-related proteins and carbohydrate antigen 19-9 (CA19-9) in the discovery cohort. Results: Sixteen protein signatures, including 2 to 82 proteins, were generated. All signatures included CA19-9 and chemokine C-C motif ligand 20. Signatures discriminated between patients with BTC vs. controls, with AUCs ranging from 0.95 to 0.99 in the discovery cohort and 0.94 to 0.97 in validation cohort 1. In validation cohort 2, AUCs ranged from 0.84 to 0.94. Nine signatures achieved a specificity of 82% to 84% while keeping a sensitivity of 100% in validation cohort 2. All signatures performed better than CA19-9, and signatures including >15 proteins showed the best performance. Conclusion: The study demonstrated that it is possible to generate protein signatures that can successfully differentiate patients with BTC from non-cancer controls. Impact and implications: We attempted to find blood sample-based protein profiles that could differentiate patients with biliary tract cancer from those without cancer. Several profiles were found and tested in different groups of patients. The profiles were successful at identifying most patients with biliary tract cancer, pointing towards the utility of multiprotein signatures in this context.

Background: A majority of the patients with gall bladder cancer (GBCa) present at an advanced stage and have poor survival. The aim is to retrospectively study the role of guided FNA in the diagnosis of GBCa in a superspecialty institute and to describe the cytomorphologic spectrum of gall bladder (GB) lesions in the North Indian population. Materials and Methods: All suspected cases of GBCa who underwent guided FNA from the primary GB mass or metastatic liver space-occupying lesion from 2017 to 2019 were included. The aspirate smears were retrieved and analyzed for cytomorphological features independently by two cytopathologists. The neoplastic lesions were classified according to the WHO 2019 classification. Results: Of 489 cases, fine needle aspiration cytology (FNAC) was diagnostic in 463 cases (94.6%), of which 417 (90.1%) were positive for malignancy, 35 (7.5%) were inflammatory, and 11 (2.4%) were inconclusive for malignancy. Adenocarcinoma not otherwise specified (NOS) was the most common type seen in 330 cases (79.1%) and 87 (20.9%) were unusual variants. These included papillary adenocarcinoma (22, 5.2%), mucinous adenocarcinoma (12, 2.8%), signet ring carcinoma (2,0.4%), adenosquamous carcinoma (8, 1.9%), squamous cell carcinoma (10, 2.4%), neuroendocrine neoplasms (7, 1.7%), undifferentiated carcinoma (24, 5.7%) and non-Hodgkin lymphoma (2,0.4%), respectively. Immunohistochemistry on the cell block confirmed the diagnosis wherever possible. Histopathology was discordant in 5 out of 33 cases. Conclusion: Guided FNAC is a sensitive investigation that plays a crucial role in confirming the diagnosis and deciding the further treatment options in advanced-stage GBCa patients. The uncommon variants of GBCa can be reliably categorized on cytology. [ABSTRACT FROM AUTHOR]

Purpose: The data on the prognostic significance of red cell distribution width (RDW) in gallbladder cancers is sparse, especially in the potentially resectable cohort of patients. The aim was to assess the prognostic significance of RDW in gallbladder cancer patients undergoing surgery. Methods: Retrospective analysis of prospectively maintained database of gallbladder cancer patients undergoing surgery at a tertiary cancer institute from 2010 till 2018. Baseline values were collected. Patients were grouped as per the median RDW value and compared. Survival analysis was done using the Kaplan Meier method. Results: A total of 605 patients were included. The median follow up period was 23 months (range: 6–120 months). The median value of RDW was 14. Comparison between RDW > 14 and RDW < 14 groups showed no difference in outcomes. RDW did not predict overall survival or recurrences. However, in combined stages II and III, a statistically significant improvement in OS and DFS (p < 0.001) was noted in the RDW < 14 group. Conclusion: RDW did not predict recurrence or survival in potentially resectable gallbladder cancer patients. However, in the subset of stages II and III in combination, lower RDW value was associated with better outcomes. More prospective studies are needed to conclusively establish the prognostic value of RDW. [ABSTRACT FROM AUTHOR]

Background: Management of pancreaticobiliary (PB) malignancies remains a clinical challenge. In this review, we focus on the management of oncological emergencies in PB malignancies and the potential complication of associated therapeutic interventions. Methods: Biobliographic review of current evidence on the management of oncological emergencies, their potential complications, as well as synthesis of recommendations was performed. The pathogenesis, frequency, related symptoms as well as appropriate investigations are presented. Results: The oncologic emergencies in PB patients were summarised in six categories: (1) hematological (including febrile neutropaenia, thrombocytopenia, coagulopathies), (2) gastrointestinal (gastric outlet and biliary obstruction, gastrointestinal bleeding), (3) thromboembolic events, (4) ascites, (5) metabolic disorders and (6) neurologic complications. The pathogenesis, frequency, related symptoms as well as appropriate investigations are also presented. Conclusion: Patients with PB malignancies are at increased risk of a wide variation of medical emergencies. Clinical knowledge, early recognition and collaboration with the relevant specialties are critical to manage these complications effectively, tailoring overall management around the actual prognosis and individuals' expectations. [ABSTRACT FROM AUTHOR]

Extensive surgery is the mainstay treatment for gallbladder cancer and offers a long-term survival benefits to the patients. However, the optimal extent of surgery remains debatable. We aimed to perform a meta-analysis of hepatectomy and no hepatectomy approaches in patients with T2 gallbladder cancer. We searched the following electronic databases for systematic literature: PubMed, Google Scholar, and the Cochrane Library. We selected studies that compared patients with T2 gallbladder cancer who underwent hepatectomy with those who did not. While the long-term overall survival (OS) and disease-free survival (DFS) were the primary outcomes, perioperative morbidity and mortality were the secondary outcome. We analysed over 18 studies with 4,587 patients. Of the total patients, 1,683 and 1,303 patients underwent hepatectomy and no hepatectomy, respectively. The meta-analysis revealed no significant difference between the hepatectomy and no hepatectomy groups, in terms of the overall morbidity (risk ratio [RR] = 1.85, 95% confidence interval [CI] = 0.66–5.20) and 30-day mortality (RR = 0.9, 95% CI = 0.1–8.2). The results were comparable in terms of the OS (RR = 0.76, 95% CI = 0.57–1.01), (HR = 0.74, 95% CI = 0.49–1.12), and DFS (RR = 0.99, 95% CI = 0.88–1.11). In conclusion, the perioperative and long-term outcomes of hepatectomy and no hepatectomy approaches were comparable. Hepatectomy may not be required in T2 gall bladder cancer if the preoperative evaluation confirms the depth of the tumour in the perimuscular connective tissue and the intraoperative frozen sections confirm microscopic negative margins. Likewise, for those whom gall bladder cancer was diagnosed from the pathological report after simple cholecystectomy, further hepatectomy may not necessary.

Neuroendocrine tumor (NET) of gallbladder (GB) is very rare, accounting for 0.5% of all neuroendocrine malignancies and 2% of all GB cancers. It is very difficult to differentiate between carcinoma GB and NET GB. Here, we present a case of NET GB diagnosed in a 40-year-old female. The clinical features were nonspecific and the diagnosis was confirmed only on histopathological examination. The management of carcinoma GB and NET GB is discussed in detail.

Radical surgery remains the primary treatment option for gall bladder cancer (GBC). Margin-negative liver resection is a critical component of radical cholecystectomy. Anatomical segment IVb and V resection is preferred in primary GBC with liver infiltration and incidental GBC patients with puckering of gall bladder (GB) bed. Despite the initial scepticism, minimally invasive radical cholecystectomy is recommended as a treatment option in selected GBC patients. However, anatomical Segment IVb and V resection using the minimally invasive approach is scarcely reported. The standardised technique of robotic (daVinci®XiTM) anatomical Segment IVb and V liver resection guided by indocyanine green fluorescence is described here. The systematic fluorescence-guided anatomical resection described in this report could facilitate minimally invasive Segment IVb and V resection with radical lymphadenectomy in selected patients with GBC.

Background: Percutaneous Transhepatic Biliary Drainage (PTBD) is a minimally invasive procedure to palliate the biliary obstruction caused by unresectable malignancy. Aims and Objective: To analyze the outcome of PTBD in patients of unresectable gall bladder cancer presenting with obstructive jaundice in terms of reduction in serum bilirubin levels, symptomatic improvement, and overall survival (OS) at 4 weeks and 12 weeks following the procedure. Materials and Methods: In this retrospective study, PTBD was attempted on 30 patients diagnosed with inoperable gall bladder cancer. Various patient and procedure-related variables were analyzed and recorded both pre and post-PTBD. Outcome data on OS was collected at 4 weeks and 12 weeks. Results: Technical success was achieved in 29 (99.66%) patients. The mean fall in the serum bilirubin at the 7th post-procedural day was 41.5% after the successful PTBD. The most common complication in our study was cholangitis noted in six (21%) patients. OS at 4 weeks and 12 weeks was 79% and 41%, respectively. Conclusion: Younger age and good performance status favored better survival rate in our study.

Laparoscopic cholecystectomy is a fairly common procedure and is currently considered the gold standard for cholecystectomy. However, the laparoscopic procedure in the presence of gall bladder cancer (GBC) is associated with the risk of port-site metastasis (PSM). Furthermore, in few cases, GBC remains occult even on postoperative histopathology and presents with PSM remotely. Here, we describe two such cases of GBC with occult primary who presented with PSM and also defined the role of fluorine-18 fluorodeoxyglucose positron emission tomography-computed tomography in the management of such cases. [ABSTRACT FROM AUTHOR]

Sayed K Elagan,1 Saad J Almalki,1 MR Alharthi,1 Mohamed S Mohamed,1 Mohamed F EL-Badawy2 1Department of Mathematics and Statistics, College of Science, Taif University, Taif, 21944, Saudi Arabia; 2Department of Microbiology and Immunology, Faculty of Pharmacy, University of Sadat City, Sadat City, 32958, EgyptCorrespondence: Mohamed F EL-BadawyDepartment of Microbiology and Immunology, Faculty of Pharmacy, University of Sadat City, Menoufia Governorate, Sadat City, 32958, EgyptTel +20-103-205-9964Email Mohamed.elbadawy@fop.usc.edu.egAbstract: Despite the wide medical knowledge about the direct role of many viruses in the pathogenesis of certain cancers, there is still ambiguity and hazy vision about the direct role of bacteria in cancer incidence. Understanding the role of bacteria in carcinogenesis is no longer a scientific luxury, but it has become an urgent and extremely important necessity to realize the pathogenesis of cancer caused by oncogenic bacteria as an attempt to overcome the oncogenic mechanisms exhibited by these oncogenic bacteria. This review shed the light on the indirect role of the host’s inflammatory and immunological responses in the pathogenesis of bacteria-induced cancer. Also, this review discussed the indirect role of the bacterial toxins and virulence factors in the induction of common gastrointestinal cancers, such as gallbladder cancer (GBC), colorectal cancer (CRC), and gastric cancer (GC). Finally, this review dealt with the debate about the possibility of bacterial DNA integration into the human genome and cancer incidence.Keywords: cancer, oncogenic bacteria, DNA, genome, gall bladder cancer

Radical surgery remains the primary treatment option for gall bladder cancer (GBC). Margin-negative liver resection is a critical component of radical cholecystectomy. Anatomical segment IVb and V resection is preferred in primary GBC with liver infiltration and incidental GBC patients with puckering of gall bladder (GB) bed. Despite the initial scepticism, minimally invasive radical cholecystectomy is recommended as a treatment option in selected GBC patients. However, anatomical Segment IVb and V resection using the minimally invasive approach is scarcely reported. The standardised technique of robotic (daVinci®XiTM) anatomical Segment IVb and V liver resection guided by indocyanine green fluorescence is described here. The systematic fluorescence-guided anatomical resection described in this report could facilitate minimally invasive Segment IVb and V resection with radical lymphadenectomy in selected patients with GBC. [ABSTRACT FROM AUTHOR]

Gallbladder cancer (GBC) is the most common type of biliary tract cancer. The GBC is often diagnosed at an advanced stage, which limits surgical intervention due to its aggressive nature, and as a consequence of its insensitivity to chemotherapy, more effective treatments are required. In GBC, the efficacy of chemotherapy combined with anti-PD-L1/VEGF inhibition remains to be clarified. The present case report describes successful treatment by toripalimab in combination with bevacizumab and gemcitabine in a patient with metastatic GBC and PD-L1 combined positive score (CPS) =30. After six courses of therapy, a partial response was observed in the patient's clinical condition. So far, her PFS has exceeded 15 months. To the best of our knowledge, there was no other case where toripalimab plus bevacizumab were used in combination with gemcitabine as an effective treatment strategy for GBC. The remarkable response is likely to be related to the positive expression of PD-L1. Further, VEGF inhibition in combination with chemotherapy may result in improved clinical outcomes due to increased antitumor immunity. Chemotherapy regimens combined with anti-PD-L1/VEGF inhibition are promising therapies for GBC. Further well-designed prospective clinical trials are needed in order to confirm the efficacy and safety of the three-drug regimen. [ABSTRACT FROM AUTHOR]

Aim: To study the feasibility of constant dose rate volumetric modulated arc therapy (CDR-VMAT) in radiotherapy for gallbladder cancer by comparing dosimetric parameter suggested by International Commission on Radiation Units and Measurements-83 (ICRU-83) with step and shoot intensity-modulated radiation therapy (SS IMRT). Methods: For this study, we selected 21 post-operative gallbladder cancer patients, which were treated with the IMRT technique from 2016 to 2019. For each patient, we generated SS IMRT plan and CDR-VMAT plan and were dosimetrically compared by parameters suggested by ICRU-83 for PTV. Homogeneity Index (HI) and Conformity Index (CI) were also calculated. For evaluation of Organ at Risk (OAR), we compared the mean doses, volume doses to the right kidney, left kidney, both kidneys combined, liver and max dose to the spinal cord. Monitor units (MUs) and treatment delivery time were also compared. Results: On comparing, we found that CDR-VMAT plans were highly conformed as CI and PCI (CI define by Paddick) were found more (0·98 ± 0·01 vs. 0·97 ± 0·03 and 0·86 ± 0·05 vs. 0·85 ± 0·05) than IMRT plans but not statistically significant. Better dose HI was found for IMRT plans with statistical significant difference (p < 0·001). The tumour coverage was found similar 98·24% and 97·83% for SS IMRT and CDR-VMAT, respectively. For D2%, the maximum dose to PTV was significantly lower in IMRT (p = 0·001). D50% and mean dose to PTV were also comparable to IMRT with no statistically significant difference. The OAR parameters were comparable in both the techniques. The mean doses and volume doses V10, V20 and V30 to the right kidney, left kidney and liver were also comparable with no significant difference (p > 0·05) was noted among them. However, the maximum dose to the spinal cord was significantly less in CDR-VMAT (21·1 Gy vs. 25·1Gy) than SS IMRT with p = 0·006. More MUs were associated with the CDR-VMAT technique, but shorter treatment delivery time than the IMRT technique. Conclusions: On dosimetric comparison of two treatment techniques, we conclude that CDR-VMAT can be a valid option in radiotherapy as it achieved highly conformed dose distribution, comparable tumour coverage and OAR sparing as IMRT technique for gallbladder cancer. [ABSTRACT FROM AUTHOR]

Simple Summary: Cancers from the bile ducts and gall bladder are lethal. Cure by surgery is not possible in most of these tumors as they are often identified in later stages. Unlike other cancers, they have few chemotherapy treatment options. Multiple clinical trials in the past decade failed and could not replace the combination of two drugs, gemcitabine and cisplatin, as the preferred drug in new cases. Patients who fail to respond to this combination do not have reliable treatment options. The success of therapy directed at a specific genetic change (mutation) and activating the patient's immune system (alone or in combination with chemotherapy) are encouraging. If we follow the current trials, the focus is on these newer treatments, with there being a high chance they may replace traditional chemotherapy in the future. Biliary tract cancers (BTC) are often diagnosed at advanced stages and have a grave outcome due to limited systemic options. Gemcitabine and cisplatin combination (GC) has been the first-line standard for more than a decade. Second-line chemotherapy (CT) options are limited. Targeted therapy or TT (fibroblast growth factor 2 inhibitors or FGFR2, isocitrate dehydrogenase 1 or IDH-1, and neurotrophic tyrosine receptor kinase or NTRK gene fusions inhibitors) have had reasonable success, but <5% of total BTC patients are eligible for them. The use of immune checkpoint inhibitors (ICI) such as pembrolizumab is restricted to microsatellite instability high (MSI-H) patients in the first line. The success of the TOPAZ-1 trial (GC plus durvalumab) is promising, with numerous trials underway that might soon bring targeted therapy (pemigatinib and infrigatinib) and ICI combinations (with CT or TT in microsatellite stable cancers) in the first line. Newer targets and newer agents for established targets are being investigated, and this may change the BTC management landscape in the coming years from traditional CT to individualized therapy (TT) or ICI-centered combinations. The latter group may occupy major space in BTC management due to the paucity of targetable mutations and a greater toxicity profile. [ABSTRACT FROM AUTHOR]

Hepatopancreatoduodenectomy (HPD) can offer a survival advantage in selected patients with locally advanced gall bladder cancer (GBC). While the safety and feasibility of minimally invasive radical cholecystectomy have been recently documented, laparoscopic HPD for GBC has not been previously reported. A 73-year-old male with GBC infiltrating the bile duct underwent laparoscopic HPD to achieve R0 resection. The patient had an uneventful post-operative course except for delayed gastric emptying that improved with conservative management. The feasibility of laparoscopic HPD for locally advanced GBC reported in the present case needs to be documented in a large case series.

Abstract Background Role of tumor markers in gall bladder carcinoma (GBC) is not well established. We evaluated the prognostic value of carbohydrate antigen 19–9 (CA19–9) and carcinoma embryonic antigen (CEA) in patients with GBC. Methods Of the 225 patients of GBC enrolled,176 patients were included in the study (excluded 49 patients with jaundice). Patients were divided into 3 groups; resectable n = 92, unresectable n = 17, metastatic n = 67. The clinico-pathological characteristics, tumor markers and survival data were analysed. The cutoff values of CA19–9 & CEA for predicting metastases were computed using receiver operating characteristic curve. Kaplan Meir survival and Cox regression analysis were done for factors predicting survival and recurrence. Results The median value of Ca19–9 was significantly higher in metastatic group [resectable: 21.3, unresectable: 53.9 and metastatic: 79; p 4 (p = 0.041), Ca19.9 > 37 (p = 0.019), T3/T4 (p = 0.001), node positive (p = 0.001) and presence of perineural invasion (p = 0.001). However, on multivariate analysis, only Ca19.9 > 37 predicted recurrence (p = 0.002, HR 5.8). Conclusions Raised CA19.9 and CEA predict metastatic disease in patients with GBC without jaundice with a high specificity and may help in prognostication of the patient. CA19–9 was better than CEA in prediction of tumor burden and in predicting recurrence.

Aim: Biliary tract carcinoma (BTC), including gall bladder carcinoma (GBC) and biliary duct carcinoma (BDC), has a poor prognosis. Comprehensive genomic profiling has important roles in evaluation of the carcinogenesis of BTC. Materials & methods: We examined somatic copy number alterations (SCNAs) using a single nucleotide polymorphism array system to analyze 36 BTC samples (11 GBCs and 25 BDCs). Results: In hierarchical cluster analysis, two clusters were identified (subgroup 1 with low SCNAs and subgroup 2 with high SCNAs). GBC was predominant in subgroup 1, whereas BDC was predominant in subgroup 2, suggesting that GBC and BDC had different genetic backgrounds in terms of SCNAs. Conclusion: These findings could be helpful for establishing the molecular carcinogenesis of BTCs.

Extensive surgery is the mainstay treatment for gallbladder cancer and offers a long-term survival benefits to the patients. However, the optimal extent of surgery remains debatable. We aimed to perform a meta-analysis of hepatectomy and no hepatectomy approaches in patients with T2 gallbladder cancer. We searched the following electronic databases for systematic literature: PubMed, Google Scholar, and the Cochrane Library. We selected studies that compared patients with T2 gallbladder cancer who underwent hepatectomy with those who did not. While the long-term overall survival (OS) and disease-free survival (DFS) were the primary outcomes, perioperative morbidity and mortality were the secondary outcome. We analysed over 18 studies with 4,587 patients. Of the total patients, 1,683 and 1,303 patients underwent hepatectomy and no hepatectomy, respectively. The meta-analysis revealed no significant difference between the hepatectomy and no hepatectomy groups, in terms of the overall morbidity (risk ratio [RR] = 1.85, 95% confidence interval [CI] = 0.66–5.20) and 30-day mortality (RR = 0.9, 95% CI = 0.1–8.2). The results were comparable in terms of the OS (RR = 0.76, 95% CI = 0.57–1.01), (HR = 0.74, 95% CI = 0.49–1.12), and DFS (RR = 0.99, 95% CI = 0.88–1.11). In conclusion, the perioperative and long-term outcomes of hepatectomy and no hepatectomy approaches were comparable. Hepatectomy may not be required in T2 gall bladder cancer if the preoperative evaluation confirms the depth of the tumour in the perimuscular connective tissue and the intraoperative frozen sections confirm microscopic negative margins. Likewise, for those whom gall bladder cancer was diagnosed from the pathological report after simple cholecystectomy, further hepatectomy may not necessary. [ABSTRACT FROM AUTHOR]

Introduction: Percutaneous Transhepatic Biliary Drainage (PTBD) is a minimally invasive procedure to palliate the biliary obstruction caused by unresectable malignancy. Aim and Objectives: To analyze the outcome of PTBD in patients of unresectable gall bladder cancer presenting with obstructive jaundice in terms of reduction in serum bilirubin levels, symptomatic improvement, and overall survival (OS) at 4 weeks and 12 weeks following the procedure. Materials and Methods: In this retrospective study, PTBD was attempted on 30 patients diagnosed with inoperable gall bladder cancer. Various patient and procedurerelated variables were analyzed and recorded both pre and post-PTBD. Outcome data on OS was collected at 4 weeks and 12 weeks. Results: Technical success was achieved in 29 (99.66%) patients. The mean fall in the serum bilirubin at the 7th post-procedural day was 41.5% after the successful PTBD. The most common complication in our study was cholangitis noted in six (21%) patients. OS at 4 weeks and 12 weeks was 79% and 41%, respectively. Conclusion: Younger age and good performance status favored better survival rate in our study. [ABSTRACT FROM AUTHOR]

Aim of doing this review was to give a uniform consensus on prognostic impact of tumor location (hepatic vs peritoneal), liver resection and adjuvant chemotherapy in gall bladder cancer and, to compare them with previous well-studied factors of survival. We systematically review PubMed, Scopus and Cochrane for relevant articles with no date restrictions, language was restricted to English. Those articles were included that had provided Hazard ratio (HR) of survival for T2 gall bladder cancer. We identified nine retrospective studies published between 2014 and 2020 with 2345 patients. Meta-analysis showed that T2b (hepatic) cancers had higher odds of mortality (HR 3.16 [2.11, 4.74], I2 = 0%). Liver resection was associated with significantly higher odds of 5-year overall survival only in T2b (2.20 [1.33, 3.63], I2 = 67%), adjuvant chemotherapy was not associated with any significant decrease in mortality risk (0.98 [0.83–1.16]. I2 = 20%). Hepatic sided gall bladder tumors carry higher odds for mortality and recurrence. T2a tumors can be managed without hepatic resection. To risk stratify patients we also formulated a scoring system for mortality risk. [ABSTRACT FROM AUTHOR]

Gall bladder cancer (GBC) is an aggressive and most common malignancy of biliary tract lacking effective treatment due to unavailability of suitable biomarkers and therapeutics. SMAD4 is an essential mediator of transforming growth factor-β pathway involved in various cellular processes like growth, differentiation and apoptosis and also recognized as therapeutic target for GBC and other gastrointestinal tract cancers. In the present study, 3D structure of SMAD4 mutants was optimized through molecular dynamics simulation (MDS) along with wildtype. Furthermore, binding site of protein was predicted through hybrid approach and structural based virtual screening against two drug libraries was performed followed by docking. MDS of top docking score protein–ligand complexes were carried, and binding free energy was rescored. Two potential inhibitors, namely ZINC2098840 and ZINC8789167, were screened that displayed higher binding affinity towards mutant proteins compared with wildtype and both hydrophilic as well as hydrophobic interactions play a crucial role during protein–ligand binding. Current study identified novel and potent inhibitors of SMAD4 mutant that could be used as a drug candidate for the development of personalized medicine for gall bladder and other associated cancers. [ABSTRACT FROM AUTHOR]

Abstract Background Gall bladder cancer (GBC) is associated with abdominal pain, lump, nausea, vomiting, and jaundice due to either gall bladder mass or the involved adjacent peritoneal structures. Gall bladder cancer presenting as refractory epilepsy is rare. Here we report a young female GBC patient who presented with an atypical and refractory frontal lobe seizures as the first manifestation of gall bladder cancer. Case presentation A 46 years young female presented first time to the hospital with uncontrolled seizures and headache in 5 months duration. Seizures were very atypical in semiology with ptosis and mydriasis to either side along with ipsilateral ocular deviation. The episodes were bilateral but right eyelid ptosis, mydriasis and right horizontal conjugate deviation were frequent. MRI brain showed encephalomalacia in the left frontal region on axial T2 and coronal T1 weighted images without any enhancement on gadolinium contrast. CECT abdomen revealed a heterogeneously enhancing gall bladder mass with the evidence of lung metastasis from chest CT scan. CSF for malignant cytology was negative. Seizures were refractory to the treatment. Conclusion Though CNS involvement is uncommon but it can be the only presentation in gall bladder cancer.

Hepatopancreatoduodenectomy (HPD) can offer a survival advantage in selected patients with locally advanced gall bladder cancer (GBC). While the safety and feasibility of minimally invasive radical cholecystectomy have been recently documented, laparoscopic HPD for GBC has not been previously reported. A 73-year-old male with GBC infiltrating the bile duct underwent laparoscopic HPD to achieve R0 resection. The patient had an uneventful post-operative course except for delayed gastric emptying that improved with conservative management. The feasibility of laparoscopic HPD for locally advanced GBC reported in the present case needs to be documented in a large case series. [ABSTRACT FROM AUTHOR]

Background: Few studies have focused on the risk factors for dysfunction of endoscopic biliary drainage (EBD) in preoperative patients with malignant hilar biliary obstruction (MHBO). Methods: We searched the database between February 2011 and December 2018 and identified patients with MHBO who underwent radical operation. The rate of dysfunction of the initial EBD, risk factors for dysfunction of the initial EBD and survival after surgery were retrospectively evaluated. Results: We analyzed a total of 131 patients [95 males (72.5%); mean age, 69.5 (±7.3) years; Bismuth‐Corlette classification (BC) I/II/IIIa/IIIb/IV, 50/26/22/17/16; hilar cholangiocarcinoma/gall bladder cancer, 115/16]. Dysfunction of the initial EBD occurred in 28 patients (21.4%). The cumulative incidences of dysfunction of the initial EBD in all patients were 18.4%, 38.2% and 47.0% at 30, 60 and 90 days, respectively (Kaplan–Meier method). The rate of dysfunction of the initial EBD increased in patients with BC‐IV (P =.03). Multivariate analysis showed that BC‐IV and pre‐EBD cholangitis were significantly associated with the occurrence of dysfunction of the initial EBD. Survival rates were not significantly different according to the initial biliary drainage methods and presence/absence of the initial EBD dysfunction. Conclusions: Dysfunction of the initial EBD frequently occurs in patients with the BC‐IV and those with pre‐EBD cholangitis. [ABSTRACT FROM AUTHOR]

Only few retrospective studies have looked into the ability of PET-CT to diagnose distant metastases in gall bladder cancer (GBC) patients with variable results. This study aims to determine the utility of PET –CT in potentially resectable GBC. All GBC patients with resectable disease on CECT chest, abdomen & pelvis were subjected to FDG- PET-CT scan. Incidental GBC was excluded. All additional findings and change in management plan was recorded. Out of 149 patients, 99 (66.4%) were females and the mean age was 56.7 ± 11.0 years,. After PET scan, additional findings were seen in 46/149 (30.9%) patients and it lead to change in management plan in 35 (23.4%) patients due to the presence of distant metastases. Impact of PET scan in changing the stage was higher in patients having node positive disease on CECT (26/96, 27%) as compared to node negative patients (9/53, 16.9%), but this difference was not statistically significant (p = 0.233). After assessment on CECT, 76 patients were planned for NACT in view of locally advanced disease but after PET-CT in these patients, the management plan changed to palliative chemotherapy in 26 (34.2%) cases whereas it changed in only 9 out of 73 (12.3%) patients who were planned for upfront surgery (p = 0.003). Our results show that preoperative staging workup for GBC should include PET-CT as it changed the management plan in approximately one-fourth of all resectable GBC patients and in one-third of locally advanced cases. [ABSTRACT FROM AUTHOR]

Opinion Statement: The standard of care first-line therapy for patients with advanced biliary tract cancers eligible for treatment continues to be the combination of gemcitabine and cisplatin. Based on the promising results of a phase II study, an ongoing multi-institutional phase III study is assessing the benefit of adding nab-paclitaxel to the chemotherapy doublet, and appropriate patients should be considered for enrollment at participating centers. We would recommend early comprehensive genomic profiling of patients' tumors to identify potentially targetable aberrations with available therapies. Results with therapeutic implications include tumors with microsatellite instability/deficient mismatch repair, alterations in FGFR, IDH1/2, and HER-2, and potentially other molecular vulnerabilities. Patients in whom a targetable genomic abnormality is found should be matched with appropriate agent. If a targetable fusion or mutation is not detected, patients eligible for second-line therapy should be considered for either clinical trial enrollment or a second-line cytotoxic chemotherapy regimen such as modified FOLFOX. Strategies incorporating immunotherapy into the treatment of patients with microsatellite stable advanced biliary tract cancers have yielded largely disappointing results thus far, and routine use of checkpoint inhibitors outside of a clinical trial is not recommended. [ABSTRACT FROM AUTHOR]

Abstract Background The prognosis of advanced (stage IV) cancer of the digestive organs is very poor. We have previously reported a case of advanced breast cancer with bone metastasis that was successfully treated with combined treatments including autologous formalin-fixed tumor vaccine (AFTV). Herein, we report the success of this approach in advanced stage IV (heavily metastasized) cases of gall bladder cancer and colon cancer. Case presentation Case 1: A 61-year-old woman with stage IV gall bladder cancer (liver metastasis and lymph node metastasis) underwent surgery in May 2011, including partial resection of the liver. She was treated with AFTV as the first-line adjuvant therapy, followed by conventional chemotherapy. This patient is still alive without any recurrence, as confirmed with computed tomography, for more than 5 years. Case 2: A 64-year-old man with stage IV colon cancer (multiple para-aortic lymph node metastases and direct abdominal wall invasion) underwent non-curative surgery in May 2006. Following conventional chemotherapy, two courses of AFTV and radiation therapy were administered sequentially. This patient has had no recurrence for more than 5 years. Conclusion We report the success of combination therapy including AFTV in cases of liver-metastasized gall bladder cancer and abdominal wall-metastasized colon cancer. Both patients experienced long-lasting, complete remission. Therefore, combination therapies including AFTV should be considered in patients with advanced cancer of the digestive organs.

Background: Carcinoma of the gall bladder (GB) is the most common malignancy of the gastrointestinal tract. One percent of cholecystectomy specimens show incidental gall bladder cancers (GBCs).Aim: Our aim of the study to was evaluate the utility of routine histopathology of cholecystectomy specimens removed with a diagnosis of gall bladder diseases (GBD).Materials and Methods: A retrospective study was done reviewing the histopathological records of 906 patients who underwent cholecystectomy. Demographic details, gross findings, and microscopic findings noted. All the cases were categorized into two groups, A and B. Group A included the cases with any gross abnormality including wall thickness ≥4 mm and group B included rest of the cases.Results: Majority of the patients were in the age group of 31-40 years of age. Out of 906 patients studied, majority of them were females with F:M ratio of 6.14:1. Of the 47 cases which were included in group A (with macroscopic abnormality), six cases had gall bladder carcinoma on microscopy. One case from group B with macroscopically normal-appearing GB had invasive carcinoma on microscopy. In our study, we found a sensitivity of 85.71% and specificity of 95.44%, while positive predictive value (PPV) was 91.11% and negative predictive value (NPV) was 99.65% of macroscopic abnormality in the diagnosis of invasive carcinoma.Conclusion: All cholecystectomy specimens must be examined by histopathologists who must decide whether processing for microscopy is needed. Microscopic examination may be reserved for the specimen with a macroscopic lesion. This will result in a reduction of costs and pathology workload without compromising patient management. [ABSTRACT FROM AUTHOR]

Background: Management of operable gall bladder cancer (GBC) is closely related to its tumor (T) and nodal (N) status. The magnitude of benefit with adjuvant chemotherapy in completely resected, node negative T2 cancers is not completely defined.Materials and Methods: Retrospective analysis of patients diagnosed with pathological T2N0 (stage II, 7th edition AJCC) GBCs from January 2011 to June 2016 was evaluated for adverse risk factors, adjuvant treatment received, recurrence-free survival (RFS), and overall survival (OS). Survival analysis was done using Kaplan-Meier and Cox regression tools.Results: Of the 88 patients included, 30 received adjuvant chemotherapy while 58 were observed. The OS and RFS in the entire cohort were 82.9% and 62.7%, respectively, at a median follow-up of 44.18 months. The OS and RFS in the chemotherapy group were 85.1% and 76.4% while it was 81.4% and 55.5% in the observation group (p = 0.50). Recurrent disease was seen in 30.7%.The presence of lymphovascular invasion predicted inferior RFS (p = 0.031).Conclusions: Adjuvant chemotherapy may reduce distant failure rates but did not improve OS in completely resected T2N0 GBC patients in this study. LVI predicted inferior RFS in T2N0 patients. An evaluation of adverse prognostic factors would help design personalized treatment strategies for this select cohort of T2N0 GBC. [ABSTRACT FROM AUTHOR]

Background: Gall bladder cancer (GBC) is associated with abdominal pain, lump, nausea, vomiting, and jaundice due to either gall bladder mass or the involved adjacent peritoneal structures. Gall bladder cancer presenting as refractory epilepsy is rare. Here we report a young female GBC patient who presented with an atypical and refractory frontal lobe seizures as the first manifestation of gall bladder cancer.Case Presentation: A 46 years young female presented first time to the hospital with uncontrolled seizures and headache in 5 months duration. Seizures were very atypical in semiology with ptosis and mydriasis to either side along with ipsilateral ocular deviation. The episodes were bilateral but right eyelid ptosis, mydriasis and right horizontal conjugate deviation were frequent. MRI brain showed encephalomalacia in the left frontal region on axial T2 and coronal T1 weighted images without any enhancement on gadolinium contrast. CECT abdomen revealed a heterogeneously enhancing gall bladder mass with the evidence of lung metastasis from chest CT scan. CSF for malignant cytology was negative. Seizures were refractory to the treatment.Conclusion: Though CNS involvement is uncommon but it can be the only presentation in gall bladder cancer. [ABSTRACT FROM AUTHOR]

Hepatic infarction is known as a rare disease entity in nontransplant patients. Although a few cases of hepatic infarction have been reported to be linked with invasive procedures, trauma, and hypercoagulability, a case of spontaneous hepatic infarction in a nontransplanted patient has hardly ever been reported. However, many clinical situations of patients with cancer, in particular biliary cancer, can predispose nontransplant patients to hepatic infarction. Besides, the clinical outcome of hepatic infarction in patients with cancer can be worse than in patients with other etiologies. As for treatment, anticoagulation treatment is usually recommended. However, because of its multifactorial etiology and combined complications, treatment of hepatic infarction is difficult and not simple. Herein, we report a case of fatal hepatic infarction that occurred spontaneously during the course of treatment in a patient with gallbladder cancer. Hepatic infarction should be considered as a possible fatal complication in patients during treatment of biliary malignancies.