European Radiology

, Volume 29, Issue 12, pp 6458–6468 | Cite as

Preoperative CT findings for prediction of resectability in patients with gallbladder cancer

  • Seo-Youn Choi
  • Jung Hoon KimEmail author
  • Hyun Jeong Park
  • Joon Koo Han



To predict residual tumor (R) classification in patients with a surgery for gallbladder (GB) cancer, using preoperative CT.


One hundred seventy-three patients with GB cancer who underwent CT and subsequent surgery were included. Two radiologists assessed CT findings, including tumor morphology, location, T stage, adjacent organ invasion, hepatic artery (HA) invasion, portal vein invasion, lymph node metastasis, metastasis, resectability, gallstone, and combined cholecystitis. The R classification was categorized as no residual tumor (R0) and residual tumor (R1 or R2). We analyzed the correlation between CT findings and R classification. We also followed up the patients as long as five years and analyzed the relationship between the R classification and the overall survival (OS).


There were 134 patients with R0 and 39 patients with R1/R2. On multivariable analysis, liver invasion (Exp(B) = 3.19, p = 0.010), bile duct invasion (Exp(B) = 3.69, p = 0.031), and HA invasion (Exp(B) = 3.74, p = 0.039) were independent, significant predictors for residual tumor. When two of these three criteria were combined, the accuracy for predicting a positive resection margin was 83.38% with a specificity of 93.28%. The OS and the median patient survival time differed significantly according to the resection margin, i.e., 56.0% and 134.4 months in the R0 resection and 5.1% and 10.8 months in the R1/R2 resection group (p < 0.001).


Preoperative CT findings could aid in planning surgery and determining the resectability using the high-risk findings of residual tumor, including liver invasion, bile duct invasion, and HA invasion.

Key Points

• Liver invasion, bile duct invasion, and HA invasion were significant preoperative CT predictors for residual tumor in GB cancer.

• HA invasion showed the highest OR on multivariate analysis and the highest predictor point on a nomogram for predicting a positive resection margin.

• Association of two factors can predict positive resection margin with an accuracy of 83.38% and a specificity of 93.28%.


Gallbladder Neoplasm Multidetector computed tomography Residual tumor Survival 



American Joint Committee on Cancer


Confidence interval


Computed tomography




Hepatic artery


Hazard ratio


Lymph node


Negative likelihood ratio


Positive likelihood ratio


Negative predictive value


Overall survival


Positive predictive value


Standard deviation



We would like to thank Bonnie Hami, MA (USA), for her editorial assistance in the preparation of this manuscript.


The authors state that this work has not received any funding.

Compliance with ethical standards


The scientific guarantor of this publication is Joon Koo Han, M.D.

Conflict of interest

The authors declare that they have no competing interests.

Statistics and biometry

Seo-Youn, Choi, M.D., has significant statistical expertise and no complex statistical methods were necessary for this paper.

Informed consent

Written informed consent was waived by the Institutional Review Board.

Ethical approval

Institutional Review Board approval was obtained (IRB No. 1702-010-829).


• Retrospective

• Diagnostic or prognostic study

• Performed at one institution


  1. 1.
    Mekeel KL, Hemming AW (2007) Surgical management of gallbladder carcinoma: a review. J Gastrointest Surg 11:1188–1193CrossRefGoogle Scholar
  2. 2.
    Löhe F, Meimarakis G, Schauer C, Angele M, Jauch KW, Schauer RJ (2009) The time of diagnosis impacts surgical management but not the outcome of patients with gallbladder carcinoma. Eur J Med Res 14:345–351PubMedPubMedCentralGoogle Scholar
  3. 3.
    Takada T, Amano H, Yasuda H et al (2002) Is postoperative adjuvant chemotherapy useful for gallbladder carcinoma? A phase III multicenter prospective randomized controlled trial in patients with resected pancreaticobiliary carcinoma. Cancer 95:1685–1695CrossRefGoogle Scholar
  4. 4.
    Miyazaki M, Itoh H, Ambiru S et al (1996) Radical surgery for advanced gallbladder carcinoma. Br J Surg 83:478–481CrossRefGoogle Scholar
  5. 5.
    Creasy JM, Goldman DA, Dudeja V et al (2017) Systemic chemotherapy combined with resection for locally advanced gallbladder carcinoma: surgical and survival outcomes. J Am Coll Surg 224:906–916CrossRefGoogle Scholar
  6. 6.
    Wakai T, Shirai Y, Tsuchiya Y, Nomura T, Akazawa K, Hatakeyama K (2008) Combined major hepatectomy and pancreaticoduodenectomy for locally advanced biliary carcinoma: long-term results. World J Surg 32:1067–1074CrossRefGoogle Scholar
  7. 7.
    Agarwal AK, Mandal S, Singh S, Sakhuja P, Puri S (2007) Gallbladder cancer with duodenal infiltration: is it still resectable? J Gastrointest Surg 11:1722–1727CrossRefGoogle Scholar
  8. 8.
    Mishra PK, Saluja SS, Prithiviraj N, Varshney V, Goel N, Patil N (2017) Predictors of curative resection and long term survival of gallbladder cancer - a retrospective analysis. Am J Surg 214:278–286CrossRefGoogle Scholar
  9. 9.
    Creasy JM, Goldman DA, Gonen M et al (2017) Predicting residual disease in incidental gallbladder cancer: risk stratification for modified treatment strategies. J Gastrointest Surg 21:1254–1261CrossRefGoogle Scholar
  10. 10.
    Liang JL, Chen MC, Huang HY et al (2009) Gallbladder carcinoma manifesting as acute cholecystitis: clinical and computed tomographic features. Surgery 146:861–868Google Scholar
  11. 11.
    Chen FM, Ni JM, Zhang ZY, Zhang L, Li B, Jiang CJ (2016) Presurgical evaluation of pancreatic cancer: a comprehensive imaging comparison of CT versus MRI. AJR Am J Roentgenol 206:526–535CrossRefGoogle Scholar
  12. 12.
    Tamburrino D, Riviere D, Yaghoobi M, Davidson BR, Gurusamy KS (2016) Diagnostic accuracy of different imaging modalities following computed tomography (CT) scanning for assessing the resectability with curative intent in pancreatic and periampullary cancer. Cochrane Database Syst Rev 9:CD011515PubMedGoogle Scholar
  13. 13.
    Menassel B, Duclos A, Passot G et al (2016) Preoperative CT and MRI prediction of non-resectability in patients treated for pseudomyxoma peritonei from mucinous appendiceal neoplasms. Eur J Surg Oncol 42:558–566CrossRefGoogle Scholar
  14. 14.
    Kumaran V, Gulati S, Paul B, Pande K, Sahni P, Chattopadhyay K (2002) The role of dual-phase helical CT in assessing resectability of carcinoma of the gallbladder. Eur Radiol 12:1993–1999CrossRefGoogle Scholar
  15. 15.
    Li B, Xu XX, Du Y et al (2013) Computed tomography for assessing resectability of gallbladder carcinoma: a systematic review and meta-analysis. Clin Imaging 37:327–333CrossRefGoogle Scholar
  16. 16.
    Al-Hawary MM, Francis IR, Chari ST et al (2014) Pancreatic ductal adenocarcinoma radiology reporting template: consensus statement of the Society of Abdominal Radiology and the American Pancreatic Association. Radiology 270:248–260CrossRefGoogle Scholar
  17. 17.
    Tamm EP, Balachandran A, Bhosale PR et al (2012) Imaging of pancreatic adenocarcinoma: update on staging/resectability. Radiol Clin North Am 50:407–428CrossRefGoogle Scholar
  18. 18.
    Simel DL, Samsa GP, Matchar DB (1991) Likelihood ratios with confidence: sample size estimation for diagnostic test studies. J Clin Epidemiol 44:763–770CrossRefGoogle Scholar
  19. 19.
    Shimizu H, Kimura F, Yoshidome H et al (2007) Aggressive surgical approach for stage IV gallbladder carcinoma based on Japanese Society of Biliary Surgery classification. J Hepatobiliary Pancreat Surg 14:358–365CrossRefGoogle Scholar
  20. 20.
    Kobayashi A, Oda T, Fukunaga K, Sasaki R, Ohkohchi N (2012) Invasion of the hepatic artery is a crucial predictor of poor outcomes in gallbladder carcinoma. World J Surg 36:645–650CrossRefGoogle Scholar
  21. 21.
    Zaky AM, Wolfgang CL, Weiss MJ, Javed AA, Fishman EK, Zaheer A (2017) Tumor-vessel relationships in pancreatic ductal adenocarcinoma at multidetector CT: different classification systems and their influence on treatment planning. Radiographics 37:93–112CrossRefGoogle Scholar
  22. 22.
    Buchs NC, Chilcott M, Poletti PA, Buhler LH, Morel P (2010) Vascular invasion in pancreatic cancer: imaging modalities, preoperative diagnosis and surgical management. World J Gastroenterol 16:818–831CrossRefGoogle Scholar
  23. 23.
    Amin MB, Edge S, Greene F et al (2017) AJCC cancer staging manual, 8th edn. Springer International Publishing, New York, NYCrossRefGoogle Scholar
  24. 24.
    Miura F, Sano K, Amano H, Watanabe T, Takada T, Matsubara H (2012) Gallbladder cancer involving the extrahepatic bile duct. Ann Surg 255:e20CrossRefGoogle Scholar
  25. 25.
    Nishio H, Ebata T, Yokoyama Y, Igami T, Sugawara G, Nagino M (2011) Gallbladder cancer involving the extrahepatic bile duct is worthy of resection. Ann Surg 253:953–960CrossRefGoogle Scholar
  26. 26.
    Hawkins WG, DeMatteo RP, Jarnagin WR, Ben-Porat L, Blumgart LH, Fong Y (2004) Jaundice predicts advanced disease and early mortality in patients with gallbladder cancer. Ann Surg Oncol 11:310–315CrossRefGoogle Scholar
  27. 27.
    Regimbeau JM, Fuks D, Bachellier P et al (2011) Prognostic value of jaundice in patients with gallbladder cancer by the AFC-GBC-2009 study group. Eur J Surg Oncol 37:505–512CrossRefGoogle Scholar
  28. 28.
    D'Angelica M, Dalal KM, DeMatteo RP, Fong Y, Blumgart LH, Jarnagin WR (2009) Analysis of the extent of resection for adenocarcinoma of the gallbladder. Ann Surg Oncol 16:806–816CrossRefGoogle Scholar
  29. 29.
    Higuchi R, Ota T, Araida T et al (2014) Surgical approaches to advanced gallbladder cancer: a 40-year single-institution study of prognostic factors and resectability. Ann Surg Oncol 21:4308–4316CrossRefGoogle Scholar
  30. 30.
    Balachandran P, Agarwal S, Krishnani N et al (2006) Predictors of long-term survival in patients with gallbladder cancer. J Gastrointest Surg 10:848–854CrossRefGoogle Scholar
  31. 31.
    Min JH, Kang TW, Cha DI et al (2019) Apparent diffusion coefficient as a potential marker for tumour differentiation, staging and long-term clinical outcomes in gallbladder cancer. Eur Radiol 29:411–421CrossRefGoogle Scholar
  32. 32.
    Kang MJ, Song Y, Jang JY, Han IW, Kim SW (2012) Role of radical surgery in patients with stage IV gallbladder cancer. HPB (Oxford) 14:805–811CrossRefGoogle Scholar
  33. 33.
    Araida T, Higuchi R, Hamano M et al (2009) Hepatic resection in 485 R0 pT2 and pT3 cases of advanced carcinoma of the gallbladder: results of a Japanese Society of Biliary Surgery survey--a multicenter study. J Hepatobiliary Pancreat Surg 16:204–215CrossRefGoogle Scholar
  34. 34.
    Pilgrim CH, Groeschl RT, Turaga KK, Gamblin TC (2013) Key factors influencing prognosis in relation to gallbladder cancer. Dig Dis Sci 58:2455–2462CrossRefGoogle Scholar
  35. 35.
    Chaudhari VA, Ostwal V, Patkar S et al (2018) Outcome of neoadjuvant chemotherapy in “locally advanced/borderline resectable” gallbladder cancer: the need to define indications. HPB (Oxford) 20:841–847Google Scholar

Copyright information

© European Society of Radiology 2019

Authors and Affiliations

  1. 1.Department of Radiology, Soonchunhyang University College of MedicineBucheon HospitalBucheonRepublic of Korea
  2. 2.Department of RadiologySeoul National University HospitalSeoulRepublic of Korea
  3. 3.Department of RadiologySeoul National University College of MedicineSeoulRepublic of Korea
  4. 4.Institute of Radiation MedicineSeoul National University Medical Research CenterSeoulRepublic of Korea
  5. 5.Department of Radiology, Chung-Ang University HospitalChung-Ang University College of MedicineSeoulRepublic of Korea

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