LAUSR

Editor Kwon et al reported the “Role of tumour location and surgical extent on prognosis in T2 gallbladder cancer: an international multicentre study”1. Authors concluded lack of impact of tumour location (T2) on disease free survival (DFS) and extended cholecystectomy (EC) should be performed in all T2 gall bladder carcinomas (GBC). But, there are concerns between the results obtained and conclusions made. First, overall significant 5-year DFS between T2a and T2b tumours (P = 0⋅028) became null when subgroup analysis was done in lymph node (L.N.) positive and negative patients. This discrimination might be due to the exclusion of significant number Nx L.N. (∼13%) or confounding factors like adjuvant therapy (P = 0⋅016). Further, Figure 2b looks erroneous as it depicts that T2b has better survival than T2a whether in presence or absence of L.N. positivity and also not matches with detailed data. Second, in T2a disease, 5 year DFS was similar between simple and extended cholecystectomy (P = 0⋅094). Yet in discussion, it was mentioned as significant and concluded that EC should be performed in all T2a diseases. Third, some confounding factors were present in T2a/T2b analysis. R1 resections were not excluded from comparison, as R0 status is one of the important factor for DFS2. Next, nearly one-fifth of the patients in T2b underwent simple cholecystectomy, (without lymphadenectomy) which is insufficient for this stage, needs justification. As mentioned nodal status is more important than T stage, then while comparing simple and extended cholecystectomy in T2b lesions, why Nx category was not excluded. Fourth, premise of this study was from the analysis by Shindoh et al3. They reported higher 5 yr survival in T2a GBC. On other hand, Lee H et al showed laparoscopic cholecystectomy with lymphadenectomy in subset of T2a patients is adequate4. So survival analysis for EC (including lymphadenectomy) with and without liver resection must be done before final conclusion. In the last, latest AJCC staging emphasizes the need for minimum 6 L.Ns. retrieval for accurate staging5. This aspect needed emphasis as patients with inadequate L.N. retrieval might have created higher false positive or negatives rates in analysis.