Gall bladder carcinoma as a whole

1. CARCINOMA GALLBLADDER
Moderator: Dr M Talukdar (Assoc Professor, Dept of Surgery)
Presenter: Dr Monitosh Paul, PGT Surgery
Silchar Medical College

2. Outline:
 Relevant anatomy
 Epidemiology
 Etiology / Pathogenesis
 Presentation
 Workup
 Treatment
 Follow Up

3. Embryology
• Liver primordium begins to form in 3rd week of IUL from caudal end of
foregut.
• It elongates cranially and gives a small bud on right side-”pars cystica”
and the main part gives rise to “pars hepatica”.
• From pars cystica gall bladder and cystic duct are formed.
• Initially extra hepatic biliary apparatus is occluded with endodermal cells
which gets canalized in later period.

5. Relevant anatomy
Gall bladder:
• It is a Pear shaped
• 7.5-12 cm length
• Capacity- 30-60 ml
• Parts: Fundus, body, infundibulum, neck
Cystic duct: 3cm long, lumen 1-3mm
• Runs downwards, backwards and to the left
• Ends by joining CHD at an acute angle to
become CBD.
• Right and left hepatic duct joins to form-
common hepatic duct(<2.5 cm long)

6. • Hartmann’s pouch: Out pouching of wall of GB at the junction of neck and cystic duct
• Mucus membrane indentations of mucosa of the gall bladder- crypts of Luschka
• Mucous membrane of the cystic duct forms a series of crescentic folds arranged
spirally- Valve of Heister
• Sphincter structure around the cystic duct- Sphincter of Lutkens

7. Common Bile Duct- around 7.5 cm
long
Parts:
i. Supraduodenal
ii. Retrodoudenal
iii. Infradoudenal
iv. Intraduodenal
Enters the 2nd part of duodenum at
Ampulla of Vater. It is surrounded by
Sphincter of Oddi complex

8. Blood Supply
Arterial
• Cystic artery- gall bladder, cystic duct, hepatic
ducts, and upper part of common bile duct.
• Posterior superior pancreaticoduodenal artery-
lower part of common bile duct.
• Right hepatic artery – minor source of middle
part of common bile duct.
Venous drainage:
• Superior surface of GB drains into hepatic
veins.
• Rest of GB is drained by one or two cystic
veins which enters right branch of portal vein.
• Lower part of bile duct drains into portal vein.

10. Liver Anatomy
• Falciform ligament divides liver into right and left hemi-liver
• Anatomically, rt & lt hemi-livers are divided based on blood supply i.e. hepatic arteries
& portal veins
International Hepato-Pancreatico-Biliary Association nomenclature:
• Segment– third order division of liver which is Couinaud segments based on division of
hepatic artery. Eight segments are there
• Section– second order division based on hepatic artery & bile duct divisions
• Sector– second order division based on route of hepatic veins with in the hepatic
scissurae.
During resection each segment of liver can be safely removed without interfering blood
and biliary supply of rest of the segments

11. Segmental Anatomy (Couinaud System)
• Caudate Lobe – Segment I
• Left Lobe – Segments II – IV
• Right Lobe – Segments V-VIII
GOLDSMITH AND WOODBURNE CLASSIFICATION
■ Goldsmith and Woodburne divided the liver into the
caudate lobe and four distinct segments:
■ Left lateral (Couinaud segments 2 and 3)
■ Left medial (Couinaud segment 4)
■ Right anterior (Couinaud segments 5 and 8)
■ Right posterior (Couinaud segments 6 and 7

12. BISMUTH CLASSIFICATION:
■ Bismuth divided the liver based on fissures: three vertical
lines corresponding to the divisions made by the three major
hepatic veins.
■ The fourth fissure, named the transverse fissure, is based
on the level of the portal vein bifurcation within the liver and
divides the “upper” liver from the “lower” liver.
■ Bismuth identified eight subsegments:
■ Caudate lobe (Couinaud segment 1)
■ Left superior subsegment (Couinaud segment 2)
■ Left inferior subsegment (Couinaud segment 3)
■ Left medial subsegment (Couinaud segment 4)
■ Right anterior inferior subsegment (Couinaud segment 5)
■ Right posterior subsegment (Couinaud segment 6)
■ Right posterior superior subsegment (Couinaud segment 7)
■ Right anterior superior subsegment (Couinaud segment 8)

13. Epidemiology
• It accounts for 2% to 4% of all malignant GI tumors
• Age group highest incidence: 6th- 7th decade of life
• F : M = 2-3 : 1
• Increased risk in Indian & Pakistani female population
• Its occurrence in random autopsy series is about 0.4%,
• but approximately 1% of patients undergoing cholecystectomy for gallstone
disease are found incidentally to have gallbladder cancer.
• At diagnosis, ~25% of GB cancers -- localized to the gallbladder wall,
35% have regional nodal involvement and/or extension into adjacent liver,
~40% have distant metastasis

14. Etiology:
The most important risk factor for the development of gallbladder cancer is-- chronic
inflammation associated with gallstones. Also large stones (>3mm)
Gallstones are present in 70% to 90% of patients diagnosed with gallbladder cancer
Other Risk factors:
• Porcelain gallbladder
• Adenomatous polyps of the gallbladder
• Chronic Salmonella typhi infection
• Carcinogens (eg, radon)
• Anomalous pancreaticobiliary junction (APBJ)
• Choledochal cyst
• Primary sclerosing cholangitis (PSC)

15. Pathology:
Chronic inflammation of the gallbladder mucosa related to gallstones - major factor
leading to malignant transformation in gallbladder cancer.
The progression from dysplasia  carcinoma in situ (CIS) to  invasive cancer;
less common pathway -- progression of adenomas to gallbladder cancer.
Molecular changes associated : frequently altered genes include p53, K-ras, P16INK4A,
and ERBB2/HER2.
 80% and 90% of the gall bladder tumors are adenocarcinomas.
• Rarely Squamous cell, adenosquamous, oat cell, and other anaplastic lesions
• Histologic subtypes of gallbladder adenocarcinomas -- papillary, nodular, and tubular.
• Papillary 10%, but overall better prognosis – limited to GB wall

16. Cancer of the gallbladder spreads through --
a) lymphatics,
b) venous drainage, and
c) direct invasion into the liver parenchyma.
d) Transperitoneal spread
Lymphatic flow from the gallbladder
• Level 1: cystic duct node (Calot’s), then the peri-choledochal and hilar nodes,
• Level 2: LN around portal vein, common hepatic artery, the peripancreatic,
periduodenal LN, and
• Level 3: celiac, and superior mesenteric artery nodes, para-aortic LN.
• The gallbladder veins drain directly into the adjacent liver, usually segments IV and V --
tumor invasion is common
• Histologically gallbladder wall lacks a muscularis mucosa and submucosa. Lymphatics
are present in the subserosal layer only. Therefore, cancers invading but not growing
through the muscular layer have minimal risk of nodal disease.

17. Staging:

19. Clinical features:
• Since 90% originate in fundus or body, no symptoms seen in mild disease
• Early stage diseases: features of cholecystitis with GB neck obstruction—
• These include-- abdominal discomfort, right upper quadrant pain, nausea, and
vomiting.
• Jaundice, weight loss, anorexia, ascites, and abdominal mass --less common in
early stage.
• Last stage dieses: weight loss, jaundice, abdominal mass
• Chronic cholecystitis
• Others: Chronic epigastric pain, early satiety, sense of fulness

20. Work Up
• Laboratory studies-- nonspecific for gallbladder cancer.
• Liver function enzyme levels levels are generally not elevated in stages I and II.
• An elevated bilirubin or alkaline phosphate level indicates advanced or
obstructive disease.
Tumour Marker Sensitivity Specificity

21. Imaging studies
Ultrasonography: Useful tool for primary workup of gallbladder cancer.
• Polypoid lesions need to be at least 5 mm in size to be detected by
ultrasonography.
• Cholesterol polyps (benign) generally appear as pedunculated lesions
attached to the gallbladder wall.
• Ultrasonographic findings that indicate possible malignancy
– a thick gallbladder wall,
– vascular polyp,
– a mass projecting into the lumen or invading the wall, multiple masses or
a fixed mass in the gallbladder,
– a porcelain gallbladder, and an extracholecystic mass. Invasion of the
liver can also be seen on ultrasonograms.

22. This image demonstrates heterogeneous thickening of the gallbladder
wall (arrows). The diagnosis was primary papillary adenocarcinoma of
the gallbladder.

23. Computed tomography (CT) scanning and magnetic resonance
imaging (MRI)—
• Useful in evaluating the extent of invasion and resectability of gall bladder
tumors.
• CT scan features of gallbladder cancer -- asymmetrical wall thickening or
gallbladder mass with or without invasion into the liver.
• CT scanning of the chest, abdomen, and pelvis is a common staging modality
that can determine the presence of distant metastases and give reliable
information about involvement of other organs and vascular structures.
Positron emission tomography (PET) scanning has a sensitivity of 75% and
a specificity of 88% in gallbladder cancer but is not used routinely.

24. Partially calcified gallbladder (arrow). CT scan showing squamous cell carcinoma of
gall bladder showing Liver metastasis

25. Diagnostic procedures
• Percutaneous CT scan – guided biopsy is a useful diagnostic tool in patients with
a nonresectable tumor. Tissue diagnosis is necessary for palliative treatment.
• It is avoided in patients with resectable tumors based on preoperative imaging.
• Because of the risk of peritoneal seeding, percutaneous biopsy and diagnostic
cholecystectomy are not necessary in the patient suspected of having gallbladder
cancer. In these patients, exploration with curative intent is planned based on
preoperative imaging alone.
• Endoscopic ultrasonography with fine-needle aspiration Biopsy can be used to
evaluate for peripancreatic and periportal lymphadenopathy.

26. Diagnostic Scenarios:
I. Preoperatively Diagnosed On Imaging
II. Intraoperative incidental detection
III. Incidental detection on pathology
IV. Patient Presents At Advanced Stage

27. I. Preoperatively Diagnosed On Imaging:
• Patient mostly presents with features of cholecystitis—
 Rt upper quadrant pain
 Nausea, vomiting
 Tenderness over rt hypochondrium
• In this case preoperative imaging is important for staging of the
disease

28. Pre-operative Imaging:
• When surgery is being considered, preoperative imaging is important to identify feasibity of
surgery.
• Imaging is less sensitive for peritoneal disease, present in a significant number of patients and
requires diagnostic staging laparoscopy.
USG:
• Doubtful features are, mural thickening or calcification, a mass protruding into the lumen, a fixed
mass in the GB.
• Endoscopic USG: more accurate.
• Compared with transabdominal US, EUS more often correctly predicted the histologic diagnosis

29. EUS is a useful to assess:
• the depth of tumor invasion into the GB wall and
• for defining lymph node involvement
• bile for cytologic analysis, sensitivity of 73 % for the diagnosis of GBC.
• EUS guided FNAC on lymph nodes
CT: Most important for staging
GB Carcinoma can appear as:
• a polypoid mass protruding into the lumen or completely filling it, a focal or diffuse thickening of
the gallbladder wall, or a mass in the gallbladder fossa;
• liver invasion, suspected nodal involvement, or distant metastases.

30. • Dynamic MRI and MR cholangiopancreatography (MRCP) can help to differentiate benign
from malignant gallbladder lesions in equivocal cases.
• MRI is particularly useful for visualizing invasion into the hepatoduodenal ligament, portal vein
encasement, and lymph node involvement
PET Scan:
• Most GB cancers are PET avid
• Help differentiate between benign and malignant tumours and diagnose extrahepatic spread
• Limited in differentiating between inflammatory states and malignancy
• More accurate in diagnosing metastatic disease than CT scan.
• PET/CT had a sensitivity of 100% compared to 25% with CT alone, and PET alone changed
surgical management.

31. Management of Preoperatively diagnosed GBC:
• If preoperative evaluation suggests possibly resectable gallbladder cancer without metastatic
disease attempt at resection. Commonly it is advanced locoregional disease -- require an
extended liver resection.
• At first a diagnostic laparoscopy done to identify small volume peritoneal or hepatic metastases
-- if present avoided.
• In the setting of metastatic disease, nonoperative strategies used to palliate symptoms.
• T3 and T4 lesions-- Radical resection {includes at least segments IVB and V but more often
requires a central hepatectomy, including all of segments IV, V, and VIII.}
• It is necessary to achieve R0 margin status.
• Direct extension of tumor into adjacent structures such as hepatic flexure may be resected as
long as negative margins can be obtained and all disease resected.
• In case of no definite diagnosis preoperatively with suspicion of carcinoma , cholecystectomy is
done (with intraoperative frozen section) and definitive resection in same setting if pathology
confirms cancer.

32. II. Intraoperative incidental detection
• 0.2% of patients undergoing cholecystectomy will have incidental GBC
• The surgeon should maintain a high index of suspicion in patients with
risk factors
• Suspicion arises when gross changes seen such as—
• Inflamed GB or surrounding mass
• Thick GB with fibrotic walls
• Enlarged lymphnode
• Suspicious intraoperative field
• Intraoperative staging should be done, before an attempt for resection

33. Managing an incidental GBC found intraoperatively:
• Patients relatives should be informed along with informing anaesthesia
team
• If an obviously malignant lesion is encountered, it is best not to sample the lesion
laparoscopically to reduce the hazard of seeding.
• A through laparoscopic examination of abdominal cavity is done
• Inra-op ultrasound may be used
• The procedure should be converted to an open resection, if resection will be
undertaken.
• Distant metastasis rule out by frozen section of suspicious lesion or lymph node
• Look for celiac lymph nodes and inter aortocaval nodes

34. Cont..
• After resection of GB, a frozen section should be sent for negative
margin;
• If the cystic duct stump is negative, only regional lymph node dissection is
performed (except T1a tumors).
• And if it is positive, extended cholecystectomy should be performed
• In case of unavailability of expertise surgery should be deferred and
transferred to an experienced centre
• For incidentally detected cancer, the surgical management is similar to
primary resection of gallbladder cancer.

35. Frozen section:
If frozen section positive for GB Carcinoma:
• Extended cholecystectomy after conversion to open, negative margin confirmed by
frozen section.
Accuracy- 88%; Sensitivity- 90%; Specificity- 100%
Diagnostic staging laparoscopy
Diagnostic staging laparoscopy frequently identifies metastatic disease or other findings
that contraindicate tumor resection that may not be apparent on preoperative imaging
studies.

36. III. Incidental detection on pathology
• Identified in .3-1.5 % of cholecystectomy specimen
• On gross specimen examination 10-35 % GB carcinoma cannot be identified
with certainty
• Features seen in a specimen are
• GB mass, thick fibrotic wall
• Suspicious cut surface
• Wall thickening
• Polypoidal lesion
• Mucosal ulceration etc

37. Approach:
• Managed by an expert in hepatobiliary surgery
• History and physical examination
• Preoperative symptoms and signs are evaluated
• Preoperative imaging
• Reassess histopathology by an expert - T stage, N stage, cystic duct margin
• Talk to surgeon –bile spillage? retrieval bag? Any doubtful lesion? location?
• Patient’s comorbidity
• Restaging- CT scan (chest, abdomen and pelvis) + MRI / PET CT scan
• Staging laparoscopy – around 20% yield
• Inter-aortocaval lymph node sampling: 18% yield.

38. • Reassessment of the histological examination has to be performed with a possible second
opinion
• This is important in order to
i. Confirm (pathological T stage)
ii. Specify exact site/location of the tumour
iii. Histology of cystic duct margin
iv. Evaluate whether cystic lymph node is included in histological examination

39. Managing an incidental gallbladder cancer found on pathology:
• Timing of re resection: 3- 4 weeks (partial regression of pre & post operative inflammation);
at least within 6 wks.
Revision Surgery:
• Objective–
i. R0 resection of liver parenchyma with adjacent involved structure & locoregional lymph
node clearance
ii. Extent of surgery depends on depth of invasion
• T1a– Cholecystectomy only
• T1b– extended cholecystectomy (non-anatomical resection with 2-3cm neg margin) with
lymph node dissection
• T2 & Advanced– liver resection with GB bed & lymph node resection
# R0 resection is most important for determining prognosis

40. IV. Patient Presents At Advanced Stage
• Presenting features:
-- mass in the rt upper abdomen – hard & non tender
-- jaundice – suggests porta hepatis involvement ( poor prognosis)
-- pain, and intestinal obstruction.
-- wt. loss, anorexia
-- palpable nodular liver secondaries may be present
• Reported as advanced disease with dismal prognosis.

41. Management:
Goal– Palliation of symptoms
• Jaundice can be managed by endoscopic biliary stenting, and self-expanding endobiliary metal
stents
• Pain is generally treated with oral narcotics but may progress to require parenteral opioids
• Percutaneous neurolysis of the celiac ganglion can help with the palliation of pain
• Intestinal obstruction is usually gastric outlet obstruction from local extension of tumor and is
generally managed by an endoscopic duodenal wall stent

42. Palliative procedures
• Pallation for jaundice, upper abdominal pain, and symptoms of biliary
obstruction
Methods:
• Endoscopic or percutaneous biliary drainage
• Endoscopic stenting or intestinal bypass
• Biliary bypass –in patients who can tolerate surgery is biliary bypass, but many
patients fail these procedures with recurrent obstruction.

43. • Surgical exploration – will determine the need to resect other organs that may be
involved, such as the stomach, duodenum, and colon.
– It may be difficult to distinguish scar from malignancy. In these cases,
suspicious tissue should be treated as malignancy in order to improve the
chances of a margin- negative resection.
– If tumor is suspected on the bile duct based on a previous pathology report or
operative exploration, the presence of tumor on the right hepatic duct must be
evaluated.
– Suspicion of tumorous involvement of the right hepatic duct will require an
extended right hepatectomy, excision of the extrahepatic biliary tree, and Roux-
en-Y hepaticojejunostomy to the left hepatic duct.

44. Hepatic resection
• The basic principle is achieving a negative surgical margin, while preserving the
maximal amount of liver parenchyma.
• The rational of resection includes:
• Resection of liver invaded or likely to be invaded directly by the
tumor.
• Toremove micro-metastasis in segment IVb + V as a result of direct venous
drainage of gallbladder through cystic vein to these segments,
• Toresect en bloc Glisson’s sheath because of potential invasion of
hepatoduodenal ligament.

45. • In extended cholecystectomy – removal of at least a 2 cm margin of liver
adjacent the gallbladder bed.
• Veins from the gallbladder drain mostly into the middle hepatic vein provide
support for anatomic IVb/V resection over nonanatomic resection
• Also anatomic approach reduces the risk for bleeding or bile leakage.
• At present either non anatomical or anatomical resection can be done.
• The standard resection is an anatomic resection of segments IVb and V, but it is
possible to do a smaller wedge resection for early-stage cancers with no
radiographic disease in the liver.

46. • Right extended hemihepatectomy should be performed, if possible, for tumors
of the body or neck that involve the right portal triad or with inflammation,
distinction between tumor and scar is obscured .
• A study compared these two methods-- of GB bed resection and
segment 4b and 5 resection
No difference in 5-year survival rate and disease free survival rate,
nor difference in incidence of recurrence in two groups is seen

47. Extent of lymph nodal excision
• The lymphatic drainage of the gallbladder is via several pathways and does
not always follow a predictable drainage pattern.
• In some cases, lymph nodes associated with gallbladder cancer can first be
seen posterior to the pancreas or portal vein.
• LN involvement seen in 35 to 80 % with ≥T2.
• LN dissection is still indicated for >T1a even when lymph node involvement is
not obvious intraoperatively.
• LN involvement is one of the best predictors of a poor outcome after surgery

49. • According to AJCC, at least 3 lymph nodes have be removed for proper
staging of gallbladder cancer.
• Other experts(Memorial Sloan Kettering Cancer Centre) advocate
removal of more, at least 6 lymph nodes.

50. Bile duct excision
• When the tumor extends into the common bile duct, or frozen section
analysis of the cystic duct margin is positive, extrahepatic bile duct
resection should be performed.
• Reconstruction done with Roux-en-Y hepaticojejunosotmy.

51. Port site excision
• After laproscopic manipulation, port site recurrences can occur.
• Radical resection does not require resection of the previous laparoscopy
port sites.
• If tumor is found in the port sites, is a marker for peritoneal spread and removal of
the port sites will not be curative.
• Port site resection is not associated with overall survival or recurrence-free
survival.
• Thus port site excision is beneficial but not necessary

52. Specific management according to depth of invasion:
T1a tumor- it means its involving lamina propria
• Cystic duct margin negative
• Cure rates following simple cholecystectomy almost 100 percent
• Re resection for T1a tumors does not appear to provide an overall survival
benefit.

53. T1b tumor- involving muscular layer
• The optimal approach to T1b disease is controversial.
• Initial reports have showed no significant difference in overall survival.
• But presently re resection was supported because,
• Higher incidence of lymph nodes mets
• High loco regional recurrence
• High rates of liver involvement
• Increased median survival
Preferred approach: Cholecystectomy with 3cm wedge resection of liver bed
with locoregional clearance

54. T2 tumor- involvement of peri muscular connective tissue.
• Extended cholecystectomy is indicated.
• As high chances of residual disease
• High chances of liver and lymph nodal involvement
• High rates of local recurrence after simple cholecystectomy.
• 5 year survival is 24 to 40 % without reresection , may approaches up to 80 to
100% after resection
• Survival in patients with T2 lesions is related to the number of lymph nodes removed.

55. Resectable T3, T4 and node positive cancer.
• with locally advanced (T3/4) there is an overall poor prognosis.
• Radical surgery improves long term survival in patients with T3 and T4 tumors
• extensive resection involving hepatectomy, pancreaticoduodenectomy, colectomy, and
even nephrectomy may be indicated.
• But morbidity and mortality rates are high, with median survival time of 17 months.
• In general, patients with lymph node metastases outside the hepatoduodenal ligament
should not undergo resection.
• Results with radical lymphadenectomy are less favorable with N2 disease.
• If preoperative FNAC confirms involvement of N2 nodes, surgery should be
performed only for palliation of specific problems.

56. Contraindications to resection
Absolute contraindications to surgery for gallbladder cancer:
• include liver metastasis, peritoneal metastases,
• involvement of N2 nodes,
• malignant ascites,
• extensive involvement of the hepatoduodenal ligament, and
• encasement or occlusion of major vessels.
Surgery should only be considered to palliate specific problems.

57. Complications:
• The overall complication and morbidity rate is approximately 25%.
• Complications are similar to those experienced with cholecystectomy
and-- infection, hematoma, and bile leaks.
• Complication rates are higher in patients undergoing more
extensive resections.
• Liver failure can occur following extended hepatectomy, especially
if jaundice is present preoperatively.

58. Inter aorto caval lymph node sampling
• Interaortocaval (16b1) lymph node (LN) involvement in gallbladder cancer is
a sign of advanced disease with a dismal prognosis equivalent to that of distant
metastasis
• CT indicator - (size >10 mm and heterogeneous internal architecture) of the
16b1 LN. But positive predictive value is less.
• And that is why detection of 16b1 LNs, intraoperative biopsy and frozen-
section analysis of these nodes have been proposed
• Patients with aortocaval lymph node positive had a high preoperative CA19-9 ,
CEA and jaundice.

59. Hepatopancretoduodenectomy
• The philosophy of achieving of R‘0’ resection
• In advanced GBC with adjacent organ removal including
hepatopancreaticoduodenectomy (HPD).
Indications –
• direct invasion of pancreas or duodenum
• To facilitate excision of densely adherent peripancreatic
lymph nodes.
• Former indication is usually considered worth HPD as survival is likely to be
more after R‘0’resection isachieved.

60. Laparosocpic radical surgery
• Traditionally, laparoscopic surgery has not been routinely recommended
in the non incidental setting.
• Recent studies suggesting equivalent outcomes between laparoscopic
and open approaches.
• Robotic-assisted procedures have also been described and are carried out.

61. Adjuvant therapy
• m/c chemotherapeutic agent used : 5-flurouracil or capecitabine
• Concurrent chemoradiation can also be used with these drugs
• Monotherapy may be used or a combination is used with— gemcitabine or
fluoropyrimidine

62. No standard adjuvant treatment protocol has been
defined for gall bladder cancer.
– A study found that only 20% of patients with gall bladder cancer received
adjuvant treatment.[
– In the report, no benefit from adjuvant therapy could be demonstrated, but
only a small number of patients received this treatment.
– Generally, fluoropyrimidine-based chemoradiotherapy or single-agent
chemotherapy with fluoropyrimidines or gemcitabine is used.[10]
– Because of the high cure rate with surgery alone for T1N0 lesions,
adjuvant therapy is not commonly offered to these patients.

63. Neoadjuvant therapy
• Neoadjuvant chemotherapy is thought to provide an opportunity to be
determine, biologically aggressive tumors who, arguably, may not benefit
from extensive operations.
• Small case series suggested gemcitabine-platinum based combinations
have some role.
• In a recent study, a retrospective review of their gallbladder cancers
resected with wide 1-cm negative margins and received either neoadjuvant
or adjuvant therapy. 5 year survival was 50.6%.
• Adjuvant therapy showed no improvement in survival, and neoadjuvant
treatment had only served to significantly delay time to operation in their
study.

64. STAGE 5 YEAR SURVIVAL RATE
T1b 100% especially with hepatectomy
T2 38% to 77% after extended
cholecystectomy
III and IV 25 % with extended resection
Unresectabe disease < 5% ( 1 year survival rate)
Patients with unresectable disease have a median survival of 2-4 months
PROGNOSIS

65. Follow Up
• There are no data to support aggressive surveillance following
resection of gall bladder cancer, because treatment of recurrences is
not generally effective. However, many clinicians and patients prefer
follow-up imaging every 6 months.

71. Thank You