This document summarizes the surgical aspects of treating gallbladder cancer. It discusses the epidemiology, risk factors, staging, diagnosis, and management of gallbladder cancer. For early stage I tumors, surgery including cholecystectomy may be sufficient. For more advanced stages II-III, aggressive surgery with liver resection and lymphadenectomy can improve survival rates compared to surgery alone. Stage IV cancer with metastases has a very poor prognosis with chemotherapy and palliation the only options. An aggressive surgical approach for select non-metastatic patients can provide a significant survival benefit.
Global launch of the Healthy Ageing and Prevention Index 2nd wave – alongside...
Gallbladder ca
1. Surgical Aspects of the
Multidisciplinary Treatment
of Gallbladder Cancer
Eduardo A Guzman MD
2. “In malignancy of the gallbladder, when a diagnosis
can be made without exploration, no operation
should be performed, inasmuch as it only shortens
the patient’s life”
Alfred Blalock, 1924
4. Epidemiology
• Rare tumor
• Incidence 2.5 cases per 100,000 residents
• Most common malignancy of the biliary tract
• 5th most common gastrointestinal malignancy
• 2 times more common in women
• More than 75 % are older than 65
6. Etiology
• Chronic gallgladder irritation
and inflammation
• Gallstones
– Gallstones in 80 % GB
cancer
– GB cancer is 7 times more
common in people with
gallstones
• Porcelain gallbladder
• Primary sclerosing cholangitis
• Polyp
7. Gallbladder polyp
• > 1 cm increased
incidence of cancer
• Treatment is
laparoscopic
cholecystectomy
• If mass do open
choelcystectomy
8. Pathology
Tumor Type Percent of
Total
Adenocarcinoma 75.8
Papillary 5.8
Mucinous 4.6
Adenosquamous 3.6
Oat cell 0.5
Nonspecific 7.6
14. Stage
I T1 N0 M0
T2 N0 M0
II T3 N0 M0
T1-3 N1 M0
III T4 N0 M0
IV Tx Nx M1
AJCC / TNM 6th edition
Limited to gallbladder
Local invasion
Locally advanced
Metastasis
15. Other points
• Stage I includes 2
different surgical
therapies
• T4 tumors can be
resectable
• N2 nodes are
considered metastatic
disease
16. Extent of disease on initial presentation
Stage
I 25 %
II - III 35 %
IV 40 %
17. Laparoscopic cholecystectomy and positive margins
Mucosa
Submucosa
Muscularis
Serosa
Liver
During a laparoscopic cholecystectomy the plane
of dissection is subserosal
18. Clinical presentation
• Undistinguishable from benign
gallstone disease
– Right upper quadrant pain
– Weight loss
– Anorexia
– Abdominal mass
• Yet, one should suspect
gallbladder cancer in an elderly
person with weight loss and
constant pain
20. Diagnosis
• Usually diagnosed late in the disease course
• Ultrasound
– Heterogeneous mass
– Irregular GB wall
– Sensitivity 70 – 100 %
• CT scan
– Mass replacing the gallbladder or with direct extension
• MRI
– Identifies plane between gallbladder mass and adjacent liver
• Cholagiography
– Stricture of the common hepatic duct
21. Incidental diagnosis
• It is the most common
presentation
• Intraoperative
• Postoperative
– Pathology
• 1 % of all elective
cholecystectomies for
cholelithiasis harbor an occult
GB cancer
22. Management
• Depends on stage
• Do open cholecystectomy
if cancer suspected pre-
operatively
• Convert to open procedure
if cancer identified intra-
operatively
• Avoid bile spillage or
tumor implantation into
port sites
23. Biopsy
• Risk of seeding cancer along the needle tract
• Worse with core biopsy
• Gallbladder cancer has a tendency to seed the
peritoneum
• Percutaneous biopsy is indicated if disease has been
determined to be unresectable and prior to initiation
of chemotherapy
24. Staging Laparoscopy
• Important consideration
• Staging modality
• Patients with incurable
disease can avoid a
laparotomy
• Yield 50 %
25. Stage I
• T1a
– Disease limited to mucosa
– Almost always diagnosed following
cholecystectomy
– Negligible probability of lymph node metastasis
– Excellent survival 95 %
– No further intervention required
– Make sure cystic duct margin is negative for
tumor
26. Stage I
• T1b
– Disease limited to muscularis
– Higher locoregional recurrence
– 5 year survival = 85 %
– Treatment remains controversial
– Selected patients (young and healthy) may benefit
from liver resection of segment IVb and V along
with local lymphadenectomy
28. Stage I
• T2
– Transmural invasion
– Positive margin after cholecystectomy
– Good probability for lymph node positivity
– Optimal patient for aggressive surgical
intervention. 5 yr survival 18 % Vs 61 %
– Liver resection of segment IVb and V and
lymphadenectomy
• Cystic
• Pericholedochal
• Portal
• Right celiac
• Hepatic
• Posterior pancreaticoduodenal
30. Stage II
• T3N0 / N1 disease
– Cancer invades into contiguous liver for less than
2 cm and/or has positive hepatoduodenal lymph
nodes
– Tumor is still resectable
– High increased incidence of lymph node
metastasis
– Ideal patient for staging laparoscopy
– Liver resection of segment IVb and V and
lymphadenectomy
31. Stage III
• T4N0MO
– Cancer invades into contiguous liver for more than
2 cm and negative lymph nodes
– Anecdotal evidence of resectability
– Extended liver resection
• Trisegmentectomy
32. Some other important surgical considerations
• Resect port sites
• Avoid spillage of bile
• En bloc resection
• Do not hesitate to do
CBD resection
• Do anatomic liver
resections
• Tumors in the
infundibulum may require
a trisegmentectomy
33. Adjuvant Chemotherapy
• 85 % of the recurrences occur in distant disease sites
• Minimal data
• Regimens
– 5 flouroracil
– Mitomycin C
– Gemcitabine
34. LNLN++
PatientsPatients
SEER National Database 1992 - 2002SEER National Database 1992 - 2002
YEARSYEARS
100
20
40
60
80
1 2 3 4 5
SURVIVAL%SURVIVAL%
RadiationRadiation
No RadiationNo Radiation
p <0.0001p <0.0001
11% 5yr11% 5yr
04% 5yr04% 5yr
survival
Mojica, Smith and Ellenhorn 2006
Adjuvant Radiation
36. • S Kim et al – Korea
• 29 pts inoperable GB cancer
• Median age 52 yrs
• No complete responses
• 34 % partial response
• Time to progression = 3 months
• Overall survival = 11 mo
• Toxicity (3 or 4) = 17 %
• Tolerable combination
• Modest response rates
38. Summary
• Gallbladder cancer is a bad disease
• Accurate staging is critical
• Cholecystectomy is an inadequate operation in most
of the cases
• T1a tumors have excellent prognosis
• Selected patients would obtain significant benefit
from aggressive surgical interventions
• Nearly all patients without metastatic disease require
surgical evaluation to determine resectability
39. “In malignancy of the gallbladder, after careful
patient selection, an aggressive surgical approach
can have a significant impact in the patient’s life”
Eduardo Guzman, 2007