Gallbladder Cancer

Epidemiology Incidence ~ th most common GI malignancy Women > men High incidence in S America (Chile) ~ 1% of pts undergoing cholecystectomy for symptomatic gallstones

Risk Factors Gallstones Gallbladder Polyps Chronic Salmonella infection Abnormal Pancreaticobiliary duct junction * Porcelain gallbladder * Age

Presentation/Diagnostic Imaging Presentation is non-specific Diagnositic Imaging –Sono –CT –MR/MRCP –EUS

Histology / Pathology * Progression to Ca may take up to 15 yrs Adenocarcinoma 80-90% Anaplastic 7% Squamus 6% Lymphoma, Sarcoma

Staging

Surgical Management Only 10-30% time of diagnosis Three Presentations: –GB CA discovered during or after lap/open chole for assumed benign dz –GB CA suspected after diagnostic evaluation –GB CA advanced stage at presentation

Surgical Options Simple cholecystectomy Radical cholecystectomy Radical chole w/ anatomic liver resection Radical chole w/ Whipple

What to do during elective lap chole if GB Ca is suspected intraoperatively ? ~ 0.5 % of asx cases found to have GB CA in lap chole Convert to OPEN Resect PORTS No place for laparoscopic resection

Management of T1 lesions 5Yr survival rates have improved for T1a dz following simple cholecystectomy % T1b (muscularis) is controversial –Simple v radical chole –Wakai (2001) – 10 yr survival for T1b tumors after simple chole was 87%

Management of T2 lesions Incidentally detected GB Ca in specimen Re-exploration w/ radical chole for T2 lesions or greater MSKCC (1998) – improved disease free survival from ~ 20 60% –De Aretxabala Chile (1997) showed improvement from 20% 70% 5Yr survival

Management of locally advanced T3/T4 lesions High morbidity & mortality rates (~50% & 15%) Reluctance to operate because of poor prognosis Nakamura (1999) found extensive surgery for stage IV pts showed significant improvement in 5Yr survival when compared to palliative operation/unresectable dz

Management of locally unresectable dz (major vascular encasement) NO DEBULKING Chemoradiotherapy –No identified impact on survival & remains investigational –Systemic chemotherapy – no optimal regimen defined (5-FU based)

Contraindications to resection Mets to liver, peritoneum, or encasement of major vessels Direct involvement of adjacent organs is NOT absolute contraindication