Gallbladder Cancer

Epidemiology
Incidence ~ 5000 5th 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% resectable @ 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 75100% 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
Fong @ 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