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Gallbladder Cancer

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Epidemiology

Incidence ~ 5000

5th most common GI malignancy

Women > men High incidence in S America (Chile)

~ 1% of pts undergoing cholecystectomy

for symptomatic gallstones

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Risk Factors

Gallstones

Gallbladder Polyps

Chronic Salmonella infection Abnormal Pancreaticobiliary duct junction

* Porcelain gallbladder* Age

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Presentation/Diagnostic Imaging

Presentation is non-specific

Diagnositic Imaging Sono

CT

MR/MRCP EUS

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Histology / Pathology

* Progression to Ca may take up to 15 yrs

Adenocarcinoma 80-90% Anaplastic 7%

Squamus 6%

Lymphoma, Sarcoma

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Staging

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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

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Surgical Options

Simple cholecystectomy

Radical cholecystectomy

Radical chole w/ anatomic liver resection Radical chole w/ Whipple

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Wh t t d d i l ti l

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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

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Management of T1 lesions

5Yr survival rates have improved forT1a

dz following simple cholecystectomy75-

100%

T1b(muscularis) is controversial

Simple v radical chole

Wakai (2001) 10 yr survival for T1b tumors

after simple chole was 87%

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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) showedimprovement from 20% 70% 5Yr survival

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Management of locally advanced

T3/T4 lesions

High morbidity & mortality rates (~50% &15%)

Reluctance to operate because of poor

prognosis

Nakamura (1999) found extensive surgeryfor stage IV pts showed significantimprovement in 5Yr survival whencompared to palliativeoperation/unresectable dz

Management of locall

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Management of locally

unresectable dz (major vascular

encasement) NO DEBULKING Chemoradiotherapy

No identified impact on survival & remainsinvestigational

Systemic chemotherapy no optimal regimen

defined (5-FU based)

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Contraindications to resection

Mets to liver, peritoneum, or encasement

of major vessels

Direct involvement of adjacent organs

is NOT absolute contraindication