Joint Hospital Surgical Grand Round Management of Gallbladder

Joint Hospital Surgical Grand Round Management of Gallbladder Carcinoma

INTRODUCTION l Fifth most common cancer in gastrointestinal tract l l l Most preoperatively suspected cases are unresectable l l 1. 2. More frequent in women Age standardized incidence rate ~3/100, 000 in Hong Kong (including biliary tract cancer)1 Aggressive tumour biology Multiple mechanisms of disease spread Late presentation Overall 5 -year survival of 3 -13%2 Hospital Authority: Hong Kong Cancer Registry web site. www 3. ha. org. hk/cancereg/e_stat. asp (accessed April 2012) Jin K, Lan H, Zhu T, He K, Teng L. Gallbladder carcinoma incidentally encountered during laparoscopic cholecystectomy: how to deal with it. Clinical and Translational Oncology. 2011; 13(1): 25 -33.

PRESENTATION l l Incidental finding Mimicking benign biliary tract diseases l l l Late presentation l l 1. 2. 70% discovered incidentally by pathologist 1 0. 2 -2. 9% of all cholecystectomies 2 Biliary obstruction Palpable mass / Hepatomegaly Anorexia, weight loss Malignant ascites Goetze TO, Paolucci V. Immediate re-resection of T 1 incidental gallbladder carcinomas: a survival analysis of the German Registry. Surgical endoscopy. 2008; 22(11): 2462 -5. Toyonaga. T, Chijiiwa K, Nakano K, Noshiro H, Yamaouchi K, Sada M, Terasaka R, Konomi K, Nishikata F, Tanaka M. Completion radical surgery after cholecystectomy for accidentally undiagnosed gallbladder carcinoma. World J Surg.

INVESTIGATIONS l l Routine blood tests Ultrasound CT MRI (MRCP/MRA)

PRINCIPLE OF MANAGEMENT l Complete surgical removal of tumour is the only chance of cure l l l No truly effective chemotherapy or radiotherapy Survival much higher if complete removal achieved during first resection Treatment strategy depends heavily on staging

T 1 a (invades lamina propria) Systematic review by SE Lee et al. (2011) l No significant difference between simple or extended cholecystectomy in terms of survival l Lymph node metastasis 1. 8% l Recurrence rate 1. 1% l Most studies showed 5 -year survival rate >90%

T 1 b (invades muscular layer) ü Simple cholecystectomy l l 5 -year survival rate of over 80% irrespective of surgical procedure 1 10 -year survival also comparable to extended cholecystectomy 3 ü Extended cholecystectomy l Frequent lymph node metastasis 1 for T 1 b (11% in T 1 b VS 2% in T 1 a; p <0. 01) l Some studies showed significantly higher 5 year survival rate 2 (79% VS 42%; p = 0. 03) l 1. 2. 3. Lower rate of recurrence 1 (12. 5% VS 2. 7%; p <0. 01) Lee SE, Jang J-Y, Lim C-S, Kang MJ, Kim S-W. Systematic review on the surgical treatment for T 1 gallbladder cancer. World journal of gastroenterology  WJG. 2011; 17(2): 174 -80. Goetze, T. O. , & Paolucci, V. Immediate re-resection of T 1 incidental gallbladder carcinomas: a survival analysis of the German Registry. Surgical endoscopy. 2008; 22(11), 2462 -5. Wakai T, Shirai Y, Yokoyama N et al. Early gallbladder carcinoma does not warrant radical resection. Br J Surg 2001; 88: 675 -8.

EXTENDED CHOLECYSTECTOMY Extent of operation l Regional lymph node dissection l Liver resection l Wedge resection of liver bed l l l 1. Variable resection margin Formal segment IVb/V resection Right hepatectomy / extended right hepatectomy No consensus on extent of liver resection Morbidity 28%; Mortality 1. 5%1 Lee SE, Jang J-Y, Lim C-S, Kang MJ, Kim S-W. Systematic review on the surgical treatment for T 1 gallbladder cancer. World journal of gastroenterology  WJG. 2011; 17(2): 174 -80.

T 2 (perimuscular connective tissue) l Radical resection Liver resection l Regional lymph node dissection l l 5 -year survival of 1 Simple cholecystectomy 10 -61% l Radical resection 54 -100% l 1. Jin K, Lan H, Zhu T, He K, Teng L. Gallbladder carcinoma incidentally encountered during laparoscopic cholecystectomy: how to deal with it. Clinical and Translational Oncology. 2011; 13(1): 25 -33.

T 3 AND T 4 (beyond serosa / into liver) l l 1. Long-term benefit of aggressive surgery unclear Aggressive resection only considered if potentially curative resection is feasible 5 -year survival 0 -32%1 after radical surgery Consider palliative care +/- metallic stenting if tumour not resectable Jin K, Lan H, Zhu T, He K, Teng L. Gallbladder carcinoma incidentally encountered during laparoscopic cholecystectomy: how to deal with it. Clinical and Translational Oncology. 2011; 13(1): 25 -33.

LYMPH NODE DISSECTION l N 1 N 2 l l T 1 b →N 12 T 2/above → N 1&2 Significantly lower survival for node positive disease (5 -year survival, 58– 77% vs. 0– 45%) 1. 2. Curley SA. The Gallbladder. In: Bast RC Jr, Kufe DW, Pollock RE, et al. , editors. Holland-Frei Cancer Medicine. 5 th edition. Hamilton (ON): BC Decker; 2000 Lai CHE, Lau WY. Gallbladder cancer--a comprehensive review. The surgeon  journal of the Royal Colleges of Surgeons of Edinburgh and Ireland. 2008; 6(2): 101 -10. Available at: http: //www. ncbi. nlm. nih. gov/pubmed/18488776.

PRE-OPERATIVE DIAGNOSIS Proper staging Patient selection Diagnostic laparoscopy +/laparotomy + frozen section Suspected Gallbladder Cancer Resectabl e disease Unresectabl e disease / Distant metastasis Extended cholecystecto my No resection +/- Bile duct excision Curley SA. The Gallbladder. In: Bast RC Jr, Kufe DW, Pollock RE, et al. , editors. Holland-Frei Cancer Medicine. 5 th edition. Hamilton (ON): BC Decker; 2000.

INTRA-OPERATIVE DIAGNOSIS Suspected Gallbladder Cancer Laparoscopic cholecystectomy Diagnostic laparoscopy +/- laparotomy + frozen section Proper staging Patient selection No obvious metastasis Re-resection +/- Port site excision No resection Distant metastasi s No resection +/- Bile duct excision Jin K, Lan H, Zhu T, He K, Teng L. Gallbladder carcinoma incidentally encountered during laparoscopic cholecystectomy: how to deal with it. Clinical and Translational Oncology. 2011; 13(1): 25 -33.

POST-OPERATIVE DIAGNOSIS Gallbladder Cancer Specimen inspection / Pathology report Resection margin Spillage Proper staging Patient selection T 1 a No resection +/- Port site excision T 1 b / T 2 T 3 or above Re-resection only if potentially curative +/- Bile duct excision Jin K, Lan H, Zhu T, He K, Teng L. Gallbladder carcinoma incidentally encountered during laparoscopic cholecystectomy: how to deal with it. Clinical and Translational Oncology. 2011; 13(1): 25 -33.

SUMMARY l l l Aim at complete resection of the tumour Individualized approach for different stage of disease and timing of diagnosis Ongoing debate about management of T 1 b cancers and extent of lymphadenectomy, liver resection for each stage

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