Gall Bladder Cancer.pptx

Mucocele of GB presenting as
Carcinoma Gall bladder
Pushpa Lal Bhadel
Department of Surgical oncology
BCH

Case Summary
 67 Y/F from Sindhuli
 C/O: RUQ pain for 1 month, gradual onset, non-radiating, on/off, no
aggravating or relieving factors
 Associated with decreased appetite and nausea
 No h/o fever, vomiting, yellowish discoloration of skin, altered stool color,
water brash, abdominal distention, SOB, chest pain, cough or weight loss
 Unremarkable medical or surgical history
 Reformed smoker, doesn’t consume alcohol
 O/E: icterus absent
 Per abdomen: Smooth globular swelling of size ~15x6 cm mass felt over the
right hypochondrium extending up to the umbilicus, smooth margin, upper
border not felt, non-tender, moves with respiration and dull on percussion.

Blood investigations:
oHb: 10.4
oTLC: 7,700 N:67%
oPlts: 564,000
oBil T/D: 0.4/0.1
oALP: 112
oSGPT/SGOT: 22/19
oCA 19.9: 166 U/ml
Initially managed symptomatically at other center

CBD
GB
Cholelithiasis
Thickened GB neck wall
Fig. USG images

CECT Abdomen and pelvis
GB neck mass
Complex
cystic lesion

Tumor, Node, Metastasis (TNM) staging 1
1 Zhu AX, Pawalik TM, Kooby DA, et al. Gallbladder. In: AJCC Cancer Staging Manual, 8th ed, Amin MB (Ed), AJCC, Chicago 2017. p.303

In our case
 T2a (perimuscular connective tissue)
 N1 (pericholedochal nodes)
 M0
 i.e., Stage IIIB

 Intraoperative findings:
 Ascites absent, no e/o hepatic or peritoneal metastases
 Grossly distended GB extending up to the umbilicus
 GB body communicating inferiorly with cystic cavity of size ~7x6 cm which is densely
adhered to the hepatic flexure

 Aggressive radical surgical approach to
achieve R0 curative resection is shown
to have improved outcome and better
overall 5-year survival for patients
with gallbladder cancer

Management
Resection remains the only potential for cure
oSimple cholecystectomy
oRadical (Extended) cholecystectomy
oBile duct resection
oHepatic resection
oLymph node dissection

Radical Cholecystectomy
 En bloc removal of gall bladder with a rim of at least 2 cm adjacent gall
bladder bed
 Formal central liver resection (segments IVb and V) may be appropriate
depending upon the location of tumor (fundus, body, neck)
 Laparoscopic vs open surgery?
o Wullstein, C., Woeste, G., Barkhausen, S., Gross, E., & Hopt, U. T. (2002). Do
complications related to laparoscopic cholecystectomy influence the prognosis of
gallbladder cancer? Surgical Endoscopy, 16(5), 828–832
o Matthews, J. B. (2010). Planned laparoscopic approach for early-stage gallbladder
cancer: The glass is one-third full. Archives of Surgery (Chicago, Ill.: 1960), 145(2),
133

Extent of liver resection: wedge vs segment IVb/V

 In some cases it involves resection of
o Entire liver lobe (hepatic lobectomy)
o Suprapancreatic segment of extrahepatic
bile duct (bile duct resection)
o Regional LN dissection in an En bloc
fashion.
 Main difference between this procedure
and original radical cholecystectomy
described by Glenn et.al compromise
the extent of regional
lymphadenectomy and presence or
absence of bile duct resection.
Fig. Extended" radical cholecystectomy for gallbladder
cancer. The dashed line indicates the scope of wedge
resection. The double-headed arrows indicate lines of
division of the extrahepatic bile duct. The pale blue area
indicates the extent of regional lymph node dissection

Bile duct resection
 Tumor extending into CBD or negative cystic duct margin (via frozen
section) can’t be achieved: extrahepatic bile duct resection should be
performed
 Reconstruction with Roux-en-Y hepaticojejunostomy
 Some recommends routine excision of extrahepatic bile duct as a mean of
achieving more complete lymphadenectomy
 When ducts compromised during skeletonization of porta hepatis:
resection and reconstruction is warranted

Fig. Roux-en-Y hepaticojejunostomy with biliary stent placement to reduce stricture at
the anastomosis

Conclusion: Combined EHBD resection is justified for advanced GBC patients with
T3 lesion, T4 lesion and lymph-node metastasis. Considering the high post-operative
morbidity, EHBD resection for advanced GBC patients should be performed by high-
volume experienced surgeons in highly specialized medical centers

Inter aortocaval LN sampling
 Interaortocaval (16b1) LN involvement: sign of
advanced disease with a dismal prognosis
equivalent to that of distant metastasis
 CT indicator (size >10 mm and heterogeneous
internal architecture) of 16b1 LN
o But positive predictive value is less
 That’s why detection of 16b1 LNs, intraoperative
biopsy and frozen section analysis of these nodes
have been proposed 1
1 Noji, T., Kondo, S., Hirano, S. et al. CT evaluation of paraaortic lymph node metastasis in patients with biliary cancer. J Gastroenterol 40, 739–743 (2005)

Lymph node dissection
 Indicated whether or not bile duct resection is performed if GBC >T1a
 LN mets found in 35-80% with tumors invading peri muscular connective
tissues(≥T2) 1
 More reliable predictors of poor outcome after surgery
o 5-yr survival: 57% without vs 12% with LN metastases2
 Involves removal of all LN in porta hepatis and along hepaticoduodenal ligaments
including those of cystic duct, CBD, hepatic artery and portal vein
1 Pilgrim, C. H. C., Usatoff, V., & Evans, P. (2009). Consideration of anatomical structures relevant to the surgical strategy for managing gallbladder carcinoma. European
Journal of Surgical Oncology: The Journal of the European Society of Surgical Oncology and the British Association of Surgical Oncology, 35(11), 1131–1136.
2 Birnbaum, D. J., Viganò, L., Russolillo, N., Langella, S., Ferrero, A., & Capussotti, L. (2015). Lymph node metastases in patients undergoing surgery for a gallbladder
cancer. Extension of the lymph node dissection and prognostic value of the lymph node ratio. Annals of Surgical Oncology, 22(3), 811–818

Lymph node dissection cont.
 At least 6 LNs should be removed for proper staging 1
 Number of metastatic LN and LN ratio are more prognostic than
location of metastatic LN
1 Zhu AX, Pawlik TM, Kooby DA. et al. Gallbladder. In: AJCC Cancer Staging Manual, 8th, Amin MB (Ed), Springer 2017. p.303

 Identifies metastatic disease or other findings that contraindicate
tumor resection 1
 Recommended prior to laparotomy for all suspected or proven GBC
>pT1b 2
 Use of two ports avoid missing detectable lesions
Staging laparoscopy
1 Shih, S. P., Schulick, R. D., Cameron, J. L., Lillemoe, K. D., Pitt, H. A., Choti, M. A., Campbell, K. A., Yeo, C. J., & Talamini, M. A. (2007). Gallbladder cancer: The role of
laparoscopy and radical resection. Annals of Surgery, 245(6), 893–901
2 Agarwal, A. K., Kalayarasan, R., Javed, A., Gupta, N., & Nag, H. H. (2013). The role of staging laparoscopy in primary gall bladder cancer--an analysis of 409 patients: A
prospective study to evaluate the role of staging laparoscopy in the management of gallbladder cancer. Annals of Surgery, 258(2), 318–323

Staging laparoscopy cont.
A prospective study of primary GBC
patients between May 2006 and
December 2011: Of the 409 primary GBC
patients who underwent SL, 95 had
disseminated disease [(surface liver
metastasis (n = 29) and peritoneal
deposits (n = 66)]. The overall yield of SL
was 23.2% (95/409)

Resectable disease
 Early T stage disease: tumors confined to the wall of GB (ie, stage 0, I or II; Tis, T1 or T2)
 Tumors extending beyond the mucosa (ie, T1a): better outcomes with more radical
surgery 1
1 Sternby Eilard, M., Lundgren, L., Cahlin, C., Strandell, A., Svanberg, T., & Sandström, P. (2017). Surgical treatment for gallbladder cancer—A systematic literature review. Scandinavian
Journal of Gastroenterology, 52(5), 505–514

Optimal timing of re-resection:
 Reoperations between 4th-8th week from original cholecystectomy
had better overall survival 1
o4 weeks: 23.7 mths, 8 weeks: 26.6 mths
 Due to
oReduced inflammation
oFull appreciation of subclinical disease (compared with reoperating <4 week)
but does not allow too much time for disease dissemination
1 Ethun, C. G., Postlewait, L. M., Le, N., Pawlik, T. M., Buettner, S., Poultsides, G., Tran, T., Idrees, K., Isom, C. A., Fields, R. C., Jin, L. X., Weber, S. M., Salem, A., Martin, R. C. G.,
Scoggins, C., Shen, P., Mogal, H. D., Schmidt, C., Beal, E., … Maithel, S. K. (2017). Association of optimal time interval to re-resection for incidental gallbladder cancer with overall
survival: A multi-institution analysis from the us extrahepatic biliary malignancy consortium. JAMA Surgery, 152(2), 143–149

Bile spillage
 Association with incomplete resection and systemic recurrence
Conclusion: When GB cancer is suspected during LC; conversion to open
surgery for preventing bile spillage and achieving curative resection
should be considered

Reference
 Schwartz’s Principle of surgery, 10th edition
 Bailey short practice of surgery, 27th edition
 Sabiston textbook of surgery, 20th edition
 https://www.uptodate.com/contents/gallbladder-cancer-epidemiology-risk-
factors-clinical-features-and-
diagnosis?search=gallbladder%20cancer&source=search_result&selectedTitle=1~
71&usage_type=default&display_rank=1#H17
 Internet sources

Gall Bladder Cancer.pptx

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