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Gallbladder carcinoma (usually adenocarcinoma) currently affects about 5,000 new patients per year in the United States. Gallbladder carcinoma is typically observed as an abnormality on preoperative imaging or very commonly as an incidental finding during cholecystectomy or in subsequent pathological evaluation of the gallbladder.
Ultrasound image of polypoid gallbladder cancer
CT scan of localized cancer of the gallbladder
Preoperative diagnosis of gallbladder carcinoma is often initially determined via ultrasound, appearing as either a polyp of the gallbladder or asymmetric thickening of the gallbladder wall. When these findings suggest the presence of cancer, the patient should undergo additional abdominal imaging, either magnetic resonance imaging or computerized tomography, and a chest X-ray study to detect any other signs of metastatic disease.
In patients with either a radiographic finding suspicious for gallbladder cancer or a previous cholecystectomy showing adenocarcinoma of the gallbladder, diagnostic laparoscopy is a critical step in carefully evaluating for metastatic disease. This tumor has a high propensity for intraperitoneal spread, and the laparoscopist should look closely for peritoneal seeding.
Patients who have already undergone laparoscopic cholecystectomy, particularly if the gallbladder was removed without a collection bag through one of the ports, require evaluation for involvement of the port site. This evaluation should be carried out early in the operation, since involvement of one trocar site or more often implies peritoneal spread.
Involvement of the liver and distant metastasis in the liver itself are common and should also be evaluated. Anything suggestive of disease spread beyond the gallbladder fossa and regional lymph nodes within the hepatoduodenal ligament is generally considered unresectable disease.
When gallbladder carcinoma is diagnosed on the basis of a previous cholecystectomy specimen, the depth of the tumor involvement determines what additional treatment is required.
Carcinomas in situ and carcinomas involving just the submucosal layers but not muscle (T1A lesions) can be observed after simple cholecystectomy. If the tumor involves the muscle (T1B cancers), most experts recommend treatment with a radical cholecystectomy, with the removal of 2 to 3 centimeters of normal liver around the gallbladder bed (segments IVB and V) and the lymph nodes within the hepatoduodenal ligament, behind the head of the pancreas and along the common hepatic artery.
Multiple uncontrolled experiences have shown some improvement in patient survival with this radical approach, when compared with observation after simple cholecystectomy. Any structure adherent to the gallbladder fossa needs to be considered potentially involved by residual cancer and should also be resected en bloc with the liver specimen.
Options for adjuvant therapy remain limited. Radiation therapy with fluorouracil radiosensitization is the most commonly used postoperative treatment. Current trials are investigating the role of capecitabine, gemcitabine, oxaliplatin and bevacizumab in the management of gallbladder carcinoma.
Carcinoma of the gallbladder is a disease with poor outcomes because it is a very biologically aggressive tumor, often not amenable to curative resection. However, it is important not to rule out curative possibilities for patients with early-stage disease, either found incidentally at cholecystectomy or in patients who have X-ray findings suggestive of gallbladder cancer preoperatively. In these patients, aggressive surgical management offers the best chance for cure.
Surgery and treatment undertaken at larger centers such as Mayo Clinic, where experienced teams help with perioperative management of the patient as well as adjuvant therapy, have strong track records for yielding positive outcomes.
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