Jose Baez, M.D.09/24/10

LICH

downstatesurgery.org

68 y/o F with symptomatic cholelithiasis who presented for an elective laparascopic cholecystectomy

PMHx• Obesity• HTN• Cholelithiasis

downstatesurgery.org

PShx: denied

NKDA

Medications: HCTZ, Atenolol

Shx: denied

downstatesurgery.org

OR: Laparoscopic cholecystectomy• GB aspirated due difficulty to grasp• Removed in endo-bag

Pt discharged POD#0

Pathology: moderate to poorly differentiated adenocarcinoma of GB ,involving lamina propia and muscle layer, + proximal margin (cystic duct)

Stage: T1b, Nx, Mx

downstatesurgery.org

PHYSICAL EXAM STUDIES/LABS

VS: 98.6, 148/82, 77

Alert and oriented

Chest clear bilaterally

Abdomen: soft nt/nd

WBC: 7

Hct: 37

LFTs: WNL

RUQ sono: Gallstones

downstatesurgery.org

Associated with a poor prognosis (5 yr survival 0-12%)

Majority of cases present with advanced, unresectable dz

Increasing number of early-stage dz cases are found incidentally during or post cholecystectomy

Most common cancer of biliary tract, 5th most common of GI tract

downstatesurgery.org

Strong association between GBC and cholelithiasis (65-90%)

Prevalence:• Female > Male• US 2.5/100k, but higher in Native Americans and

Hispanics• 50% greater incidence in Caucasians vs AA

Gallstone size: <3cm RR of 2.5 >3cm RR of 10

downstatesurgery.org

Other risk factors• Adenomatous polyps, calcification of GB,

anomalous pancreaticobliliary duct junctions

NIH Consensus Guidelines of Gallstones and Laparocopic cholecystectomy (1992)• Only porcelain GB is considered an indication

for prophylactic cholecystectomy• (GBC in up to 25% of pts)

downstatesurgery.org

downstatesurgery.org

GB polyps• Incidence in healthy pts

3-10%• Mostly cholesterol

polyps• If >1cm, CT to eval for

GBC• If >1cm, sessile, and

over 50 yrs of age• If small, US q 6mo x

2yrs

downstatesurgery.org

Progresses slowly from dysplasia to Cis to invasive carcinoma over 15 yrs

Chronic inflammation (stones or other)-inciting event in dysplasia to CA pathway

80-95% are adenocarcinomas, anaplastic (7%), squamous cell(1-6%),adenosquamous (1-4%)

downstatesurgery.org

downstatesurgery.org

GBC- ability to spread regionally and distant via four routes• Direct invasion through GB wall• Lymphatics• Hematogenous- MC to lung (>30%) and brain• Peritoneum

downstatesurgery.org

Cholecystoretropancreatic nodes

Cholecystoceliac path

Cholecystomesenteric path

downstatesurgery.org

TX- primary tumor cannot be assessed

T0- no tumor Tis- in situ T1a- invades lamina propia T1b- invades muscle layer T2- perimuscular connective

tissue T3- through serosa or

adjacent tissues T4- into PV, HA, or multiple

adjacent organs

NX- not assessed N0- no regional LNs N1- regional LNs

MX- mets not assessed M0- no distant mets M1-distant mets

downstatesurgery.org

PRESENTATION WORKUP

Incidentally after cholecystectomy

Symptoms- pain (75%) or jaundice (45%)

Nausea, vomiting and anorexia

US- 50% accuracy for GBC

CT/MRI- eval extent of dz and local invasion

Chest eval- mets PET- most sensitive for

distant mets MRCP- CBD involvement ERCP- stent in advanced

dz

downstatesurgery.org

Surgery is potentially the only curative therapy

Overall 5yr survival is < 5%Treatment based on T-stage of tumorCI for surgery- liver and peritoneal mets,

ascites, distant dz, encasement or occlusion of major vessels, poor performance status, para-aortic LNs

downstatesurgery.org

Early lesions (Tis/T1a)

• Simple cholecystectomy- cure rate 85-100% as long as margins are negative

• If GBC suspected- recommend open cholecystectomy

downstatesurgery.org

T1b/T2 tumors• T1b associated with 15% LN mets• T2 associated with 40% LN mets• Tx- radical cholecystectomy- GB, GB fossa,

min of 2cm of liver parenchyma, and lymphadenectomy

• Radical vs simple for T2 lesions 61-100% vs 19-40% survival rate

• Radical- 1% mortality

downstatesurgery.org

T3/T4 tumors• May benefit from radical surgery if no distant or

peritoneal mets• No role for debulking, need R0 resection• DL prior to laparotomy• 25-44% 5 yr survival with radical resection

• Need negative margins for survival (> 2cm)

downstatesurgery.org

Occurs in 1-2% of lap cholescytectomies

New problems• Port site seeding (5-20%)• Spillage and Perforation- 40% rate of port site

recurrence

Most are Tis/T1a lesions• 85-100% 5yr survival if CD margin is negative

If suspected intraop- convert to open

downstatesurgery.org

If suspicious lesion-frozen T2 or greater• Proceed with radical cholecystectomy• Close, image and stage, refer to HB expert

Pts with T1b or greater should be offered resection• Staging, imaging and DL prior to resection

downstatesurgery.org

downstatesurgery.org

Palliation (unresectable)• Choledochojejunostomy, gastrojejunostomy• ERCP or percutaneous drainage• Chemo/RT- mostly unsuccessful

Adjuvant Tx- limited data to support• NCCN- chemo/RT should be considered in

except T1 or N0 pts

Surveillance- q 6mo

downstatesurgery.org

Literature supports aggressive resection for T1b or greater dz

Suspicious lesion should be done via open surgery

DL- useful in re-resections or advanced dzMore data needed on adjuvant txRadical surgery has improved chances for

cure

downstatesurgery.org

Restrospective analysis of pts referred to MSKCC with GBC from 1995-2005

Major therapeutic modality and only curative tx is surgery, despite this majority of pts will develop recurrence, therefore a strong rationale for adjuvant tx should be considered

Purpose: 1) most common mode of presentation of GBC over 10 yrs at MSKCC

2) describe their experience with adjuvant tx in pts after potentially curative surgery

downstatesurgery.org

Surgical details• Candidates for re-exploration after incidental

finding of GBC were:• Based on T-stage, performance status,

radiological staging, DL performed- if nometastatic dz

• Radical resection- porta hepatis, supraduodenal LN, and partial hepatectomy

• If no liver involvement- resection of segments 4b/5 and laparoscopic port sites (+/- biliary reconstruction)

• +

downstatesurgery.org

435 pts: 285 F, 150 M

Mean age 67

Path: adenocarcinoma 391pts (88%)

159 pts (37%)- stage IV dz206 pts (49%)- incidental

downstatesurgery.org

downstatesurgery.org

downstatesurgery.org

Decision based on MD and Pt discussion

23 pts with R0 resection received adjuvant therapy• 8 some form of adjuvant tx• 8 chemotherapy• 8 chemo/RT

downstatesurgery.org

downstatesurgery.org

GBC is a relatively uncommon dz with poor Px

Almost ½ the pts presented after incidental finding of the tumor

GBC occurs in <1% of laparoscopic cholecystectomies

Surgical re-exploration with radical resection proved beneficial

Unmet need for effective adjuvant tx

downstatesurgery.org

Lazcano-Ponce EC, Miquel JF, Munoz N, et al: Epidemiology and moleculte pathology of gallbladder cancer. CA: Cancer J Clin 2001; 51:349-364.

Fong Y.Jarnagin W, Blumgart LH: Gallbladder cancer: Comparison of patients presenting initially for definitive operation with those presenting after noncurative intervention. Ann Surgery 2000;232:557-569.

Donohue JH, Stewart AK, Menck HR: The National Cancer Data Base report on carcinoma of the gallbladder, 1989-1995. Cancer 1998;83:2618-2628

Department of Health and Human Services Centers for Disease Control and Prevention. National Health and Nutrition Examination Survey. Available at: www.cdc.gov/nchs/data/nhanes/databriefs/viralhep.pdf. Accessed: February 19, 2009.

downstatesurgery.org