Gallbladder cancer

39
Surgical Aspects of the Multidisciplinary Treatment of Gallbladder Cancer Eduardo A Guzman MD

Transcript of Gallbladder cancer

Page 1: Gallbladder cancer

Surgical Aspects of the Multidisciplinary Treatment of Gallbladder Cancer

Eduardo A Guzman MD

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“In malignancy of the gallbladder, when a diagnosis

can be made without exploration, no operation

should be performed, inasmuch as it only shortens

the patient’s life”

Alfred Blalock, 1924

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Introduction

•Aggressive malignancy

•Elderly patients

•Poor prognosis

•Many tumors are unresectable

•Distant metastasis

•Selected patients will benefit from an aggressive surgical

approach

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Epidemiology

• Rare tumor

• Incidence 2.5 cases per 100,000 residents

• Most common malignancy of the biliary tract

• 5th most common gastrointestinal malignancy

• 2 times more common in women

• More than 75 % are older than 65

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Epidemiology

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Etiology

• Chronic gallgladder irritation and inflammation

• Gallstones– Gallstones in 80 % GB

cancer

– GB cancer is 7 times more common in people with gallstones

• Porcelain gallbladder

• Primary sclerosing cholangitis• Polyp

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Gallbladder polyp

• > 1 cm increased incidence of cancer

• Treatment is laparoscopic cholecystectomy

• If mass do open choelcystectomy

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Pathology

Tumor Type Percent of Total

Adenocarcinoma 75.8

Papillary 5.8

Mucinous 4.6

Adenosquamous 3.6

Oat cell 0.5

Nonspecific 7.6

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Location

• Neck 10 %

• Body 30 %

• Fundus 60 %

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Lymphatic drainage of the gallbladder

• Cystic

• Pericholedocal

• Posterior pancreaticoduodenal

• Periportal

• Common hepatic artery nodes

• Celiac, interaortocaval, SMA

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Staging

• Multiple classifications

– Nevin– Japanese– AJCC / TNM

• Recent modification of AJCC / TNM

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T1 = Mucosal or muscular invasion

T2 = Transmural invasion

T3 = < 2 cm hepatic invasion

T4 = > 2 cm hepatic invasion

N0 = No lymph node involvement

N1 = Lymph node involvement within hepatoduodenal ligament

N2 = Lymph node involvement beyond hepatoduodenal ligament

M0 = No distant metastasis

M1 = Distant metastasis

AJCC / TNM 6th edition

a b

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T1a

T1b

T2

T3

T4

T stage

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Stage

I T1 N0 M0

T2 N0 M0

II T3 N0 M0

T1-3 N1 M0

III T4 N0 M0

IV Tx Nx M1

AJCC / TNM 6th edition

Limited to gallbladder

Local invasion

Locally advanced

Metastasis

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Other points

• Stage I includes 2

different surgical

therapies

• T4 tumors can be

resectable

• N2 nodes are

considered metastatic

disease

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Extent of disease on initial presentation

Stage

I 25 %

II - III 35 %

IV 40 %

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Laparoscopic cholecystectomy and positive margins

Mucosa

Submucosa

Muscularis

Serosa

Liver

During a laparoscopic cholecystectomy the plane of dissection is subserosal

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Clinical presentation

• Undistinguishable from benign gallstone disease– Right upper quadrant pain – Weight loss

– Anorexia

– Abdominal mass

• Yet, one should suspect gallbladder cancer in an elderly person with weight loss and constant pain

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Clinical syndromes

Chronic cholecystitis

32%

Acute Cholecystitis

16%

Malignant biliary obstruction

24%

Malignant non biliary tumors

24%

Other4%

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Diagnosis

• Usually diagnosed late in the disease course

• Ultrasound– Heterogeneous mass

– Irregular GB wall

– Sensitivity 70 – 100 %

• CT scan– Mass replacing the gallbladder or with direct extension

• MRI– Identifies plane between gallbladder mass and adjacent liver

• Cholagiography– Stricture of the common hepatic duct

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Incidental diagnosis

• It is the most common presentation

• Intraoperative

• Postoperative

– Pathology

• 1 % of all elective cholecystectomies for cholelithiasis harbor an occult GB cancer

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Management

• Depends on stage

• Do open cholecystectomy if cancer suspected pre-operatively

• Convert to open procedure if cancer identified intra-operatively

• Avoid bile spillage or tumor implantation into port sites

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Biopsy

• Risk of seeding cancer along the needle tract

• Worse with core biopsy

• Gallbladder cancer has a tendency to seed the peritoneum

• Percutaneous biopsy is indicated if disease has been determined to be unresectable and prior to initiation of chemotherapy

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Staging Laparoscopy

• Important consideration

• Staging modality

• Patients with incurable

disease can avoid a

laparotomy

• Yield 50 %

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Stage I

• T1a

– Disease limited to mucosa

– Almost always diagnosed following

cholecystectomy

– Negligible probability of lymph node metastasis

– Excellent survival 95 %

– No further intervention required

– Make sure cystic duct margin is negative for

tumor

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Stage I

• T1b

– Disease limited to muscularis

– Higher locoregional recurrence

– 5 year survival = 85 %

– Treatment remains controversial

– Selected patients (young and healthy) may benefit

from liver resection of segment IVb and V along

with local lymphadenectomy

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Couinaud Segments

Liver Anatomy

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Stage I

• T2– Transmural invasion– Positive margin after cholecystectomy

– Good probability for lymph node positivity

– Optimal patient for aggressive surgical intervention. 5 yr survival 18 % Vs 61 %

– Liver resection of segment IVb and V and lymphadenectomy

• Cystic• Pericholedochal • Portal

• Right celiac• Hepatic• Posterior pancreaticoduodenal

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Liver resection of segment IVb and V and lymphadenectomy

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Stage II

• T3N0 / N1 disease– Cancer invades into contiguous liver for less than

2 cm and/or has positive hepatoduodenal lymph nodes

– Tumor is still resectable

– High increased incidence of lymph node metastasis

– Ideal patient for staging laparoscopy

– Liver resection of segment IVb and V and lymphadenectomy

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Stage III

• T4N0MO

– Cancer invades into contiguous liver for more than

2 cm and negative lymph nodes

– Anecdotal evidence of resectability

– Extended liver resection

• Trisegmentectomy

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Some other important surgical considerations

• Resect port sites

• Avoid spillage of bile

• En bloc resection

• Do not hesitate to do

CBD resection

• Do anatomic liver

resections

• Tumors in the infundibulum may require a trisegmentectomy

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Adjuvant Chemotherapy

• 85 % of the recurrences occur in distant disease sites

• Minimal data

• Regimens

– 5 flouroracil

– Mitomycin C

– Gemcitabine

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LNLN+ + PatientsPatients

SEER National Database 1992 - 2002SEER National Database 1992 - 2002

YEARSYEARS

100

20

40

60

80

1 2 3 4 5

SUR

VIV

AL

%SU

RV

IVA

L %

RadiationRadiationNo RadiationNo Radiation

p <0.0001p <0.0001

11% 5yr11% 5yr04% 5yr04% 5yr

survival

Mojica, Smith and Ellenhorn 2006

Adjuvant Radiation

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Stage IV

• M1

– N2 lymph nodes

– Extrahepatic metastasis

– Chemotherapy

– Palliation

• Obstructive jaundice

• Pain

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• S Kim et al – Korea• 29 pts inoperable GB cancer• Median age 52 yrs• No complete responses• 34 % partial response• Time to progression = 3 months• Overall survival = 11 mo• Toxicity (3 or 4) = 17 %

• Tolerable combination• Modest response rates

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Survival

• Overall 5 yr survival 15 %

• T1a 95 %

• T1b 85 %

• T2

– Cholecystectomy 18 %

– Liver resection 60 %

• Stage IV

– Median survival 2 months

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Summary

• Gallbladder cancer is a bad disease

• Accurate staging is critical

• Cholecystectomy is an inadequate operation in most

of the cases

• T1a tumors have excellent prognosis

• Selected patients would obtain significant benefit

from aggressive surgical interventions

• Nearly all patients without metastatic disease require

surgical evaluation to determine resectability

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“In malignancy of the gallbladder, after careful

patient selection, an aggressive surgical approach

can have a significant impact in the patient’s life”

Eduardo Guzman, 2007