Gallbladder Cancer Flashcards
RF ?
- Chronic inflammation with subsequent development of neoplasia
- Presence of gallstones is considered to be the primary risk facto
» larger stones (>3 cm) carry an increased risk of cancer development - APBJ
- Choledochal cysts
- PSC
- Porcelain gallbladder ( occurring in less than 10% )
- Polyp larger than 10 mm
Gallbladder cancer spreads via
- lymphatics
- hematogenously
- notoriously into the peritoneal cavity
- or along biopsy or surgical wound tracts
Gross descriptions of gallbladder cancer
infiltrative, nodular, papillary, and combined forms
Most tumors have infiltrative pattern
> > spread in a subserosal plane
invade the entire gallbladder wall and even into the porta hepatis.
Nodular types
> > grow as a more circumscribed mass
invade the liver
papillary subtype
> > better prognosis
indolent course and are commonly limited to the gallbladder wall at the time of diagnosis
The first draining nodal basin for gallbladder cancer includes
the cystic and peri-choledochal nodes.
> > the primary drainage areas are the retroportal and pancreaticoduodenal notes.
so to properly stage a patient with gallbladder cancer
it is important to explore the retropancreatic area with a full Kocher maneuver at time of surgery
Why Gb cancer can invade the liver early ?
The gallbladder wall is thin, contains a narrow lamina propria, and is only a single muscular layer with no serosal covering between it and the liver.
they can spread to which segment directly ?
> > venous drainage of the gallbladder includes direct venous tributaries into the liver parenchyma, these tumors may spread directly into segment IV of the liver.
> > Transperitoneal spread is also common and can progress to carcinomatosis.
Why most GB cancer dont produce Symptoms till advanced ?
Because 90% of gallbladder cancers originate in the fundus or body
what tumor markers might be elevated ?
Carcinoembryonic antigen
carbohydrate antigen 19-9
may be elevated in gallbladder cancer
Ultrasonography Features
> > irregularly shaped lesion in the subhepatic space
heterogeneous mass in the gallbladder lumen
asymmetrically thickened gallbladder wall
polyp larger than 10 mm should raise the suspicion of gallbladder cancer.
CT and MRI , PET CT
> > demonstrate peritoneal metastases
hepatic parenchymal metastases
lymphadenopathy
adjacent vascular involvement
Should you do Bx ?
- If the diagnosis is suspected, the surgeon and patient must be prepared for a definitive operation.
> > In the setting of unresectability (vascular encasement or extensive hepatic involvement) or incurability (hepatic or peritoneal metastases), a biopsy for confirmatory tissue diagnosis should be used
Remember»_space; tendency to seed biopsy tracts
which type of Gallbladder polyp has high rate of malignancy ?
adenomatous polyps
The most consistent predictors of malignancy in gallbladder polyps are
single polyp
size greater than 1 cm
age older than 50 years
Polyps smaller than 1 cm ?
> > undergo surveillance to demonstrate stability
with the exception in the setting of PSC
Post Cholecystectomy , With T1a lesions
carcinoma penetrates the lamina propria but does not invade the muscle layer
» cholecystectomy suffices for therapy
» The cystic duct margin should be reviewed to ensure a negative margin, and sometimes, it is necessary to resect the CBD to obtain a negative margin
Risk of Nodal Disease < 3 %
T1b lesions
> > penetrating the muscularis but not the deeper connective tissue or serosa
> > With T1b lesions and perineural, lymphatic, or vascular invasion, the likelihood of nodal disease increases significantly.
Therefore, extended cholecystectomy is generally recommended for all patients who are medically fit with T1b or greater level of invasion.
The extended cholecystectomy
> > obtaining an R0 resection
draining lymph node basins.
removal of the hepatoduodenal, gastrohepatic, and retroduodenal lymph nodes should be included.
Resection of the cystic duct margin to uninvolved mucosa may require resection of the CBD with Roux-en-Y reconstruction.
2 cm of apparently normal hepatic parenchyma from the gallbladder fossa is resected
T2 lesions
> > the cancer extends past the muscularis but not beyond the serosa, a similar approach with radical cholecystectomy
in the setting of T3 and T4 lesions
> > Radical resection
at least segments IVB and V
May require a central hepatectomy, including all of segments IV, V, and VIII.
To achieve R0 margin status in large tumors, a right trisegmentectomy may be required.
Direct extension of tumor into adjacent structures such as the hepatic flexure is not a contraindication to resection as long as negative margins can be obtained and all disease resected.
Patients with advanced disease at presentation
- Jaundice»_space; endoscopic biliary stenting, and self-expanding endobiliary metal stents can provide a durable solution
- Oral Narcotics
- IV Narcotics
- Percutaneous neurolysis of the celiac ganglion can help with the palliation of pain.
- Intestinal obstruction is usually gastric outlet obstruction»_space; endoscopic duodenal wall stent
