What is the standard treatment for gallbladder cancer?

Standard Treatment for Gallbladder Cancer

The standard treatment for gallbladder cancer is surgical resection with cholecystectomy, en bloc hepatic resection, and lymphadenectomy with or without bile duct excision, as this is the only potentially curative treatment option. 1

Treatment Algorithm Based on Stage

Early Stage Disease

• T1a (tumor invades lamina propria):

  • Simple cholecystectomy is sufficient if margins are negative 1
  • No further treatment needed if incidentally found with negative margins 1
  • 5-year survival rate: approximately 60% 1

• T1b (tumor invades muscle layer):

  • Extended cholecystectomy recommended 1, 2
  • Radical re-resection highly recommended if found incidentally 1

Advanced Resectable Disease

• T2 or greater:
  • Extended cholecystectomy including:
    • En bloc hepatic resection (wedge resection of GB bed or segmentectomy IVb/V) 1, 2
    • Lymphadenectomy of porta hepatis, gastrohepatic ligament, and retroduodenal regions 1
    • With or without bile duct excision 1
  • 5-year survival rates: 39% for T2, 15% for T3, 5% for T4 1

Unresectable Disease

• Locally advanced/borderline resectable:

  • Neoadjuvant chemotherapy (gemcitabine plus cisplatin) with potential for conversion to resectable status 3, 4
  • Response rate to neoadjuvant therapy: approximately 52.5% 4

• Metastatic disease:

  • Palliative chemotherapy (gemcitabine-based or fluoropyrimidine-based) 1, 5
  • Biliary drainage for jaundice before chemotherapy 1
  • Median survival: approximately 5.8 months 1

Surgical Considerations

Pre-operative Assessment

• Complete staging with CT/MRI, chest imaging 1
• Staging laparoscopy recommended before laparotomy (high yield for detecting metastases) 1, 5
• Surgery should only be performed by surgeons experienced in cancer operations 1

Lymphadenectomy Extent

• Should include lymph nodes in:
  • Porta hepatis
  • Gastrohepatic ligament
  • Retroduodenal regions 1, 2
• Nodal disease outside these areas (celiac, retropancreatic, interaortocaval) indicates unresectable disease 1

Adjuvant Therapy Options

For patients with resected disease:

• Fluoropyrimidine chemoradiation (except T1b, N0) 1
• Fluoropyrimidine or gemcitabine chemotherapy 1, 6
• Particularly beneficial for:
  • Locally advanced disease (T3/T4)
  • Node-positive disease
  • R1 resection (positive margins) 6

Common Pitfalls to Avoid

1. Inadequate surgical approach: Surgery should be performed by surgeons experienced in cancer operations 1

2. Inappropriate surgical extent: Major hepatectomy and bile duct excision should only be performed when necessary to remove disease, as they increase complications 1

3. Missing residual disease: 74% of patients with incidental gallbladder cancer found after laparoscopic cholecystectomy have residual disease when re-explored 1

4. Inadequate staging: Failure to perform staging laparoscopy before attempting curative resection 1, 5

5. Delaying biliary drainage: In patients with unresectable disease and jaundice, biliary drainage should be performed before chemotherapy 1

The prognosis for gallbladder cancer remains poor, with overall 5-year survival rates highly dependent on stage at diagnosis. Surgical resection with negative margins offers the best chance for long-term survival and cure.