Management of Gallbladder Carcinoma
Complete surgical resection with cholecystectomy, en bloc hepatic resection, and lymphadenectomy represents the only curative treatment for gallbladder carcinoma, though only 10% of patients present with resectable disease. 1, 2
Preoperative Workup and Staging
Essential Imaging
- High-quality cross-sectional imaging (CT/MRI) to evaluate tumor penetration through gallbladder wall, direct organ invasion, vascular involvement, and nodal/distant metastases 1
- Chest imaging to exclude pulmonary metastases 1
- Staging laparoscopy is recommended before laparotomy for potentially curative resection to identify occult peritoneal or hepatic metastases and avoid unnecessary laparotomy 1
- PET scanning is increasingly useful for detecting distant metastatic disease in otherwise potentially resectable cases 1
Biliary Evaluation for Jaundiced Patients
- MRCP is preferred over ERCP or PTC unless therapeutic intervention is planned 1
- Preoperative biliary drainage should be considered selectively, though controversy exists regarding routine use 1
Tumor Markers
- CA 19-9 and CEA may be elevated but are not specific for gallbladder cancer 1
Surgical Management by Stage
Resectable Disease (T1b-T3 without distant metastases)
Surgical Approach:
- Cholecystectomy with en bloc hepatic resection and lymphadenectomy is the standard operation 1
- Hepatic resection should include segments IVb and V (wedge resection minimum) to achieve R0 margins 1
- Major hepatectomy should only be performed when necessary to remove disease, as it increases complications without independent survival benefit 1
Lymphadenectomy:
- Must include porta hepatis, gastrohepatic ligament, and retroduodenal regions 1
- Nodal disease beyond these regions (celiac, retropancreatic) indicates unresectable disease 1
Bile Duct Resection:
- Not routinely required but should be performed when necessary to achieve negative margins 1
- Consider if cystic duct margin is positive 3
Port Site Resection:
- Controversial; consider for laparoscopic cholecystectomy cases with bile spillage 4
Incidental Gallbladder Cancer
For T1a (confined to lamina propria):
- Simple cholecystectomy is adequate 3
For T1b-T3 disease:
- Re-resection is recommended with hepatic resection and lymphadenectomy 3
- Many patients will have residual disease at re-exploration 3
Unresectable or Metastatic Disease
First-Line Systemic Therapy:
- Gemcitabine plus cisplatin is the standard first-line regimen for advanced disease 5, 6
- Gemcitabine plus oxaliplatin is an alternative if cisplatin is contraindicated 5
Palliative Procedures:
- Biliary stenting via ERCP for symptomatic obstruction 5
- Metal stents preferred over plastic stents if life expectancy exceeds 6 months 5
- Surgical bypass has not been demonstrated superior to stenting 5
Second-Line Options:
- Fluoropyrimidine-based chemotherapy after progression 5
- Clinical trial enrollment 1
- Best supportive care 1
Postoperative Management
After R0 Resection with Negative Nodes
- Observation alone is acceptable 1
- Adjuvant fluoropyrimidine chemoradiation or fluoropyrimidine/gemcitabine chemotherapy may be considered 1
- Capecitabine adjuvant therapy can significantly improve survival 7
- Clinical trial enrollment is encouraged given limited data 1
After R1/R2 Resection or Positive Nodes
Multidisciplinary review required with options including: 1
- Additional resection if feasible 1
- Fluoropyrimidine chemoradiation (brachytherapy or external beam) followed by additional chemotherapy 1
- Fluoropyrimidine- or gemcitabine-based chemotherapy 1
Surveillance
- No data support aggressive surveillance protocols 1
- Consider imaging every 6 months for 2 years 1
- Re-evaluate according to initial workup if disease progression occurs 1
Critical Pitfalls to Avoid
- Attempting radical resection in presence of peritoneal spread - this represents stage IVB disease requiring systemic therapy, not surgery 5
- Performing major hepatectomy or bile duct excision unnecessarily when not required for R0 resection 1
- Delaying palliative chemotherapy while pursuing multiple surgical opinions in metastatic disease 5
- Neglecting biliary drainage in symptomatic obstruction 5
- Proceeding with definitive oncologic operation at initial cholecystectomy unless surgeon has appropriate hepatobiliary expertise 3