Gallbladder Cancer Treatment
Complete surgical resection with extended cholecystectomy (en bloc hepatic resection of segments IVb/V and regional lymphadenectomy) is the only curative treatment for resectable gallbladder cancer, while gemcitabine plus cisplatin is the standard systemic therapy for advanced/metastatic disease. 1
Surgical Management by Disease Stage
Incidentally Discovered T1a Disease
- Observation alone is appropriate if the gallbladder was removed intact with negative margins during cholecystectomy 2
- No additional resection is required for tumors limited to the lamina propria 2
T1b or Greater Disease (Muscle Layer Invasion or Beyond)
- Radical re-resection is mandatory after complete staging including laparoscopy to confirm resectability 2
- Staging must include high-quality CT/MRI, chest imaging, and staging laparoscopy before proceeding 1
- Extended cholecystectomy includes:
- Major hepatectomy should be avoided unless absolutely required for R0 resection, as it increases complications without independent survival benefit 2, 1
Unresectable Disease Criteria
- Nodal disease beyond porta hepatis/gastrohepatic/retroduodenal regions (celiac, retropancreatic, interaortocaval) indicates unresectability 2, 1
- Peritoneal spread represents stage IVB disease requiring systemic therapy, not surgery 1
Postoperative Management
After R0 Resection with Negative Nodes
- Observation alone is acceptable 2, 1
- Adjuvant fluoropyrimidine chemoradiation (except T1b, N0) or fluoropyrimidine/gemcitabine chemotherapy may be considered 2, 1
- Clinical trial enrollment is strongly encouraged given limited data 1
After R1/R2 Resection or Positive Nodes
- Multidisciplinary review is mandatory 1
- Options include:
Systemic Therapy for Advanced/Metastatic Disease
First-Line Treatment
- Gemcitabine plus cisplatin is the standard of care, providing approximately 3.6 months survival benefit over gemcitabine alone 3, 1
- Gemcitabine plus oxaliplatin is an alternative if cisplatin is contraindicated 1
Second-Line and Beyond
- Fluoropyrimidine-based chemotherapy after progression 1
- Clinical trial enrollment strongly encouraged 2, 1
- Best supportive care is appropriate when performance status declines 2, 1
Palliative Interventions
- Biliary stenting via ERCP for symptomatic obstruction 1
- Metal stents preferred over plastic if life expectancy exceeds 6 months 1
- Surgical bypass has not demonstrated superiority to stenting 1
Critical Staging and Preoperative Considerations
Mandatory Staging Components
- High-quality cross-sectional imaging (CT/MRI) to evaluate wall penetration, organ invasion, vascular involvement, and nodal/distant metastases 1
- Chest imaging to exclude pulmonary metastases 1
- Staging laparoscopy before laparotomy to identify occult peritoneal or hepatic metastases and avoid unnecessary laparotomy 2, 1
- PET scanning increasingly useful for detecting distant metastatic disease 1
Preoperative Biliary Drainage
- Should be considered selectively, not routinely 1
- Controversy exists regarding routine use, with some guidelines recommending avoidance except for acute cholangitis 2
Prognostic Information
Five-Year Survival by Stage
Median Survival for Advanced Disease
- Stage Ia-III: 12 months 2, 1
- Stage IV: 5.8 months 2, 1
- R0 resection status is the most important predictor of survival 1
Common Pitfalls to Avoid
- Never attempt radical resection in the presence of peritoneal spread (stage IVB disease requires systemic therapy) 1
- Do not perform major hepatectomy or bile duct excision unnecessarily when not required for R0 resection 2, 1
- Avoid delaying palliative chemotherapy while pursuing multiple surgical opinions in metastatic disease 1
- Do not neglect biliary drainage in symptomatic obstruction 1
- Surgery should only be performed by surgeons trained in cancer operations and after resectability is established 2