What are the treatment options for gallbladder cancer, specifically the role of surgical intervention (e.g. cholecystectomy) versus interventional radiology (e.g. transcatheter arterial chemoembolization (TACE))?

Gallbladder Cancer Treatment: Surgery is Primary, Interventional Radiology is Palliative

Gallbladder cancer is definitively managed by surgical gastroenterology, as surgery remains the only curative treatment modality; interventional radiology plays a supportive role limited to palliation of unresectable disease through biliary stenting and, in select cases, transarterial therapies. 1, 2

Primary Treatment Approach

Surgical Management is the Gold Standard

Surgery is the only treatment that can provide cure and long-term survival for gallbladder cancer. 1, 2 The surgical approach depends entirely on tumor stage:

• T1a tumors: Simple cholecystectomy alone is sufficient 2, 3, 4
• T1b and beyond: Extended cholecystectomy with en bloc hepatic resection (minimum segments IVb and V) and regional lymphadenectomy is required 2, 5
• Lymphadenectomy must include: Porta hepatis, gastrohepatic ligament, and retroduodenal regions 1, 2
• Nodal disease beyond these regions (celiac, retropancreatic, interaortocaval) indicates unresectable disease 1, 2

The evidence strongly supports radical resection. Patients undergoing radical cholecystectomy have median survival of 24 months versus only 6 months with simple cholecystectomy and 4 months with noncurative treatment. 5 Five-year survival rates by stage are: 60% (stage 0), 39% (stage I), 15% (stage II), 5% (stage III), and 1% (stage IV). 1, 2

Critical Surgical Principles

Major hepatectomy and bile duct excision should only be performed when necessary to achieve R0 resection, as they significantly increase complications without independent survival benefit. 1, 2 The goal is microscopically negative margins while maintaining adequate future liver remnant. 1

Staging laparoscopy is mandatory before laparotomy to identify occult peritoneal or hepatic metastases and avoid unnecessary laparotomy. 1, 2 This detects dissemination not otherwise found in 20-28.6% of cases. 6

Role of Interventional Radiology

Limited to Palliative Care

Interventional radiology has no curative role in gallbladder cancer management. Its applications are strictly palliative:

Biliary Stenting (Primary IR Role)

• ERCP with stent placement is the preferred palliative treatment for symptomatic biliary obstruction in unresectable disease 2, 7
• Metal stents are preferred over plastic stents if life expectancy exceeds 6 months 2, 7
• Surgical bypass has not been demonstrated superior to stenting 2, 7
• Stenting improves survival and quality of life compared to other palliative procedures 7

Transarterial Therapies (Not Standard for Gallbladder Cancer)

The evidence provided discusses TACE and radioembolization primarily for cholangiocarcinoma, not gallbladder cancer. 1, 8 These modalities are not established treatments for gallbladder carcinoma and should not be confused with the standard approach.

Treatment Algorithm by Resectability

Resectable Disease (15-30% of patients at diagnosis)

1. Staging laparoscopy first 1, 2
2. If no metastases: Proceed with surgical resection (cholecystectomy + hepatic resection + lymphadenectomy) 1, 2
3. Postoperative management: Observation after R0 resection with negative nodes, or adjuvant chemotherapy/chemoradiation for R1/R2 or node-positive disease 2

Unresectable or Metastatic Disease

1. Systemic chemotherapy: Gemcitabine plus cisplatin is standard first-line treatment 2
2. Biliary stenting via ERCP for symptomatic obstruction 2
3. Best supportive care as appropriate 2

Common Pitfalls to Avoid

• Do not perform laparoscopic cholecystectomy when malignancy is suspected, as gallbladder perforation and bile spill lead to tumor dissemination 3
• Do not attempt radical resection in the presence of peritoneal spread (stage IVB), which requires systemic therapy, not surgery 2
• Do not delay palliative chemotherapy while pursuing multiple surgical opinions in metastatic disease 2
• Do not perform routine preoperative biliary drainage except for acute cholangitis 2, 7

Key Prognostic Factors

R0 resection status is the most important predictor of survival. 2 In a retrospective analysis, 74% of patients who underwent surgical re-exploration after incidental diagnosis had residual cancer, emphasizing the importance of adequate initial resection. 1