Treatment of Gallbladder Cancer
Surgical resection with extended cholecystectomy including en bloc hepatic resection and lymphadenectomy is the cornerstone of curative treatment for resectable gallbladder cancer, with treatment strategy determined by tumor stage at diagnosis. 1, 2
Surgical Management by Stage
T1a Tumors (Lamina Propria Invasion)
- Simple cholecystectomy alone is curative and no further resection is needed if the gallbladder was removed intact with negative margins 1, 2
- Observation only is recommended after complete removal 1
T1b Tumors (Muscle Layer Invasion) and Beyond
- Radical re-resection is highly recommended after complete staging including laparoscopy to confirm resectability 1
- Extended cholecystectomy must include en bloc hepatic resection and lymphadenectomy with or without bile duct excision 1, 2
- Lymphadenectomy should encompass lymph nodes in the porta hepatis, gastrohepatic ligament, and retroduodenal regions 1
- Nodal disease beyond these areas (celiac, retropancreatic, or interaortocaval) renders the tumor unresectable 1
Incidental Findings During Surgery
- When gallbladder cancer is discovered intraoperatively, immediate staging must be performed and extended cholecystectomy considered based on surgeon expertise and resectability 1
- Frozen section of the gallbladder should be obtained 1
Staging Requirements Before Treatment
Complete staging is mandatory and must include:
- Complete history, physical examination, blood counts, and liver function tests 1, 3
- Chest X-ray or CT chest 3, 2
- Abdominal imaging with CT or MRI 1, 3
- Laparoscopy to detect peritoneal or superficial liver metastases (present in 10-20% at presentation) 3, 2
- Endoscopic retrograde or percutaneous transhepatic cholangiography when indicated 1, 3
Adjuvant and Additive Therapy
After Curative Resection
- Fluoropyrimidine-based chemoradiation should be considered for all stages except T1b N0 disease, given the 52% local failure rate after surgical resection 1
- Fluoropyrimidine or gemcitabine chemotherapy is an option 1
- Fluorouracil has been the traditional agent for chemoradiotherapy, though gemcitabine with or without oxaliplatin has shown feasibility 1
After Noncurative Resection
- Additive fluorouracil-based chemotherapy provides a small survival benefit 1
- Both supportive care and palliative chemotherapy/radiotherapy may be considered 1
Treatment of Unresectable Disease
Biliary Drainage
- Biliary drainage via endoscopic or percutaneous stenting should be performed before chemotherapy if technically feasible, as it improves quality of life 1, 4
- Metal stents are preferred over plastic stents when life expectancy exceeds 6 months 4
- Urgent biliary drainage with broad-spectrum antibiotics is crucial for cholangitis 1
- MRCP planning before stent placement may reduce post-procedure cholangitis risk in complex cases 2, 4
Systemic Chemotherapy
- Gemcitabine combined with platinum compounds (particularly cisplatin) is the standard palliative chemotherapy, offering improved quantity and quality of life 1
- This combination demonstrated the highest rates of objective response and tumor control in advanced biliary cancer 1
- Concurrent chemoradiation is an additional option for localized unresectable disease 1
Prognosis and Critical Considerations
Even with aggressive surgery, 5-year survival rates are only 5-10% for gallbladder cancer 1
Common Pitfalls to Avoid
- Do not perform surgery when resectability has not been established through complete staging 1, 2
- Surgery should only be performed by surgeons trained in hepatobiliary oncology 1
- Lymph node involvement is present in 50% of patients at presentation and portends poor surgical outcomes 3, 2
- Peritoneal and distant metastases are present in 10-20% at presentation, representing stage IVB disease 3, 2
- Inadequate biliary drainage increases sepsis risk and compromises surgical outcomes 2