Gallbladder Cancer: expert consensus statement

Abstract

An American Hepato-Pancreato-Biliary Association (AHPBA)-sponsored consensus meeting of expert panellists was convened on 15 January 2014 to review current evidence on the management of gallbladder carcinoma in order to establish practice guidelines. In summary, within high incidence areas, the assessment of routine gallbladder specimens should include the microscopic evaluation of a minimum of three sections and the cystic duct margin; specimens with dysplasia or proven cancer should be extensively sampled. Provided the patient is medically fit for surgery, data support the resection of all gallbladder polyps of >1.0 cm in diameter and those with imaging evidence of vascular stalks. The minimum staging evaluation of patients with suspected or proven gallbladder cancer includes contrasted cross-sectional imaging and diagnostic laparoscopy. Adequate lymphadenectomy includes assessment of any suspicious regional nodes, evaluation of the aortocaval nodal basin, and a goal recovery of at least six nodes. Patients with confirmed metastases to N2 nodal stations do not benefit from radical resection and should receive systemic and/or palliative treatments. Primary resection of patients with early T-stage (T1b-2) disease should include en bloc resection of adjacent liver parenchyma. Patients with T1b, T2 or T3 disease that is incidentally identified in a cholecystectomy specimen should undergo re-resection unless this is contraindicated by advanced disease or poor performance status. Re-resection should include complete portal lymphadenectomy and bile duct resection only when needed to achieve a negative margin (R0) resection. Patients with preoperatively staged T3 or T4 N1 disease should be considered for clinical trials of neoadjuvant chemotherapy. Following R0 resection of T2-4 disease in N1 gallbladder cancer, patients should be considered for adjuvant systemic chemotherapy and/or chemoradiotherapy.

Incidental Gallbladder Cancer

“…Diagnostic laparoscopy prevented unnecessary laparotomy in 27.6% of these cases, with a mortality rate of 0.09% and morbidity of 0.37%. These data indicate that staging laparoscopy prior to laparotomy, which can be performed within the same seting, is the recommended procedure for all GBC cases [41].…”

“…In contrast, T3 disease with direct involvement of the duodenum, colon, or liver does not preclude resectability if R0 en-bloc resection can be achieved safely [41]. It is not considered a contraindication even though it is an indicator of aggressive disease and carries the increased possibility of lymph node involvement, which results in poor survival outcomes.…”

“…This concern makes open cholecystectomy the standard of care if the surgeon cannot guarantee an adequate resection with no spillage during laparoscopy [41].…”

“…Extended cholecystectomy and lymphadenectomy improve cancer-speciic survival and are recommended over cholecystectomy alone [41,49] mainly because of the high risk of Incidental Gallbladder Cancer http://dx.doi.org/10.5772/67654 85 lymph node metastasis (11.5%) in GBC T1b. The recurrence rate after simple cholecystectomy is higher than that after extended cholecystectomy (12.5 vs. 2%, respectively) [41,50]. However, this survival beneit has been debated in the literature, and simple cholecystectomy is considered suicient for GBC T1b, especially in eastern countries [51].…”

“…Furthermore, major hepatectomies are associated with higher morbidity rates than partial hepatectomies are, with no added survival beneit [56][57][58]. Therefore, achieving R0 with limited liver resection and fewer complications is the recommended procedure for GBC [26,41].…”