Implications of the Index Cholecystectomy and Timing of Referral for Radical Resection of Advanced Incidental Gallbladder Cancer

Abstract

INTRODUCTION Advanced (pT2/T3) incidental gallbladder cancer is often deemed unresectable after restaging. This study assesses the impact of the primary operation, tumour characteristics and timing of management on re-resection. METHODS The records of 60 consecutive referrals for incidental gallbladder cancer in a single tertiary centre from 2003 to 2011 were reviewed retrospectively. Decision on re-resection of incidental gallbladder cancer was based on delayed interval restaging at three months following cholecystectomy. Demographics, index cholecystectomy data, primary pathology, CA19-9 tumour marker levels at referral and time from cholecystectomy to referral as well as from referral to restaging were analysed. RESULTS Thirty-seven patients with pT2 and twelve patients with pT3 incidental gallbladder cancer were candidates for radical re-resection. Following interval restaging, 24 patients (49%) underwent radical resection and 25 (51%) were deemed inoperable. The inoperable group had significantly more patients with positive resection margins at cholecystectomy (p=0.002), significantly higher median CA19-9 levels at referral (p=0.018) and were referred significantly earlier (p=0.004) than the patients who had resectable tumours. On multivariate analysis, urgent referral (p=0.036) and incomplete cholecystectomy (p=0.048) were associated significantly with inoperable disease following restaging. CONCLUSIONS In patients with incidental, potentially resectable, pT2/T3 gallbladder cancer, inappropriate index cholecystectomy may have a significant impact on tumour dissemination. Early referral of breached tumours is not associated with resectability.

Systematic review of management of incidental gallbladder cancer after cholecystectomy

“…The proportion of patients with unresectable advanced disease at reoperation varies, but the systematic review by Choi and colleagues reported an overall pooled rate of 23 per cent. Some recent studies from the UK suggest the unresectability rate is twice as high, at about 50 per cent.…”

“…The unexpected finding of a cancer comes with a sense of urgency for both treating surgeon and patient, and, even from the side of the receiving centre of the referral, urgent or even emergency transfers may occur after the diagnosis is confirmed. However, there are few data to support a need for an emergency referral and immediate redo surgery if an incidental cancer is detected, although the timing of surgery remains debated. In several studies, the unresectability rate at restaging (before redo surgery) is as high as 50 per cent for incidental cancers, despite early referral.…”

“…However, there are few data to support a need for an emergency referral and immediate redo surgery if an incidental cancer is detected, although the timing of surgery remains debated. In several studies, the unresectability rate at restaging (before redo surgery) is as high as 50 per cent for incidental cancers, despite early referral. Indeed, in one study early referral was a strong predictor of unresectability.…”

“…In several studies, the unresectability rate at restaging (before redo surgery) is as high as 50 per cent for incidental cancers, despite early referral. Indeed, in one study early referral was a strong predictor of unresectability. Together, this may suggest that biology, rather than time, is the most essential factor for progression of disease.…”

“…In particular, if perforation occurred during first operation, a period of observation may be allowed, as perforation may be associated with higher risk of disease dissemination and poor survival. Early surgery is not associated with an improved outcome if the cancer has spread beyond the resection planes of the initial surgery 75 . In a large multicentre study 35 , the investigators found inferior outcomes for patients treated within the first 4 weeks of the primary operation, and also for those treated more than 8 weeks after surgery; a 4-8-week window had the best outcome.…”