Treatment of Biliary Tract Cancers
Gallbladder Cancer
Case Presentation
A 57-year-old woman from Chile presents with a 3-week history of progressive right upper quadrant abdominal pain. She denies nausea, vomiting, dysphagia, odynophagia, alterations in bowel habits, fever, or jaundice. Her past medical history is significant for obesity and hypertension. She has no history of smoking, alcohol, or illicit drug use. Laboratory studies show marked leukocytosis (23,800/µL) with neutrophilia (91%). Liver function test results are within normal limits. Ultrasound of the abdomen reveals gallbladder wall thickening and cholelithiasis.
The patient undergoes an uneventful laparoscopic cholecystectomy and is discharged from the hospital after 48 hours. Pathology report reveals a moderately differentiated adenocarcinoma of the gallbladder invading the perimuscular connective tissue (T2). No lymph nodes are identified in the specimen.
- What is the appropriate surgical management of gallbladder cancer?
Gallbladder cancer can be diagnosed preoperatively or can be found incidentally by intraoperative or pathological findings. In one large series, gallbladder cancer was incidentally found during 0.25% of laparoscopic cholecystectomies.67
For patients who are diagnosed with previously unsuspected gallbladder cancer by pathology findings, the extent of tumor invasion (T stage) indicates the need for re-resection (Figure 3).64
Alternatively, when gallbladder cancer is documented or suspected preoperatively, adequate imaging is important to identify patients with absolute contraindications to resection. Contraindications to surgery include metastasis, extensive involvement of the hepatoduodenal ligament, encasement of major vessels, and involvement of celiac, peripancreatic, periduodenal, or superior mesenteric nodes.72 Notwithstanding, retrospective series suggest individual patients may benefit, and surgical indications in advanced disease should be determined on an individual basis.73 Staging imaging should be obtained using multiphasic contrast-enhanced CT or MRI of the chest, abdomen, and pelvis. PET-scan can be used in selected cases where metastatic disease is suspected.64 Laparoscopic diagnostic staging should be considered prior to resection.64 This procedure can identify previously unknown contraindications to tumor resection in as much as 23% of patients, and the yield is significantly higher in locally advanced tumors.73
Patients with a diagnosis of potentially resectable, localized gallbladder cancer should be offered definitive surgery. Extended cholecystectomy is recommended for patients stage T2 or above. This procedure involves wedge resection of the gallbladder bed or a segmentectomy IVb/V and lymph node dissection, which should include the cystic duct, common bile duct, posterior superior pancreaticoduodenal lymph nodes, and those around the hepatoduodenal ligament.72 Bile duct excision should be performed if there is malignant involvement.64
Conclusion
BTCs are anatomically and clinically heterogeneous tumors. Prognostic factors and therapeutic approaches for BTCs differ depending upon their location in the biliary tree and, accordingly, TNM classification systems for intrahepatic, hilar, and distal cholangiocarcinoma and gallbladder cancer have been separated. Surgical resection is the only potentially curative treatment for localized BTC. However, recurrence following complete resection is a primary limitation for cure, which provides a rationale for the use of adjuvant therapy. The prognosis of patients with advanced BTC is poor and OS for those undergoing supportive care alone is short. Multiple randomized clinical trials have demonstrated a benefit of chemotherapy for metastatic disease. For patients with adequate performance status, second-line therapy can be considered, and data from studies that evaluated targeted therapy for specific molecular subgroups is promising.
