About Carcinoma of Gall Bladder

1. CARCINOMA OF GALL BLADDER
PRESENTER : BIBEK KARKI
UNIT III, GENERAL SURGERY
DATE : 3/1/2023

2. WHY A NIGHTMARE DISEASE FOR A CLINICIAN/ PATIENT
 Aggressive malignancy
 Late in presentation
 Lack of effective systemic chemotherapy
 Dismal prognosis

3. INCIDENCE
 More common in 6-7th decade
 F > M
 Ethnicity
 High incidence in Chile, North India
BLUMGART'S SURGERY OF LIVER, BILIARY TRACT AND PANCREAS, 6TH EDITION

4. RISK FACTORS
 Presence of gall stones
 Stone size > 3 cm
 Choledochal cyst
 APBJ
 PSC
 GB polyp > 1 cm
 Porcelain Gall bladder

5. ANATOMIC CONSIDERATIONS
 Gall Bladder partially intraperitoneal structure
 No peritoneal covering attached to side of liver
 Fibrous lining cystic plate --- occupies this space
 Simple cholecystectomy – Plane of muscularis of GB and cystic plate dissected
-- Inadequate resection for malignancy
 Body and fundus of GB – at a distance from major inflow structure to liver
 Infundibulum and cystic duct encroach porta hepatis
-- Tumors abut and involve portal structures.

6. HOW DOES IT SPREAD?
Spreads via
 Lymphatics
 Hematogenous
 Into peritoneal cavity
 Along surgical wound tracts or Bx
 Imp to analyze retropancreatic area
-- Radiologically
-- At surgery

7. WHY DOES IT INVADE AND METASTASIZE EARLY
 Gall bladder wall is thin.
 Contains a narrow lamina propria, single muscular layer.
 No serosal covering between the GB and liver
 Venous drainage of GB
-- includes direct venous tributaries into the liver parenchyma.

8. PATHOLOGY
Gross Morphology
 Infiltrative, nodular, papillary and
combined forms
 Most tumors – infiltrative pattern –
spread in subserosal plane
-- Can invade whole GB wall
and invade porta hepatis
 Papillary – better prognosis
Histopathology

9. VARIOUS DEFINITION IN CARCINOMA GALL
BLADDER

10. OBVIOUS
 Diagnosis apparent on - Clinical examination
- Radiological investigation

11. SUSPECTED
 USG or CT show focal, asymmetric, irregular GB wall thickening
 What if Diffuse, circumferential thickening ????

12. UNSUSPECTED/ UNEXPECTED
 No preoperative clinical/radiological suspicion of Ca GB
 Suspected during surgery for Gallstone
- Densely adherent omentum
- Contracted thick walled GB
- Obliterated Calot’ s triangle
- Difficult Gall bladder bed
- Ulcer, nodule or focal GB wall thickening on gross examination

13. UNSUSPECTED ( CONT’D)
ADVANCES IN SURGERY, INCIDENTAL GALL BLADDER CANCER, BEHARI A, KAPOOR VK

14. INCIDENTAL GB CARCINOMA
 Not suspected during surgery or even on gross examination
 Detected for the first time on histological examination.
 Approx 1% of all cholecystectomies.
 Rate higher in some subgroup of patients. Who ???

15. MISSED CA GB
 Routine histological examination didn’t reveal Ca GB
 But patient developed recurrence within few months.

16. STAGING OF CARCINOMA GALL BLADDER: AJCC 8TH EDITION

17. HOW DOES PATIENT PRESENT TO YOU
 Identified by final pathology after routine
cholecystectomy.
 Discovered intraoperatively
 Suspected before surgery
Asymptomatic – constant dull RUQ pain
Jaundice + anorexia + wt loss = Advanced
disease

18. RADIOLOGICAL INVESTIGATION
Ultrasonography
 Discontinuous mucosa, echogenic mucosa, submucosal echolucency.
 Doppler assessment of blood flow
-- Through area of mucosal abnormalities
 Intraluminal mass
 Asymmetric, focal thickening of GB wall

19. CROSS SECTIONAL IMAGING
 Info about local extent of disease
and distant metastasis
 Assessment of regional and distant
LN

20. WHEN DO YOU DO A TISSUE DIAGNOSIS
 Resectable – not required ??? / Not recommended ????
 Do it if
 Unresectable
 Neoadjuvant
 Major resection

21. WHY JAUNDICE IN CARCINOMA GALL BLADDER
? Pain/ painless
 Tumor in neck of GB infiltrating Hepatic hilum,
CHD, CBD
 Enlarged nodes in HDL causing CBD obstruction
 Multiple liver metastasis
 Associated CBD stones
 Intraductal spread from papillary tumor in GB

22.  Lower resectability
 Lower R0 resection rate
 Higher major hepatectomy
 Higher concurrent bile duct resection rate

23. RESECTABILITY
Resectable
 Confined to GB
 Infiltrating liver, colon and
omentum
 LN confined to HDL
Unresectable
 Hepatic artery, portal vein
 ? Pancreas ? Duodenum
 Distant LN ( aortocaval, celiac, sup
mesenteric)
 Multiple Liver Metastasis

24. ROLE OF INTERAORTOCAVAL LN BIOPSY
Routine 16 b1 LN bx prevented
 non therapeutic radical resection in 18.6 % of
pts deemed resectable on
-- preop imaging
-- Staging laparoscopy

25. EUS FOR IAC LYMPH NODE
 EUS assessment for IAC assessment and FNAC
-- Make sure it is IAC, not Retropancreatic
-- Avoids surgical procedure in IAC positive patients.

26. WHY IS STAGING LAPAROSCOPY DONE
 At laparoscopy, 34 (37%) out of 91 patients had
disseminated disease.
 Reduced surgical exploration and improve
resectability rate.

27. STAGING LAPAROSCOPY ( CONT’D)
 Yield of SL 23.22 % (95/409)
 Accuracy of SL for detectable lesion
94.06%(95/101)
 Accuracy of SL for unresectable disease 55.88%

28. EXTENDED CHOLECYSTECTOMY
Gall Bladder Lymphadenectomy
Hepatic Resection
+/- Associated
visceral/biliovascular involvement

29. J HEPATOBILIARY PANCREAT SCI. 2013 JUN

30. STANDARD LYMPHADENECTOMY

31. IS BILE DUCT EXCISION ESSENTIAL
 Not routinely
 Only if
 Direct involvement ( neck tumour )
 Positive cystic duct margin
 Choledochal cyst
 Extensive HDL lymphadenopathy

32. TREATMENT
4 subgroup of patients
 Gb polyp
 Incidental finding of GB cancer during or post-cholecystectomy
 Suspected gall bladder cancer preoperatively
 Advanced disease at presentation

33. GB POLYP
Consider cholecystectomy in
 Single polyp
 Size > 1 cm
 Age > 50 years.
 Co existing PSC

34. GB CANCER AFTER CHOLECYSTECTOMY
 Depends on depth of penetration of GB wall and Surgical margins.
 For T1a lesions – simple cholecystectomy suffice
 For T1 b – Cholecystectomy sufficient if cystic duct margin negative; debated
--Perineural, lymphatic and vascular invasion --- completion extended cholecystectomy
 T2 lesions – similar approach with Extended/ Radical cholecystectomy

35. SUSPECTED OF GALL BLADDER CANCER PREOPERATIVELY
 Go for curative resection if resectable and without metastatic disease
 Radical resection in setting of T3, T4
-- Also requires central hepatectomy with removal of IV, V & VIII.

36. ADVANCED STAGE: PALLIATIVE TREATMENT
 Palliate pain, jaundice and bowel obstruction.
 Endoscopic and percutaneous intervention – from symptoms of obs jaundice.
 Palliative chemotherapy – little benefit.
 EUS guided celiac block
 Endoscopic duodenal wall stent

38. ADJUVANT THERAPY
 Post resection R1/ 2
 R0 ( T3, N+)
 Papillary tumor
 Poor histologic features
 Bile spillage
 Systematic review of 27 articles
-- Moderate for CT
-- poor for CRT
-- Very poor for RT
MANTREOLA . HPB ( OXFORD) 2019; 21: 1427 -35

39. ANTICIPATORY EXTENDED CHOLECYSCTECTOMY
 Cholecystectomy adequate for AC< CC or XGC.
 If simple cholecystectomy performed for GBC
-- Breach in tumor planes and oncological
principles
 If EC is performed all TWGB – Overkill for
majority TWGB

40. PROSPECTS OF MINIMAL INVASIVE PROCEDURE

41. SURVIVAL
 Depends on stage of presentation and whether surgical resection performed
 Factors affecting survival -- T stage, N stage , histologic differentiation, CBD
involvement & R0 resection.
 Metastatic disease – median survival – 13 months