Joint Hospital Surgical Grand Round

Fifth most common cancer in gastrointestinal tract More frequent in women Age standardized incidence rate ~3/100,000

in Hong Kong (including biliary tract cancer)1

Most preoperatively suspected cases are unresectable Aggressive tumour biology Multiple mechanisms of disease spread Late presentation Overall 5-year survival of 3-13%2

1. Hospital Authority: Hong Kong Cancer Registry web site. www3.ha.org.hk/cancereg/e_stat.asp (accessed April 2012)

2. Jin K, Lan H, Zhu T, He K, Teng L. Gallbladder carcinoma incidentally encountered during laparoscopic cholecystectomy: how to deal with it. Clinical and Translational Oncology. 2011;13(1):25-33.

Incidental finding Mimicking benign biliary tract diseases

70% discovered incidentally by pathologist1

0.2-2.9% of all cholecystectomies2

Late presentation Biliary obstruction Palpable mass / Hepatomegaly Anorexia, weight loss Malignant ascites

1. Goetze TO, Paolucci V. Immediate re-resection of T1 incidental gallbladder carcinomas: a survival analysis of the German Registry. Surgical endoscopy. 2008;22(11):2462-5.

2. ToyonagaT, Chijiiwa K, Nakano K, Noshiro H, Yamaouchi K, Sada M, Terasaka R, Konomi K, Nishikata F, Tanaka M. Completion radical surgery after cholecystectomy for accidentally undiagnosed gallbladder carcinoma. World J Surg. 2003;27(3):266-71.

Routine blood tests Ultrasound CT MRI (MRCP/MRA)

Complete surgical removal of tumour is the only chance of cureNo truly effective chemotherapy or

radiotherapy Survival much higher if complete

removal achieved during first resection Treatment strategy depends heavily on

staging

Systematic review by SE Lee et al. (2011) No significant difference between

simple or extended cholecystectomy in terms of survival

Lymph node metastasis 1.8% Recurrence rate 1.1% Most studies showed 5-year survival

rate >90%

Simple cholecystectomy 5-year survival rate

of over 80% irrespective of surgical procedure1

10-year survival also comparable to extended cholecystectomy3

Extended cholecystectomy Frequent lymph node

metastasis 1 for T1b(11% in T1b VS 2% in T1a; p <0.01)

Some studies showed significantly higher 5-year survival rate 2

(79% VS 42%; p = 0.03)

Lower rate of recurrence 1

(12.5% VS 2.7%; p <0.01)

1. Lee SE, Jang J-Y, Lim C-S, Kang MJ, Kim S-W. Systematic review on the surgical treatment for T1 gallbladder cancer. World journal of gastroenterology : WJG. 2011;17(2):174-80.

2. Goetze, T. O., & Paolucci, V. Immediate re-resection of T1 incidental gallbladder carcinomas: a survival analysis of the German Registry. Surgical endoscopy. 2008;22(11), 2462-5.

3. Wakai T, Shirai Y, Yokoyama N et al. Early gallbladder carcinoma does not warrant radical resection. Br J Surg 2001;88:675-8.

Extent of operation Regional lymph node dissection Liver resection

Wedge resection of liver bedVariable resection margin

Formal segment IVb/V resection Right hepatectomy / extended right

hepatectomy No consensus on extent of liver resection

Morbidity 28%; Mortality 1.5%1

1. Lee SE, Jang J-Y, Lim C-S, Kang MJ, Kim S-W. Systematic review on the surgical treatment for T1 gallbladder cancer. World journal of gastroenterology : WJG. 2011;17(2):174-80.

Radical resectionLiver resectionRegional lymph node dissection

5-year survival of1

Simple cholecystectomy 10-61%Radical resection 54-100%

1. Jin K, Lan H, Zhu T, He K, Teng L. Gallbladder carcinoma incidentally encountered during laparoscopic cholecystectomy: how to deal with it. Clinical and Translational Oncology. 2011;13(1):25-33.

Long-term benefit of aggressive surgery unclear

Aggressive resection only considered if potentially curative resection is feasible

5-year survival 0-32%1 after radical surgery

Consider palliative care +/- metallic stenting if tumour not resectable

1. Jin K, Lan H, Zhu T, He K, Teng L. Gallbladder carcinoma incidentally encountered during laparoscopic cholecystectomy: how to deal with it. Clinical and Translational Oncology. 2011;13(1):25-33.

N1 N2

T1b →N12

T2/above → N1&2

Significantly lower survival for node positive disease(5-year survival, 58–77% vs. 0–45%)

1. Curley SA. The Gallbladder. In: Bast RC Jr, Kufe DW, Pollock RE, et al., editors. Holland-Frei Cancer Medicine. 5th edition. Hamilton (ON): BC Decker; 2000

2. Lai CHE, Lau WY. Gallbladder cancer--a comprehensive review. The surgeon : journal of the Royal Colleges of Surgeons of Edinburgh and Ireland. 2008;6(2):101-10. Available at: http://www.ncbi.nlm.nih.gov/pubmed/18488776.

Curley SA. The Gallbladder. In: Bast RC Jr, Kufe DW, Pollock RE, et al., editors. Holland-Frei Cancer Medicine. 5th edition. Hamilton (ON): BC Decker; 2000.

Jin K, Lan H, Zhu T, He K, Teng L. Gallbladder carcinoma incidentally encountered during laparoscopic cholecystectomy: how to deal with it. Clinical and Translational Oncology. 2011;13(1):25-33.

Jin K, Lan H, Zhu T, He K, Teng L. Gallbladder carcinoma incidentally encountered during laparoscopic cholecystectomy: how to deal with it. Clinical and Translational Oncology. 2011;13(1):25-33.

Aim at complete resection of the tumour

Individualized approach for different stage of disease and timing of diagnosis

Ongoing debate about management of T1b cancers and extent of lymphadenectomy, liver resection for each stage