Gallbladder carcinoma is the fifth most common neoplasm of the digestive tract and has an overall incidence of 3 per 100000 people.

1. CARCINOMA GALL BLADDER
‘A HISTOLOGICAL SURPRISE’
BY :- Prujal Parekh
Under guidance of –
Dr. P.R. Modi
Dr. A.G. Shah
Dr. M.B. Mehta
Dr. V.F. Chauhan

2. INTRODUCTION:-
• GALL BLADDER CARCINOMA (GBC) as an incidental finding has been
reported in 0.25%-3% patients and almost 50% of these are discovered
during or after laparoscopic cholecystectomy for benign pathology.
NOMENCLATURE :-
• GBC detected intraoperatively or on histology after cholecystectomy done
for presumably benign disease is termed as INCIDENTAL GBC (IGBC).
• If detected postoperatively, Simple Cholecystectomy- Index
Cholecystectomy

3. RULES TO BE FOLLOWED DURING
LAPAROSCOPIC CHOLECYSTECTOMY
1. Thorough pre-operative diagnosis.
2. When in doubt convert laparoscopic to open access.
3. Preserve integrity of gall bladder handle as little as possible.
4. Close possible breaches in wall of GB with clips
5. Use of endobag
6. Inspect GB once extracted .
7. Always go for histopathological diagnosis.
8. Examine liver surface.

4. • On gross examination 10%-35% GBCs cannot be diagnosed with certainty
as macroscopic findings are similar to those of chronic cholecystitis.
MACROSCOPIC EXAMINATON OF GB POST EXCISION:-
• Wall thickening >3mm
• Polyploidal lesions
• Mucosal ulcerations
None of the GB specimens without macroscopic abnormality have been
found to have GBC.

5. How to proceed in case of confirmatory
IGBC:-
• Review of the slide and block
• Consult GI PATHOLOGIST.
• Repeat evaluation in form of radiology
• Ask previous surgeon, review operative note.
• Refer if required to high volume centres

6. Reassessment of histological examination:-
1. Confirm pathological T stage.
2. Specify exact site of tumour (hepatic side , bottom , infundibulum).
3. Histology of cystic duct margin.
4. Evaluate cystic lymph nodes if included in the histological
examination.

9. REASSESSMENT FOR STAGING AND
RESECTABILITY :-
Essential to restage patient carefully by CT, MRI and PET with targeted
study of liver bed, peritoneum and orifices of trocars.
• One of the most difficult radiological survey- requires a
multidisciplinary team.
• CECT OF ABDOMEN AND PELVIS – standard for loco regional
extension and to detect distant metastasis. But low sensitivity for
lymphnode spread and peritoneal carcinomatosis.

10. MRI – promising for detecting CBD and Vascular invasion. Better sensitivity
for peritoneal metastasis as compared to CECT abdomen.
FDG-PET CT-sensitive for non clinically evident metastatic disease in GBC.
Can detect metastatic disease in 23% patients which has not seen in previous
studies. Important in detecting residual disease in the gall bladder bed.
Only limitation of FDG PET is small volume carcinomatosis and signet ring cell
tumors.

11. • However surgery should not be overly delayed to obtain this
information.
• NO ROLE OF TUMOUR MARKERS since there is no relation between
the staging and the value of tumour markers.
• NO ROLE OF EUS.
• SOME ROLE OF DIAGNOSTIC LAPAROSCOPY BEFORE REVISIONAL
SURGERY.

12. Don’t miss clinical examination!
• Nutritional status
• Virchow’s node
• Hepatomegaly
• RHC lump
• Scar site recurrence
• Ascites
• Per rectal examination for pelvic deposits

13. When to reoperate after Index
Cholecystectomy?
• In malignancy, tumour biology in addition to technical considerations
plays an important role in defining the optimal timing of reoperation.
• 4 to 8 weeks after the Index Cholecystectomy has been shown to be
the optimal time for resurgery and shows the maximum median
overall survival.
• Beyond 8 weeks, resurgery showsthe median survival is the least
owing to the aggressive nature of Carcinoma Gall Bladder.

14. • Resurgery before 4 weeks does not allow complete tumour evaluation
and staging.
• Inflammation in the operative field may make visualization of
important structures on cross sectional imaging nearly impossible in
the early post operative period.
• Can lead to unnecessary laparotomies for unresectable disease.

15. Another school of thought:
• To go for interval imaging i.e. imaging re-evaluation to be done 8
weeks after the surgery and resectabilitiy decided.
• Serum CA 19-9 also noted at the time of index cholecystectomy and
the time of re-evaluation.
• This was done to prevent the many laparotomies done in the early
resectional surgeries taken up which ended up being abandoned
because of unresectability.

16. Indications of Revisional Surgery:
- Grade 2 and 3 are the major indications of revisional surgery.
- Newer guidelines include T1b of Stage 1.
- Controversy exists whether to do revisional surgery in grade 4 IGBC-
super radical cholecystectomy. No added survival benefits.
- Nonsurgical Palliative Management.

17. Further stage wise plan of management:-
• Stage 0 and 1
• (Tis and T1A) – Simple Cholecystectomy is sufficient in such cases.
5 year survival- 90-95 percent
Only exception being if positive cystic duct margins on HPE.
Then complete resection of CBD with hepatico-jejunostomy with
regional lymphadenectomy should be done.

18. • If Tis is positive in cystic duct margins, should we proceed with CBD
resection?

19. T1b :-
Surgery- Radical Cholecystectomy
Radical cholecystectomy has been shown to confer 90% 5 year survival
as compared to 50% in cases with the simple cholecystectomy.
5 year survival- 70-90 %

20. T2 (STAGE 2):-
Why not simple cholecystectomy here?
Revisional surgery shows regional lymph node spread in 60 percent cases
and residual disease in 55 percent patients. (Even when the tumour has NOT
invaded the serosa of the gall bladder!).
Radical cholecystectomy with hepatic resection including gall bladder bed
(Glenn resection- 2-3 cm of GB bed) or anatomical
segmentectomy(resection of liver segment IVb and V and lymph nodes.
5 year survival rate- 70-90 %

21. T3 (Stage 3A/B): Surgery is tailored according to each patient.
Further more if Glisson’s capsule of right lobe is involved then right
hepatectomy should be done.
If isolated colonic involvement is seen then colonic resection can be
done to achieve R0 status.
Extension to hepatic flexure is not a contraindication to resection if
negative margin can be obtained.
Regional Lymphadenectomy is an integral part.
5 year Survival- 20-60 %

22. • T4 (Stage 4- N1/N2) - supra-radical cholecystectomy was considered
previously with multiple organ resection as well as liver resection.
• 5 year survival- 30 percent
Studies have shown that palliation in form of symptomatic
treatment is better.

23. Extended cholecystectomy directed towards R0 resection of disease include
resection of following draining lymph nodes :-
● Peri choledochal
● Periportal
● Hepatoduodenal
● If during surgery; pericoeliac; pericaval: peraaortic lymph nodes are
enlarged and frozen section is positive for metastasis- ABANDON and
PALLIATE NONSURGICALLY.

25. Port site involvement :-
In about 3 % of patients undergoing laparoscopic cholecystectomy,
unsuspected gall bladder carcinoma could be detected at
histopathology.
It has been suggested that patients undergoing laparoscopic
cholecystectomy are at increased risk of developing scar recurrence at
laparoscopic port sites compared to those undergoing open
cholecystectomy . (CO2 Pneumoperitoneum Theory)
Very rarely, the primary GBC may remain occult even at histopathology
and present later as port site metastasis. .

26. Functional imaging with 18F-flurodeoxyglucose (18F-FDG) positron
emission tomography/computed tomography (PET/CT) has been
employed for diagnosis of port site metastasis after laparoscopic
surgery.

27. Even though all port site resection is considered due to recurrences
data suggest that port site metastes suggest a more disseminated
problem which may not benefit from operative management.
When compared to stage matched patients who did not got port site
excision , NO DIFFERENCE in survival was found even among only R0
patients.

28. According to a study conducted by Fuks et al over 54 patients who
underwent portsite excision among which only 2 had port site
involvement.
The patients developed generalized peritoneal carcinomatosis after 7
months of reoperation and died of disease 8 months later.
Not only there was no difference in overall survival but also the study
reported 15% incidence of portsite incisional hernia at sites of
resection underscoring the potential morbidity of this procedure.

29. Analysis from French Registry(1998-2006)
• 218 patients with IGBC; 148 underwent radical resection.
• 54- Port site excision done
• 94- PSE not done
• Port site metastasis was found only in 1 patient who had T3 staging
and died with peritoneal metastasis 15 months after resection.
• No improvement in 5 year Overall Survival.
• 8 percent patients who underwent port site excision developed
Incisional Hernia.

30. Routine Port site exicision – MultiInstitution
Analysis from the US Extrahepatic Biliary
Malignancy Consortium
• 266 patients with IGBC- 193 underwent curative resection.
• 47 underwent – port site excision
• 146 did not.
• Both groups had comparable staging, demographics and operative
procedure.
• NO IMPROVEMENT IN 5 year OVERALL SURVIVAL in patients who
underwent PSE.

31. Adjuvant Therapy?
• Various chemotherapy agents such as 5-fluorouracil and capecitabine
are being utilized along or without radiotherapy.
• There have been NO prospective trials to show their benefit.

32. THANK
YOU