Speaker
Dr. Mohammed Abu Khair
IMO, SU-3
Chairman
Dr. Md. Ashraf Uddin
Associate professor, SU-3
Incidental gallbladder cancer
diagnosed during or after
laparoscopic cholecystectomy
with gallstone disease
Source:
Turk J Gastroenterol.
Author:
Volkan GENC, Elvan ONUR KIRIMKER,
Cihangir AKYOL, Akin Firat KOCAAY,
Ayea KARABORK, Acer TUZUNAR, Esra
ERDEN, Kaan KARAYALCIN.
Published on: 2011; 22 (5): 513-516.
Background:
Gallbladder cancer is a rare
neoplasm that is diagnosed
incidentally during or after
laparoscopic
cholecystectomy
performed for gallstone disease.
Introduction:
Gallbladder cancer is the fifth most common
cancer of gastrointestinal tract. About 15-30
% of patients show no pre and post-operative
evidence of gallbladder cancer.
Laparoscopic cholecystectomy (LC) is the
goldstandard treatment for gallstone disease
and the incidence of gallbladder cancer
following LC is 0.2- 2.85 %.
Risk factors:
1. Gallstone disease.
2. Porcelain gallbladder.
3. Sclerosing cholangitis.
4. Advanced age.
Risk factors (continue):
Ultrasound examination. Single large gallstone casting an
‘acoustic shadow’
Risk factors(continue):
Plain radiograph showing radio-opaque
stones in the gall bladder.
Risk factors (continue):
Porcelain gallbladder
Risk factors (continue):
Sclerosing cholangitis in a patient with
ulcerative colitis
Materials and Methods:
An observational (retrospective) study was
conducted on 5164 patients who underwent
laparoscopic cholecystectomy in the surgery
department of Ankara University Medical
Faculty from may 1999 to 2010.
Pre-operatively all patients were assessed by liver
function test (LFT), abdominal ultrasonography
of hepatobiliary system.
Materials and Methods:
Inclusion criteria:
Patients with gallstone disease undergoing
laparoscopic cholecystectomy.
Exclusion criteria:
Suspicion of malignancy and or gallbladder
polyp
detected
on
pre-operative
ultrasonography.
Materials and Methods:
Operative procedure:
All the operations were conducted by
senior surgeons and trainees under
supervision using four-port, two-hand
technique. Intraoperative cholangiogram
and drains were used where applicable.
Materials and Methods:
Operative procedure of laparoscopic Cholecystectomy
Materials and Methods:
Operative procedure (continue):
During surgical intervention gallbladder
was assessed, abnormal gallbladder
was found in 98 patients, in remaining
patients morphology of gallbladder
was normal.
Materials and Methods:
Operative procedure (continue):
Irregularity and nodularity of the
gallbladder wall was the suspicion of
cancer. No bag was used to extract
the gallbladder and there was no
evidence of port site metastasis.
Materials and Methods:
All the relevant information of the patients
regarding demography, operative procedure,
peri-operative outcome, histopathology,
follow-up was recorded in a pre-designed
data collection sheet. In the post-operative
period they were followed up with clinical
examination; serum CEA, CA 19-9 level;
ultrasound and CT scan.
Results:
Out of 5382 patients 5164 patients
were included in this study.
Patients with polyps (n=202) and
suspecion of malignancy (n=16)
before surgery were excluded from
this study.
Results (continue):
Mean age of the patients was 49.3
± 11.1 years (from 16-89 years)
and 3594 (69.6 %) patients were
female.
Male to female ratio was 1:2.3
Results (continue):
Out of 5164 patients adenocarcinoma was
diagnosed in only 5 (4 female and 1 male )
patients (0.09%).
Mean age of this group was 66.2±14.2 years
and was significantly higher in comparison
to the remaining population (p<0.001).
80% of the malignant patients were > 60
years of age.
Results (continue):
Age and sex distribution of Malignant patients:
Patient No.
1.
2.
3.
4.
5.
Age (years)
76
75
42
65
73
Sex
F
F
M
F
F
Diagnosis
Post-operatively
Post-operatively
Intra-operatively
Intra-operatively
Intra-operatively
Results (continue):
All the patients with adenocarcinoma
presented with cholecystitis without
jaundice. Three patients were converted
to open surgery as frozen section biopsy
reveled carcinoma.
Results (continue):
In two patients there was no suspicion
of malignancy intra-operatively but
routine histopathology report reveled
malignancy and they underwent only
LC due to low stage (pTis, pT1b) .
Results (continue):
Tumor staging was performed on
American Joint Committee on Cancer
(AJCC), 7th edition. Only one patient
had pTis, one had pT1b, pT2 in one and
pT3 in two patients. No patient had pT4
disease or metastasis.
Median survival rate was 32 months
(8.1- 68 months).
Results (continue):
Stage, operation and outcome of malignant
patients :
Stage
Operation
Outcome
pT1b
LC (no additional surgery)
No evidence of disease, 7m
pTis
LC (no additional surgery)
No evidence of disease, 22m
pT3
Converted from LC to OC + LBx +
LND
No evidence of disease, 52m
pT2
Converted from LC to OC + LBx +
LND
No evidence of disease, 32m
pT3
Converted from LC to OC + LBx +
LND
Died of MI, 15m
Results (continue):
One of the five patients died with
acute myocardial infarction, 15
months after operation without
recurrence. Remaining four patients
were alive without any complication.
Discussion:
Gallbladder carcinoma is not an uncommon
health problem with poor prognosis.
Incidence is highest in Woman from India,
Chile, and Pakistan. Incidence of
incidentally diagnosed gallbladder cancer is
up to 2.85% but recently the incidence has
raised. In this study this value was 0.09%.
Discussion (continue):
This was the lowest rate in the published
English literature, possible cause may be
due to diagnosis at advanced stage due to
avoidance of elective cholecystectomy.
Advanced age and female persons are more
susceptible to this type of deadly disease.
Discussion (continue):
In this study ratio of incidentally diagnosed
cancer in male and female is 1:4 and the
mean age of this group was significantly
higher in comparison to the remaining
patients. Median survival for this group
was 32 months (8.1- 68 months).
Discussion (continue):
Surgical resection of gallbladder carcinoma
depends upon the stage of the disease. One
patient with pTis and one patient with
pT1b underwent simple cholecystectomy.
Many
authors
advocated
only
cholecystectomy is sufficient for pT1a
tumor but necessity of further surgery for
pT1b is controversial.
Discussion (continue):
Staging (AJCC):
Primary tumor (T):
TX
Primary tumor can not be assessed.
T0
No evidence of primary tumor.
Tis
Carcinoma in situ.
T1
Tumor invades lamina propria or muscle layer.
T1a
Tumor invades lamina propria.
T1b
Tumor invades muscle layer.
T2
Tumor invades peri-muscular connective tissue, no extension beyond
serosa or liver involvement.
T3
Tumor perforates the serosa and invades the liver or other organs like
stomach, duodenum, colon, pancreas, omentum, extra hepatic bile
duct.
T4
Tumor invades portal vein, hepatic artery or at least two extra hepatic
organs.
Discussion (continue):
Staging (AJJCC):
Regional lymph node (N):
NX
N0
N1
N2
Regional lymph node can not be assessed.
No regional lymph node metastasis.
Metastasis to lymph nodes to cystic duct, common bile
duct, hepatic artery and/ or portal vein.
Metastasis to peri-aortic, peri-caval, superior mesenteric
artery and/ or celiac artery lymph node.
Discussion (continue):
Staging (AJJCC):
Distant metastasis (M):
M0
M1
No distant metastasis.
Distant metastasis.
Anatomic stage:
Stage
0
I
II
IIIA
IIIB
IVA
IVB
T
Tis
T1
T2
T3
T1-3
T4
Any T
Any T
N
N0
N0
N0
N0
N1
N0-1
N2
Any N
M
M0
M0
M0
M0
M0
M0
M0
M1
Discussion (continue):
For pT2 tumor liver resection and lymph
node dissection was mandatory and for
pT3 was also managed by same
procedure but long time survival rate was
only 5%. In this study only one patient
with pT2 and two patient with pT3
patient received same type of surgical
intervention.
Conclusion:
The incidence of incidentally diagnosed
carcinoma gallbladder vary from center to
center, up to 2.85%. Study conducted in the
department of surgery Ankara University
Medical Faculty the incidence rate was
0.09%. Female persons and aged persons are
more susceptible to this type of gravely
disease. But if diagnosed early prognosis is
better.