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Gallbladder

1. Screening

There are no effective means of screening for gall bladder cancer at this time.​

2. Diagnostic and Staging Workup

  • ​The diagnosis may be made by suspicious findings on work-up for suspected gallstone disease or unexplained abdominal pain
  • Diagnosis is often an incidental finding of pathology post-cholecystectomy.
  • If there appears to be an isolated lesion, refer to a hepatobilliary surgeon who will determine if the disease is resectable or unresectable and arrange for the appropriate investigations
  • Tissue diagnosis can be difficult to obtain 
  • Triphasic CT scan of the abdomen is recommended to assess extent of local involvement 
  • Contrast-enhanced MRI may also provide information on diagnosis and extent of disease
  • CT scan of the chest and pelvis are recommended to exclude distant metastases
  • The presence of a bile duct stricture and/or jaundice is an ominous feature
  • PET scan is not routinely recommended for staging purposes
  • Laparoscopy may be considered for staging
  • Recommend baseline tumour markers at diagnosis: CEA, CA 19-9

3. Primary Surgical Therapy

  • ​Surgical treatment of gall bladder cancer should be undertaken by hepatobiliary surgeons with expertise and experience with these tumours
  • For gall bladder cancer identified incidentally at the time of cholecystectomy:
    • pTis - pT1a, N0M0: no further therapy necessary
    • pT2 pT3, N0M0: partial hepatectomy with peri-portal lymph node dissection should be considered. Bile duct resection has not been shown to increase survival
    • pT1b: role of radical surgery is controversial but should be considered in otherwise healthy patients
    • pT4 or any T stage with N2 nodal involvement is generally considered a contraindication for surgery

4. Pathology

​(per College of American Pathologists 2012)

  • Specimen: specify 
    • Type
    • Procedure 
  • Tumour: specify 
    • Site 
    • Maximum tumor size
    • Histologic type
    • Histologic grade
    • Microscopic tumour extension
    • Margins
    • Lymph-Vascular invasion
    • Perineural invasion
    • pTNM (AJCC 7th edition)
      • Lymph nodes: number examined, number involved
    • Additional pathologic findings

6. Treatment Options

Treatment options are based on current evidence. 

Localized and potentially resectable disease

  • Primary surgery as described above
  • There is no  proven role for adjuvant chemotherapy or radiotherapy for completely resected early-stage gallbladder cancer

Unresectable or metastatic disease

  • Patients should be referred for consideration of palliative chemotherapy, clinical trials, and/or supportive care
  • Palliative radiotherapy may be a consideration for local symptoms (e.g. alleviation of pain bleeding or jaundice) 
  • Palliative chemotherapy can extend survival in appropriately selected patients and may help improve symptoms and quality of life 
  • Currently approved chemotherapeutic agents for unresectable biliary and gall bladder cancer include: gemcitablne, cisplatin, and 5-fluorouracil (5-FU)
    • The most commonly used regimens are:
      • gemcitabine and cisplatin (GIAVPG) 
      • gemcitabine (GIPGEM)
      • 5-FU and cisplatin (GIFUC)
      • single-agent 5-FU (GIAVFL)
    • The choice and sequence of chemotherapy is determined by disease-related factors, patient factors and patient preferences as assessed by the medical oncologist
  • Consider treatment on a clinical trial, if available
  • Symptom management, best supportive care, and involvement of palliative care services as indicated by patient’s clinical status

7. Follow-up

There is no evidence that routine imaging or laboratory investigations are useful in detecting recurrences or metastases at a stage where interventions are curative. Early detection of asymptomatic metastases does not enhance survival.

Investigations should be performed based the clinical presentation of a patient who is suspected of having recurrent or metastatic disease.​​
SOURCE: Gallbladder ( )
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