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Gallbladder

Disclaimer

  • This manual is not a substitute for consultation with an appropriate specialist.
  • The contents of this manual have been developed through consensus of a Provincial Tumour Group. Please note the various update dates for each section as some of the content of the manual may not be up to date.



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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