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Essential Features

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  • • 5% overall survival

    • Risk factors

    • –Gallstones (70–90% of patients have gallstones)

      –Native American heritage

      –Stones > 3 cm (10-fold increased risk)

      –Porcelain gallbladder (at least 25% develop cancer)

      –Choledochal cyst

      –Gallbladder adenoma > 1 cm

    • 0.5% of patients with cholelithiasis have adenocarcinoma

    • 1% of patients undergoing elective cholecystectomy have unsuspected adenocarcinoma identified

    • Only 25% of patients have chance for curative resection

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Epidemiology

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  • • 6000–7000 cases annually

    • 3:1 female:male ratio

    • Peak incidence in seventh decade

    • Risk is at least 5% among Native Americans who have gallstones

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Clinical Findings

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Symptoms and Signs

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  • • Biliary colic or cholecystitis

    • Jaundice

    • Weight loss

    • Anorexia

    • Palpable right upper quadrant mass

    • Hepatomegaly

    • Ascites

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Laboratory Findings

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  • • Leukocytosis

    • Hyperbilirubinemia

    • Elevated alkaline phosphatase

    • Elevated transaminases

    • Elevated carcinoembryonic antigen (CEA)

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Imaging Findings

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  • Right upper quadrant US

    • –Gallbladder inflammation and/or gallstones

      –Occasional gallbladder mass

      –Portal or cystic lymphadenopathy

      –Dilated common bile duct (CBD)

      –Direct tumor extension into liver

    CT or MRI

    • –Gallbladder mass (90% sensitive) with occasional portal lymphadenopathy

      –Hepatic extension of tumor

    ERCP or percutaneous transhepatic cholangiogram (PTC)

    • –Intraluminal gallbladder mass

      –Occasional CBD dilatation

      –Intraluminal extension of tumor

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Diagnostic Considerations

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  • • Lymph node involvement

    • Extension into extrahepatic biliary tree

    • Extension into hepatic parenchyma

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Work-up

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  • • History and physical exam

    • CBC

    • Liver function tests

    • Right upper quadrant US

    • Abdominal CT or MRI

    • CEA level

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Treatment and Management

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Surgery

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  • • Cholecystectomy (T1 tumors—limited to muscular wall)

    • Cholecystectomy with segment 4b, 5 liver resection and portal lymphadenectomy (T2 tumors—invasion to perimuscular tissue but not to serosa)

    • Right extended hepatectomy (for some T3 and T4s and recurrence after cholecystectomy or 4b, 5 segmental resection)

    • Right extended hepatectomy and resection of CBD followed by hepaticojejunostomy for invasion into CBD

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Treatment Monitoring

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  • • CEA levels

    • US or CT scanning

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Complications

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  • • Biliary leak or injury

    • Anastomotic leak or stricture

    • Liver failure

    • Perihepatic infection

    • Disease recurrence

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Prognosis

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  • • 5-year survival with resection for curative intent, 17%

    • > 95% survival for T1 tumors treated with cholecystectomy

    • Range from 70% to > 90% for T2 and T3 if 4b and 5 segment resections performed and no nodal involvement

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Resources

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References

Kondo S et al. Regional and para-aortic lymphadenectomy in radical surgery for advanced gallbladder carcinoma. Br J Surg. 2000;87:418.  [PubMed: 10759735]

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Practice Guidelines

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