Jose Baez, M.D.09/24/10
LICH
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68 y/o F with symptomatic cholelithiasis who presented for an elective laparascopic cholecystectomy
PMHx• Obesity• HTN• Cholelithiasis
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PShx: denied
NKDA
Medications: HCTZ, Atenolol
Shx: denied
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OR: Laparoscopic cholecystectomy• GB aspirated due difficulty to grasp• Removed in endo-bag
Pt discharged POD#0
Pathology: moderate to poorly differentiated adenocarcinoma of GB ,involving lamina propia and muscle layer, + proximal margin (cystic duct)
Stage: T1b, Nx, Mx
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PHYSICAL EXAM STUDIES/LABS
VS: 98.6, 148/82, 77
Alert and oriented
Chest clear bilaterally
Abdomen: soft nt/nd
WBC: 7
Hct: 37
LFTs: WNL
RUQ sono: Gallstones
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Associated with a poor prognosis (5 yr survival 0-12%)
Majority of cases present with advanced, unresectable dz
Increasing number of early-stage dz cases are found incidentally during or post cholecystectomy
Most common cancer of biliary tract, 5th most common of GI tract
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Strong association between GBC and cholelithiasis (65-90%)
Prevalence:• Female > Male• US 2.5/100k, but higher in Native Americans and
Hispanics• 50% greater incidence in Caucasians vs AA
Gallstone size: <3cm RR of 2.5 >3cm RR of 10
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Other risk factors• Adenomatous polyps, calcification of GB,
anomalous pancreaticobliliary duct junctions
NIH Consensus Guidelines of Gallstones and Laparocopic cholecystectomy (1992)• Only porcelain GB is considered an indication
for prophylactic cholecystectomy• (GBC in up to 25% of pts)
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GB polyps• Incidence in healthy pts
3-10%• Mostly cholesterol
polyps• If >1cm, CT to eval for
GBC• If >1cm, sessile, and
over 50 yrs of age• If small, US q 6mo x
2yrs
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Progresses slowly from dysplasia to Cis to invasive carcinoma over 15 yrs
Chronic inflammation (stones or other)-inciting event in dysplasia to CA pathway
80-95% are adenocarcinomas, anaplastic (7%), squamous cell(1-6%),adenosquamous (1-4%)
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GBC- ability to spread regionally and distant via four routes• Direct invasion through GB wall• Lymphatics• Hematogenous- MC to lung (>30%) and brain• Peritoneum
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Cholecystoretropancreatic nodes
Cholecystoceliac path
Cholecystomesenteric path
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TX- primary tumor cannot be assessed
T0- no tumor Tis- in situ T1a- invades lamina propia T1b- invades muscle layer T2- perimuscular connective
tissue T3- through serosa or
adjacent tissues T4- into PV, HA, or multiple
adjacent organs
NX- not assessed N0- no regional LNs N1- regional LNs
MX- mets not assessed M0- no distant mets M1-distant mets
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PRESENTATION WORKUP
Incidentally after cholecystectomy
Symptoms- pain (75%) or jaundice (45%)
Nausea, vomiting and anorexia
US- 50% accuracy for GBC
CT/MRI- eval extent of dz and local invasion
Chest eval- mets PET- most sensitive for
distant mets MRCP- CBD involvement ERCP- stent in advanced
dz
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Surgery is potentially the only curative therapy
Overall 5yr survival is < 5%Treatment based on T-stage of tumorCI for surgery- liver and peritoneal mets,
ascites, distant dz, encasement or occlusion of major vessels, poor performance status, para-aortic LNs
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Early lesions (Tis/T1a)
• Simple cholecystectomy- cure rate 85-100% as long as margins are negative
• If GBC suspected- recommend open cholecystectomy
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T1b/T2 tumors• T1b associated with 15% LN mets• T2 associated with 40% LN mets• Tx- radical cholecystectomy- GB, GB fossa,
min of 2cm of liver parenchyma, and lymphadenectomy
• Radical vs simple for T2 lesions 61-100% vs 19-40% survival rate
• Radical- 1% mortality
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T3/T4 tumors• May benefit from radical surgery if no distant or
peritoneal mets• No role for debulking, need R0 resection• DL prior to laparotomy• 25-44% 5 yr survival with radical resection
• Need negative margins for survival (> 2cm)
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Occurs in 1-2% of lap cholescytectomies
New problems• Port site seeding (5-20%)• Spillage and Perforation- 40% rate of port site
recurrence
Most are Tis/T1a lesions• 85-100% 5yr survival if CD margin is negative
If suspected intraop- convert to open
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If suspicious lesion-frozen T2 or greater• Proceed with radical cholecystectomy• Close, image and stage, refer to HB expert
Pts with T1b or greater should be offered resection• Staging, imaging and DL prior to resection
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Palliation (unresectable)• Choledochojejunostomy, gastrojejunostomy• ERCP or percutaneous drainage• Chemo/RT- mostly unsuccessful
Adjuvant Tx- limited data to support• NCCN- chemo/RT should be considered in
except T1 or N0 pts
Surveillance- q 6mo
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Literature supports aggressive resection for T1b or greater dz
Suspicious lesion should be done via open surgery
DL- useful in re-resections or advanced dzMore data needed on adjuvant txRadical surgery has improved chances for
cure
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Restrospective analysis of pts referred to MSKCC with GBC from 1995-2005
Major therapeutic modality and only curative tx is surgery, despite this majority of pts will develop recurrence, therefore a strong rationale for adjuvant tx should be considered
Purpose: 1) most common mode of presentation of GBC over 10 yrs at MSKCC
2) describe their experience with adjuvant tx in pts after potentially curative surgery
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Surgical details• Candidates for re-exploration after incidental
finding of GBC were:• Based on T-stage, performance status,
radiological staging, DL performed- if nometastatic dz
• Radical resection- porta hepatis, supraduodenal LN, and partial hepatectomy
• If no liver involvement- resection of segments 4b/5 and laparoscopic port sites (+/- biliary reconstruction)
• +
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435 pts: 285 F, 150 M
Mean age 67
Path: adenocarcinoma 391pts (88%)
159 pts (37%)- stage IV dz206 pts (49%)- incidental
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Decision based on MD and Pt discussion
23 pts with R0 resection received adjuvant therapy• 8 some form of adjuvant tx• 8 chemotherapy• 8 chemo/RT
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GBC is a relatively uncommon dz with poor Px
Almost ½ the pts presented after incidental finding of the tumor
GBC occurs in <1% of laparoscopic cholecystectomies
Surgical re-exploration with radical resection proved beneficial
Unmet need for effective adjuvant tx
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Lazcano-Ponce EC, Miquel JF, Munoz N, et al: Epidemiology and moleculte pathology of gallbladder cancer. CA: Cancer J Clin 2001; 51:349-364.
Fong Y.Jarnagin W, Blumgart LH: Gallbladder cancer: Comparison of patients presenting initially for definitive operation with those presenting after noncurative intervention. Ann Surgery 2000;232:557-569.
Donohue JH, Stewart AK, Menck HR: The National Cancer Data Base report on carcinoma of the gallbladder, 1989-1995. Cancer 1998;83:2618-2628
Department of Health and Human Services Centers for Disease Control and Prevention. National Health and Nutrition Examination Survey. Available at: www.cdc.gov/nchs/data/nhanes/databriefs/viralhep.pdf. Accessed: February 19, 2009.
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