Incidentally Detected Gallbladder Cancer- The Controversies and Algorithmic Approach to Management

Abstract

Incidentally discovered gallbladder cancer (IGBC) is defined as the gallbladder cancer (GBC) diagnosed during or after the cholecystectomy done for unsuspected benign gallbladder disease. Laparoscopic cholecystectomy (LC) is the most common procedure performed for benign gallbladder disease worldwide. Majority of GBC patients have associated gallstones. With the advent of ultrasonography more patients are being diagnosed with gallstones and are being subjected to cholecytectomy. IGBC is found in 0.2-2.9 % of all cholecytectomies done for gallstone disease. It represents 27-41 % of all GBC. Patients with IGBC having Tis and T1a stage, with negative cystic duct margin can be treated by simple cholecystectomy alone. Patients with stage T1b and beyond should undergo restaging, and should be treated with radical re -resection (R0). Residual disease is found in 40-76 % patients on re-exploration. The survival rates of patients undergoing re resection for IGBC is similar to those undergoing primary radical surgery. LC is contraindicated in patients with GBC. Patients presenting post LC should undergo radical re-resection and additional port site excision, as they have a high incidence of port site metastasis. At cholecystectomy for benign gallbladder disease all gallbladder specimens should be opened before closing abdomen and if available all suspicious specimens should be sent for immediate frozen section. All gallbladder specimens should be subjected to histopathology examination to avoid missing GBC. The surgeon should have a high index of suspicion for GBC if encountering difficult cholecystectomy for a benign disease, and in patients with atypical clinical and ultrasound findings in high incidence areas.

Routine histopathological examination of gallbladder specimens after cholecystectomy: Is it time to change the current practice?

“…Northern India and Pakistan, East Asia, South America, and Eastern Europe are found to have the highest rates of GBC (1). Incidental GBC is found in 0.2%-2.9% of all cholecystectomies performed for gallstone disease (4,5). Patients with incidental GBC diagnosed with stages Tis and T1a can be treated by simple cholecystectomy alone.…”

“…Patients with incidental GBC diagnosed with stages Tis and T1a can be treated by simple cholecystectomy alone. Patients with stage T1b and beyond should undergo further surgical treatment (2,5). However, several recent studies have questioned the necessity for routine HPE of all gallbladder specimens.…”

Study of Incidental Carcinoma on Routine Cholecystectomy Specimens - A Story of a Diligent Pathologist

“…For pT2 tumors, the 5-year survival rate improves from 20% to 70% if simple cholecystectomy is followed by radical cholecystectomy after the diagnosis of IGBC. 3 Results of this study showed 12 out of 14 cases of IGBC in pT2 stage and 2 case in pT1 stage. Therefore, histopathology should be done for all surgically resected gallbladders, as it is the only tool, which can detect IGBC accurately which improves patient's survival as compared to GBC.…”

“…It is also known as occult/inapparent/missed Gallbladder carcinomas. 3 Most of these patients do not have a radiological or intraoperative suspicion for malignancy.…”

Carcinoma Gallbladder- an Indian Problem

“…Number of patients have GBC incidentally detected at the time of cholecystectomy for gallstone disease, or at the time of histopathological examination of the gallbladder specimen [4]. Similarly, despite looking operable on conventional imaging, many patients of GBC have metastatic disease on laparotomy/diagnostic laparoscopy.…”