New trends in diagnosis and management of gallbladder carcinoma

Abstract

Gallbladder (GB) carcinoma, although relatively rare, is the most common biliary tree cholangiocarcinoma with aggressiveness and poor prognosis. It is closely associated with cholelithiasis and long-standing large (> 3 cm) gallstones in up to 90% of cases. The other main predisposing factors for GB carcinoma include molecular factors such as mutated genes, GB wall calcification (porcelain) or mainly mucosal microcalcifications, and GB polyps ≥ 1 cm in size. Diagnosis is made by ultrasound, computed tomography (CT), and, more precisely, magnetic resonance imaging (MRI). Preoperative staging is of great importance in decision-making regarding therapeutic management. Preoperative staging is based on MRI findings, the leading technique for liver metastasis imaging, enhanced three-phase CT angiography, or magnetic resonance angiography for major vessel assessment. It is also necessary to use positron emission tomography (PET)-CT or 18F-FDG PET-MRI to more accurately detect metastases and any other occult deposits with active metabolic uptake. Staging laparoscopy may detect dissemination not otherwise found in 20%-28.6% of cases. Multimodality treatment is needed, including surgical resection, targeted therapy by biological agents according to molecular testing gene mapping, chemotherapy, radiation therapy, and immunotherapy. It is of great importance to understand the updated guidelines and current treatment options. The extent of surgical intervention depends on the disease stage, ranging from simple cholecystectomy (T1a) to extended resections and including extended cholecystectomy (T1b), with wide lymph node resection in every case or IV-V segmentectomy (T2), hepatic trisegmentectomy or major hepatectomy accompanied by hepaticojejunostomy Roux-Y, and adjacent organ resection if necessary (T3). Laparoscopic or robotic surgery shows fewer postoperative complications and equivalent oncological outcomes when compared to open surgery, but much attention must be paid to avoiding injuries. In addition to surgery, novel targeted treatment along with immunotherapy and recent improvements in radiotherapy and chemotherapy (neoadjuvant-adjuvant capecitabine, cisplatin, gemcitabine) have yielded promising results even in inoperable cases calling for palliation (T4). Thus, individualized treatment must be applied.

Current considerations for the surgical management of gallbladder adenomas

“…Otherwise, for more advanced disease, an additional operation will be needed. Some of the additional operations include wide lymphadenectomy in every case, accompanied by complementary gallbladder bed hepatic resection, in patient with T1b stage; resection of the IV and V hepatic segments for patients with T2 stage; hepatic trisegmentectomy or major hepatectomy with Roux-Y hepaticojejunostomy and, if needed, adjacent organ resection for patients with T3 stage[ 9 , 65 ].…”

“…The transformation is related to the adenoma’s size, and the transformation rate can be as high as 5% when the size of the adenoma is ≥ 10 mm and is up to 40% when the size of the adenoma is ≥ 20 mm[ 2 , 6 , 8 ]. The early-stage diagnosis of gallbladder cancer is important for optimizing therapeutic management[ 9 , 10 ]. It is obvious that timely cholecystectomy prevents the progression of any adenoma, but whether timely cholecystectomy is necessary in all patients or constitutes overtreatment in some patients remains unclear[ 11 ].…”