In a male after laparoscopic cholecystectomy specimen is sent for histopathology which shows carcinoma gallbladder stage T la. Appropriate management is:
Excision of all po sites Repeat from Nov 08 The appropriate management for gallbladder cancer depends on the stage of cancer. Let's first see the TNM staging for gallbladder cancer. TNM staging of Gallbladder cancer Primary tumor (T) TO No evidence of primary tumor Tis Carcinoma in situ T1 Tumor invades lamina propria or muscle layer T1 a Tumor invades lamina propria TI b Tumor invades muscle layer T2 Tumor invades perimuscular connective tissue; no extension beyond serosa or into liver T3 Tumor perforates the serosa (visceral peritoneum) and/or directly invades the liver and/or one other adjacent organ or structure, such as the stomach, duodenum, colon, or pancreas, omentum or extrahepatic bile ducts T4 Tumor invades main poal vein or hepatic aery, or invades multiple extrahepatic organs or structures Regional lymph nodes (N) NX Regional lymph nodes cannot be assessed NO No regional lymph node metastasis NI Regional lymph node metastasis Distant metastasis (M) MX Distant metastasis cannot be assessed MO No distant metastasis MI Distant metastasis Stage grouping Stage 0 Tis NO MO Stage IA TI NO MO Stage 1B T2 NO MO Stage 11A T3 NO MO Stage 11B T1 T2 T3 N1 N1 N1 MO MO MO Stage III T4 Any N MO Stage IV Any T Any N M1 For stage Ia: Tla staged tumors (tumors confined to lamina propria)? - These tumors are recognized incidentally at the time of pathologic review. No fuher t/t is needed. Simple cholecystectomy is sufficient for them. - In laparoscopic cholecystectomy, recurrent cancer has been seen at the po site. Hence all po sites should be excised. - Patients with preoperatively suspected gallbladder cancer should under go open cholecystectomy to minimize the chances of tumor dissemination. Tlb staged tumors (tumors invading muscular layer)? - Invasion of the muscular layer allows access to lymphatics and vessels. For Tlb staged tumors, an extended cholecystectomy is indicated, as these tumors have been repoed to recur after simple cholecystectomy. For stage lb, II, selected stage III tumors: These are managed by extended cholecystectomy. Stage IV tumors: - Should be treated with appropriate palliation as indicated. No randomized data have demonstrated improved survival with either chemotherapy or radiation and its use depends on case to case basis. Treatment after incidental finding of gallbladder cancer: Treatment after incidental finding of gallbladder cancer on pathologic review: For T1a tumors (tumor invades lamina propria) - Observation only is open cholecystectomy done. - Excision of all po sites if cholecystectomy done laparoscopically. For Tlb tumors (tumor invades muscle layer) or greater - A radical re-resection (after a complete staging including laparoscopy demonstrating resectability) is highly recommended Treatment after incidental finding of gallbladder cancer at surgery: After incidental finding of gallbladder cancer at surgery staging has to be performed intraoperatively and extended cholecystectomy including en bloc hepatic resection and lymphadenectomy with or without bile duct excision has to be considered depending on resectability and expeise of the surgeon
Conservative and follow up.
Extended cholecystectomy
Excision of all po sites
Radiotherapy