gallbladder polyps and neoplasia - department of surgery at suny

Frequency gallbladder polyps

Type Benign polyps

Cholesterol polyps Adenomyomas Inflammatory polyps Adenomas Miscellaneous:

Leiomyomas Fibromas Lipomas, etc. Malignant polyps

Adenocarcinoma Miscellaneous:

Mucinous cystadenomas Squamous cell carcinoma Adenoacanthomas

Frequency 60 percent 25 percent 10 percent 4 percent 1 percent 80 percent 20 percent

Weedon, D. Benign mucosal polyps. In pathology of the gallbladder, Mason, New York 1984

Classification of Malignant Tumors of the Gallbladder

www.downstatesurgery.org

Relative Incidence of Gallbladder Cancer by Histologic Type


Giant cell adenocarcinoma of the gallbladder. This

tumor has an infiltrative nature, but it fills most of the

lumen of the gallbladder.


Papillary adenocarcinoma of the gallbladder: this

tumor has a cauliflower-like appearance and protrudes into the lumen with minimal invasion of the

gallbladder wall.


Imaging Modalities Used to Diagnose Gallbladder Cancer


Benign Polyps

Some clinicians have recommended cholecystectomy for any patient with fewer than three polyps

Cholecystectomy recommended for any polyp greater than 1 cm

The exception to this recommendation is for those arising in the setting of primary sclerosing cholangitis

(Shinkai et al, 1998) (Ito et al, 2009) (Buckles et al, 2002)


A prevalence of gallbladder cancer with polypoid lesions of the gallbadder equal to 0.08% was reported in white patients

On periodic US 4 to 12 months after the original US, polyps grew 1.4 to 4 times larger

US follow-up at 6- to 12-month intervals for 2 years; if polyp size is stable, routine survelliance can be stopped

(Aldouri et al, 2009) (Kubota at al, 1995)


Incidentally Discovered Gallbladder Carcinoma During or After Routine

Cholecystectomy

Gallbladder cancer is found in 0.27% to 2.1% of all laparoscopic cholecystectomies

Outcomes after prior noncurative resection were similar to outcomes from primary curative resections

Re-resection is recommended for all patients who are medically fit with T1b or greater level of invasion

Resection of the bile duct required for a complete resection in cases with a positive cystic duct stump margin

(Darmas et al, 2007; Kwon et al, 2008). (Fong et al, 2000). (Pawlik et al, 2007)


AJCC Staging System for Gallbladder Cancer


Anatomic Stage and Prognostic Groups

Stage 0 Tis N0 M0

Stage I T1 N0 M0

Stage II T2 N0 M0

Stage IIIA T3 N0 M0

Stage III B T1-3 N1 M0

Stage IVA T4 N0-1 M0

Stage IVB Any T N2 M0 Any T Any N M1

From Edge SB, Byrd DR, Compton CC, et al (eds): AJCC cancer staging manual, ed 7, New York, 2010, Springer, pp 213–214.


PORT SITE RECURRENCES There is a theoretical risk of port site seeding after

laparoscopic cholecystectomy for what is eventually diagnosed as gallbladder cancer

It is rare for port site recurrences to occur as the sole site of disease

General practice does not include empirically resecting prior port sites during reexploration for gallbladder cancer

(Winston et al, 1999) (Povoski et al, 2004; Shoup & Fong, 2002)


Algorithm gallbladder polyps

* Symptoms: Biliary type pain, common duct obstruction, cholangitis, or recurrent pancreatitis. Dyspepsia is not an indication for surgery.


Treatment Recommendations for Gallbladder Cancer Diagnosed After

Cholecystectomy


Observed survival rates for 10,705 gallbladder cancers. Data from the National Cancer Data Base (Commission on Cancer of the American College of Surgeons and the American Cancer Society) diagnosed in years 1989–1996.


Following cholecystectomy, an adenocarcinoma of the gallbladder extending into the subserosa

is discovered incidentally. The recommended treatment includes which of the following?

A. Nothing further at this time

B. External beam radiation therapy

C. Radiation therapy and chemotherapy

D. Reoperation for liver resection and lymphadenectomy

E. Reoperation for performance of pancreatoduodenectomy


Ultrasound imaging demonstrates a 15-mm polypoid lesion in the gallbladder of an

asymptomatic 60-year-old patient. Which of the following best describes the recommended

treatment?

A. Observation with repeat ultrasound studies in 6 months

B. Cholecysectomy

C. Cholecysectomy if the patient is female

D. Cholecysectomy only if symptoms develop

E. Cholecysectomyonly if the patient also has gallstones


Which of the following is a contraindication to resection of an adenocarcinoma of the bile duct?

A. Tumor location in the distal common bile duct

B. Tumor location at the bifurcation of the bile duct

C. Peritoneal metastases

D. Invasion of the right portal vein and right hepatic artery

E. None of above


gallbladder polyps and neoplasia - department of surgery at suny

Documents