Management of Incidentally Discovered Gallbladder Cancer

  • May Chen Tee
  • KMarie Reid-LombardoEmail author
Part of the Difficult Decisions in Surgery: An Evidence-Based Approach book series (DDSURGERY)


The management of incidentally discovered gallbladder cancer, identified either intra-operatively or post-operatively, is still hotly debated. Surgical management options for incidentally discovered gallbladder cancer include observation after simple cholecystectomy (open or laparoscopic) or radical surgical re-excision of the gallbladder fossa with hilar lymphadenectomy. Adjuvant therapy after diagnoses remains controversial and is often individualized. Evidence to date strongly favors radical re-excision in cases of T1a tumors with positive margins or lymph nodes and T1b-T3 tumors without evidence of distant nodal (N2) or metastatic (M1) disease. The role of adjuvant therapy appears to be one that complements definitive surgical resection and is advised for increased stage, residual disease after surgical resection (R1/R2 resection), and/or the presence of lymph node metastasis (N1 disease). Improved overall survival and disease-free recurrence has been demonstrated for radical surgical re-excision with consideration of adjuvant therapy for the aforementioned indications.


Gallbladder cancer Gall bladder adenocarcinoma Simple cholecystectomy Radical cholecystectomy Surgical re-excision Adjuvant therapy Cholecystectomy 


  1. 1.
    Reid KM, Ramos-De la Medina A, Donohue JH. Diagnosis and surgical management of gallbladder cancer: a review. J Gastrointest Surg. 2007;11(5):671–81.CrossRefPubMedGoogle Scholar
  2. 2.
    Wernberg JA, Lucarelli DD. Gallbladder cancer. Surg Clin N Am. 2014;94(2):343–60.Google Scholar
  3. 3.
    Z’Graggen K, Birrer S, Maurer CA, Wehrli H, Klaiber C, Baer HU. Incidence of port site recurrence after laparoscopic cholecystectomy for preoperatively unsuspected gallbladder carcinoma. Surgery. 1998;124(5):831–8.CrossRefPubMedGoogle Scholar
  4. 4.
    Network NCC. Hepatobiliary Cancers. 2014.Google Scholar
  5. 5.
    Brozek JL, Akl EA, Alonso-Coello P, Lang D, Jaeschke R, Williams JW, et al. Grading quality of evidence and strength of recommendations in clinical practice guidelines. Part 1 of 3. An overview of the GRADE approach and grading quality of evidence about interventions. Allergy. 2009;64(5):669–77.CrossRefPubMedGoogle Scholar
  6. 6.
    Brozek JL, Akl EA, Compalati E, Kreis J, Terracciano L, Fiocchi A, et al. Grading quality of evidence and strength of recommendations in clinical practice guidelines part 3 of 3. The GRADE approach to developing recommendations. Allergy. 2011;66(5):588–95.CrossRefPubMedGoogle Scholar
  7. 7.
    Lee SE, Jang JY, Lim CS, Kang MJ, Kim SW. Systematic review on the surgical treatment for T1 gallbladder cancer. World J Gastroenterol. 2011;17(2):174–80. PMCID: 3020370.CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Abramson MA, Pandharipande P, Ruan D, Gold JS, Whang EE. Radical resection for T1b gallbladder cancer: a decision analysis. HPB. 2009;11(8):656–63.CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Wakai T, Shirai Y, Yokoyama N, Nagakura S, Watanabe H, Hatakeyama K. Early gallbladder carcinoma does not warrant radical resection. Br J Surg. 2001;88(5):675–8.CrossRefPubMedGoogle Scholar
  10. 10.
    Bartlett DL, Fong Y, Fortner JG, Brennan MF, Blumgart LH. Long-term results after resection for gallbladder cancer. Implications for staging and management. Ann Surg. 1996;224(5):639–46. PMCID: 1235441.CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Dixon E, Vollmer Jr CM, Sahajpal A, Cattral M, Grant D, Doig C, et al. An aggressive surgical approach leads to improved survival in patients with gallbladder cancer: a 12-year study at a North American Center. Ann Surg. 2005;241(3):385–94. PMCID: 1356976.CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Fong Y, Jarnagin W, Blumgart LH. Gallbladder cancer: comparison of patients presenting initially for definitive operation with those presenting after prior noncurative intervention. Ann Surg. 2000;232(4):557–69. PMCID: 1421188.CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Goetze TO, Paolucci V. Immediate re-resection of T1 incidental gallbladder carcinomas: a survival analysis of the German Registry. Surg Endosc. 2008;22(11):2462–5.CrossRefPubMedGoogle Scholar
  14. 14.
    Hari DM, HJ, Chiu CG, Leung AM, Sim M, Bilchik AJ. A 21-year analysis of T1 gallbladder carcinoma: Is cholecystectomy alone adequate? HPB. 2012; Conference: 12th Annual Americas Hepato-Pancreato-Biliary Congress Miami Beach, FL United States. Conference Start: 20120307 Conference End: 11. Conference Publication: (var.pagings). 14 (pp 33).Google Scholar
  15. 15.
    You DD, Lee HG, Paik KY, Heo JS, Choi SH, Choi DW. What is an adequate extent of resection for T1 gallbladder cancers? Ann Surg. 2008;247(5):835–8.CrossRefPubMedGoogle Scholar
  16. 16.
    Toyonaga T, Chijiiwa K, Nakano K, Noshiro H, Yamaguchi K, Sada M, et al. Completion radical surgery after cholecystectomy for accidentally undiagnosed gallbladder carcinoma. World J Surg. 2003;27(3):266–71.CrossRefPubMedGoogle Scholar
  17. 17.
    Foster JM, Hoshi H, Gibbs JF, Iyer R, Javle M, Chu Q, et al. Gallbladder cancer: defining the indications for primary radical resection and radical re-resection. Ann Surg Oncol. 2007;14(2):833–40.CrossRefPubMedGoogle Scholar
  18. 18.
    Downing SR, Cadogan K-A, Ortega G, Oyetunji TA, Siram SM, Chang DC, et al. Early-stage gallbladder cancer in the surveillance, epidemiology, and end results database: effect of extended surgical resection. Arch Surg. 2011;146(6):734–8.CrossRefPubMedGoogle Scholar
  19. 19.
    Coburn NG, Cleary SP, Tan JC, Law CH. Surgery for gallbladder cancer: a population-based analysis. J Am Coll Surg. 2008;207(3):371–82.CrossRefPubMedGoogle Scholar
  20. 20.
    Duffy A, Capanu M, Abou-Alfa GK, Huitzil D, Jarnagin W, Fong Y, et al. Gallbladder cancer (GBC): 10-year experience at Memorial Sloan-Kettering Cancer Centre (MSKCC). J Surg Oncol. 2008;98(7):485–9.CrossRefPubMedGoogle Scholar
  21. 21.
    Fuks D, Reqimbeau JM, Le Treut YP, Bachellier P, Raventos A, Pruvot FR, Chiche L, Farges O. Incidental gallbladder cancer by the AFC-GBC-2009 Study Group. World J Surg. 2011;35(8):1887–97.CrossRefPubMedGoogle Scholar
  22. 22.
    Pawlik TM, Gleisner AL, Vigano L, Kooby DA, Bauer TW, Frilling A, et al. Incidence of finding residual disease for incidental gallbladder carcinoma: implications for re-resection. J Gastrointest Surg. 2007;11(11):1478–86; discussion 86–7.CrossRefPubMedGoogle Scholar
  23. 23.
    D’Angelica M, Dalal KM, DeMatteo RP, Fong Y, Blumgart LH, Jarnagin WR. Analysis of the extent of resection for adenocarcinoma of the gallbladder. Ann Surg Oncol. 2009;16(4):806–16.CrossRefPubMedGoogle Scholar
  24. 24.
    Wibbenmeyer LA, Wade TP, Chen RC, Meyer RC, Turgeon RP, Andrus CH. Laparoscopic cholecystectomy can disseminate in situ carcinoma of the gallbladder. J Am Coll Surg. 1995;181(6):504–10.PubMedGoogle Scholar
  25. 25.
    Lundberg O, Kristoffersson A. Port site metastases from gallbladder cancer after laparoscopic cholecystectomy. Results of a Swedish survey and review of published reports. Eur J Surg. 1999;165(3):215–22.CrossRefPubMedGoogle Scholar
  26. 26.
    Fuks D, Regimbeau JM, Pessaux P, Bachellier P, Raventos A, Mantion G, et al. Is port-site resection necessary in the surgical management of gallbladder cancer? J Visceral Surg. 2013;150(4):277–84.CrossRefGoogle Scholar
  27. 27.
    Maker AV, Butte JM, Oxenberg J, Kuk D, Gonen M, Fong Y, et al. Is port site resection necessary in the surgical management of gallbladder cancer? Ann Surg Oncol. 2012;19(2):409–17.CrossRefPubMedGoogle Scholar
  28. 28.
    Ricardo AE, Feig BW, Ellis LM, Hunt KK, Curley SA, MacFadyen Jr BV, et al. Gallbladder cancer and trocar site recurrences. Am J Surg. 1997;174(6):619–22; discussion 22–3.CrossRefPubMedGoogle Scholar
  29. 29.
    Sarli L, Contini S, Sansebastiano G, Gobbi S, Costi R, Roncoroni L. Does laparoscopic cholecystectomy worsen the prognosis of unsuspected gallbladder cancer? Arch Surg. 2000;135(11):1340–4.CrossRefPubMedGoogle Scholar
  30. 30.
    Whalen GF, Bird I, Tanski W, Russell JC, Clive J. Laparoscopic cholecystectomy does not demonstrably decrease survival of patients with serendipitously treated gallbladder cancer. J Am Coll Surg. 2001;192(2):189–95.CrossRefPubMedGoogle Scholar
  31. 31.
    Horgan AM, Amir E, Walter T, Knox JJ. Adjuvant therapy in the treatment of biliary tract cancer: a systematic review and meta-analysis. J Clin Oncol. 2012;30(16):1934–40.CrossRefPubMedGoogle Scholar
  32. 32.
    Wang SJ, Lemieux A, Kalpathy-Cramer J, Ord CB, Walker GV, Fuller CD, et al. Nomogram for predicting the benefit of adjuvant chemoradiotherapy for resected gallbladder cancer. J Clin Oncol. 2011;29(35):4627–32. PMCID: 3236647.CrossRefPubMedPubMedCentralGoogle Scholar
  33. 33.
    Kresl JJ, Schild SE, Henning GT, Gunderson LL, Donohue J, Pitot H, et al. Adjuvant external beam radiation therapy with concurrent chemotherapy in the management of gallbladder carcinoma. Int J Radiat Oncol Biol Phys. 2002;52(1):167–75.CrossRefPubMedGoogle Scholar
  34. 34.
    Taner CB, Nagorney DM, Donohue JH. Surgical treatment of gallbladder cancer. J Gastrointest Surg. 2004;8(1):83–9; discussion 9.CrossRefPubMedGoogle Scholar
  35. 35.
    Chan SY, Poon R, Lo CM, Ng KK, Fan ST. Management of carcinoma of the gallbladder: a single-institution experience in 16 years. J Surg Oncol. 2008;97(2):156–64.CrossRefPubMedGoogle Scholar
  36. 36.
    Clemente G, Nuzzo G, de Rose AM, Giovannini I, la Torre G, Ardito F, Giuliante F. Unexpected gallbladder cancer after laparoscopic cholecystectomy for acute cholecystitis: a worrisome picture. J Gastrointest Surg. 2012;16(8):1462–8.CrossRefPubMedGoogle Scholar
  37. 37.
    Yi X, Long X, Zai H, Xiao D, Li W, Li Y. Unsuspected gallbladder carcinoma discovered during or after cholecystectomy: focus on appropriate radical re-resection according to the T-stage. Clin Transl Oncol. 2013;15(8):652–8.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2016

Authors and Affiliations

  1. 1.Department of SurgeryMayo ClinicRochesterUSA
  2. 2.Division of Subspecialty General Surgery, Department of SurgeryMayo ClinicRochesterUSA

Personalised recommendations