Cancer was found in the pathology report after cholecystectomy. What now?

Clarify the depth of tumor invasion into the gallbladder wall and the status of the cystic duct margin, have CT or MRI and discuss the result with a surgical oncologist. If the tumor is confined to the mucosa and the cystic duct margin is clear, surveillance is usually sufficient; if it has grown deeper, a repeat operation is recommended.

Is a repeat operation mandatory?

Not always. It is recommended when the tumor has invaded the muscle layer of the gallbladder wall or deeper and there are no distant metastases. With a tumor confined to the mucosa and a clear duct margin, a repeat operation is usually not needed.

Could the cancer have been prevented by removing the gallbladder earlier?

Sometimes, yes: removing the gallbladder for polyps of 1 cm or more, a “porcelain” gallbladder or other high-risk factors reduces the risk of cancer. But the vast majority of people with gallstones never develop cancer, so prophylactic removal of every gallbladder with stones in the absence of symptoms is not recommended.

Why remove part of the liver?

The gallbladder lies directly against the liver, and a tumor that has grown through the wall spreads first into the gallbladder bed and the nearby lymph nodes. Removing this part of the liver and the lymph nodes removes the tissue where tumor cells are most likely to remain and gives an accurate stage.

Is chemotherapy needed after surgery?

After radical surgery, adjuvant chemotherapy is usually discussed to reduce the risk of recurrence. The decision and regimen are determined by the medical oncologist based on the pathology report.

Gallbladder cancer: incidental finding and re-resection

Gallbladder cancer is often found by chance, in the pathology report after a routine cholecystectomy for gallstones. The news is frightening, but it is in exactly this situation that the patient most often has a chance of curative treatment. If the tumor has grown deeper than the mucosal layer, a repeat operation is usually needed: removal of the part of the liver the gallbladder was attached to, and of the lymph nodes. When cancer is suspected before surgery and the tumor is resectable, the gallbladder is removed radically from the start, en bloc with the surrounding tissue.

Kateryna Valikhnovska, MD, surgical oncologist, during a laparoscopic operation — The laparoscopic stage of an operation: the lights in the operating room are dimmed because the surgeon works from the camera image on the monitor.

Why gallbladder cancer develops

The main risk factor is gallstone disease with long-standing chronic inflammation of the gallbladder wall, although the vast majority of people with gallstones never develop cancer. The risk is higher with large stones, calcification of the gallbladder wall (“porcelain” gallbladder), gallbladder polyps of 1 cm or more, primary sclerosing cholangitis and congenital anomalies of the junction of the bile and pancreatic ducts.

That is why gallbladder polyps of 1 cm or more, as well as growing polyps, are usually recommended to be removed together with the gallbladder, while smaller ones are usually monitored with ultrasound; with additional risk factors (a broad-based polyp, wall thickening, primary sclerosing cholangitis, age over 60), cholecystectomy may be recommended even for polyps of 6–9 mm.

Are there symptoms

In the early stages there are no specific symptoms: pain under the right ribs, nausea and discomfort after meals are the same as in gallstone disease, for which the patient ends up having surgery. That is why early cancer is usually found by the pathologist, not by the surgeon or the ultrasound doctor.

Jaundice, noticeable weight loss, a palpable firm gallbladder or ascites more often indicate an advanced tumor. If jaundice is caused by compression of the bile ducts, bile drainage is restored first; see the page malignant obstructive jaundice.

Examinations needed

A detailed pathology report, if the gallbladder has already been removed: depth of wall invasion (T stage), status of the cystic duct margin, vascular and perineural invasion, and which side of the gallbladder the tumor is on. Whether a repeat operation is needed depends on the depth of invasion.
Review of the slides in another laboratory, when the report is incomplete or questionable.
Contrast-enhanced CT of the chest, abdomen and pelvis and liver MRI: assessment of the gallbladder bed, liver, lymph nodes and distant metastases.
Tumor markers CA 19-9 and CEA.
Staging laparoscopy before a major operation when there is an increased risk of peritoneal spread not visible on CT.
PET-CT when indicated, if the extent of spread is in doubt.

If the tumor is suspected before surgery, a percutaneous biopsy is usually not performed when the tumor appears resectable: the diagnosis is confirmed on the resected specimen.

When surgery is possible

If cancer is found after cholecystectomy, the approach depends on the depth of invasion. When the tumor is confined to the mucosa (T1a) and the cystic duct margin is clear, the standard cholecystectomy is usually sufficient, followed by surveillance. When the tumor has invaded the muscle layer or deeper (T1b and above), a radical re-operation is recommended if there are no distant metastases and the patient’s condition allows it.

The re-operation is performed after further work-up, once the acute effects of the first operation have passed, usually after a few weeks. A tumor suspected before surgery is operated on radically from the start, under the same conditions: no distant metastases, and the tumor can be removed with clear margins.

If surgery is not possible now

With distant metastases, peritoneal deposits or spread that does not allow complete removal of the tumor, treatment is based on systemic therapy: the first-line standard for patients in good general condition is chemotherapy combined with immunotherapy. For some patients, molecular analysis of the tumor opens up the option of targeted treatment.

If the tumor compresses the bile ducts or the bowel, bile drainage and patency are restored with stents. Sometimes the tumor shrinks enough after treatment for surgery to be reconsidered; the final plan is determined by the MDT.

How the operation is performed

The radical operation includes removal of the part of the liver the gallbladder was attached to, usually segments IVb and V or a wedge resection of the gallbladder bed with a margin of healthy tissue, and of the regional lymph nodes: of the hepatoduodenal ligament, along the common hepatic artery and behind the head of the pancreas; for accurate staging at least six nodes are examined. If the gallbladder has not yet been removed, it is removed en bloc with the liver without being opened, so that tumor cells do not enter the abdominal cavity.

The bile duct is not always removed, only when tumor is present at the cystic duct margin or extends onto it; bile drainage is then restored through a loop of small bowel. For more extensive tumors, the extent of liver resection is increased.

When the tumor’s location and the extent of resection allow, the operation is performed laparoscopically, through several small incisions.

An incidental finding of cancer after cholecystectomy is neither a death sentence nor a reason to wait. It is a reason to quickly establish the depth of invasion and, if necessary, complete the operation radically.

Kateryna Valikhnovska, MD, surgical oncologist

Recovery after surgery

Care follows the enhanced recovery after surgery (ERAS) protocol: early mobilization, early feeding, controlled pain relief. After resection of the gallbladder bed without bile duct removal, recovery is usually faster than after major liver resections; after bile duct reconstruction the hospital stay is longer.

After radical surgery adjuvant chemotherapy is usually discussed; its regimen is determined by the medical oncologist based on the pathology report.

Follow-up

For the first years, CT or MRI and tumor markers are done regularly, every few months, then less often; the schedule is set by the doctor. Warning signs such as jaundice, pain, weight loss or abdominal swelling should be reported to the doctor without waiting for the scheduled examination.

What to bring to the consultation

the pathology report of the removed gallbladder with depth of invasion and cystic duct margin status;
blocks and slides, for review in another laboratory;
the discharge summary and operative report of the first operation: open or laparoscopic, whether the gallbladder was opened;
CT or MRI discs and reports, ultrasound before surgery;
tumor markers CA 19-9 and CEA, blood biochemistry.

If some materials are missing, that is no reason to postpone the consultation: some examinations can be done on site.

The consultation is free of charge. How it goes and how long it takes is described on the page “Oncologist Consultation”.