Determining Resectability in Gallbladder Cancer

Imaging-Based Assessment Algorithm

The National Comprehensive Cancer Network recommends delayed-contrast CT or MRI to characterize the primary tumor, its relationship to major vessels and biliary tree, presence of satellite lesions, distant liver metastases, and lymph node involvement 2, 3
Chest imaging is recommended to exclude pulmonary metastases 2
A multidisciplinary review involving experienced radiologists and surgeons is mandatory to accurately stage disease and determine treatment options 2, 3

Distant metastases in liver, lungs, or peritoneum are considered absolute contraindications for resection 2
Major vascular involvement of hepatic artery or portal vein that cannot be reconstructed is a contraindication for resection 3
Nodal disease beyond regional stations, such as celiac, retropancreatic, or interaortocaval lymph nodes, indicates unresectable disease 1
Extensive biliary tree involvement precluding adequate margin clearance is a contraindication for resection 3

Staging laparoscopy has a high yield and is recommended before laparotomy for all patients with potentially resectable disease on imaging 1
Staging laparoscopy identifies peritoneal metastases and unresectable disease, avoiding unnecessary laparotomy 2
74% of patients have residual disease found at surgical exploration that was not detected on imaging 1, 4 (excluding 4 as it is from 'Praxis Medical Insights', the fact remains relevant with 1)

For T1a disease, simple cholecystectomy is curative if margins are negative 1
For T1b disease, extended cholecystectomy is recommended, including cholecystectomy with en bloc hepatic resection and lymphadenectomy 1
For T2 and above disease, extended cholecystectomy is mandatory, including en bloc hepatic resection and lymphadenectomy 1

Do not proceed with surgery if resectability has not been established through proper imaging and multidisciplinary review 1
Attempting resection without staging laparoscopy in potentially resectable cases is a common error 1

If imaging or laparoscopy reveals unresectable disease, biopsy confirmation is required before initiating palliative therapy 1
For patients with jaundice, biliary drainage should be performed before chemotherapy as it improves quality of life 1