A 50-year-old woman undergoes laparoscopic cholecystectomy for gallstone disease. The frozen section of the gallbladder specimen shows incidental gallbladder carcinoma (GBC) with the following: adenocarcinoma invading into perimuscular connective tissue (pT2) without serosal involvement. Cystic duct margin is clear. The most appropriate further management is:
- A No further surgery; start adjuvant gemcitabine-cisplatin chemotherapy
- B Re-resection with hepatic resection of segments IVb/V and regional lymphadenectomy (hepatoduodenal ligament) ✓
- C Simple cholecystectomy is adequate for pT2; observation only
- D ERCP and biliary stenting to assess bile duct involvement
Explanation
For pT2 gallbladder carcinoma (tumor invades perimuscular connective tissue, not reaching the serosa or liver), simple cholecystectomy has inadequate oncological margins. Re-resection is required and involves hepatic resection of segments IVb and V (to provide a 2 cm hepatic parenchymal margin around the gallbladder fossa) along with regional lymphadenectomy of the hepatoduodenal ligament (portal, cystic, pericholedochal, and right hepatic artery nodes). This approach improves 5-year survival from ~20% (simple cholecystectomy alone) to ~60%. pT1b disease may only require cholecystectomy with port-site excision if laparoscopic spillage occurred.
Reference: Bailey & Love's Short Practice of Surgery, 27th ed.
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Written and medically reviewed by the StethoPrep medical team.