Podsumowanie

Chorzy z przypadkowo rozpoznanym w preparacie histopatologicznym rakiem pęcherzyka żółciowego T1b, T2, T3 wymagają reoperacji. Przed reoperacją konieczne jest wykonanie badań obrazowych (USG, TK, NMR, czasem PET) i/lub diagnostycznej laparoskopii (w przypadku guzów T3). Im guz rozpoznany przed reoperacją jest większy (cecha T), tym częściej w czasie reoperacji znajdowany jest rak i tym gorsze przeżycie.

Resekcja loży pęcherzyka żółciowego i limfadenektomia więzadła wątrobowo-dwunastniczego poprawiają przeżycie chorych na wczesnego raka pęcherzyka żółciowego. Rutynowe poszerzanie limfadenektomii i wycinanie blizn po trokarach nie są wskazane.

Rozleglejsze resekcje wątroby i/lub wycięcie pozawątrobowych dróg żółciowych są zalecane w wybranych przypadkach zaawansowanego raka, ale bez przerzutów odległych, pod warunkiem że możliwe jest wykonanie resekcji R0.

Management of incidentally discovered gallbladder cancer on receipt of surgical pathology report

Abstract
Gallbladder cancer is the most common biliary tract malignancy with the worst overall prognosis. More gallbladder cancers are presently being diagnosed incidentally in biopsy specimens, at an earlier stage and with better prognosis. The assessment of routine gallbladder specimens should include the microscopic evaluation of a minimum of three sections and the cystic duct margin. Specimens with dysplasia or proven cancer should be extensively sampled. The minimum staging evaluation of patients with proven gallbladder cancer includes contrasted cross-sectional imaging (high-resolution computed tomography, magnetic resonance imaging, positron emission tomography) and, rarely, diagnostic laparoscopy. Surgical management, with R0 resection as the objective, offers the best prognosis with the only hope of cure. In patients with margin negative T1a disease (invasion of lamina propria), there is no role for additional operation. Revision surgery (resection of the liver bed + lymphadenectomy of the hepatico-duodenal ligament) is recommended for T1b (invasion into muscular layer), T2 (invasion into perimuscular connective tissue), and T3 tumors (perforates the serosa and/or directly penetrates the liver and/or one other adjacent organ). No residual disease at the time of reoperation is a marker for improved prognosis. Re-resection should include complete portal lymphadenectomy and bile duct resection only when needed to achieve R0 resection but in the setting of R0 resection, more radical liver and bile duct resections do not seem, in some series, to improve survival. The stage of disease is the more important predictor of complete resectability and, therefore, outcome in gallbladder carcinoma.

Dziękuję prof. Markowi Krawczykowi i prof. Krzysztofowi Zieniewiczowi za udostępnienie rycin i fotografii.


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