Surgical Science, 2013, 4, 486-493
Published Online November 2013 (http://www.scirp.org/journal/ss)
http://dx.doi.org/10.4236/ss.2013.411095
Open Access SS
Early Gallbladder Cancer: Clinical, Morphological,
Therapeutic and Evolutionary Aspects
Berkane Salah*, Abid Larbi
Unit of Visceral and Oncological Surgery, Bologhine Hospital, Algiers, Algeria
Email: *salahberkane07@yahoo.fr
Received September 23, 2013; revised October 20, 2013; accepted October 28, 2013
Copyright © 2013 Berkane Salah, Abid Larbi. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
ABSTRACT
Introduction: The early cancer of gallbladder is an entity which is not well recognized currently. It is a cancer which
does not extend beyond the muscularis layer of the gallbladder and it is characterized in almost of cases by the absence
of lymph node and visceral invasion. Patients and Method: We have conducted this retrospective study of all our cases
of early gallbladder cancer treated in our surgical unit. We have studied these through clinical, morphological, thera-
peutical and evolutionary aspects. Results: Of 202 gallbladder carcinoma, 33 cancers were classified as early cancer. 25
were females and 8 were males. The mean age was 56.4 years (41 - 70 years). All patients were free of g allbladder can-
cer symptoms and all except one had normal CEA and CA19.9. 2 patients had synchronous tumors (one colonic cancer
and one rectal cancer). For 16 patients, the diagnosis was done by ultrasonography and 17 by histological examination
of the specimen removed for biliary lithiasis. 8 patients had PT1a tumor (confined only to mucosa) and 25 had PT1b
tumor (tumor infiltration of the muscular layer). For 19 patients who benefited from extensive lymphadenectomy, only
one (5.3%) had lymph node infiltration. 16 patients had a simple cholecystectomy and in two cases, the cholecystec-
tomy was associated with bile duct resection. 17 patients had hepatectomy with extensive lymphadenectomy. 2 patients
had a simultaneous right colectomy and abdominoperineal resection and another one benefited from choledocal cyst
resection. 3 patients benefited from stone removal from bile duct and two had tumor removal from bile duct (ruptured
tumor in the bile duct). 1 patient (3.7%) died in postoperative course (hospital mortality). In the follow-up period, 4
patients died from intercurrent causes. Two patients presented a recurrence at 14 and 36 months and died respectively at
19 and 42 months. One patient presented a bile duct cancer at 66 months. She died at 78 months after palliative treat-
ment. Currently, 22 patients (66.7%) are still alive without recurrence with mean and median survival of 53 and 31
months. Conclusion: Early gallbladder cancer is an entity which must be known by the radiologist and the surgeon.
Recognized on time and well treated, early gallb ladder cancer can be cured and its pro gnosis is excellent.
Keywords: Early Cancer; Gallbladder Cancer; Ultrasonography; Expert Radiologist; Surgical Treatment
1. Introduction
The early gallbladder cancer is an entity which is not well
recognized currently. It is a tumor whose extension does
not extend beyond the muscularis layer of the ga llbladder
and does not have frequent lymph node infiltration and
metastatic spread [1]. Moreover, it represents a proportion
of all gallbladder cancer which could be easily cured. In
spite of modern morphologic examination and specifi-
cally an ultrasonography since twenty years, there is not a
clear improvement in the diagnosis for this disease [2-4].
This form is often diagnosed after histological examina-
tion of specimen removed for biliary lithiasis. Making an
exact diagnosis before surgery has an importance to im-
prove the prognosis of this fatal disease in its invasive
form. Surgery is debated when the muscular layer is in-
vaded (pT1b) between cholecystectomy and radical re-
section whereas the cholecystectomy is the best treatment
for the pT1a (tumor confined to mucosa). In this article,
we present our experience of patients who were managed
in our unit during the fifteen last years and to analyze
immediate and long-term prognosis of this disease.
2. Patients and Method
We analyzed all cases of our patients treated for early
gallbladder cancer. We reported the clinical, morpho-
*Corresponding a uthor.
B. SALAH, A. LARBI 487
logical, biological, surgical and evolutionary features of
these patients. The histological specimen was reanalyzed
for the cancer discovered after cholecystectomy done for
biliary lithiasis. All the following features were asked to
the histologist: histological form and grade (differentia-
tion), parietal extension, perineural, vascular and node
infiltration. In our un it, pT1a tumor (confined to mucosa)
is treated by cholecystectomy and pT1b (muscular infil-
tration) is treated by cholecystectomy alone for the patient
above 70 years and by bisugmen tal IV-V with fatal asso-
ciated disease and extensive lymphadenectomy for pa-
tients under 70 years and without fatal associated disease.
On the postoperative course, the patient is followed
clinically, biologically (Ca 19.9 and CEA) and morpho-
logically (ultrasound) each 3 months during 2 years and
each 6 months during the following 2 years. After 5 years,
we propose only clinically follow up. If a recurrence is
diagnosed, a CT scan or MRI is done to have an exact
diagnosis and if the disease is curable we propose a new
surgery for resection and in the contrary only diversion is
practiced. If there is no need of surgery we propose pal-
liative chemotherapy.
3. Results
Of 202 gallbladder cancer resected since 1996, we report
33 patients with early form (16.3%). There were 25 fe-
males and 8 males, with mean age of 56.4 years (41 - 70
years). No patient had any symptoms related to cancer
before the su rgery and physical examination were normal
or related to lithiasis disease (pain , jaundice and palpable
gallbladder in acute cholecystitis). 20 patients (60.6%)
had associated biliary lithiasis. One patient had a history
of choledocal cyst since 25 years. The diagnosis was done
in the pr eopera tive co urse in 1 6 cases (48 .5%) by the ra di-
ologist with the ultrasonography and CT Scan. 3 last pa-
tients had an endoscopic ultrasonography. 17 cases were
diagnosed on the histologist specimen. All of 24 car-
cino-embryonary antigen (CEA) and carbohydrate anti-
gen 19.9 (CA19.9) measured out were normal except for
one CA19.9 which was at 5618 UI/ml for patient with
ruptured tumor in the bile du ct and jaundice. One patient
was treated for Hodgkin disease 10 years ago; 2 patients
had their polypoid tumors known (diagnosed by ultra-
sonography) respectively 1year and ten years ago. The
tumoral aspect was polypoid in 22 cases (66.7%), thick-
ening wall in 6 cases (18%), unapparent form in 4 cases
(12%) and nodular in 1 case. 2 patients had ruptured tumor
in the bile duct (pT1a and pT1b). Microscopically, all
these cases were adenocarcinoma. 8 cases (24.2%) were
pT1a and 25 cases (75.8%) were pT1b (Table 1: charac-
teristics of 27 cases). 1 patient had a choledocal cyst di-
agnosed and followed by a gastroenterologist during 16
years. 16 patients benefited from a cholecystectomy as-
sociated with bile duct resection in two cases for a tumoral
related cause and another had her choledocal cyst re-
moved with a gallbladder. 2 patients who have had a
cholecystectomy benefited from a lymphadenectomy. For
17 patients, IV-V bisugmental hepatectomy with exten-
sive lymphadenectomy was done. 2 patients had respec-
tively colonic and rectal resection simultaneously. 3 pa-
tients benefited from stone removal from bile duct. Only
one patient presented node infiltration between 19 who
benefited from lymphadenectomy (5.3%). 24 patients
(72.7%) had one op eration and 9 (27.8%) two op erations .
The postoperative course was uneventful for 26 patients
(78.8%) and complicated in 7 cases (21.2%). One patient
(3%) died from myocardial infarction (Table 2: surgical
treatment). Two patients benefited from systemic che-
motherapy, one because she had had cystic infiltrative
node and another had associated liver metastatic lesion.
On the long term follow up, one patient received ex ternal
beam therapy for uterine cervix cancer diagnosed 2 years
after the cholecystectomy. One patient died from a colon
cancer recurrence at 15 months without any evident gall-
bladder cancer recurrence. 2 patients (6%) presented a
recurrence at respectively 14 and 36 months. They were
initially treated by cholecystectomy. One benefited from
bisugmental IV-V with lymphadenectomy and chemo-
therapy and died from a new recurrence at 19 m onths. The
second patient had exploratory laparotomy and died at 42
months. One patient presented a bile duct cancer (upper
part) at 66 months. She refused a surgery and died at 78
months. One patient died from acute diabetes complica-
tions at 5 6 months a nd other di ed from gastri c hemorrhage
secondary to gastric ulcus. One patient died from another
disease at 67 months (portal high pressure). One was lost
for follow up at 39 months. 22 patients (66.7%) are still
alive with mean survival of 51 months and median sur-
vival of 32 months. The global 3 and 5 year survival are
respectively 53% and 34%. 11 patients (33.3%) had more
than 5 year survival and the two oldest had more than 10
years. No recurrence case occurred until nowadays for
PTa tumor.
4. Discussion
The early cancer of gallbladder is a form which can be
recognized by modern morphological examination but it
is still diagnosed after surgery for biliary lithiasis. On
clinical aspect, it is a silent disease (without any symp-
toms). This feature c ould expl ain this absenc e of diagnosi s.
Currently, it can be recognized in 2 situations:
On preoperative cou rse with ultrasonogr aph y [3-5].
On the histological exam ination after cholecystectomy
for biliary lithiasis [5-8].
For a clinician to make a diagnosis before a surgical
step, he need s an expert ra diologist w ho should be vigilant
during ultrasound examination. There are two funda-
mentals lesions which are in favor of an early cancer:
Open Access SS
B. SALAH, A. LARBI
Open Access SS
488
Table 1. Characteristics of patients.
Case Age Sex LB D M M’ L D (mm) AP CA19.9CEA
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30*
31
32
33
56
56
62
69
65
41
57
61
61
63
68
62
48
46
56
70
58
60
50
45
45
58
55
60
58
47
56
46
60
47
70
54
56
F
F
F
F
F
F
F
M
F
F
M
F
F
M
F
F
F
M
F
F
M
M
F
F
F
M
F
M
F
F
F
F
F
No
No
Yes
No
No
Yes
Yes
No
No
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
No
Yes
Yes
Yes
No
Yes
Yes
No
Yes
No
No
No
Yes
Yes
Yes
Yes
HD
UD
HD
UD
UD
HD
HD
UD
UD
HD
UD
HD
HD
HD
HD
UD
HD
UD
UD
UD
HD
UD
HD
HD
UD
HD
UD
UD
UD
HD
HD
HD
HD
UNA
P
P
P
P
TW
P
P
P
TW
P
P
P
TW
P
P
UNA
P
P
P
TW
P
P
UNA
P
UNA
P
P
P
TW
NOD
P
ADKNS
ADK (MIXED)
ADK (WD)
ADK (NS)
ADK (WD)
ADK (MD)
ADK (MD)
ADK (WD)
ADK (WD) PAP
ADK (WD) PAP
ADK(WD)
ADK (WD)
ADK (WD) PAP
ADK (MIXED)
ADK (WD)
ADK (WD) PAP
ADK (WD)
ADK (WD) PAP
ADK (WD) + CM
ADK (WD)
ADK (MD)
ADK (WD)
ADK (WD)
ADK (WD)
ADK (WD)
ADK (WD)
ADK (WD)
ADK (WD)
ADK (WD)
ADKNS
ADK (WD)
ADK (WD)
ADKWD
F
C
F + C
F
C
-
F
F + C
C
F
F
Ne
NP
F
UNA
F
C
F
C
F
Ne
F
Ne
F
F
F
Ne
Ne
NP
TW
NO
P
TW
40
30
8 - 9
30
15
-
12 - 15 - 20
20
25
30 - 10
30
8
50
30
30
40
15
50
20
-
30
35
25
15
-
-
-
25
-
-
20
-
No
No
No
No
No
No
No
Synchronous Colon
cancer
No
No
No
No
No
No
No
No
No
No
No
BPM
No
No
No
URC + rectal cancer
No
No
No
No
No
No
No
No
NA
NA
NA
NA
NA
NA
NA
NA
N
N
N
E
N
N
N
N
N
N
E
N
N
N
N
N
N
N
N
N
N
N
NA
N
N
NA
NA
NA
NA
NA
NA
NA
NA
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
NA
N
N
BPM: biliary pancreatic maljunction; BL: biliary lithiasis; D: diagnosis; E: elevated; F: fundus; C: corpus; Ne: neck. HD: histological d iscovery; CC: choled ocal
cyst; ADKWD: adenocarcin oma well-differentiated, M: Macr oscopic asp ect. M’: micr oscop y; AMD: adeno carcino ma mean di fferentiated, ADK NS: aden ocar-
cinoma not specified; L: location; N: no rmal; AP: a ssociated path ology; Ca19 .9: carbohy drate antige n 19.9; CEA: c arcino-embry onary antigen; P: polypoid lesion;
TW: thickened wall; NOD: nodal aspect; UD: ultrasound discovery UN: unapparent; URC: ulcerative.
The most easie r form to be detect ed is a polypoid form
(Figure 1).
It is an image which is appended to the gallbladder wall.
It has the same ultrasound-structure than the liver. It is
immobile at the patient positions changes and does not
give an acoustic shadow. This polyp could be single or
multiple, with or without a pedicle. Some features could
orient to the malignant nature, but the strong element is
the polyp diameter (Table 2: malignant criterion of gall-
bladder polyp). If the polypoid form is easily recognized
in a gallbladder without stones by the radiologist, this last
could misinterpret the diagnosis when the gallbladder
contains several stones. In this case, the tumor lesion
could be hidden by stones and this diagnosis become
difficult if not impossible. For this reason, the ultrasono-
graphy should be done on 2 different positions (lying on
the back and on the side). With the lithiasis, acute chole-
cystitis with the inflammatory changes induced could
impede the polyp detection by the radiologist.
Figure 1. Image of polypoid lesion of the fundus of the gall-
bladder on ultrasound examination.
a thickening wall (infiltrative form). This abnormality
could be localized or generalized in the gallbladder
wall.
The second image of the early cancer is re presented by
B. SALAH, A. LARBI 489
Table 2. Therapeutic and evolutionary aspec ts.
Case Treatment Postoperative course Current status Cause of death
1 CX Simple AWD at 120 months
2 CX Simple AWD at 126 months
3 IV-V+ lymphadenectomy Simple AWD at 156 months
4 CX Simple DWD at 56 months*
5 IV-V + lym p h a d e nectomy Simple AWD at 140 months
6 IV-V + lymphadenectomy External biliary fistula LOF at 39 months
7 CX Simple AWD at 96 months
8 CX + colonic resection Simple DWD at 15 mon ths* Died from colonic
cancer recurrence
9 CX Simple DWD at 78 months Bile duct cancer
10 CX Simple AWD at 81 months
11 IV-V + lymphadenectomy + tumor
removal from bile duct Residual tumor in bile duct Alive at 69 months
12 CX Simple DOD at 19 months Hepatic recurrence
13 CX + bile duct resection Simple AWD at 68 months
14 CX Simple AWD at 72 months
15 CX Simple DOD at 42 months Hepatic recurrence
16 IV-V + lymphadenectomy + chemoth erapy Simple DWD at 67 months Hypertension portal?
17 CX + IV-V + lymphadenectomy Lymphatic fistula DWD at 20 months Gastric ulcer Hemor-
rhage
18 CX+ IV-V + lymphadenectomy Postoperative death POD Myocardial infarction
19 IV-V + lym p h a d e nectomy + tumor rem o v a l
from bile duct External biliary fistula AWD at 37 months
21 IV-V + lym p hadenectomy Simple AWD at 37 months
20 CX + choledocal cyst resection Simple AWD at 36 months
22 IV-V + lym p hadenectomy Wound sepsis AWD at 28 months
23 IV-V + lymphadenectomy Hepatic necrosis AWD at 28 months
24 CX + abdominoperineal resection Simple AWD at 25 months
25 IV-V + lym p hadenectomy Simple AWD at 27 months
26 CX Simple AWD at 25 months
27 IV-V lymphadenectomy Simple AWD at 20 months
28 CX+IV-V+ lymphadenectomy Simple AWD at 18 mont hs
29 IV-V+ lymphadenectomy + chemotherapy Wound sepsis AWD at 20 months
32 CX+ IV-V+ lymphadenectomy Simple AWD at 10 months
31 CX Simple AWD at 8 months
30* CX+ bile duct resection Simple AWD at 7 months
33 CX + IV – V + lymphadenectomy Acute renal failure AWD at 4 months
AWD: alive without disease; DWD: died witho ut disease; DOD: died with disease; LOF: lost for follow up; POD: postoperative deat h; CX: cholecystectomy;
IV-V: bisugmental he patectomy.
For the radiologist, each lesion of this kind detected
with a meticulous examination of the gallbladder wall
should be considered as a malignant lesion especially
when it is limited to one part of the wall. The difficulty is
represented by the presence of the acute cholecystitis.
Onoyama [3] had used the ultrasonography for 53 patients
with an early cancer. He was able to do the diagnosis in
34% of all form of cases. For the polypoid form, the
preoperative diagnosis had been done in 75% of cases in
the absence of lithiasis whereas it was possible only in
38.1% of cases in presence of lithiasis. For the infiltrative
form (thickening wall), the diagnosis was done respec-
tively in 5.9% et 0%. Tsuchiya [5] founds the same dif-
ficulty in his series in presence of lithiasis and with the
thickening wall. The early cancer of the gallbladder is
suspected b etween the patie nts of the first group (INF 0) of
the Japanese Society of biliary su rgery (JSBS) [9]. In our
series and with the same examination (trans-cutaneous
ultrasonography), the preoperative diagnosis have been
done only in 16 cases (48.5%) and all these cases were
Open Access SS
B. SALAH, A. LARBI
490
polypoid form. Between these, 5cases had lithiasis and 5
did not have. The contribution of the CT scan (Figure 2)
for the diagnostic is good and the endoscopic ultrasono-
graphy seems also to be an excellent tool if well executed
[4,10]. The endoscopic ultrasonography should be done
after the trans-cutaneous ultrasonography (second inten-
tion). This examination could show the degree of parietal
extension and then made a difference between an early
form (pT1) and invasive form (pT2 and pT3) of gall-
bladder cancer [10]. But, few studies had been done with
this examination currently. In our experience, we have
started the prac tice of the endo scopic ultrasonog raphy and
the preliminary results are encouraging.
The second possibility to recognize this form of gall-
bladder cancer is represented by the histological exami-
nation of gallbladder specimen resected for biliary lithi-
asis and it is more common until nowadays. It is well
known that in the almost cases, the surgeon can perfectly
suspect this cancer after opening the gallbladder. It is
macroscopically apparent on the mucosa of the gallblad-
der in almost cases [2,3,6,7,11,12]. I n our se ries, it was the
case (macroscopically visible) in 29 cases (87.8%) after
the opening of the gallbladder by the surgeon . It was easy
for a polypoid form and difficult for the thickening form
especially when it is associated with cholecystitis. This
fact is very important for the treatment and binds the
surgeon to open the gallbladder at the end of the inter-
vention and scr uti nize t he gall bl adder m ucosa and i ts wa ll
[8] (Figure 3). 4 unapparent forms (mucosa apparently
normal in case of acute cholecystitis) were encountered in
our series (intraepithelial adenocarcinoma) and not rec-
ognized. For us, each resected gallbladder should be
opened and carefully ex amined at the end of intervention
and before the abdominal closure or port ablation by the
surgeon. The specimen should have a histological ex-
Figure 2. Image of polypoid lesion of the fundus of the gall-
bladder on CT scan examination.
Figure 3. Specimen of PT1b gallbladder cancer.
amination in a short delay. All parts of the gallbladder
must be examined. In th is series, we encountered infiltra-
tive cystic stump in which high degree of dysplasia was
found after the second operation done 2 months later in
patient who benefited from bile duct resection after a
cholecystectomy.
The treatment of early gallbladder cancer is surgery
[6,11-15]. T he best t reatm ent is cholecystectomy which is
curative for the majority of the authors [8,16-19]. For
others, the cholecyst ectomy is suf ficient only for t he pT1a
form (mucosal tumor). A radical resection (cholecystec-
tomy associated with hepatectomy and lymphadenectomy)
is indicated for the pT1b form (involvement of the mus-
cularis layer) [20-22]. This controversy seems to found its
explanation in the fact that these authors find a node ex-
tension in the PT1b form [14,20]. For Shimizu et al. [23]
and Shukla et al. [24], the best treatment for PT1b is a
radical cholecystectomy and then the reoperation is rec-
ommended. In our series, two patients with pT1b tumor
presented recurrence at 14 and 36 months (6%) after
cholecystectomy alone and on e have an infiltrative cystic
node. No patient has presented any recurrence until now
after radical resection for PT1b. Another explanation of
this controversy could be the imperfection of the histo-
logical examination and som e cases of the PT1b are in fact
invasive form PT2 or even PT3 for which the cholecys-
tectomy is insufficient. We have an example with patient
who had 2 foci of tumor, one PT1b in the corpus of the
gallbladder and another PT3 in the neck (data not shown).
M. A. Abramson et al. [25] demonstrated that the greatest
benefit in gained life-years is achieved for the youngest
ages having radical resection. We agree with this view.
For us, if the patient with pT1b tumor is 70-year-old or
less and without a serious general disease and a long life
Open Access SS
B. SALAH, A. LARBI 491
expectancy, the radical surgery (re-resection) is indicated
but if the age is upon 70 years or the patient has a serious
general disease or a short life expectancy, the radical
surgery in must be avoided. It is what we have chosen for
our patient. A recent and large study has reported a good
prognosis with radical surgery which contains hepatec-
tomy and lymphadenectomy [25].
If the diagnosis is done in the preoperative step, the
radical approach is indicated for us when we do not know
infiltrative degree in the gallbladder wall. We started
recently the use of endoscopic ultrasonography after
trans-cutan eous ultr asonogr aphy in the aim to exp lore th e
wall extension and to not misinterpret an invasive form
(PT2 or PT3) and make a difference between PT1a and
PT1b. In the opposite case, the decision is difficult.
Should we do a simple cholecystectomy or a radical re-
section? During the intervention, the surgeon could lead
himself on the aspect of the serous layer for the tumor
located on peritoneal side of the gallbladder. If it is an
early form, the serous layer is normal but if it is the con-
trary (retraction of serous surface and white color…),
invasi ve f orm m ust be susp ec t ed. I f t he dou b t pers is ts , t he
surgeon could practice a radical cholecystectomy if the
patient can support this surgery. If the diagnosis is done
after the opening of the gallbladder at the end of the op-
eration, it is wiser to wait the definitive histological ex-
amination. If it is a pT1a cancer the cholecystectomy is
sufficient. The invasive form (PT2-T3) and PT1b needs a
second operation [6,8]. The quality of the histological
examination is fundamental. The histologist should verify
with a multiple sections if there is not foci of invasive
tumor or a lesi on in the Rokitanski-As choff sinus and f or a
lesion near cystic channel (tumor of the neck) in which a
surgeon would h ave cut in the tumor [8]. Others criterion
are perineural infiltration and vascular embolus which
must be noted in the histological report. If the patient
presents a node infiltration, we advocate a systemic
chemotherapy as adjuvant therapy. We have used sys-
temic chemotherapy for two of our (one with infiltrative
node and one with small liver metastasis).
The postoperative course is sim ple in almost cases. T he
prognosis of this form of gallbladder cancer is excellent
with a cholecystectomy [2,11,14,16,18] and radical
cholecystectomy. The 5 year survival fluctuates between
70% and 100% [2,7,8,11, 14,16-21,26]. In our experience,
we encountered one death (radical cholecystectomy) not
related to the surgery (myocardial infarction). It is one of
the favorable form in which we can talk about a complete
recovery after a treatment, even if late recurrences have
been reported in the literature [11,21].
5. Conclusion
There is a clear evidence through our experience and
literature that the early gallbladder cancer could be rec-
ognized in the preop erative course with the modern mor-
phologic examination (trans-cutaneous ultrasonography,
CT scan, endoscopic ultrasonography…) and on histo-
logical specimen. This form is without gallbladder cancer
symptoms, and tumor markers (CEA and CA19.9) are
usually normal. A polypoid is the easy recognizable
morpholo gical form by the ra diologist. The t hickened wall
form is more difficult to be diagnosed on ultras onography.
We focus on the fact that all the specialized teams (radi-
ologist, surgeon, gastroenterologist, histologist…) are
concerned in order to have a well conducted diagnosis
approach and treatment. The radiologist is the key-ele-
ment in this way. The trans-cutaneous ultrasonography
examination (referential examination) should be done in
minimally two positions in order to not misinterpret a
tumoral lesion. Each infiltrative lesion (thick wall) must
be addressed to a surgeon for a cholecystectomy. For the
polypoid lesion, each polyp whose the diameter is above
10 mm is an indication of a cholecystectomy. Follow-up
with ultrasonography for a lesion under 10 mm is indi-
cated (Figure 4). The surgeon must do a simple chole-
cystectomy in case of PT1a and radical resection for the
PT1b for the majority of cases. Well treated, almost of
these patients will be cured.
Polypoid lesion
of the gallbladder
Symptomatic Asymptomatic
Cholecystecto my Ultrasound
follow-up
Negative Positive
Abstention
Great polyp > 10 mm Small polyp < 10 mm
Complications Without
complications
Ultrasound
follow-up at
3 - 6 mo nths.
Figure 4. Algorithm of gallbladder polyp follow-up.
Open Access SS
B. SALAH, A. LARBI
492
REFERENCES
[1] R. Mizumoto, Y. Ogura and T. Kusuda, “Definition and
Diagnostic of Early Cancer of Biliary Tract,” Hepato-
Gastroenyterology, Vol. 40, No. 1, 1993, pp. 69-77.
[2] A. Koga, S. Yamaguchi, Y. Izumi and N. Hamanaka,
“Ultrasonographic Detection of Early and Curable Carci-
noma of the Gallbladder,” British Journal of Surgery, Vol.
72, No. 9, 1988, pp. 728-730.
http://dx.doi.org/10.1002/bjs.1800720919
[3] H. Onoyama, M. Yamamoto, M. Takada, T. Urakawa, T.
Ajiki, I. Yamada, T. Fujita and Y. Saitoh, “Diagnostic
Imaging of Early Gallbladder Cancer: Retrospective
Study of 53 Cases,” World Journal of Surgery, Vol. 23,
No. 7, 1999, pp. 708-712.
http://dx.doi.org/10.1007/PL00012373
[4] K. Ouchi, M. Suzuki, S. Saijo, K. Ito and S. Matsuno,
“Do Recent Advances in Diagnosis and Operative Man-
agement Improve the Outcome of Gallbladder Carci-
noma,” Surgery, Vol. 113, 1993, pp. 324-329.
[5] Y. Tsuchiya, “Early Carcinoma of the Gallbladder: Mac-
roscopic Features and Us Findings,” Radiology, Vol. 179,
No. 1, 1991, pp. 171-175.
[6] O. Glehen, O. Czyglik, A. D. V. Donsbeck, S. Isaak, F. N.
Gilly, Y. François and J. Vignal, “Cancers Vésiculaires de
Découverte Fortuite,” Annales de Chirurgie, Vol. 125, No.
2, 2000, pp. 137-143.
http://dx.doi.org/10.1016/S0001-4001(00)00114-8
[7] E. Kraas, D. Frauenschuh and S. Farke, “Intraoperative
Suspicion of Gallbladder Carcinoma in Laparoscopic
Surgery: What to Do?” Digestive Surgery, Vol. 19, No. 6,
2002, pp. 489-493. http://dx.doi.org/10.1159/000067602
[8] Y. Shirai, K. Yoshida, K. Tsukada and T. Muto, “Unap-
parent Carcinoma of the Gallbladder,” Annals of Surgery,
Vol. 215, 1992, pp. 326-331.
http://dx.doi.org/10.1097/00000658-199204000-00004
[9] F. Iida, S. Kajikawa and N. Horigone, “Evaluation of
Imaging Examination for Hepatic Invasion of Carcinoma
of the Gallbladder and Post Operative Outcome,” Journal
of the American College of Surgeons, Vol. 180, No. 1,
1995, pp. 72-76.
[10] T. Azuma, T. Yoshikawa, T. Araida and K. Takasaki,
“Differential Diagnosis of Polypoid Lesions of the Gall-
bladder by Endoscopic Ultrasonography,” American Jour-
nal of Surgery, Vol. 181, No. 1, 2001, pp. 65-70.
http://dx.doi.org/10.1016/S0002-9610(00)00526-2
[11] R. M. Appleman, C. G. Morlock, D. C. Dahlin and M. A.
Adson, “Long Term Survival in Carcinoma of the Gall-
bladder,” Surgical, Gynecology and Obstetric, Vol. 117,
1963, pp. 459- 464.
[12] X. de Aretxabala, I. Roa, L. Burgos, J. C. Araya, L.
Fonseca, I. Wistuba and P. Flores, “Gallblader Cancer in
Chile. A Report on 54 Potentially Resectable Tumors,”
Cancer, Vol. 69, No. 1, 1992, pp. 60-65.
http://dx.doi.org/10.1002/1097-0142(19920101)69:1<60::
AID-CNCR2820690112>3.0.CO;2-N
[13] H. Isman and M. Brisard, “L’espoir de Guérison du
Cancer de la Vésicule Biliaire. Arguments Pour une
Conception Nouvelle des Stades Précoces,” Journal de
Chirurgie, Vol. 121, No. 1, 1984, pp. 51-55.
[14] Y. Ogura, R. Mizumoto, S. Isaji, T. Kusuda, S. Matsuda
and M. Tabata, “Radical Operations for Carcinoma of the
Gallbladder: Present Status in Japan,” World Journal of
Surgery, Vol. 15, No. 3, 1991, pp. 337-343.
http://dx.doi.org/10.1007/BF01658725
[15] K. Ouchi, M. Suzuki, T. Tominaga, S. Saijo and S. Ma-
tsuno, “Survival after Surgery for Cancer of the Gall-
bladder,” Briti sh Journal of Surgery, Vol. 81, No. 11, 1994,
pp. 16655-1657.
http://dx.doi.org/10.1002/bjs.1800811131
[16] T. Wakai, Y. Shirai, N. Yokoyama, S. Nagakura, H. Wa-
tanabe and K. Hatakeyama, “Early Gallbladder Carci-
noma Does Not Warrant Radical Resection,” British
Journal of Surgery, Vol. 88, No. 5, 2001, pp. 675-678.
http://dx.doi.org/10.1046/j.1365-2168.2001.01749.x
[17] M. Yamamoto, H. Onoyama, T. Ajiki, I. Yamada, T.
Fujita and Y. Saitoh, “Surgical Results of Operation for
Carcinoma of the Gallbladder,” Hepato-Gastroenterology,
Vol. 46, No. 27, 1999, pp. 1552-1556.
[18] K. Yamaguchi and M. Tsuneoshi, “Subclinical Gallblad-
der Carcinoma,” American Journal of Surgery, Vol. 163,
No. 4, 1992, pp. 382-386.
http://dx.doi.org/10.1016/0002-9610(92)90038-S
[19] K. Yamaguchi, K. Chijiiwa, S. Saiki, K. Nishihara, M.
Takashima, K. Kawakami and M. Tanaka, “Retrospective
Analysis of 70 Operations for Gallbladder Carcinoma,”
British Journal of Surgery, Vol. 84, No. 2, 1997, pp.
200-204. http://dx.doi.org/10.1002/bjs.1800840217
[20] H. Kinoshita, K. Hashiro, M. Hashimoto, T. Kodama, K.
Nishimura, M. Kawataba, S. Furukawa, T. Tamae, J. Na-
gashima, M. Hara, H. Imayama and S. Aoyagi, “Clinico-
pathological Evaluation of Surgical Treatment for Early
Gallbladder Cancer,” Kurume Medical Journal, Vol. 48,
No. 4, 2001, pp. 267-271.
http://dx.doi.org/10.2739/kurumemedj.48.267
[21] G. Wagholikar, D. Gajanan, A. Behari, N. Krishnani, A.
Kumar, S. S. Sadiq, R. Saxena and V. K. Kapoor, “Early
Gallbladder Carcinoma,” Journal of the American Col-
lege of Surgeons, Vol. 194, No. 5, 2002, pp. 137-141.
http://dx.doi.org/10.1016/S1072-7515(01)01136-X
[22] E. Yildrim, O. Celen, K. Gulben and U. Berberuglu, “The
Surgical Management of Incidental Gallbladder Carci-
noma,” European Journal of Surgery, Vol. 31, N o . 1, 2005,
pp. 45-52.
[23] T. Shimizu, Y. Arima, S. Yokomuro, H. Yoshida, Y.
Mamada, T. Numura , N. Tania i, T. Aimoto, Y. Nakamura,
Y. Mizuguchi, Y. Kawahigashi, E. Uchida, K. Akimaru
and T. Tajiri, “Incidental Gallbladder Cancer Diagnosed
during and after Laparoscopic Cholecystectomy,” Journal
of Nippon Medical School, Vol. 73, 2006, pp. 136-140.
[24] P. J. Shukla, G. Barreto, A. Karade and S. V. Shrikhande,
“Revision Surgery for Incidental Gallbladder: Factors In-
fluencing Operability and Further Evidence for pT1b
Tumors,” HPB, Vol. 10, No. 1, 2008, pp. 43-47.
http://dx.doi.org/10.1080/13651820701867794
[25] M. A. Abramson, P. Pandharipande, D. Ruan, J. S. Gold
and E. E. Whang, “Radical Resection for pT1b Cancer: A
Open Access SS
B. SALAH, A. LARBI
Open Access SS
493
Decision Analysis,” HPB, Vol. 11, No. 8, 2009, pp. 656-
663. http://dx.doi.org/10.1111/j.1477-2574.2009.00108.x
[26] D. M. Hari, J. H. Howard, A. M. Leung, C. G. Chui, M. S.
Sim and A. J. Bilchik, “A 21-Year Analysis of Stage I
Gallbladder Carcinoma: Is Cholecystectomy Alone Ade-
quate?” HPB, Vol. 15, No. 1, 2013, pp. 40-48.
http://dx.doi.org/10.1111/j.1477-2574.2012.00559.x