Adequate treatment for a gallbladder lesion involving the lamina propria of the gallbladder includes:
Tumors limited to the muscular layer of the gallbladder (Tl) are usually identified incidentally, after cholecystectomy for gallstone disease. There is near universal agreement that simple cholecystectomy is an adequate treatment for Tl lesions and results in a near 100% overall 5-year survival rate.
All of the following are different morphological classifications of bile duct adenocarcinomas EXCEPT:
Over 95% of bile duct cancers are adenocarcinomas. Morphologically, they are divided into nodular (the most common type), scirrhous, diffusely infiltrating, or papillary.
According to the Bismuth-Corlette classification system, perihilar cholangiocarcinomas extending into the right secondary intrahepatic ducts are classified as:
Perihilar cholangiocarcinomas, also referred to as Klatskin tumors, are further classified based on anatomic location by the Bismuth-Corlette classification. Type I tumors are confined to the common hepatic duct, but type II tumors involve the bifurcation without involvement of the secondary intrahepatic ducts. Type Ilia and IIIb tumors extend into the right and left secondary intrahepatic ducts, respectively. Type IV tumors involve both the right and left secondary intrahepatic ducts.
The best initial imaging test for evaluating for suspected cholangiocarcinoma includes:
The initial tests are usually ultrasound or CT scan. A perihilar tumor causes dilatation of the intrahepatic biliary tree, but normal or collapsed gallbladder and extrahepatic bile ducts distal to the tumor. Distal bile duct cancer leads to dilatation of the extra- and intrahepatic bile ducts as well as the gallbladder. Ultrasound can establish the level of obstruction and rule out the presence of bile duct stones as the cause of the obstructive jaundice. It is usually difficult to visualize the tumor itself on ultrasound or on a standard CT scan. Either ultrasound or spiral CT can be used to determine portal vein patency. The biliary anatomy is defined by cholangiography. PTC defines the proximal extent of the tumor, which is the most important factor in determining resectability. ERCP is used, particularly in the evaluation of distal bile duct tumors. For the evaluation of vascular involvement, celiac angiography may be necessary. With the newer types ofMRI, a single noninvasive test has the potential of evaluating the biliary anatomy, lymph nodes, and vascular involvement, as well as the tumor growth itself.
All of the following examples are considered resectable lesions EXCEPT:
Patients should undergo surgical exploration if they have no signs of metastasis or locally unresectable disease. However, despite improvements in US, CT scanning, and MRI, more than one-half of patients who are explored are found to have peritoneal implants, nodal or hepatic metastasis, or locally advanced disease that precludes resection. For these patients, surgical bypass for biliary decompression and cholecystectomy to prevent the occurrence of acute cholecystitis should be performed.
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