Prediction Of Residual Disease In Unsuspected "incidental" Gallbladder Cancer: Experience Of A Tertiary Care Hospital In Northern India.

Introduction Unsuspected Gall bladder carcinoma (UGBC) is erroneously leveled as incidental carcinoma gallbladder. An attempted radical surgery later is not possible in sizable number of cases as the tumor is either disseminated or locally unresectable at laparotomy. Purpose of this report was to study the preoperative imaging and to predict the presence of residual disease from retrospective analysis of prospectively maintained database. Materials and Methods The study comprises of retrospective analysis of 16 patients of UGBC out of 84 patients of Gallbladder carcinoma (GBC) admitted from 2011 to 2016. Ultrasound (USG) abdomen and intraoperative findings prior to initial cholecystectomy were studied. The clinical evaluation and CECT± FDGPET scan was performed in all as a protocol to stage the tumor prior to definitive surgery. Resectable patients were subjected to laparotomy. Results Laparoscopic cholecystectomy was performed in 7, open in 6 and in three patients; laparoscopy was converted to open cholecystectomy. All but one patient were operated outside. The median time from cholecystectomy to attempted radical surgery was 7 weeks (5 days-4.5 months). All patients were referred with histopathological report for further surgery, out of these 6 had persistent pain, 2 had postoperative jaundice and 4 patients had severe anorexia and weight loss. 81.25% (13/16) patients presented with their ultrasound report prior to cholecystectomy. 43.75% patients (7/16) had features of uncomplicated cholelithiasis (normal gallbladder wall thickness, single or multiple stones or mucocele) and suspicious clinical features of malignancy were reported in 56.25% (9/16) cases prior to cholecystectomy. On staging CT, 68.75% (11/16) had gall bladder wall thickening (asymmetrical=6) with or without associated periportal lymphnodes and loss of interphase with adjoining liver. 85.71% (6/7) patients with uncomplicated cholelithiasis reported on preoperative U/S underwent R0 resections and 4 of them had no evidence of residual diseases in resected specimen while remaining 3 patients had e/o resectable residual or recurrent GB mass. Surgery could not be contemplated in 1 patient due to locally unresectable disease. 44.45% (4/9) patients with suspicious U/S findings underwent R0 resections. All of them had residual/ recurrent diseases without or with GB fossa mass. The remaining 5 patients (55.55%), could not undergo surgery (distant metastasis=3, locally unresectable disease=2) Conclusions: The incidental GBC masquerading as uncomplicated cholelithiasis on U/S can later develop GB mass in 42.8% cases (3/7). The incidence of finding GB mass increases to 100% (8/15) in presence of suspicious lesions on U/S. Intra operative frozen calot's triangle, duodenal adhesions and thickened GB wall should raise the suspicion of tumor. The study reinforces alertness and calls for high index of suspicion of GBC on U/S in patients undergoing cholecystectomy in endemic region and recommends further investigations in cases of suspicious lesions on U/S prior to cholecystectomy. [ABSTRACT FROM AUTHOR]