Treatment Options Based on the Extent of Gallbladder Cancer

The extent of gallbladder cancer is an important factor in deciding on treatment options. Whenever possible, surgery is the main treatment. It's the best chance of curing the cancer. Because of this, doctors generally divide gallbladder cancers into 2 groups:

• Resectable cancers are those that doctors believe can be removed completely by surgery, based on the results of imaging procedures and other tests.
• Unresectable cancers have spread too far or are in too difficult a place to be removed entirely by surgery.

Resectable gallbladder cancers

Stage I and II cancers and some stage III cancers that have not spread far beyond the gallbladder may still be treatable with surgery. But it's not an option if the cancer has spread into major blood vessels. Other factors, such as whether a person is healthy enough for surgery, also affect whether surgery is a good option. For instance, if the cancer has only invaded the liver in one area and not too deeply, it may be possible to remove all of the cancer. On the other hand, if the cancer has spread to both sides of the liver, to the lining of the abdominal cavity, to organs far away from the gallbladder, or if it surrounds a major blood vessel, surgery is unlikely to remove it all.

How the cancer is first found can impact treatment options, too. For example, some cancers are found on imaging tests before surgery, while others are found only after the gallbladder has been taken out to treat another condition such as gallstones.

If gallbladder cancer is suspected or diagnosed, it’s a good idea to be seen by a surgeon with experience treating this type of cancer. Gallbladder cancer is rare, and not all surgeons are skilled at the more extensive operations needed to treat it.

No matter what stage the cancer is, it’s very important that you understand the goal of treatment before it starts – whether it’s to try to cure the cancer or to help relieve symptoms – as well as the likelihood of the benefits and risks. This can help you make good decisions when looking at your treatment options.

Gallbladder cancers that might be resectable

These are earlier stage cancers that doctors believe might be removed completely by surgery. Treatment of these cancers depends in part on how they're first found.

Cancer found after surgery for another gallbladder problem

Some gallbladder cancers are found when the gallbladder is removed to treat gallstones or chronic inflammation. The removed gallbladder is looked at and tested in a lab, at which time the cancer is found. These are often early-stage cancers. If the cancer is confirmed to be only in the inner layers of the gallbladder (T1a), with no signs of spread outside the gallbladder, no further treatment may be considered because there's a good chance that all of the cancer was removed.

If the cancer is found to be in deeper layers of the gallbladder wall (T1b or greater), other tests will be done to look for any remaining cancer in the body and to see if it can be removed. These tests may include CT or MRI scans and a staging laparoscopy.

If the cancer is thought to be resectable after these tests, another more extensive operation will be done to remove part of the liver, nearby lymph nodes, and possibly parts of the bile duct. If the initial surgery was a laparoscopic cholecystectomy, the skin around the original incision sites may be removed as well. This is done just in case cancer cells may have gotten on the skin when the gallbladder was removed through these small holes. It's not clear how useful this is. This may be followed by adjuvant chemotherapy (chemo after surgery), with or without radiation, to try to keep the cancer from coming back.

If the imaging tests or staging laparoscopy show that the cancer can’t be removed, treatment options will be like those used for unresectable cancers.

Cancer found during surgery for another gallbladder problem

Sometimes, gallbladder cancer is discovered during surgery to remove the gallbladder (simple cholecystectomy). In this case, during the operation, the surgeon sees changed areas that look like they may be cancer. Small pieces of these changes (samples) are sent to the lab to be checked while the operation goes on. If cancer cells are seen in the samples, the next step will depend on the surgeon:

• If the surgeon is experienced in treating gallbladder cancer and believes the cancer can be removed (is resectable), the operation may be changed to a more extensive operation called an extended cholecystectomy. (See Surgery for Gallbladder Cancer for details.)
• If the surgeon isn’t experienced in treating gallbladder cancer or isn’t sure if the cancer is resectable, the operation may be stopped at this point. Other tests such as CT or MRI scans will then be done to look for any remaining cancer in the body and find out whether it's resectable. If the cancer is thought to be resectable after these tests, an extended cholecystectomy may be done. This may be followed by adjuvant chemotherapy, with or without radiation, to try to keep the cancer from coming back.

If the scans show that the cancer can’t be removed, treatment options will be like those used for unresectable cancers.

Cancer found on imaging tests or because of symptoms

Sometimes, gallbladder cancer is suspected because a person is having symptoms like jaundice. Imaging tests may then show areas suspicious for cancer in or near the gallbladder. Further imaging tests and staging laparoscopy may be done to look for any other suspicious areas. These tests can help determine if these areas are cancer and whether it can be removed (is resectable).

If the cancer is thought to be resectable and the person is healthy enough for surgery, an extended cholecystectomy (removing the gallbladder, part of the liver, nearby lymph nodes, and possibly the bile duct and other nearby organs) is the preferred treatment. If the person has jaundice before the surgery, a stent or catheter may be placed in the bile duct first to allow the bile to flow. This can help relieve symptoms over a few days and might make a person healthy enough for surgery. After the surgery, adjuvant chemotherapy, with or without radiation, may be advised to try to lower the chance that the cancer will come back.

If the imaging tests or a staging laparoscopy show that cancer is likely but that it can’t be removed, a biopsy may be done to confirm the diagnosis. Treatment options will then be like those used for unresectable cancers.

Unresectable gallbladder cancers

If surgery isn't an option (for example, because of the size or location of the cancer or because of a person’s general health), the focus of treatment is usually on trying to control the cancer. This can help with symptoms and may help people live longer.

Many people with unresectable gallbladder respond well to a combination of immunotherapy and chemotherapy as an initial treatment. Immunotherapy can also be given alone if the tumor has certain traits, such as having a defect in a mismatch repair gene (dMMR), many specific genetic changes (a high level of microsatellite instability or MSI-H), or a generally high number of genetic changes (a high tumor mutational burden or TMB-H). Another option might be to treat with a targeted therapy, if the tumor has a targetable mutation.

For those who are jaundiced because of bile duct blockage, a stent or catheter may be placed in the duct to allow the bile to flow. If needed, surgery to bypass the bile duct may be an option if the person is healthy enough. Relieving bile duct blockage is often the first thing done, before starting other treatments such as chemo.

Because these cancers can be very hard to treat, taking part in clinical trials of newer treatments may be an option.

Palliative care

Palliative care is supportive care. It's aimed at preventing and treating symptoms or problems caused by the cancer. Palliative care is used with every type of cancer treatment at every stage of gallbladder cancer. It includes things like medicines to prevent nausea, pain control, and maintaining the flow of bile where a tumor may block it. Palliative care is focused on helping you feel better. It's not used to cure the cancer.

Maintaining your quality of life is an important goal. Please don’t hesitate to discuss pain, other symptoms, or any quality-of-life concerns with your cancer care team.

See Palliative Therapy for Gallbladder Cancer for details on some of these treatments.

Recurrent gallbladder cancer

Cancer is called recurrent when it comes back after treatment. Recurrence can be local (in or near the same place it started) or distant (it comes back in organs, like the lungs or bone). If the cancer comes back, further treatment depends on where the cancer recurs, the kind of treatment used in the past, and the patient’s overall health.

Rarely, the cancer may recur in a small area near where it started, in which case surgery to try to remove it (perhaps followed by chemo and/or radiation therapy) might be an option. But in most cases the recurrent cancer is unresectable and is treated as described above.

Recurrent gallbladder cancer is often very hard to treat, so people might want to consider taking part in a clinical trial of newer treatments.