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Year : 2020  |  Volume : 57  |  Issue : 1  |  Page : 2--3

Should every cholecystectomy specimen be sent for histopathology to identify incidental gall bladder cancer?

Ganesh Nagarajan1, Kaushal Kundalia2,  
1 Consultant HPB and GI Surgical Oncologist, P D Hinduja Hospital, Mumbai, Maharashtra, India
2 Fellow in HPB and Liver Transplant Surgery, Kings College London, London, United Kingdom

Correspondence Address:
Ganesh Nagarajan
Consultant HPB and GI Surgical Oncologist, P D Hinduja Hospital, Mumbai, Maharashtra

How to cite this article:
Nagarajan G, Kundalia K. Should every cholecystectomy specimen be sent for histopathology to identify incidental gall bladder cancer?.Indian J Cancer 2020;57:2-3

How to cite this URL:
Nagarajan G, Kundalia K. Should every cholecystectomy specimen be sent for histopathology to identify incidental gall bladder cancer?. Indian J Cancer [serial online] 2020 [cited 2020 Mar 30 ];57:2-3
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Full Text

Gall bladder cancer (GBC) is the fifth most common gastrointestinal cancer. It is a common cancer in India especially in the Northern belt with a reported incidence of 7–10 per 100,000[1] in some areas unlike the Western world where the incidence is to the tune of 1.2 per 100,000.[2] GBC is known to have an extremely poor prognosis with overall 5-year survival across all stages being about 5%.[3]

Among all cases of gall bladder cancer, the only ones with a good chance of long-term survival are the early-stage cancers. In pT2 cases, the overall survival jumps from 20% to 70% with a radical re-surgery. Hence, it is of paramount importance that all early-stage GBC receive the optimal surgery to give them the best chance at long-term survival.

It is interesting to note that many cases of gall bladder cancer are seen to have concomitant gall stone disease.[4],[5] Most published literature on the subject report a concomitant presence of gall stones in 60-70% of all cases of GBC. In all such cases, the gall bladder is seen on ultrasound to have a thickened wall, which may not be too different as compared to chronic cholecystitis on ultrasound or even cross-sectional imaging.

It is uncommon for surgeons in India to carry out a CT scan or MRI for a gall stone disease.

Hence, many early gall bladder cancers may be missed on ultrasound, which is purely operator dependent and passed off as chronic cholecystitis with gall stone disease. In fact, even during a laparoscopic cholecystectomy, it would be very difficult for the surgeon to identify a T1 OR T2 disease. Many studies have looked at the incidence of incidental gall bladder cancer, which is defined as a 'pathological surprise' finding of a gall bladder cancer in a cholecystectomy specimen. According to Cavallaro et al., only 30% of GBC cases are suspected preoperatively in early cases and the other 70% are detected incidentally by the pathologist on the cholecystectomy specimen performed for benign conditions like gall stones, cholecystitis and polyps.[6]

The overall incidence of incidental GBC in reported literature varies from 0.3–3%. With the increasing use of ultrasound in urban and rural settings, the incidence of incidental GBC is only going to see an increasing trend. Indian studies have also reported similar rates of incidental GBC. In a country like India, where patient follow-up is erratic and stringent data maintenance is a rarity, the reported incidental GBC may be just the tip of the iceberg, especially in semiurban or rural settings.[4],[7]

In an interesting publication by Agarwal et al.,[7] they compared outcomes of those Incidental GBCs who were promptly referred as the histopathology reporting was done for the cholecystectomy specimens to those who came in late after manifestations of symptoms of the GBC as routine histopathology was not done. The R0 resectability rate was 69.9% among those who presented early while it was a dismal 7.8% among those who presented late. This emphasizes the role of histopathological examination of the routine cholecystectomy specimens for the detection of incidental GBC.

Incidental gall bladder cancer is an entity that clearly cannot be taken lightly. According to a study published by the MSKCC group,[2] 47% of their GBCs were incidentally detected at laparoscopic cholecystectomy.[2] Most of these incidental GBCs are early-stage diseases and are the T1 and T2 GBCs who have the best chance of long term survival with a 5-year overall survival upwards of 70%.[8]

It is hence of paramount importance that every specimen of cholecystectomy is examined by a pathologist. The Royal College of Pathologist guidelines clearly states the need for routine histopathology examination of all cholecystectomy specimens.[7]

Any irregular area must be sectioned and examined for the presence of cancer.

Identification of a focus of cancer facilitates prompt referral to a specialized center for revision radical cholecystectomy, which involves complete portal lymphadenectomy, excision of a 2 cm liver wedge or segment 4B-5 resection as per the requirement and a revision of the cystic duct stump.

There have been some suggestions to avoid routine histopathology examination of all cholecystectomy specimens for cholelithiasis.[9],[10] This edition of the Indian Journal of Cancer carries a interesting article by Yadav et al. eluding to the same issue of whether or not all cholecystectomy specimens should be sent for histopathology.[11] They have concluded that only gall bladder specimens with a macroscopic lesion should be sent for histopathology.

While these studies may justify their recommendation because of the low rate of incidental gall bladder cancer associated with cholelithiasis, it seems to be highly unfair to the small percentage of patients who would miss a good chance of curative surgery and cure. Some of these papers are from western centers that have a very aware patient population and well-established follow up systems. Systems like the NHS can analyze the total costs saved or the person-hours saved by not performing routine histopathology examination of the cholecystectomy specimens as the state pays for the costs. The system in India is much more complex with most of the work done in the private sector and patients being less likely to follow-up as there is no centralization.

Moreover, in today's era of litigations, would we be able to justify missing an early GBC and a more than 70% chance of cure just because we want to save the cost of histopathology which would amount to about INR 4,000–5,000 ($50–70) in most centers. If some centers want to make it a policy to avoid routine histopathology for cholecystectomy specimens, they may want to consider taking the consent of the patient accordingly.

In a study, which looked at incidental GBC, they found that only 30% had an irregular thickening on preoperative ultrasound and only 55% had macroscopic features suggestive of a malignancy. That means about 45% of patients will be missed if routine histopathology is not performed.[4] The paper by Yadav et al. in this edition has suggested a gross examination by a pathologist and performing a microscopic examination only if found suspicious. I wonder how many pathologists would want to sign out a report with only a gross examination!

Patients from northern India where gall bladder cancer is endemic are settled or travel to all parts of the country for surgical treatment and this group may have a much higher incidence of incidental gall bladder cancer concomitant with cholelithiasis.

In conclusion, in a country where some parts are highly endemic for gall bladder cancer, we can ill afford to miss incidental GBC. It would be dangerous to suggest doing away with histopathology examination of cholecystectomy specimens.


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11Butti AK, Yadav SK, Verma A, Das A, Naeem R, Chopra R, et al. Chronic calculus cholecystitis: Is histopathology essential postcholecystectomy? Indian J Cancer 2020;57:89-92.