cancer gallbladder

CANCER GALLBLADDER

INCIDENCE

• Increases with age• 2-6 times common in women• Common among population in– Western South America– Northern India– North American Indians– Mexican Americans

RISK FACTORS

• Gallstones• Porcelain gallbladder• Adenomatous polyps• Chronic infection with S.typhi• Carcinogen exposure(miners exposed to

Radon)• Abnormal PancreaticoBiliary Duct

Junction(APBDJ)

APBDJ

• It is more common in Asian countries• GB cancers with APBDJ – Tend to occur at an younger age– Lesser degree of female preponderance– Asociated less often with cholelithiasis– High prevalence of K-ras mutations & a late onset

of p-53 mutations– High prevalence of premalignant epithelial

hyperplasia with a papillary or villous histology.

CANCER & CALCULI

• Gallstones are present in 70-90% of patients diagnosed with GB cancer

• Only 0.5-3% of patients with cholelithiasis will develop GB cancer

• Risk of GB cancer is increased with increasing size & duration of cholelithiasis

PATHOGENESIS

• Chronic irritation• Dysplasia-carcinoma in-situ-invasive cancer• p 53 & K-ras(rare) mutations

PATHOLOGY• 80%-adenocarcinoma• Others

– Small cell cancer– Squamous cell cancer– Lymphoma sarcoma

• Morphologically– Infiltrative– Nodular – Papillary– Combined pattern

• Staging systems– Nevin– TNM

CLINICAL PRESENTATION

• Early lesion– Asymptomatic– Abdomonal pain– Anorexia– Nausea– Vomiting

• Advanced lesion– Weight loss– Obstructive jaundice– Duodenal obstruction– Palpable mass– Hepatomegaly– ascites

INVESTIGATIONS• Biochemical evidence of obstructive jaundice• Nonspecific

– Anaemia– Leucocytosis– Elevated liver enzymes– Increased ESR– Increased CRP

• Tumour markers-CEA/CA 19-9• USG• CECT• MRI/MRCP• EUS• ERCP/PTC

USG

• Mural thickening• Mural calcification• GB mass >1 cm• Loss of normal GB wall-liver interface• Gall stones• Polyps

CECT

• Mass protruding into the GB lumen• Mass completely replacing the GB• Focal or diffuse thickening of GB wall• Presence or absence of distant metastasis• Regional lymph node involvement• Local invasion into liver & porta hepatis

STAGE 0 & 1A

• Carcinoma in situ & T1-cancer that doesnot extend beyond the GB muscularis– Simple cholecystectomy

STAGE 1B

• T2 lesion- invasion into perimuscular connective tissue of GB– Re-exploration revealed residual disease in 40-76%– Regional lymphnode metastasis in 28-63%

• Exploration with en bloc resection of the GB with 2 cm of adjacent liver(non-anatomoic) withregional lymphadenectomy of the hepatoduodenal ligament

• En-bloc resection with anatomic resection of liver segments 4b & 5

STAGE II

• T3 Lesion-locally advanced cancers that perforate the GB serosa or directly involve the liver or adjacent organ

• Hepatic resection encompassing segment 4b & 5 or trisegmentectomy with adjacent organs

STAGE III & IV

• Unresectable• Median survival with unresectable disease is

less than 6 months• If detected intraoperatively– Radio-opaque clips– No data to support debulking cholecystectomy

PROGNOSIS

• 5-year survival rate is 5%• Median survival 12 months(stage IA-III)• Median survival 5.8 months(stage IV)

WHY POOR PROGNOSIS?

• Usually diagnosed at a late stage• Aggressive nature• Clinical presentation mimics that of biliary

colic/chronic cholecystitis• Incidental diagnosis at surgery• Incidental diagnosis after pathology report

SURVIVAL RATES.NO STAGE 5 YR.SURVIVAL RATE

1 I 60%

2 II 39%

3 III 15%

4 IV 1%

Median survival 12 months(stage IA-III)Median survival 5.8 months(stage IV)

NCCN guidelines 2010

EXTENT OF LYMPHADENECTOMY