EXPLAINING CANCER OF GALL BLADDER

EXPLAINING CANCER OF GALL BLADDER

Introduction

Cancer of gall bladder it is a malignant tumors of the gall bladder which arise mainly from the innermost layer of (mucosa )the gall bladder

It is rare malignant tumor which occur most common in old age patients but it is aggressive tumour if discovered lately and carry good prognosis if discovered early

It accounts for only 2 to 4% of all malignant gastrointestinal tumors
The patients who undergoing cholecystectomy means removal of the gall bladder for gallstone disease may found incidentally to have gallbladder cancer

Causes of gall bladder cancer

Majority of patients with carcinoma of the gall bladder have gall bladder stones but risk of developing cancer for patients with gallstones are rare

That is related to chronic inflammation and irritation of of gallbladder that more common with larger stones (3 cm) are associated with a tenfold increased risk of cancer

The risk of developing cancer of the gallbladder is higher in patients complaining from symptoms than asymptomatic gallstones

Polypoid lesions means swelling like projection of the gallbladder are associated with increased risk of cancer especially large polyps

The calcified porcelain gallbladder is associated with more than a 20% incidence of gallbladder carcinoma so the gallbladders should be removed, even if the patients are asymptomatic

Patients with bile duct (choledochal) cysts have an increased risk of developing cancer anywhere in the biliary tree, but the incidence is highest in the gallbladder

Sclerosing cholangitis which it is an autoimmune disease may be primary with no other associated diseases or secondary due to associated disease like ulcerative colitis which characterized by progressive stricture of the biliary tract it is diagnosed by ERCP and treated by prolonged T tube insertion in bile duct with long term uses of steroids

anomalous pancreaticobiliary duct junction, and exposure to carcinogens (azotoluene, nitrosamines) also are associated with cancer of the gallbladder

Pathology

Between 80 and 90% of the tumors are adenocarcinoma
Squamous cell, adenosquamous, oat cell, and other anaplastic lesions occur rarely

The histologic subtypes of gallbladder adenocarcinomas include papillary, nodular, and tubular

Less than 10% are of the papillary type, but they are associated with better out come, as they are most commonly diagnosed while localized to the gallbladder

Methods of spread

direct spread or invasion into the liver bile passages peritoneum small intestine and colon

Lymphatics spread lymphatic of the gall bladder present in the subserosa layer only and drains first to the cystic duct node (Calot's node),then to gland in porta hepatis and the pericholedochal and hilar nodes, and finally the peripancreatic, duodenal, periportal, celiac, and superior mesenteric artery nodes

Blood spread with venous drainage veins drain directly into the adjacent liver lung and bones

Symptoms and signs of gall bladder cancer

The patient may complaining from symptoms like those of chronic cholecystitis see here for more about it or gall stones these include
right upper quadrant pain, nausea, and vomiting
Abdominal discomfort
Jaundice yellowish disclouration of skin and sclera of the eye
abdominal mass may be become palpable
weight loss, anorexia
ascites fluid collection in the abdomen and become distended in late stage
More than one half of gallbladder cancers are not diagnosed before surgery

Gall bladder cancer may misdiagnosed as the following diseases

Chronic cholecystitis chronic inflammation of gall bladder as due to gall bladder stones present inside it or other causes
acute cholecystitis for more see here acute inflammation of the gall bladder due to the presence of gall stones inside it or other causes
bile duct stones choledocholithiasis
Mucocele or hydrops of gall bladder means dilatation and distension of the gall bladder due impacted stone in hartamn,s pouch or cystic duct by stones
pancreatic cancer

Investigations of gall bladder cancer

Laboratory findings are not diagnostic, but if abnormal, are most often consistent with biliary obstruction these include

Liver function test

A sample of blood are taken from vein and analyzed to check any abnormal substance related to liver disease like alkaline phosphatase enzyme aminotransferase enzyme and biliurbin

Comple blood count

A sample of blood also taken from the vein and analyzed may showing anemia decreased red blood cells (RBC) count leuckopnia decreased ( WBC) white blood cells count

Urine analysis

A sample of urine are taken by micturation and analyzed may show biliurbin or urobilinogin in case of jaundice

Tumor markers

These are substance which present in blood serum or urine or stool or tears which if present in large amount may detect cancer and help also for follow up as

Carcinoembroying antigen CEA for more details about that see here

Imaging studies

Abdominal ultrasound

Ultrasonography may showing thickened irreguller gallbladder wall or a mass replacing the gallbladder

Ultrasonograpby may visualize tumor invasion of the liver, Iympbadenopathy and a dilated biliary tree

CT scanning of the abdomen

CT scan demonstrate a gallbladder mass or an invasion into adjacent organs

spiral CT scans demonstrates the vascular anatomy
CT scan is a poor method for identifying nodal spread

Endoscopic retrograde cholangiopanceartography ERCP

Endoscope is a thin tube which passes from the mouth to esophagus to stomach to the duodenum then a catheter is inserted through endoscope to reach bile duct through sphincter of oddi then a dye injected through this catheter untill reach the bile duct then X ray is taken and visualized the bile duct and showing if there is any abnormalities like tumor or obstruction this catheter can be left in place acts as stent to relieve obstruction and also can allow for taken a biopsy

Percutaneous transhepatic cholangiagrphy PTC

In case of presence of jaundiced
may be helpful to delineate the biliary tree, and typically shows long stricture of the common bile duct

MRI and MRCP scanning of the abdomen

MRI and MRCP has evolved into a single noninvasive imaging method

That allows complete assessment of biliary, vascular. nodal, hepatic, and adjacent organ involvement

Biopsy of gall bladder cancer

If diagnostic studies suggest that the
tumor is unresectable, a CT scan or ultrasound-guided biopsy of the tumor can be obtained

Laparoscopy

Which small incisions in the abdominal wall are done and by camera video it can see the gall bladder tumor either localized to it or spread for other organ and also tissue biopsy can be taken

Treatment of gall bladder cancer

Surgery remains the only curative option for gallbladder cancer as well as for (cholangiocarcinoma) bile duct cancer

palliative procedures for patients with unresectable cancer and jaundice or duodenal obstruction remain the most frequently performed surgery for gallbladder cancer

Patients with obstructive jaundice can be managed with either endoscopic ERCP or percutaneously PTC-placed biliary stents

There are no proven effective options for adjuvant radiation or chemotherapy for patients with gallbladder cancer

Treatment of gall bladder cancer depend on the pathological stages of the cancer

Patients without evidence of distant metastasis warrant exploration for tissue diagnosis, pathologic staging, and possible curative resection

Stage 1

Tumors limited to the muscular layer of the gallbladder (TI). are usually identified incidentally, after cholecystectomy for gallstone disease

Simple cholecystectomy is an adequate treatment for Tl lesions
and give very good results

Stage 2

When the tumor invades the perimusclar connective tissue without extension beyond the serosa or into the liver

Extended cholecystectomy should be performed

That includes resection of liver segments IVB and V, and lymphadenectomy of the cystic duct, and pericholcdocbal, portal, right celiac ,and posterior pancreatoduodenal lymph nodes

One half of patients with T2 tumors are found to have nodal disease on pathologic examination

Therefore regional lymphadenectomy is an imponant part of surgery for cancers

Stage 3 and 4

For tumors that grow beyond the serosa or invade the liver or other organs (T3 and T4 tumors) there is a high likelihood of intraperitoneal and distant spread

If no peritoneal or nodal involvement is found, complete tumor excision with an extended right hepatectomy (segments IV, V
VI, vn.and VDI) must be performed for adequate tumor clearance

An aggressive approach in patients who will tolerate surgery has resulted in an increased survival for T3 and T4 lesions

Prognosis

Most patients with gallbladder cancer have umesectable disease at the time of diagnosis The 5-year survival rate of all patients with gallbladder cancer is less than 5%, with a median survival of 6 months

Patients with TI disease treated with cholecystectomy
have all excellent prognosis (85 to 100% 5-year survival rate

The 5-year survival rate for T2 lesions treated with an extended cholecystectomy and lymphadenectomy compared with simple cholecystectomy is over 70% versus 25 to 40%, respectively

Patients with advanced but resectable gallbladder cancer are respond to have 5-year survival rates of 20 to 50%

the median survival for patients with distant metastasis at the time of presentation is only 1to 3 months
Recurrence after resection of gallbladder cancer occurs most
commonly in the liver or the celiac or retropancreatic nodes

The prognosis for recurrent disease is very poor

Death occurs most commonly secondary to biliary sepsis or liver failure

The main goal of follow-up is to provide palliative care

The most common problems are itching (pruritus) and (cholangitis)inflammation of bile duct with fever pain and associated with obstructive jaundice, bowel obstruction secondary to carcinomatosis

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