“CARCINOMA GALL BLADDER” | Gallbladder | Liver

SEMINAR ³CARCINOMA GALL BLADDER´

DR AMOL KUMAR DR HARI KISHAN

Epidemiology
-The incidence of Gall Bladder cancer is extremely variable by geographic regions & racial-ethinic groups -Incidence -Highest- Chileans, Northeastern Europeans, Israelies, American Indian & Americans of Mexican origin -Intermediate- Japan -Lowest- Black Zimbabweans Black Americans & the People of Spain & India - Sex- M:F::1:2-6 - Age - incidence with age, reaching its maximum in the seventh decade of life

Gall bladder Polyps .Chemicals like methyldopa oral contraceptives isoniazid chemicals used in rubber industry .Risk Factors -Cholelithiasis usually cholesterol type stones -Anomalous pancriaticobiliary duct junction -Chronic typhoid infection -Inflammatory bowel diseases -Porcelain gallbladder .

Of sec. regardless of the cause of inflammation -A higher concentration of free radical oxidation products and a higher conc.bile acids .Etiology -It is likely to be the chronic inflammation that predisposes to neoplasia.

Early invasion . Infiltrative -Most common type -causes thickning & induration of gb wall -difficult to distinguish from a chronically inflamed but benign gb . Papillary -polypoid appearance -low invasiveness 4.Tumor to be disseminated by cholicystectomy 2.Easier to control surgically 3. Nodular .More distinctive . Combined form -much batter prognosis .Pathologic features Ca gallbladder Fundus (60%) Body(30%) Neck(10%) Ca gallbladder 1.

small cell Signet ring cell Clear cell Colloid With choriocarcinoma-like areas Squamous Adenosquamous Oat cell carcinoma MALIGNANT MESENCHYMAL TUMORS Embryonal rhabdomyosarcoma Leiomyosarcoma Malignant fibrous histiocytoma Angiosarcoma Oat cell carcinoma .Histopathological classification MALIGNENT EPITHELIAL TUMORS (99%) Adenocarcinoma Well-differentiated Papillary Intestinal type Pleomorphic giant cell Poorly-differentiated.

ras. K. C-ergB-2 genes.TUMOUR BIOLOGY Activation of protoncogenes Cell Inactivation of tumour separessor genes Gene mutation related to gall bladder carcinoma P53 . nm23 Tumor .

Only single muscle layer Posterosuperior Pancreaticoduodenal Superior mesenteric Retroportal Celiac Interaortocaval nodes .Thin gall bladder wall .Narrow lamina propria .PATTERN OF SPREAD Direct Lymphatic Haematogenous Through small veins directly into the portal venous system Via-large veins to the portal venous branch of segments IV & V of liver Iatrogenic Leproscopic colistictomy FNAC Direct spread to liver Cystic & other adjacent organ .Favourable factors for direct spread Pericholedochal .

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if this is due to a palpable gallbladder) ‡Periumbilical lymphadenopathy (Sister Mary Joseph nodes) ‡Left supraclavicular adenopathy (Virchow node) ‡Pelvic seeding: Mass is palpated on digital rectal examination (Blumer shelf) . Physical: ‡Jaundice ‡Palpable mass in the right upper quadrant (Courvoisier sign. Abdominal pain may be of a more diffuse and persistent nature than the classic right upper quadrant pain of gallstone disease.CLINICAL PRESENTATION History: The symptoms of gallbladder cancer overlap with the symptoms of gallstones and biliary colic. anorexia. and weight loss often indicate more advanced disease. Jaundice.

4% sensitivity & 79. UA: Assess renal function prior to performing an enhanced CT scan. . ‡Liver function tests: Elevated alkaline phosphatase and bilirubin levels are often found with more advanced disease. ‡BUN. ‡CBC: Anemia may be an indicator of more advanced disease.INVESTIGATIONS Lab Studies: ‡Tumor marker CA 19-9 with 79. creatinine. -CA 19-9 tests may be helpful in the appropriate situation if the clinical suspicion for gallbladder cancer is high.2% specificity -CA 19-9 may be significantly elevated in both cholangiocarcinoma and gallbladder cancer.

is a standard initial study . and the combination of CT scan and US provides accurate details of disease extension. ‡Cholangiography.demonstrate tumor invasion outside of the gallbladder and identify metastatic disease elsewhere in the abdomen or pelvis. Liver invasion occurs in 60% of cases. ‡A routine chest radiograph should also be obtained. and assist in preoperative planning for definitive resection. ‡Endoscopic ultrasonography can be useful to assess regional lymphadenopathy in conjunction with other studies.IMAGING STUDIES ‡Ultrasonography. ‡Angiography may confirm encasement of the portal vein or hepatic artery. or endoscopic retrograde cholangiography (ERCP) may establish the diagnosis of gallbladder cancer by bile cytology. It also can delineate metastatic lesions in the liver. . It can provide details of the vasculature for preoperative planning via magnetic resonance angiogram (MRA) and bile duct passages via magnetic resonance cholangiogram (MRCP). ‡Magnetic resonance imaging. via a percutaneous route. A mass can be identified in 5075% of patients with gallbladder cancer.useful in examining for disease extension into other tissues or metastatic disease in the liver. ‡Computed tomography.

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. and endoscopic ultrasonographic (EUS) fine-needle aspiration. biopsy. and shave biopsies via ERCP can provide material for histology. needle aspiration. as well as excluding ampullary pathology by endoscopic evaluation. if a mass lesion is present. ‡Percutaneous transhepatic cholangiography (PTC) may allow access to the proximal biliary tree that has become obstructed by extensive tumor growth from the gallbladder. Brush cytology. ‡Other methods to obtain tissue include CT or ultrasound needle aspiration. Material for cytology can be obtained and drainage performed as well.PROCEDURES ‡ERCP can demonstrate the site of the obstruction by direct retrograde dye injection. Palliative stenting to relieve biliary obstruction can be performed at the time of the evaluation.

colon. such as the stomach.Tumor invades lamina propria T1b . Survival is correlated directly with stage of disease. or extrahepatic bile ducts T4 . Primary tumor ‡Category T TX .Tumor invades perimuscular connective tissue.Metastases in regional lymph nodes Distant metastases ‡Category M MX .Regional lymph nodes cannot be assessed N0 . omentum. duodenum.No metastases in regional lymph nodes N1 .Presence of metastases cannot be assessed M0 . with depth of tumor penetration and regional spread defined pathologically .Tumor perforates the serosa (visceral peritoneum) and/or directly invades the liver and/or one other adjacent organ or structure.STAGING The AJCC 6th edition guidelines follow the TNM system.Carcinoma in situ T1 . pancreas.No distant metastases M1 .Tumor invades lamina propria or muscle layer T1a .Tumor invades main portal vein or hepatic artery or invades multiple extrahepatic organs or structures Regional lymph node ‡Category N NX .No evidence of primary tumor Tis .Distant metastases .Tumor invades muscle layer T2 . no extension beyond serosa or into liver T3 .Primary tumor cannot be assessed T0 .

T1 N0 M0 Stage IB .T4 any N M0 Stage IV .T3 N0 M0 Stage IIB .T2 N0 M0 Stage IIA .TNM Groupings by stage Stage 0 Tis N0 M0 Stage IA .any T any N M1 .T1 N1 M0 T2N1M0 T3N1M0 Stage III .

Particular attention is paid to the cystic duct margin -ve . Reviewed pathologic findings to ensure that margins are negative 3. 5 years survival rate is 85% to 100% .SurgicalT1diseases1. 2. Most often presents after the gall bladder has already been removed by simple colecystectomy for presumed gall stone disease.MANAGEMENT Surgical Medical .no other therapy Margin < +ve ± common bile duct excision & biliary reconstruction 4.

The plane i.. T2 tumour are associated with a high incidence of regional nodal metastasis 3. T2 diseases2 reasons to perform more extensive surgery in T2 disease 1. 5 yrs survival after radical colecystectomy is 80-90% as compared to 40% 5 yrs survival with simple colecystectomy . This includes ± a wedge resesction of the gall bladder bed and lymph node of hepatico duodenal ligament 5.e. generally taken between the liver and gall bladder is subserosal and may violate T2 tumor along the liver interphase 2.Management contd. Therefore most reasonable primary operation is radicle colecystectomy 4.

6% 5 yrs survival for Japanese Biliary Surgical Society Stage II and 44. T3 T4 diseases (advance tumour) Recently the literature absunds with review of radical surgery for advanced disease and many centre reports long term survivous after aggressive surgical management In Japan they report a 63.4% 5 yrs survival for stage III disease after extended colecystectomy This stage combined represent AJCC stage III - - .Management contd.

.Management contd.

.Management contd.

Management contd. Laproscopically discovered gall bladder cancer Standard technique for treatment of symptomatic gall stone disease is laproscopic colecystectomy With the proliferation of laproscopic cholecyetectomy a new scenario now encountered namely gb cancer discovered at or after laproscopic chlecystectomy M/m ±is re exploration & complete excision of laproscopically - Discovered GB carcinoma .

mitomycin cisplatin can have some role in management of Ca GB .Medical care Management contd. Radiotherapy 1-the role of adjuvant radiation the therapy is to control microscopic residual deposits of carcinoma in tumour bed and regional lymph node 2-palliation in unresectable diseases The role of RT for carcinoma gall bladder is unclear but data support the following statements Radiotherapy has been delivered in a variety of situations including after curative resection with close or positive microscopic margins gross macroscopic residual disease and palliative debulking with bypass -Post op RT increases survival in T2 and advance carcinoma -Chemotherapy -CT ± 5FU ± based CT is usually given in conjunction with concurrent RT both in the adjuvent and palliative settings -Adriamycin.

PALLIATIVE MANAGEMENT -The goal of palliation -Relieve of pain. Therefore all palliation treatment should be simple as possible PROPHYLACTIC CHOLECYSTECTOMY -GB polyps > 10 mm size -Porcelain GB -High risk situation that serum CA 19-9 elevation and bile cytology helpful in making a pre operative diagnosis of carcinoma GB . jaundice and bowel obstruction -Prolongation of life -Decisions on palliative treatment should take into account the short survival of patients with non resectable gall bladder cancer.

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