Gallbladder cancer (GBC)
Discuss the epidemiology of GBC?
The majority are adenocarcinomas. The majority are found incidentally in patients undergoing exploration for cholelithiasis. Women are affected two to six times more often than men.
What are the risk factors for GBC?
- Gallstone disease — is one of the strongest risk factors for the development of GBC.
- Porcelain gallbladder — is an uncommon manifestation of chronic cholecystitis that is characterized by intramural calcification of the gallbladder wall. It is associated with cholelithiasis in more than 95 percent of cases.
- Gallbladder polyps.
What are the clinical features of GBC?
- Patients with early invasive GBC are most often asymptomatic or have nonspecific symptoms.
- The most common symptoms caused by GBC are jaundice, pain, and fever.
- Patients with GBC may also present with obstructive jaundice by invasion of tumor into the porta hepatis.
- For GBC- loco regional growth predominates. Haematogenous metastases is unusual
Discuss TNM staging of GBC?
T1 Tumour invades the lamina propria (T1a) or muscle layer (T1b)
T2 Tumor invades perimuscular connective tissue; no extension beyond serosa or into liver
T3 Tumor perforates the serosa (visceral peritoneum) or directly invades one adjacent organ or both (extension 2 cm or less into the liver)
T4 Tumor extends more than 2 cm into the liver, and/or into two or more adjacent organs (stomach, duodenum, colon, pancreas, omentum, extrahepatic bile ducts, any involvement of the liver)
N0 No regional lymph node metastasis N1 Regional lymph node metastasis
M0 No distant metastasis M1 Distant metastases
Discuss the treatment of GBC?
Surgery is the only potentially curative therapy. Only T1 or T2 and N1 lesions are resectable.
A logical surgical approach to potentially resectable GBC consists of total removal of the gallbladder, a portion of the underlying liver (generally segments IVb and V), and dissection of the draining regional lymphatics. Simple cholecystectomy may be sufficient for T1 lesions.
What are the contraindications to surgery?
Among the absolute contraindications to surgery are liver or peritoneal metastases, ascites, extensive involvement of the hepatoduodenal ligament, and encasement or occlusion of major vessels.
Discuss the approach to incidental GBC discovered at cholecystectomy?
Current consensus is that patients would undergo a second curative procedure if an unexpected gallbladder cancer is diagnosed postoperatively after cholecystectomy, except for those who are found to have T1 disease. Implantation of the carcinoma at all port sites after laparoscopic removal of an unsuspected cancer is a problem. Even for stage I cancers, the port sites must be excised completely.
What is the role of adjuvant therapy?
No clear evidence that adjuvant therapy provides survival benefit
What are the treatment options for unresectable disease?
Patients with locally advanced unresectable disease are candidates for chemoradiotherapy. The relative merits of systemic chemotherapy versus basic supportive care for patients with locally advanced or metastatic disease remain to be established in controlled trials.
What is the prognosis?
Patients with cancers confined to the mucosa have 5-year survival rates of nearly 100%. Patients with muscular invasion or beyond have a survival of less than 15%.
