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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          • Advanced lesion
   –   Asymptomatic       –   Weight loss
   –   Abdomonal pain     –   Obstructive jaundice
   –   Anorexia           –   Duodenal obstruction
   –   Nausea             –   Palpable mass
   –   Vomiting           –   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) with
  regional 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 RATE
S.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
Cancer gallbladder
Cancer gallbladder
Cancer gallbladder

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Cancer gallbladder

  • 2. INCIDENCE • Increases with age • 2-6 times common in women • Common among population in – Western South America – Northern India – North American Indians – Mexican Americans
  • 3. RISK FACTORS • Gallstones • Porcelain gallbladder • Adenomatous polyps • Chronic infection with S.typhi • Carcinogen exposure(miners exposed to Radon) • Abnormal PancreaticoBiliary Duct Junction(APBDJ)
  • 4. 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.
  • 5. 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
  • 6. PATHOGENESIS • Chronic irritation • Dysplasia-carcinoma in-situ-invasive cancer • p 53 & K-ras(rare) mutations
  • 7. PATHOLOGY • 80%-adenocarcinoma • Others – Small cell cancer – Squamous cell cancer – Lymphoma sarcoma • Morphologically – Infiltrative – Nodular – Papillary – Combined pattern • Staging systems – Nevin – TNM
  • 8. CLINICAL PRESENTATION • Early lesion • Advanced lesion – Asymptomatic – Weight loss – Abdomonal pain – Obstructive jaundice – Anorexia – Duodenal obstruction – Nausea – Palpable mass – Vomiting – Hepatomegaly – ascites
  • 9. 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
  • 10. USG • Mural thickening • Mural calcification • GB mass >1 cm • Loss of normal GB wall-liver interface • Gall stones • Polyps
  • 11. 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
  • 12. STAGE 0 & 1A • Carcinoma in situ & T1-cancer that doesnot extend beyond the GB muscularis – Simple cholecystectomy
  • 13. 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) with regional lymphadenectomy of the hepatoduodenal ligament • En-bloc resection with anatomic resection of liver segments 4b & 5
  • 14. 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
  • 15. 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
  • 16. PROGNOSIS • 5-year survival rate is 5% • Median survival 12 months(stage IA-III) • Median survival 5.8 months(stage IV)
  • 17. 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
  • 18. SURVIVAL RATE S.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