Cancer gallbladder

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Cancer gallbladder

  1. 1. CANCER GALLBLADDER
  2. 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. 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. 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. 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. 6. PATHOGENESIS• Chronic irritation• Dysplasia-carcinoma in-situ-invasive cancer• p 53 & K-ras(rare) mutations
  7. 7. PATHOLOGY• 80%-adenocarcinoma• Others – Small cell cancer – Squamous cell cancer – Lymphoma sarcoma• Morphologically – Infiltrative – Nodular – Papillary – Combined pattern• Staging systems – Nevin – TNM
  8. 8. CLINICAL PRESENTATION• Early lesion • Advanced lesion – Asymptomatic – Weight loss – Abdomonal pain – Obstructive jaundice – Anorexia – Duodenal obstruction – Nausea – Palpable mass – Vomiting – Hepatomegaly – ascites
  9. 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. 10. USG• Mural thickening• Mural calcification• GB mass >1 cm• Loss of normal GB wall-liver interface• Gall stones• Polyps
  11. 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. 12. STAGE 0 & 1A• Carcinoma in situ & T1-cancer that doesnot extend beyond the GB muscularis – Simple cholecystectomy
  13. 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. 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. 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. 16. PROGNOSIS• 5-year survival rate is 5%• Median survival 12 months(stage IA-III)• Median survival 5.8 months(stage IV)
  17. 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. 18. SURVIVAL RATES.NO STAGE 5 YR.SURVIVAL RATE1 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
  19. 19. EXTENT OF LYMPHADENECTOMY

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