1. Gall Bladder Cancers in India :
A report from Population Based
Cancer Registries(1982-2010)
Dr. Meesha Chaturvedi
Indian Council of Medical Research
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2. USA
(Hispanics)
&
Western Europe
(France, Norway, UK)
Eastern & Central Europe
(Hungary, Poland, Germany)
Asia
(Republic of Korea, Japan, Bangladesh,
China, India)
South America
(Chile, Bolivia, Peru, Ecuador, Colombia, Brazil)
Extreme High
High
Moderate
Low
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GBC incidence rates in the World. Worldwide incidence of GBC in both genders has been mentioned in age standardized rate per
100,000 (www.globocan.iarc.fr). Chile – 9.7; Bolivia – 8.1; Peru – 4.0; Ecuador – 4.0; Colombia – 2.8; Brazil – 1.9; China – 2.8;
Japan – 4.7; India – 1.8; Republic of Korea – 6.5; Bangladesh – 4.2; Germany – 2.3; Hungary – 2.9; Poland – 2.9; USA- 1.6; UK –
0.5; France – 1.6; Norway – 1.6.
3. Cancer Atlas in India-
Gall Bladder cancers & Ganges River Course
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5. Comparison of Age Adjusted Incidence Rates (AARs) of All PBCRs (2012-2014)
GALLBLADDER (ICD-10: C23-C24)
8.8
5.3
5.2
4.1
3.3
2.8
2.6
2.6
2.4
2.4
2.2
2.2
2.2
1.8
1.8
1.7
1.7
1.7
1.4
1.4
1.4
1.4
1.3
1.3
1.2
1.2
1.2
1.1
0 2 4 6 8 10
Kamrup Urban District
Delhi
Cachar District
Dibrugarh District
Kolkata
Imphal West District
Tripura State
Bhopal
Nagaland
Aizawl District
Mumbai
East Khasi Hills District
Sikkim State
Chennai
Mizoram State (MZ)
Manipur State (MR)
Meghalaya
Naharlagun (NH)
Ahmedabad Urban
Kollam District
Patiala District
MR-Excl.Imphal West
Nagpur
MZ-Excl.Aizawl
Thi'puram District
Bangalore
Wardha District
Pune
Rate per 100,000
17.1
11.8
10.2
10.2
8.6
7.7
7.1
6.7
6.6
6.4
5.8
5.3
5.0
4.1
3.8
3.6
3.4
3.2
3.0
2.1
2.0
1.8
1.8
1.5
1.4
1.3
1.1
1.0
0.7
0 4 8 12 16 20
Kamrup Urban District
Delhi
Cachar District
Papumpare District
Dibrugarh District
Kolkata
East Khasi Hills District
Sikkim State
Imphal West District
Bhopal
Aizawl District
Tripura State
Meghalaya
Mumbai
Manipur State (MR)
Mizoram State (MZ)
Naharlagun (NH)
Patiala District
MR-Excl.Imphal West
MZ-Excl.Aizawl
Bangalore
Ahmedabad Urban
NH-Excl.Papumpare
Chennai
Nagpur
Pune
Thi'puram District
Kollam District
Wardha District
Rate per 100,000
Males Females
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6. Fig: Relative Proportion (%) of GALL BLADDER (ICD-10: C23- C24) cancers to ALL
TYPE of Cancers - (Pooled Data 1982-2010)
Males Females
1.7
98.3
3.0
97.0
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7. Proportion (%) and Rank of Gall Bladder Cancers
in PBCRs – featured in top 10 leading sites
Registry Proportion (%) Rank
Tripura- Females 9.0 4
Cachar- Females 10.6 4
Dibrugarh- Females 9.1 4
Delhi - Females 6.2 5
Kamrup- Females 8.4 5
Manipur State-Females 6.0 5
Kolkata- Males 6.0 5
Sikkim State- Females 5.1 7
Bhopal - Females 3.8 7
Meghalaya- Females 3.8 7
East Khasi hills- Females 3.6 7
Cachar- Males 3.3 9
Dibrugarh- Males 2.7 10
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8. Trends in Gall Bladder Cancers
PBCRs (1982-2010)
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9. Gall Bladder (ICD-10 : C23-C24)-Females Trends Over Time in AAR(1982-2011)
Five Year Trend
0
2
4
6
8
10
Bangalore Bhopal Chennai Delhi Mumbai
Year
AAR
per
100,000
persons
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10. Gall Bladder (ICD-10 : C23-C24)-Females Trends Over Time (2003 -2011) in AAR(Range of Years) - Joinpoint
regression-NEWER PBCRs
0
2
4
6
8
10
12
14
16
2003 2004 2005 2006 2007 2008 2009 2010 2011
AAR
Year
Dibrugarh Kamrup Imphal West Sikkim
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11. Changes in Broad Age Groups – Females (Bangalore)
0
2
4
6
8
10
12
1982-1986 1987-1991 1992-1996 1997-2001 2002-2006 2007-2009
AAR
per
100000
Year
0-24
25-34
35-44
45-54
55-64
65+
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14. Table: Projected Cases at India level (2015 and 2020)*
Gall Bladder and Extra Hepatic Ducts (ICD-10: C23-24)
2020
Males 36046
Females 55141
Both Sexes 91187
All Cancers 1734886
% to All cancers 5.2
*Three-year Report of the PBCRs: 2012-2014, Bengaluru, 2016
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Establishment of Population
Based Cancer Registries in the
Gangetic Belt in Allahabad (the
land of Kumbh Mela),Aligarh
and Patna India.
15. Hospital Based Cancer Registry on
Gall Bladder Cancers
(1984-2010)
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16. 78.9
15.2
1.8
3.5
0.6
80.0
14.7
1.0 3.5 0.8
Microscopic All Imaging Techniques
Clincial Others
Unknown
Microscopic
Imaging
Techniques
Proportion (%) of Gall Bladder Cancers (ICD10: C23 - 24)
according to Method of Diagnosis (1984 – 2010)
Males Females *Data from HBCR
Reports 1984 to 2010
Microscopic
Imaging
techniques
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17. Proportion (%) of Microscopically Diagnosed Gall Bladder
Patients (ICD10: C23 - 24)
(1984 – 2010)
Males Females *Data from HBCR Reports 1984 to 2010
60.5
5.6
13.0
20.9
56.2
6.0
13.6
24.3
Primary Histology Secondary Histology
Cytology of Primary Cytology of Metastasis
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18. Clincial Extent of
Disease
Males Females
# % # %
Localised (L) 526 16.7 481 12.7
Regional (R) 769 24.4 772 20.5
L + R 1295 41.2 1253 33.2
Distant 1489 47.3 2059 54.6
Others 62 2.0 92 2.4
Unknown 300 9.5 370 9.8
Total 3146 100.0 3774 100.0
Number (#) and Proporation (%) of Gall Bladder Cancer patients
(ICD10: C23 - 24) according to Clinical Extent of Disease
(Excludes Patients Previously Treated)
*Data from HBCR Reports 1984 to 2010
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19. Number (#) and Proportion (%) of Gall Bladder Cancer
patients (ICD10: C23 - 24) according to Type of Treatment
Given at Reporting Institution (1984 – 2010)
Type of Treatment
Males Females
# % # %
Surgery (S) 495 55.3 392 43.4
Radiotherapy (R) 45 5.0 56 6.2
Chemotherapy (C) 223 24.9 273 30.2
S + R 27 3.0 32 3.5
S + C 69 7.7 114 12.6
R + C 12 1.3 19 2.1
S + R + C 11 1.2 5 0.6
Others 13 1.5 13 1.4
Total 895 100.0 904 100.0
*Data from HBCR Reports 1984 to 2010
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22. • Age.
• Female.
• Diet factors
• Obesity.
Patient
Demography
• Heavy Metals.
• Medications.
• Oral Contraceptives
Patient
Exposure
• Xanthogranulomatous GB.
• Porcelain Gall Bladder.
• Incidental Carcinoma Detection on
Cholecystectomy for Cholelithiasis.
Gall Bladder
Abnormality
Risk Factors for Gall Bladder Disease/Cancers
• Geographic Pathology
• Genetic Predisposition
• Infections i.e.
Salmonella,
Helicobactor
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23. • Surgical Removal for Cholelithiasis.
• General Surgeons performing
Cholecystectomy.(ideally expertise for
extended cholecystectomy should be
available)
Incidental
finding
• Resembles Carcinoma at
surgery.
• Forms a tumour like mass in
inflammatory Gall Bladder.
Xanthogranulomatous
Cholecystitis
• Extensive Calcium encrustation of GB
wall.
• Occurrence of gallbladder carcinoma as a
complication of Porcelain Gall Bladder.
Porcelain
Gall Bladder
Missed Opportunities- CLINICAL - Gall Bladder Cancers
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24. • no biochemical tests of importance.
• Tumor markers – CEA and CA 19-9 - no role in
diagnosis.
• FNAC is not indicated (seeding of biliary tracts)
Early Detection
• detect structural changes that include
intraluminal polyp, parietal thickening.
• lumen filled by a mass.
Imaging Tools
• Surgical Removal – conditions ressemble Ca GB
• Porcelain Gall Bladder
• Xanthogranulomatous Cholecystitis .
Histopathology
Missed Opportunities- DIAGNOSTIC - Gall Bladder
Cancers
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25. • Inappropriate/No dedicated staging
system.
• Staging Laparoscopy is indicated.
Staging
• Limited studies on Disease free survival.
• Difficulty in conducting survival studies.
Survival
• Difficult for registry staff to assign -
Histology code
• most valid basis of diagnosis.
Others
Missed Opportunities- STAGING & SURVIVAL- Gall
Bladder Cancers
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26. To identify
environmental high
risk regions for gall
bladder cancer and
correlation with
ground water arsenic
in the state of Assam,
India.
Incidental Gall Bladder
Cancer and Other Pre
malignant Gall Bladder
Condition in India towards
early Detection of Gall
Bladder Cancer
Patterns of Care and Survival Studies – Gall Bladder Cancers.
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27. Roadmap Forward (1/2)
• Synchronization between Registry and clinical
practice.
• Consensus on aspects of staging and
treatment for Gall Bladder cancers.
• Specific studies on preventable risk factors,
early diagnostic and prognostic markers .
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28. Roadmap Forward (2/2)
• Disease Free survival for cases with Ca Gall
Bladder
• Special registries on Gall Bladder Cancer :
customized to scientific requirement
(Geographic pathology needs to be revisited).
• Long term benefit in planning screening
programmes in future.
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29. Acknowledgements
• Population based Cancer Registries
• Hospital Based Cancer Registries
• NCDIR-NCRP
• Indian Council of Medical Research (ICMR)
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30. International Classification of Diseases for
Oncology (ICD-O)
C23 Gallbladder
C23.9 Gallbladder
C24 Other and Unspecified Parts of Biliary Tract
C24.0 Extrahepatic Bile Duct
Bile Duct, NOS
Biliary Duct, NOS
Choledochal Duct
Common Bile Duct
Common Duct
Cystic Bile Duct
Cystic Duct
Hepatic Bile Duct
Hepatic Duct
Sphincter of Oddi
C24.1 Ampulla of Vater
Periampullary
C24.8 Overlapping lesion of biliary tract
(Note: Neoplasms involving both
intrahepatic and extrahepatic bile
ducts)
C24.9 Biliary Tract, NOS
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31. Exposure to certain
chemicals and heavy
metals, age, female
gender, family history,
obesity, cholelithiasis,
chronic cholecystitis,
porcelain gallbladder,
polyps, and chronic
infection by
Salmonella species
Environmental
Factors
Gallbladder
Cancer
Pathogenesis
Genetic Factors
Genes of Drug
Metabolism pathway,
Hormonal pathway,
Inflammatory
pathway, DNA Repair
pathway, Hedgehog
pathway, Apoptotic
pathway, Wnt
signaling pathway,
miRNA and some
other
Schematic representation of factors contributing to GBC pathogenesis
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33. Number (#) and Proportion (%) of Gall Bladder Cancers
(ICD10: C23 - 24) by Five Year Age Groups (1984 – 2010)
Age Group
Males Females
# % # %
00-04 - - - -
05-09 - - - -
10-14 - - 1 0.0
15-19 3 0.1 5 0.1
20-24 21 0.5 25 0.5
25-29 57 1.4 68 1.3
30-34 133 3.3 186 3.5
35-39 281 7.0 412 7.8
40-44 436 10.8 673 12.7
45-49 544 13.5 877 16.6
50-54 629 15.6 911 17.2
55-59 641 15.9 721 13.6
60-64 508 12.6 689 13.0
65-69 422 10.5 404 7.6
70-74 221 5.5 204 3.9
75+ 122 3.0 115 2.2
Unknown 3 0.1 1 0.0
All Ages 4021 100.0 5292 100.0
*Data from HBCR
Reports 1984 to 2010
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34. To identify
environmental high
risk regions for gall
bladder cancer and
correlation with
ground water arsenic
in the state of Assam,
India.
Life Style Behavior,
Dietary Habits,
Reproductive factors
and risk of Gall
Bladder Cancer in
Upper Assam
A multidisciplinary case control study on
Gall bladder cancer -Identification of modifiable risk factors and risk reduction.
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Editor's Notes
Zone of high incidence involves several northern states (Punjab, Uttar Pradesh, Bihar, West Bengal) - remarkable as that the overall incidence (all sites combined) in areas is low.
Highest incidence in Delhi (AAR:9.4 per 105; MAAR: 7.2 per 105).
Districts of Imphal East (MAAR: 6.9 per 105) and West (MAAR: 5.7 per 105 in Mizoram State and the Union Territory of Chandigarh.
This is what the cancer registration data over the years has shown
With more registries being established in NE sector of India in post atlas era, Zone of high incidence involves many of the registries in north eastern states (KUD,Cachar and Dibrugarh) Tripura and Manipur.The northern registries of Delhi and Bhopal have shown higher incidence .State of West Bengal has one registry Kolkata showing higher incidence Nagaland and Arunachal Pradesh also have higher incidene - remarkable as that the overall incidence (all sites combined) in areas is low.
