This document presents the diagnostic evaluation and staging of gallbladder carcinoma in a 79-year-old patient named Sambhavi Joshi. It discusses diagnostic imaging including ultrasound, CT, MRI, endoscopic ultrasound and histopathology. Staging of gallbladder cancer is described according to TNM classification including primary tumor staging, regional node staging, and metastasis. Incidental gallbladder carcinoma detected on histology is also mentioned.

1. DIAGNOSTIC EVALUATION & STAGING
GALL BLADDER
CARCINOMA
SAMBHAVI JOSHI, 79, 2K17
Dr. ZAHID IQBAL MIR (SENIOR RESIDENT)
MBBS, MS Surgery, DNB Surgery

2. DIAGNOSTIC EVALUATION

3. PATIENTS WITH SYMPTOMATIC CHOLELITHIASIS
Screening – Ultrasound
Additional cross-sectional imaging [CT, MRI/MRCP] in
patients who have concerning findings on US
• Calcification
• a mass protruding into the lumen
• loss of interface between gallbladder and liver
• direct liver infiltration
• gallbladder polyps ≥10 mm
• thickened gallbladder wall not explained by
cholecystitis

4. USG
vInitial diagnostic study for presumed gallbladder
disease
vOverall accuracy of USG for staging of GBC is
limited

5. USG FINDINGS - MALIGNANCY
üMural thickening
ücalcification
ümass protruding into lumen
üfixed mass in GB
üloss of interface between gb and liver
üdirect liver infiltration

6. ØPolyp over 1 cm in diameter - invasive
§ FNAC (cholesterolosis/GBC)
§ Adenoma/GBC – less accurate
§ CT/MRI required
ØPolyp less than 1 cm
§ adenoma/ papilloma/ cholesterosis/ GBC less likely
COLOR DOPPLER - VASCULARITY
• pulsatile flow - seen in most cases
• continuous flow pattern
• Doppler sensitivity is mandatory for diagnosis of GBC in stage T 1 a

7. Ultrasound image showing intraluminal
polypoid gallbladder wall mass (arrow) but
without extraluminal extension.
Ultrasound image of gallbladder mass
with loss of continuity of gallbladder wall
(arrow), suggesting extraluminal growth.

8. Asymmetric gallbladder wall thickening (arrow) in a patient with GBC

9. SUSPICIOUS ULTRASOUND FINDINGS OR INCIDENTAL
GALLBLADDER CANCER AT CHOLECYSTECTOMY
üPatients who have concerning findings on US -
Evaluation of potential resectability is the key factor
üIncidentally diagnosed GBC following simple
cholecystectomy -Apropriate imaging (and
detailed histopathologic analysis) is needed to
decide whether further resection is necessary

10. CECT
• CT is more useful than US for detecting lymph node
involvement, adjacent organ invasion, and distant
metastasis.
INDICATIONS
• USG detected gallbladder lesion that may
represent GBC
• Incidentally diagnosed GBC following simple
cholecystectomy.

11. CT FINDINGS - GBC
üPolypoid mass protruding into the lumen/ filling it
üFocal or diffuse thickening of gallbladder wall.
üMass in gallbladder fossa
üLiver invasion
üNodal involvement
üDistant metastasis
GBC vs cholecystitis
Higher frequency of
• lymph node enlargement
• more extensive wall thickness
• focal irregularity
• less distension

12. LIMITATIONS
• Less helpful in differentiating between benign and
malignant polyps.
Computed tomography scan showing
gallbladder cancer with invasion into the
duodenum and liver parenchyma.
Computed tomography scan showing
gallbladder mass with local invasion into
portal vein (arrow).

13. MRI
• USG findings are confirmed on MRI.
MRI/MRCP – differentiate benign from malignant GB
lesions
• GBC is typically T1 hypointense and T2 hyperintense
compared with the surrounding liver parenchyma.
INDICATIONS – AS CECT

14. üMore accurate for imaging GB than extracorporeal
transabdominal US
üDetection and differential diagnosis of gallbladder
polyps and in staging tumor extent
üTo assess the depth of tumor invasion into the wall of
the gallbladder and for defining lymph node
involvement in the porta hepatis or peripancreatic
regions.
üMeans of obtaining bile for cytologic analysis and
EUS-guided FNA
ENDOSCOPIC ULTRASOUND

15. üCholangiography, ERCP and
percutaneous transhepatic
cholangiopancreatography
are of little use
üIn cases with jaundice, ERCP
may be necessary for
definition of the extent of
biliary involvement, as well as
for stent placement.
CHOLANGIOGRAPHY
ERCP in an adult with obstructive jaundice
demonstrates an APBDJ with malignant stricture
replacing the cystic duct insertion

16. üCECT CHEST – recommended
• Dstant metastases can affect the lungs and pleura
üPET / PET CT – not recommend
COMPLETING THE STAGING EVALUATION

17. • Generally nondiagnostic
• Elevated ALP or serum bilirubin - bile duct obstruction.
• Serum tumor markers – CEA or CA 19-9 are often elevated -
lack specificity and sensitivity .
If a tumor marker is found to be elevated preoperatively, serial assay after
resection might aid in the diagnosis of persistent or recurrent disease.
LABORATORY INVESTIGATIONS
Other non specific findings :
1. anemia
2. leukocytosis
3. transaminases elevation
4. ESR elevation
5. CRP Elevation

18. PATHOLOGY
INVASIVE ADENOCARCINOMA PRESENTING AS
MULTIFOCAL, NODULAR, PAPILLARY PROLIFERATION
IN THE FUNDUS & BODY OF GB
ADENOCARCINOMA PRESENTING AS DIFFUSE
THICKENING OF GB WALL

19. Incidental gallbladder adenocarcinoma
detected in a gallbladder with focal
thickening. A well differentiated
morphology.
Invasive papillary adenocarcinoma arising in
the background of an intracholecystic
papillary neoplasm.
HISTOPATHOLOGY

20. Gall Bladder Cancer – Incidental
Incidental
on
Histology

22. STAGING

23. GALL BLADDER CANCER - GROUPS
üObvious clinical
üSuspected imaging
üUnsuspected at operation
üIncidental at histology
üMissed at follow up
Kapoor. J HBP Surg 2007;14:366-73

24. PRIMARY TUMOUR STAGING
T stage T criteria
Tx Primary tumour cannot be assesed
T0 No evidence of primary tumour
T-is Carcinoma insitu
T 1 Tumour invades the lamina propria or muscular layer
T1a Tumour invades the lamina propria
T1b Tumour invades the muscular layer
T 2 Tumour invades the perimuscular connective tissue
T2 a Tumour invades the peri-muscular tissue on the peritoneal side
without involvement of the serosa(visceral peritoneum).
T2 b Tumour invades the perimuscular tissue on the hepatic side
without extension into the liver.
T3 Tumour perforates the serosa (visceral peritoneum) and/or
directly invades the liver and/or one other adjacent organ or
structures
T4 Tumour invades the main portal vein or hepatic artery or
invades two or more extra hepatic organs or structures.

26. REGIONAL NODE STAGING
N stage N criteria
Nx Regional lymph nodes cannot be
assessed
N0 No regional lymph node
metastasized
N1 Metastasis to 1 – 3 regional lymph
nodes
N2 Metastasis to 4 or more regional
lymph nodes.
METASTASIS
M stage M criteria
M0 No distant metastasis
M1 Distant metastasis

27. PROGNOSIS STAGE GROUP
T N M STAGE
Tis N0 M0 0
T1 N0 M0 I
T2a N0 M0 IIA
T2b N0 M0 IIB
T3 N0 M0 IIIA
T1-3 N1 M0 IIIB
T4 N0-1 M0 IVA
anyT N2 M0 IVB
anyT anyN M1 IVB

28. REFRENCES