Carcinoma Gallbladder, Dr B Vinod , Gandhi Medical college and hospital,Hyderabad,Telangana.

1. Carcinoma Gallbladder
By Dr.B.Vinod (Final year PG)
Gandhi medical college and hospital,
Hyderabad, Telangana.
Under guidance of
Dr. Srinivas Goud(Professor)

2. Carcinoma Gallbladder
• Introduction
• Epidemiology
• Risk factors
• Pathology and staging
• Diagnosis
• Management

3. Introduction
 Most common biliary malignancy.
 5th most common GI malignancy.
 Most aggressive tumor because of direct spread to liver, nodal spread
and seeding of peritoneal surfaces.
 Diagnosed at advanced age ,so median survival age <6 months.
 90% are Adenocarcinomas.

4. Epidemiology
• Incidence is 22 per 100,000
• India(Delhi) > Pakistan.
• Female to male ratio is 3:1
• 1 to 2/100,000 in South America ,UK.
• Manifestation at 6-7th decade

5. Risk factors
• Gallstones
• Choledochal cysts
• Primary sclerosing cholangitis
• Porcelain gallbladder
• Genes
• Adenomatous polyps
• Anomalous pancreatobiliary junction
• Typhoid carriers

6. Gallstones
• Primary risk factor
• 0.3-3% cases will develop carcinoma
• >80% cases with GB carcinoma have gallstones
• 7 times more common in patients with gallstones than in those
without stones.
• Type of gallstones does not correlate with carcinoma.
• Risk of developing cancer increases with stone size(>3cm)

7. Anatomy and lymphatic drainage

8. Pathology
• Location
Fundus-60%
Body-30%
Neck-10%
• Macroscopic
Infiltrative
Nodular
Nodulo-infiltrative
Papillary
Combined papillary-infiltrative

9. Infiltrative
• Most common variety
• Presents as induration over wall
• Less defined margins
Nodular
Invades adjacent pericholecystic structures but has sharply
defined borders
So facilitates curative resection unlike not possible in infiltrative
type.

10. Papillary
• Grows as polypoidal fashion
• Fills lumen with minimal wall invasion
• Associated with good prognosis compared to other subtypes.

11. Histology
• Adenocarcinoma (M/C)
• Squamous cell ca.
• Oat cell
• Sarcoma
• Carcinoid
• Lymphoma
• Melanoma

12. Spread of tumor
• 60% - Direct hepatic parenchyma
• 20%- Lymph node
• 10%- Gallbladder wall at time of diagnosis
• 10%-Extra-hepatic distant metastasis

13. TNM staging
• Primary tumor(T)
• Tx-Tumor cannot be assessed
• To-No evidence of tumor
• Tis-Carcinoma in situ
• T1:
T1a-Invades lamina propria
T1b-Invades muscle layer
• T2-Invades perimuscular connective tissue
No extension beyond serosa
• T3-Perforates serosa and invades liver/or one adjacent organs stomach,
duodenum, colon, pancreas
• T4-Invades main portal vein or hepatic artery or invades two or more adjacent
organs.

14. Regional lymph nodes(N) Distant metastasis(M)
• Nx-Cannot be assessed M0-No distant metastasis
• N0-No regional LN M1-Distant metastasis.
• N1-Metastasis along cystic, CBD,
Hepatic, portal nodes
• N2-Metastasis to superior mesenteric,
paraaortic, pericaval nodes.

15. Stage

16. Clinical presentation
• Abdominal pain (RUQ)
• Jaundice
• Weight loss
• Mass

17. Diagnosis
• Ultrasonography:
Discontinous and echogenic mucosa
Asymetrical thickened GB wall.
Heterogenous mass replacing gallbladder.
Polypoidal mass in the lumen.

18. CT imaging
• GB polypoidal mass filling
• Wall thickening
• Staging and treatment
• Peritoneal, LN and vascular metastasis.

19. Tumor markers
• CEA >4ng/mL
50% sensitive
93% specificity
• CA 19.9 > 20 U/mL
80% sensitive and specific

20. Management
Stage I
T1a: Standard cholecystectomy with no additional resection
Nodal involvement <3%
Cure rate 85-100%
T1b: Muscular layer is involved
Nodal spread 20% chance
Extended cholecystectomy to achieve R0 resection of disease.
• If cystic ducts are positive -Resection done
CBD resection done and re-establishment of biliary enteric continuity
• Because of local extension into liver parenchyma is common,
2cm apparently normal hepatic parenchyma from GB fossa is resected.

21. Stage II(T2NoMo)
• Perimuscular involvement but does not cross serosa
• 40% chance of nodal spread
• 25% chance of positive margins
• Extended cholecystectomy is done

22. Stage III
• Locally advanced carcinoma which perforates serosa (T3)
• T1-3 which involves LN
• Extended cholecystectomy
• If infundibulum is involved then Right hepatectomy is done.

23. Stage IV
• Palliative
• Most common TOC because of unresectable at presentation
• Percutaneous biliary drainage is done for malignant biliary
obstructions and to decrease pruritus but not to improve quality of
life.
• Survival 2-4 months
• 1year survival <5%

24. Adjuvant Therapy
• Stage I:
• R1 and R2: concurrent chemo-radiation with
EBRT with 40-45 Gy with 5 FU based chemotherapy
Stage II: Resectable
Adjuvant chemoradiation with 40-45 Gy with 5 FU based chemotherapy
Stage II unresectable, stage III and stage IV
3 cycles neo-adjuvant chemotherapy with
Gemcitabine 1000mg/m2 on day 1 and day 3 every 21 days
cisplatin 25 mg/m2 every 21 days
followed by
concurrent chemoradiation
IMRT: 50.4 Gy with 5 FU based chemotherapy.

25. Survival
• T2 lesions > 60%
• T3 lesions < 20 %
• T4 lesions < 15 %