Carcinoma of the gall bladder is one of the common malignancy of HBS. The age group mostly affects the elderly. its grows faster than cholangiocarcinoma. most commonly found in north India and south America. Risk factors are gallbladder polyps, stones, porcelain gallbladder, carcinogens, anatomical malformation, cholangiocarcinoma, etc. Common presentations are incidentally diagnosed during cholecystectomy or diagnosed during cholecystectomy. But may present as biliary pain, jaundice, weight loss, and abdominal mass. Overall prognosis is not good. 5 year survival is only < 10%.
2. Anatomy of Gall bladder
Length – 7 to 10cm, capacity – 30-50 ml
Divided into
• Fundus
• Body
• Infundibulum
• Neck
3. Lymphatic drainage
• First level
Cystic duct, CBD
• Second level
Pancreatoduodenal, PV and HA
• Third level
Celiac artery, sup. Mesenteric, para-aortic
Enlarge metastatic lymph nodes may cause jaundice by obstructing the CBD
4. Introduction
• 5th most common GI malignancy
• Female > male
• Average age 65 year
• Growth faster than cholangiocarcinoma
• Most common in north India (22/100000), Chile and south America
• Only 15-47% are ressectable
• 5- year Overall survival is < 10% ( median survival rate – 6 month)
7. Clinical presentation
• Incidentally diagnosed during cholecystectomy
• Diagnosed after cholecystectomy
• Common clinical features
Biliary or abdominal pain
Jaundice
Weight loss
Ascites
Palpable mass Advanced disease
Compression or invasion of adjacent organs
8. Investigations
• Laboratory – Anaemia, Raised bilirubin, ALP
• CA-19-9 ( >20U/mL) and CEA
• USG
Focal or diffuse mural thickening of GB wall
Subhepatic mass that replace GB wall
Irregular, asymmetrical mural thickening >1cm depth
Nodular or smooth intraluminal mass >1cm fixed with wall, not displaced by
movement, no acoustic shadow
Color doppler can be used in indeterminate case
10. Staging
TNM Criteria
Tis Carcinoma insitu
T1a Invade lamina propria
T1b Invade muscularis propria
T2a Perimuscular tissue of peritoneal side
T2b Perimuscular tissue of hepatic side
T3 Perforate serosa or invade liver or invade adjacent organ ( stomach, duodenum,
colon, pancreas, omentum, extrahepatic bile duct)
T4 Invade portal vein or hepatic artery or >2 extrahepatic site
N1 Regional LN <3
N2 Regional LN >3
M1 Distant metastasis
11. Staging and prognosis
Tumor stage is strong prognostic
factor
• Stage 0 – 80%
• Stage I – 50%
• Stage II – 28%
• Stage III – 8%
• Stage IV - <5%
Pre-operative tissue diagnosis
Not mandatory for resectable tumor
Indicated
Inoperable
Neoadjuvent chemo
12. Treatment
• Depends on
Tumor
Extent of disease
Performance status
Co-morbid conditions
• Options
Simple or extended
cholecystectomy
CBD excision
Major hepatic resection
Multi-viscera resection
Laparoscopic port site
Chemotherapy
Palliative
13. Resectability assessment
• Unresectable
Liver metastasis
Peritoneal
Malignant ascites
Encasement of major vessel (e.g. CHA, main PV)
Para-aortic, paracaval, sup. Mesenteric artery, celiac artery
Poor performance status
Pe-operative jaundice is relative contraindication for fundus CAGB
14. Resectable disease
• Early T stage
T1a- simple cholecystectomy
T1b
T2 Radical cholecystectomy
Locally advanced or Node positive disease
T3
T4 Radical cholecystectomy
Node positive
15. Extended or radical cholecystectomy
The surgical approach is dictated by the extent of tumor
Extended or radical cholecystectomy with resection of >2 cm of the GB bed
plus lymphadenectomy of the hepatoduodenal ligament behind the 2nd
part of the duodenum, head of the pancreas, and celiac axis
Extended cholecystectomy with hepatic, segmental, or lobar resection
Extended cholecystectomy with extensive para-aortic lymph node
resection
Extended cholecystectomy with bile duct resection or
pancreaticoduodenectomy