This document discusses gall bladder cancer. It notes that gall bladder cancer is rare and traditionally incurable, with late presentation and disseminated disease at diagnosis leading to a dismal prognosis. Complete surgical resection is the main treatment option, with a 5-year survival rate of only 5%. Risk factors include chronic cholelithiasis and inflammation. Staging and surgical management depend on the extent of disease, with more advanced stages requiring liver resection or extended surgery.

1. GALL BLADDER CANCER
Dr. Zeeshan

2. OVERVIEW
 GB cancer is rare – traditionally incurable
 Late presentation
 Disseminated disease
 Dismal prognosis and lack of effective therapy
 Blalock – “ In malignancy of GB, when a diagnosis
can be made without exploration, no operation should
be performed, inasmuch as it only shortens the
patient’s life”

3. TENDENCY TO SPREAD
 Lymphatics
 Hematogenous
 Peritoneal
 Along biopsy tracts and wounds
 Overall 5 year survival : 5%
 Median survival : < 6 months
 Treatment : Complete surgical resection

4. EPIDEMIOLOGY
 Highest incidence:
- Females in India : (21.5 per 100,000)
- Females in Pakistan : (13.8 per 100,000)
 In USA : Females ( 2 per 100,000)
 Female : male – 3:1
 Increase in age : increase in incidence
 Obesity : BMI 30 – 34.9 vs 18.5 – 24.9 ---RR of
death from CA GB 2.13

5. ETIOLOGY
 Most consistent risk factor : Cholelithiasis with
chronic inflammation (75-90%)
 RR of CA GB with stone >3cm – 10.1
 Possibility of stone formation and CA sharing
same risk factors
 Stones may prompt a radiological workup /
cholecystectomy resulting in detection

7. CHRONIC INFLAMMATION
 Biliary enteric fistulas
 Typhoid infections
 Pancreaticobiliary malfunctions
 Calcification : PORCELAIN GB
- Type of calcification – degree of risk
Stippled >>>> Diffuse intramural calcification

9. CHEMICALS
 OCP
 Methyl Dopa
 INH
 Rubber industry

10. ??ADENOMA- CARCINOMA
SEQUENCE
 Poor association
 No increased risk of malignancy in polyps

11. ANATOMY OF GALL BLADDER
 GB partially intraperitoneal structure – attached
to liver on segment IV b and V
 Side of GB attached to liver bed – no peritoneal
covering
 “Cystic plate” – fibrous lining
 In simple cholecystectomy – Plane between
muscularis of GB and cystic plate dissected
---INADEQUATE FOR CA GB

13. ANATOMY
 Body and fundus : Lies at a distance from major
inflow structures
Limited segmental resection (Segment IV b and
V) adequate
 Infundibulum : Encroaches onto the porta
hepatis
Tumors of this area – involves porta
Prepare to perform bile duct resection/ major
hepatic resection

14. LYMPHATICS

15. PATHOLOGY AND STAGING
 Fundus – 60% of tumors
 Body – 30% of tumors
 Neck – 10% of tumors
 Gross findings:
- Typical of chronic cholecystitis
- Tumors in lower end of GB obstructing –
HYDROPS
- Advanced tumors in neck/infundibulum –
jaundice / vascular invasion/ hepatic atrophy

16. GROSS DESCRIPTIONS
 Infiltrative
 Nodular
 Combined nodular infiltrative
 Papillary - Better prognosis
 Combined papillary infiltrative

17. PAPILLARY ADENOCARCINOMA

18. HISTOLOGY
 Adenocarcinoma – 89.4%
 Squamous / Adenosquamous – 4%
 Neuroendocrine – 3%
 Sarcoma/Adenosarcoma – 1.6%
 Melanoma - <1%

19. CLINICAL PRESENTATION
 SCENARIOS:
1. Final pathology after routine cholecystectomy
identifies CA GB
2. GB cancer discovered intraoperatively
3. GB cancer suspected before surgery

20. HISTORY
 Constant RUQ pain – rather than episodic
crampy pain of biliary colic
 Elderly patients
 Weight loss
 Anorexia
 Jaundice

21. COMMON SYMPTOMS AND SIGNS

22. LAB EXAMINATION (HELPFUL IN
ADVANCED DISEASE)
 Anemia
 Hypoalbuminemia
 Leukocytosis
 Elevated bilirubin
 Elevated Alkaline Phosphatase
 Tumor markers:
- CEA : 90% specific but lacks sensitivity (50%)
- CA19-9 : More consistent marker
Sensitivity : 75%
Specificity : 75%

23. RADIOLOGY
 USG : Excellent modality for GB
 Findings :
- Discontinuous mucosa
- Echogenic mucosa
- Submucosal echogenicity
 Doppler assessment of blood flow: Differentiates
malignant from benign
 Limitation : Unable to stage (Nodes cannot be
visualised)

24. CT/MRI
 Can assess extent of disease
 Detects presence of distant metastases
 MC finding : Mass in GB
 Assessment of LN:
- Size > 1cm
- Ring like heterogenous enhancement

26. CT/MRI
 CT : 71 – 84 % accurate
• 79% can differentiate between T1 and T2
• 93% between T2 and T3
• 100% between T3 and T4
 MRI:
- 70 – 100% sensitive for hepatic invasion
- 60 – 75% sensitive for LN spread

27.  FDG PET scan :
- More accurate than CT in diagnosing metastatic
disease
- Poor in differentiating benign inflammatory state
vs malignancy

29. PRE-OPERATIVE PATHOLOGICAL
DIAGNOSIS
 If CA-GB suspected on clinical and radiological
grounds – Histological diagnosis NOT necessary
 Biopsy increases risk of seeding
 If concern for GB malignancy significant –
Unwise to perform simple cholecystectomy
 For unresectable disease – Percutaneous needle
biopsy – 90% accurate

30. BILE CYTOLOGY
 Less risky way of making diagnosis without risk
of peritoneal seeding.
 Justifiable in patients undergoing ERCP/PTC
 If NOT - unwarranted

32. STAGING

34. SURGICAL MANAGEMENT
 Benign polyp :
- Adenomatous polyp – ONLY polypoidal lesion
with malignant potential
- Cholesterol polyp – MC polyp
 Indicators for cholecystectomy:
- Single polyp
- Size > 1 cm
- Age > 50 years

35.  Old concept – Offer OPEN cholecystectomy
 Current concept – Offer Laparoscopic
cholecystectomy + Frozen
 Diagnosis – USG required
 If polyp presents with abdominal pain – rule out
other causes

36. INCIDENTALLY DETECTED GB CA
 Incidence : 0.27 – 2.1%
 If diagnosis made by frozen – Prepare for
curative resection
 IF NOT COMFORTABLE – REFER
NO EFFECT ON OUTCOME

37.  T1a with margins negative : Standard
cholecystectom cures 85 – 100%
 T1b – controversial
 T2 onwards – plan liver resection

38. NON CURATIVE
CHOLECYSTECTOMY
 Careful work up required which includes :
- Reviewing pre-cholecystectomy USG to localise
extent
- Discuss case with operating surgeon
- Re-review T stage and margins pathologically

39. T1B LESIONS
 If cystic duct stump / margins +ve –
Bile duct resection and reconstruction
OR
Re-resection of cystic duct stump and frozen
proceed

40. EXTENT OF RESECTION BY STAGE
 Rational approach to CA GB depends on :
- Stage of disease
- Location of tumour
- Margins status – if cholecystectomy has already
been performed.
- Whether a prior noncurative cholecystectomy has
been performed

41.  T1a – Simple cholecystectomy
 T1b – Higher locoregional recurrence rates after
simple cholecystectomy
 T2,T3 – Complete enbloc resection with segment
Ivb and V of liver

42.  If invasion of hepatic inflow vascular structures
is documented :
- Extended right hepatectomy + LN clearance of
hepatoduodenal ligament + negative cystic
duct/bile duct margins
- Abandon major resection IF:
1. Nodal spread
2. Metastases

43. LIVER RESECTION
 Goal : To ensure a margin of 1-2 cm
 Anatomic resection – better than wedge resection
 If excision of segment IV b and V inadequate –
DO extended right hepatectomy:
 ESP in cases of large tumors invading portal
pedicle
 Tumors of lower end of GB encroaching onto
porta

44.  If isolated invasion of organ system present
EG: Stomach , duodenum, colon
In absence of distant metastases – DO local
resection

45. LYMPH NODAL DISSECTION
 Weigh risks vs benefits
 Range of operations include : Excision of cystic
duct node– Portal clearance–
pancreaticoduodencetomy
 1st
manouvre : Mobilisation of duodenum – To
assess aortocaval and retropancreatic nodes
 Assess celiac node LN – If suspicious DO frozen
and terminate procedure IF MALIGNANT

46. WHETHER ROUTINE BILE DUCT
RESECTION IS NECESSARY FOR
ADEQUATE LN CLEARANCE??
 Excising extrahepatic bile duct – makes LN
dissection easy
 Increases morbidity of operation
 No difference noted in the number of LN
harvested with OR without bile duct resection
 In general – bile duct resection NOT needed----
Unless suspicion of PORTA infiltration

47.  Stage of disease and NOT extent of resection
determines survival of patients

49. DID YOU KNOW?
 “Honeymoon and alcohol”
 Roots trace back to Babylon
 Tradition for the soon to be father- in-law to
supply his daughter’s fiance with a month of
mead
 Time period referred to as the HONEYMONTH

51. DID YOU KNOW?
 Adolf Hitler was one of the world’s best known abstainers from
alcohol.