GB cancer is the 5th most common GIT malignancy(worldwide).200 years later it is still considered to be a highly malignant disease with a poor survival rate
.Here is a brief description regarding
Gall bladder carcinoma seen in Indian popluation most common in women and presents at a very late stage .Survival is in months hence palliative treatment is being preferred .
This Presentation gives summarized overview of Gall Bladder Carcinoma especially the management as per latest National Comprehensive Cancer Network(NCCN) Guidelines version 2.2013
Gall bladder carcinoma seen in Indian popluation most common in women and presents at a very late stage .Survival is in months hence palliative treatment is being preferred .
This Presentation gives summarized overview of Gall Bladder Carcinoma especially the management as per latest National Comprehensive Cancer Network(NCCN) Guidelines version 2.2013
Cholangiocarcinoma: Pathology, diagnosis and treatment.Marco Castillo
A brief description with many abdominal imaging of the Cholangiocarcinoma.
Includes definition, epidemiology, pathology, classification, clinical presentation, diagnosis, staging and treatment.
Cholelithiasis (calculi or gallstones) usually form in the gallbladder from the solid constituents of bile and vary greatly in size, shape and composition.
The stomach J-shaped. It has two surfaces (the anterior & posterior), two curvatures (the greater & lesser), two orifices (the cardia & pylorus). It has fundus, body and pyloric antrum.
Blood supply
The left gastric artery
Right gastric artery
Right gastro-epiploic artery
Left gastro-epiploic artery
Short gastric arteries
Stomach cancer begins when cancer cells form in the inner lining of your stomach. These cells can grow into a tumor. Also called gastric cancer, the disease usually grows slowly over many years.
It could be:
malignant or benign
primary or secondary
Gallbladder carcinoma is fifth most common gastrointestinal malignancy. Main indication for cholecystectomy is gallstone disease. Majority of gallbladder carcinomas are diagnosed during the course of histopathological evaluation of specimens obtained at cholecystectomy. Accomplishing radical cholecystectomy is advisable in these patients. Technically difficult gallbladder dissection during the course of laparoscopic surgery should raise a high suspicion of malignancy. Specimen retrieval bags should be used in all cases to avoid external spillage of bile giving rise to port side metastasis. A good outcome depends on prompt diagnosis and radical surgical resection. It is essential for a general surgeon to be aware of predisposing factors, pathology, patterns of presentation, and surgical options in gallbladder carcinoma.
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
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Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
3. Relevant Anatomy
Saccular structure located at the inferior surface
of the liver, at the division of the right and left
lobes, just below segments IV and V
Composed of 4 areas: fundus, body,
infundibulum, and neck
Approx. 7-10 cm long and about 2.5-3.5 cm wide
Normally contains approx. 30-50 mL of fluid(max
up to 300 mL)
5. Relevant Anatomy
Spread of GB cancer
spreads via the lymphatic channels and venous
drainage
Peritoneal metastasis common
Due to adjacent location liver, bile duct,
portal vein, hepatic artery, duodenum, and
transverse colon involvement is common
6. Relevant Anatomy
Cystic Plate*
It is reflection of the visceral peritoneum between the liver and
the gallbladder.
Dissection between the gallbladder and the liver during
cholecystectomy divides the plane between the cystic plate
and the muscle layer of the gallbladder
*anatomic basis for the improved survival in patients undergoing
liver resection for T1b gallbladder cancer.
7. Introduction
Gallbladder carcinoma was first described by Maximilian
Stoll in 1777 and more than 200 years later it is still
considered to be a highly malignant disease with a poor
survival rate
G.B cancer is relatively uncommon but it is the 5th
most
common GIT malignancy(worldwide)
most frequent malignant tumor of the biliary tract
90 % Adenocarcinomas.
Mucosal squamous metapalsia Squamous cell carcinoma
8. Introduction
Premalignant Lesions
Adenomatous polyps
Papillary adenomas grow as pedunculated, complex,
branching tumors projecting into the gallbladder lumen.
Tubular adenomas arise as a flat, sessile neoplasm.
Adenomyomatosis
extensions of Rokitansky-Aschoff sinuses through the
muscular wall of the gallbladder
USG reveals a thickened gallbladder wall with intramural
diverticula
serial evaluation with USG is indicated to rule out
enlarging adenomatous polyps and gallbladder cancer
9. Epidemiology
incidence of GC 1 to 23 per 100,000 worldwide
over the last three decades there is decrease in incidence in
developed and increase in incidence in developing countries
The highest incidence of gallbladder carcinoma is reported more
recently from the Indian-Subcontinent including India and Pakistan
(18-23/100,000) mirror image of worldwide distribution of gall
stones
A relatively rare malignancy worldwide but is the second commonest
gastrointestinal cancer in Pakistani women
Most common cause of gastrointestinal cancer related mortality in
females in subcontinent.
10. Epidemiology
Rise in incidence of GC from Northern India and Southern
Pakistan over the past two decades
Frequency of gallbladder cancer in Pakistan varies between
6-7%.
Highest incidence is found in Chelians, American Indian and
in parts of Northern India where it accounts for 9% of all
biliary tract diseases.
Female to male ratio is 3:1
Peak incidence is in 7th
decade of life.
11. Etiology/Pathophysiology
Gallstones are present in 60-90 % of GB cancer cases (World wide)
a small proportion of patients (1-3%) with gall stones developed G.B cancer
inverse relationship between the incidence of GC and rate of cholecystectomy
In pakistan 98-100 % of cases of GC have gall stone
Risk factors include
Chronic inflamation and infection.
Porcelain Gallbladder
Typhoid carrier
Adenomatous polyp (size of the polyp is strongest predictor of malignant
transformation)
Advanced age(>55 yr)
Multiparity(>5)
Presence of gallstone larger than 1-3cm.
Anomalous pancreatobiliary junction
Drugs :OCP, methyldopa
Occupational exposure to rubber,cigrette smoking
Bile acid composition.
Diet: low fibre, low calories. High fine CHO, low protein
12. Numerous studies have investigated genetic
abnormalities in gallbladder cancer and have
shown that approximately 39-59% of
gallbladder cancers are associated with the K-
ras mutation, while more than 90% of them are
associated with a p53 mutation.
13. Presentation
Usually asymptomatic at the time of diagnosis
Symptoms if present are similar to benign
diseases such as cholecystitis or biliary colic.
Jaundice and anorexia are late features
Palpable mass is a late sign
Given this presentation, less than 50% of
gallbladder cancers are diagnosed
preoperatively. Many are diagnosed
incidentally in gallbladders removed for biliary
colic or cholecystitis.
14. Work Up
Laboratory studies are generally nonspecific for
gallbladder cancer.
In the later stages, liver function enzyme levels may be
slightly elevated. These levels are generally not elevated
in stages I and II.
An elevated bilirubin or alkaline phosphate level
generally indicates advanced or obstructive disease.
TumourMarker Sensitivity Specificity
CA 19-9 * 79.4 % 79.5%
CEA 50 % 93%
*Found in 80% of the cases
15. Imaging studies
Ultrasonography is a very useful tool in the workup of
gallbladder cancer. Polypoid lesions need to be at
least 5 mm in size to be detected by ultrasonography.
Cholesterol polyps (benign) generally appear as
pedunculated lesions attached to the gallbladder wall.
Ultrasonographic findings that indicate possible
malignancy
a thick gallbladder wall,
vascular polyp,
a mass projecting into the lumen or invading the wall,
multiple masses or a fixed mass in the gallbladder,
a porcelain gallbladder, and an extracholecystic mass.
Invasion of the liver can also be seen on ultrasonograms.
16. This image demonstrates heterogeneous
thickening of the gallbladder wall (arrows). The
diagnosis was primary papillary adenocarcinoma
of the gallbladder.
17. Computed tomography (CT) scanning and magnetic
resonance imaging (MRI) are useful in evaluating the extent of
invasion and resectability of gall bladder tumors. CT scan
results suggestive of gallbladder cancer include asymmetrical
wall thickening or gallbladder mass with or without invasion
into the liver.
CT scanning of the chest, abdomen, and pelvis is a common
staging modality that can determine the presence of distant
metastases and give reliable information about involvement of
other organs and vascular structures.
Positron emission tomography (PET) scanning has a
sensitivity of 75% and a specificity of 88% in gallbladder
cancer but is not used routinely.
18. Partially calcified gallbladder (arrow).
At laparotomy and histology,
an infiltrating adenocarcinoma of the
gallbladder was confirmed.
CT scan showing squamous cell
carcinoma of gall bladder showing
Liver metastasis
19. Diagnostic procedures
Percutaneous CT scan – guided biopsy is avoided in patients
considered resectable based on preoperative imaging.
Because of the substantial risk of peritoneal seeding,
percutaneous biopsy and diagnostic cholecystectomy are not
necessary in the patient suspected of having gallbladder
cancer. In these patients, exploration with curative intent is
planned based on preoperative imaging alone.
Percutaneous CT scan – guided biopsy is a useful diagnostic
tool in patients who appear to have a nonresectable tumor.
Tissue diagnosis is necessary for palliative treatment.
Endoscopic ultrasonography with fine-needle aspiration
Biopsy can be used to evaluate for peripancreatic and
periportal lymphadenopathy.
20. Staging
The American Joint Committee on Cancer (AJCC) has designated staging by the
TNM (primary t umor, regional lymph n odes, distant m etastasis) classification as
follows [6]
TNMDefinitions
Primary tumor(T)
TX - Primary tumor cannot be assessed
T0 - No evidence of primary tumor
Tis - Carcinoma in situ
T1 - Tumor invades lamina propria or muscle layer . T1a - Tumor invades lamina
propria
T1b - Tumor invades the muscularis
T2 - Tumor invades the perimuscular connective tissue; no extension beyond the
serosa or into the liver
T3 - Tumor perforates the serosa (visceral peritoneum) and/or directly invades the
liver and/or 1 other adjacent organ or structure, such as the stomach, duodenum,
colon, pancreas, omentum, or extrahepatic bile ducts
T4 - Tumor invades the main portal vein or hepatic artery or invades multiple
extrahepatic organs or structures
21. Regional lymph nodes (N)
NX - Regional lymph nodes cannot be assessed
N0 - No regional lymph node metastasis
N1 - Portal lymph node metastasis
N2 - Distant lymph node metastasis such as
periaortic, pericaval, superior mesenteric artery, or
celiac artery
Distant metastasis (M)
MX - Distant metastasis cannot be assessed
M0 - No distant metastasis
M1 - Distant metastasis
22. AJCC Stage Groupings
Stage 0: Tis, N0, M0
Stage I: T1 (a or b), N0, M0
Stage II: T2, N0, M0
Stage IIIA: T3, N0, M0
Stage IIIB: T1 to T3, N1, M0
Stage IVA: T4, N0 or N1, M0
Stage IVB: Any T, N2, M0, OR Any T, any N,
M1
23. Non surgical Management
Small gallbladder tumors are common and many can be safely
followed with serial ultrasonographic examination. It is generally
thought that polyps of less than 1 cm are safe to follow, although a
study
has recommended that polyps that are greater than or equal
to 6 mm should be considered for cholecystectomy.
Chemotherapy is used in the adjuvant and palliative treatment of
gallbladder cancer. Phase II studies have shown that the use of
single-agent chemotherapy (with gemcitabine or 5-fluorouracil) in
the palliative setting can be beneficial.
Combination chemotherapy also has been shown to be beneficial
and is usually based on gemcitabine, capecitabine, and 5-
fluorouracil used in combination with cis-platinum or oxaliplatinum.
Fluoropyrimidine-based chemoradiotherapy is commonly employed
in the palliative and adjuvant setting as well.
24. Surgical management
Cholecystectomy recommended in
polyps larger than 1 cm or with polyps in the setting of primary sclerosing
cholangitis
porcelain gallbladder.
Diagnostic Laproscopy
In order to exclude the presence of undetected intra-abdominal metastases prior
to curative laparotomy.
Surgery is contraindicated in the presence of distant metastases.
Exploratory Laparotomy
The initial exploration focuses on the presence of metastatic disease that was not
detected by preoperative imaging and staging laparoscopy.(15%)
In view of North american surgeons Biopsy-proven metastases in the celiac nodes
preclude resection.
Aortocaval nodal metastases are considered distant metastatic disease.
25. STAGE TREATMENT
T1a Simple cholecystectomy
T1b or deeper Hepatic resection +
lymph node dissection
(portal , peripancreatic , and
retroduodenal)+
Resection of liver segments
IVb and V +/-
extended liver resection
and/or bile duct resection
26. Intraoperative ultrasonography (IOUS)
To evaluate the extent of involvement of the liver, as well
as the portal and intrahepatic vasculature.
This information is especially useful when ligating the
pedicle to segment V and avoiding injury to the right
anterior portal pedicle or segment VIII pedicle. Extended
right hepatectomy may be necessary to achieve tumor
clearance if the tumor involves the right portal pedicles
27. A schematic drawing of the
extent of lymphadenectomy
for gallbladder cancer,
especially when the
extrahepatic biliary tree is
resected.
Gallbladder
tumors. A
schematic
drawing of the
extent of resection
of liver segments
IV-b and V for
gallbladder
cancer.
28. Surgical exploration
will determine the need to resect other organs that
may be involved, such as the stomach, duodenum,
and colon.
It may be difficult to distinguish scar from malignancy.
In these cases, suspicious tissue should be treated as
malignancy in order to improve the chances of a
margin-negative resection.
If tumor is suspected on the bile duct based on a
previous pathology report or operative exploration, the
presence of tumor on the right hepatic duct must be
evaluated.
Suspicion of tumorous involvement of the right hepatic
duct will require an extended right hepatectomy,
excision of the extrahepatic biliary tree, and Roux-en-Y
hepaticojejunostomy to the left hepatic duct.
A recent study indicates that accurate staging
requires examination of at least 6 lymph nodes.
29. No standard adjuvant treatment protocol has
been defined for gall bladder cancer.
Generally, fluoropyrimidine-based
chemoradiotherapy or single-agent chemotherapy
with fluoropyrimidines or gemcitabine is used.
Because of the high cure rate with surgery alone
for T1N0 lesions, adjuvant therapy is not
commonly offered to these patients.
30.
31.
32.
33.
34.
35. Complications
The overall complication and morbidity rate is
approximately 25%.
Complications are similar to those
experienced with cholecystectomy and include
infection, hematoma, and bile leaks.
Complication rates are higher in patients
undergoing more extensive resections.
Liver failure can occur following extended
hepatectomy, especially if jaundice is present
preoperatively.
36. STAGE 5 YEARSURVIVAL RATE
T1b 100% especially with hepatectomy
T2 38% to 77% after extended
cholecystectomy
III and IV 25 % with extended resection
Unresectabe disease < 5% ( 1 year survival rate)
Patients with unresectable disease have a median survival of 2-4
months
PROGNOSIS [5][11]
37. Follow Up
There are no data to support aggressive
surveillance following resection of gall bladder
cancer, because treatment of recurrences is
not generally effective. However, many
clinicians and patients prefer follow-up
imaging every 6 months.