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%.

1. Management of Carcinoma
Gall bladder
Dr. Md Ashiqur Rahman.
Resident
Department of Gastroenterology.

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)

5. Risk factors

6. Pathology Morphology
• Site of origin
Fundus – 60%
Body – 30%
Neck – 10%
• Spread
Direct invasion- segment IV, V
Lymphatic
Blood
Intraperitoneal
Intraductal
• Infiltrative
• Nodular
• Papillary – better prognosis
Histology
• Adenocarcinoma – 90%

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

9. • Multiphasic CT scan – Staging, preoperative planing
• MRI/MRCP
• PET
• laparoscopy

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

17. Carcinoma discovered by laparoscopy or open cholecystectomy

18. Carcinoma discovered after pathological examination of excised tissue

19. Chemotherapy
• Gemcitabine combined with cisplatin
• Gemcitabine plus oxaliplatin, 5-FU, capecitabine
• Targeted agents – cetuximab, erlotinib, bevacizumab
Overall survival improve 3.6 months

20. Palliative
• Adequate biliary drainage
ERCP/PTBD/segmental bypass
• Nutritional therapy
• Pain control
• Relief of GOO