Gall Bladder Carcinoma

  • Median Survival: <6 months
  • 5 year survival: 0-10%
    Risk Factors for GB carcinoma:
  • Cholelithiasis (stone size >1cm)
    • PSC
    • Poreceline gall bladder
    • 1st degree relatives with GB cancer
    • HNPCC
    • Segmental adenomyomatosis in patients >60 years
    • Intrahepatic biliary dysplasia
    • Chronic S. typhi , paratyphi carrirer status
    • IBD
    • Cholangiocarcinoma
    • Anomalous union of pancreaticobiliary ductal system
    • Carcinogens
  • Gall stone is found in 65-90% GB cancer patients
  • 1-3% of gall stone patients develops GB carcinoma
  • At initial presentation, only 10% patients have disease confined to GB
    Location of GB carcinoma:

    • Fundus- 60%
    • Body- 30%
    • Neck-10%

Causes of early metastasis of Ca-GB

  • Thin lamina propria
  • Single muscle layer

Clinical Features:

  • 47-78% GB carcinoma found incidentally during cholecystectomy for presumed benign disease

Common clinical presentations:

  • Biliary/ abdominal pain
  • Jaundice secondary to direct invasion to bile ducts or metastasis to hepatoduodenal ligament
  • Weight loss, abdominal distension, other symptoms due to compression of adjacent organs

Investigations:

  • CA 19-9 at cut-off 20 U/ml the sensitivity and specificity both are 79%

USG finding of GB carcinoma:

  • Focal/diffuse mural thickening of the GB
  • Intraluminal mass >2 cm in size that originates in the GB wall
  • Subhepatic mass that obscure or replaces GB and often invades adjacent organs

Imaging findings indicative of malignant lesion:

  • Irregular, asymmetric mural thickening >1cm in depth
  • Nodular/smooth intraluminal mass >1cm with fixation to gallbladder that is not displaced by the patients movements and has no acoustic shadow

TNM Staging of Ca-GB:

  • Tis: Carcinoma in situ
  • T1a: Tumor invades the lamina propria
  • T1b: Tumor invades the muscularis propria
  • T2: Tumor invades the perimuscular connective tissue without extension beyond serosa or into the liver
  • T3:
    • Tumor perforates serosa and/or
    • Tumor directly invades the liver and/or
    • Tumor invades 1 adjacent organs
  • T4:
    • Tumor invades the portal vein/ hepatic artery or
    • Tumor invades >2 extrahepatic organs structures
  • N0: No regional lymph node metastasis
  • N1: LN metastasis along the cystic duct, bile duct, Hepatic artery and/or portalmvein
  • N2: Metastasis to periaortic, pericaval, sup.mesenteric artery and/or celiac artery LN

Treatment:

  • Only 15 – 47% patients are surgically resectable at diagnosis
  • Contraindications to resection:
    • Multiple hepatic or distal metastasis
    • Gross vascular invasion or encasement of major vessels
    • Malignant ascites
    • Poor functional status
  • T4:
    • Tumor invades the portal vein/ hepatic artery or
    • Tumor invades >2 extrahepatic organs structures
  • N0: No regional lymph node metastasis
  • N1: LN metastasis along the cystic duct, bile duct, Hepatic artery and/or portalmvein
  • N2: Metastasis to periaortic, pericaval, sup.mesenteric artery and/or celiac artery LN

** Direct invasion to colon, duodenum or liver is not absolute contraindication for surgical resection

Surgical options of GB Carcinoma:

  • Simple cholecystectomy : for Stage 1a disease
  • Extended/Radical cholecystectomy with additional resection of >2 cm of GB bed plus lymphadenectomy of the hepaticoduodenal ligament
  • Extended cholecystectomy with hepatic, segmental or lobar resection
  • Extended cholecystectomy with extensive para-aortic lymph node resection
  • Extended cholecystectomy with bile duct resection and pancreaticoduodenectomy
  • Surgical approach is controversial for T3, T4 disease
  • Neoadjuvant and adjuvant therapy do not provide survival benefit and are not recommended**Ca- GB is radioresistant

Gall bladder carcinoma diagnosed during laparoscopic cholecystectomy:

  • The procedure should be converted to open procedure
  • The laparoscopic port site should be resected because tumor may recur at these sites secondary to iatrogenic dissemination
  • Further management depends upon stage

Gall bladder carcinoma diagnosed post operatively:

  • Further management depends on the tumor stage
  • Presence or absence of tumor at the margin of the surgical specimen
  • T1a tumor with negative surgical margins: No further treatment is indicated
  • T1b tumor or the margins of resection are positive for malignant tissue: Re-exploration for further resection
  • T2, T3, T4 tumor: Also surgical re-exploration
  • If re-exploration reveals resectable gallbladder carcinoma, radical cholecystectomy should be performed
  • Palliative management if unresetable

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