carcinoma gall bladder

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.