gall bladder cancer

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  • GALL BLADDER CANCERDr. Zeeshan

  • OVERVIEWGB cancer is rare traditionally incurableLate presentationDisseminated diseaseDismal 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 patients life

  • TENDENCY TO SPREADLymphaticsHematogenousPeritoneal Along biopsy tracts and wounds

    Overall 5 year survival : 5%Median survival : < 6 months

    Treatment : Complete surgical resection

  • EPIDEMIOLOGYHighest 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 3:1Increase in age : increase in incidenceObesity : BMI 30 34.9 vs 18.5 24.9 ---RR of death from CA GB 2.13

  • ETIOLOGYMost 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

  • CHRONIC INFLAMMATIONBiliary enteric fistulasTyphoid infectionsPancreaticobiliary malfunctions

    Calcification : PORCELAIN GBType of calcification degree of risk Stippled >>>> Diffuse intramural calcification

  • CHEMICALSOCPMethyl DopaINHRubber industry

  • ??ADENOMA- CARCINOMA SEQUENCEPoor associationNo increased risk of malignancy in polyps

  • ANATOMY OF GALL BLADDERGB partially intraperitoneal structure attached to liver on segment IV b and VSide 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

  • ANATOMYBody 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

  • LYMPHATICS

  • PATHOLOGY AND STAGING Fundus 60% of tumorsBody 30% of tumorsNeck 10% of tumors

    Gross findings:Typical of chronic cholecystitisTumors in lower end of GB obstructing HYDROPSAdvanced tumors in neck/infundibulum jaundice / vascular invasion/ hepatic atrophy

  • GROSS DESCRIPTIONSInfiltrativeNodularCombined nodular infiltrativePapillary - Better prognosisCombined papillary infiltrative

  • PAPILLARY ADENOCARCINOMA

  • HISTOLOGYAdenocarcinoma 89.4%Squamous / Adenosquamous 4%Neuroendocrine 3%Sarcoma/Adenosarcoma 1.6%Melanoma -
  • CLINICAL PRESENTATIONSCENARIOS:Final pathology after routine cholecystectomy identifies CA GB

    GB cancer discovered intraoperatively

    GB cancer suspected before surgery

  • HISTORYConstant RUQ pain rather than episodic crampy pain of biliary colicElderly patientsWeight lossAnorexiaJaundice

  • COMMON SYMPTOMS AND SIGNS

  • LAB EXAMINATION (HELPFUL IN ADVANCED DISEASE)AnemiaHypoalbuminemiaLeukocytosisElevated bilirubinElevated Alkaline Phosphatase

    Tumor markers:CEA : 90% specific but lacks sensitivity (50%)CA19-9 : More consistent marker Sensitivity : 75% Specificity : 75%

  • RADIOLOGYUSG : Excellent modality for GBFindings :Discontinuous mucosaEchogenic mucosaSubmucosal echogenicityDoppler assessment of blood flow: Differentiates malignant from benign

    Limitation : Unable to stage (Nodes cannot be visualised)

  • CT/MRICan assess extent of diseaseDetects presence of distant metastases

    MC finding : Mass in GB

    Assessment of LN:Size > 1cmRing like heterogenous enhancement

  • CT/MRICT : 71 84 % accurate 79% can differentiate between T1 and T293% between T2 and T3100% between T3 and T4

    MRI:70 100% sensitive for hepatic invasion60 75% sensitive for LN spread

  • FDG PET scan :

    More accurate than CT in diagnosing metastatic disease

    Poor in differentiating benign inflammatory state vs malignancy

  • PRE-OPERATIVE PATHOLOGICAL DIAGNOSISIf 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

  • BILE CYTOLOGYLess risky way of making diagnosis without risk of peritoneal seeding.

    Justifiable in patients undergoing ERCP/PTC

    If NOT - unwarranted

  • STAGING

  • SURGICAL MANAGEMENTBenign polyp :Adenomatous polyp ONLY polypoidal lesion with malignant potentialCholesterol polyp MC polyp

    Indicators for cholecystectomy:Single polypSize > 1 cmAge > 50 years

  • Old concept Offer OPEN cholecystectomy

    Current concept Offer Laparoscopic cholecystectomy + Frozen

    Diagnosis USG requiredIf polyp presents with abdominal pain rule out other causes

  • INCIDENTALLY DETECTED GB CAIncidence : 0.27 2.1%If diagnosis made by frozen Prepare for curative resectionIF NOT COMFORTABLE REFER NO EFFECT ON OUTCOME

  • T1a with margins negative : Standard cholecystectom cures 85 100%

    T1b controversial

    T2 onwards plan liver resection

  • NON CURATIVE CHOLECYSTECTOMYCareful work up required which includes :

    Reviewing pre-cholecystectomy USG to localise extent

    Discuss case with operating surgeon

    Re-review T stage and margins pathologically

  • T1B LESIONSIf cystic duct stump / margins +ve Bile duct resection and reconstruction OR Re-resection of cystic duct stump and frozen proceed

  • EXTENT OF RESECTION BY STAGERational approach to CA GB depends on :

    Stage of diseaseLocation of tumourMargins status if cholecystectomy has already been performed.Whether a prior noncurative cholecystectomy has been performed

  • T1a Simple cholecystectomy

    T1b Higher locoregional recurrence rates after simple cholecystectomy

    T2,T3 Complete enbloc resection with segment Ivb and V of liver

  • 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:Nodal spreadMetastases

  • 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 pedicleTumors of lower end of GB encroaching onto porta

  • If isolated invasion of organ system present

    EG: Stomach , duodenum, colon

    In absence of distant metastases DO local resection

  • LYMPH NODAL DISSECTIONWeigh 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

  • 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

  • Stage of disease and NOT extent of resection determines survival of patients

  • DID YOU KNOW?Honeymoon and alcohol

    Roots trace back to BabylonTradition for the soon to be father- in-law to supply his daughters fiance with a month of meadTime period referred to as the HONEYMONTH

  • DID YOU KNOW?

    Adolf Hitler was one of the worlds best known abstainers from alcohol.