Gallbladder Cancer Causes/Risk Factors
Gallstones: Among many risk for gallbladder cancer one is gallbladder stones. More than 70% of patients have gallstones when they’re diagnosed however the incidence is rare as compared to gallstones
Porcelain gallbladder: It is a condition where gallbladder wall is covered with deposits of calcium.Can occur after chronic cholecystitis or long term inflammation of the gallbladder
Female gender: The incidence is more in females as compared to men.It may be correlated with increased incidence of gallstones and inflammation in the gallbladder in females
Obesity:It has been found that these patients are obese or overweight. Gallstones are also more common in obese patients which may also explain the high risk in these patients
Older age: As most cancer develop in old age .But incidence is increasing in young population also. In this age group it has been found that cancer is more aggressive. Reason may be dietary and life style change
Ethnicity and geography: Worldwide, Incidence is more in Central America, Pakistan and India. In India it is more common in North as compared to south
Choledochal cyst: These are cystic dilatation of biliary channels which are congenital
Gallbladder polyp: The incidence is more in gallbladder polyps which are more than 1cm in size, single polyp and sessile
Pain: Commonly localized to right upper abdomen
Vomitting: It occur when cancer involve gastric antrum or pylorus or duodenum.
Jaundice: Gallbladder neck cancer because of its location can cause biliary obstruction leading to jaundice. It is called as surgical obstructive jaundice. It is painless and associated with dark colored urine and pale colored stools.
Large bowel Obstruction: Locally advance malignancy can involve hepatic flexure of colon resulting in large bowel obstruction. Patient present with feature like abdomen distension, non-passage of flatus and motion.
Anorexia & Weight loss are common. Metastatic tumor present with abdomen distension in the form of ascites
Diagnosis of Gallbladder Cancer
Ultrasound Abdomen is the most common investigation done for pain abdomen. It will show mass or thickening in the gallbladder.
CECT abdomen is done for planning gallbladder cancer surgery as it show relation of tumor to surrounding structures, any lymph nodes and distant metastases.
Fine needle aspiration cytology (FNAC) is not done. The only indication is tumor unresectability when chemotherapy is planned
Treatment of Gallbladder Cancer
Gallbladder Cancer Management is team work of GI Oncosurgeon, GI Oncologist, Gastroenterologist and Intervention radiologist.Once patient is diagnosed to have gallbladder cancer further management depend on pre-operative staging of the cancer
Role of GI Oncosurgeon
If the tumor is resectable, first line of management is surgery. The standard surgical procedure performed is radical cholecystectomy. Gallbladder is situated on the inferior aspect of right lobe of liver adhered to it. Gallbladder is removed along with this part of liver to which it is adhered and standard lymphadenectomy is done. Cystic duct margin is sent for frozen section intra-operatively and if it comes to be positive then common bile duct is also excised and then Roux-en-Y Hepatico-jejunostomy is performed. Extended right hepatectomy is done if tumor is located at the neck and involve right sided portal structures. with liver bed and lympadenectomy is done. Staging laparoscopy is first step. There is high incidence of metastases which are missed on pre-operative imaging, which can be detected on staging laparoscopy and morbidity of long incision can be avoided
Role of GI Medical Oncologist
If the cancer is metastatic on imaging then palliative chemotherapy is given. For locally advanced cancer but not metastatic pre-operative chemotherapy is given to downstage the tumor and make it resectable.Once cancer seems resectable surgery is done. Chemotherapy is given in the post-op period if the tumor is beyoned certain stage
Role of Gastroenterologist
Patients who are not surgical candidates either because tumor is locally advanced or metastatic or poor peformance status, these patients if have jaundice or vomitting require endoscopic palliation. Jaundice occur when the tumor compress the biliary system and vomitting occur either due to antro-pyloric or duodenal obstruction. Endoscopic Biliary and duodenal stenting is done in these patients
Role of Intervention Radiologist
There role comes when palliative endoscopic biliary stenting is not possible because there is complete blockage of biliary system. In these patients percutaneous transhepatic biliary drainage is done to relief jaundice