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Gallbladder

Cancer
PREAMBLE
• the most common malignant tumour of the biliary
tract worldwide .
• It is also the most aggressive cancer of the biliary
tract with the shortest median survival from the
time of diagnosis.
• This poor prognosis is due, in part, to an
aggressive biologic behaviour and a lack of
sensitive screening tests for early detection -
resulting in delayed diagnosis and presentation at
an advanced stage.

C. H. E. Lai and W. Y. Lau, “Gallbladder cancer—a comprehensive review,” Surgeon, vol. 6, no. 2, pp. 101–110, 2008.
X. Zhu, T. S. Hong, A. F. Hezel, and D. A. Kooby, “Current management of gallbladder carcinoma,” The Oncologist, vol. 15, no. 2, pp. 168–181, 2010.
U. Dutta, “Gallbladder cancer: can newer insights improve the outcome?” Journal of Gastroenterology and Hepatology, vol. 27, no. 4, pp. 642–653, 2012.
INCIDENCE

• Gallbladder carcinoma is the fifth most


common gastrointestinal tumour.
• Well- to moderately differentiated
adenocarcinoma accounts for the most
common form of gallbladder carcinoma.

Gallbladder Carcinoma Update: Multimodality Imaging Evaluation, Staging, and


Treatment Options. Alessandro Furlan et al American Journal of Roentgenology.
2008;191: 1440-1447
RISK FACTORS

Adapted from -Gallbladder Cancer in the 21st Century. Rani Kanthan, Jenna-Lynn Senger,
Shahid Ahmed, and Selliah Chandra Kanthan Journal of Oncology; Volume 2015 (2015),
RISK FACTORS
• Demographic factors:
(a)advanced age,
(b)female gender,
(c)obesity,
(d)geography: South American, Indian, Pakistani,
Japanese, and Korean,
(e)ethnicity: Caucasians, Southwestern Native
American, Mexican, and American Indians,
(f)genetic predisposition.
GEOGRAPHICAL VARIATION
GEOGRAPHICAL VARIATION
in Gall Stone Disease
RISK FACTORS

• Gallbladder pathologies/abnormalities:
(a)cholelithiasis, (Kaushik 2001; Rustagi and
Dasanu 2014)
(b)porcelain gallbladder, (Hundal and Schaffer
2014)
(c) gallbladder polyps,
(d)congenital biliary cysts *,
(e)pancreaticobiliary maljunction anomalies.
In Todani 's series of 154 cancers associated with bile duct cysts, 62 were in
the gall-bladder, 1 in the liver and 2 in the pancreas.*
RISK FACTORS
• Gallbladder pathologies/abnormalities:
 The issue of microlithiasis
 Gallbladder metaplastic changes appear to be
more frequent in cases of micro-lithiasis and seem
to be associated with a chronic thickening of the
gallbladder wall.
 Further studies are needed to evaluate a possible
role of prophylactic cholecystectomy in this
population to prevent the long term evolution of
these early changes to cancerous lesions.

Metaplastic Changes in Chronic Cholecystitis: Implications for Early Diagnosis and


Surgical Intervention to Prevent the Gallbladder Metaplasia-Dysplasia-Carcinoma
Sequence. Charalampos Seretis et al; J Clin Med Res. 2014 Feb; 6(1): 26–29.
RISK FACTORS

• Chronic inflammation associated with


(a)Primary sclerosing cholangitis (Bernstein
2001)
(b)Ulcerative colitis (Bernstein 2001)
RISK FACTORS

• Infections
(a)Liver flukes (R. Hundal and E. A. Shaffer
2014),
(b)Chronic Salmonella typhi and paratyphi
infections (Nath 1997; Shukla 2000; Randi
2006; Nagaraja 2014) and
(c)Helicobacter infection (Matsukura 2002;
Kobayashi 2005).
RISK FACTORS
• Exposures
(a)Ingestion of certain medications (eg, oral
contraceptives, INH, methyldopa) can increase the
risk of gallbladder cancer.
(b)Likewise, certain chemical exposures (eg,
pesticides, rubber, vinyl chloride) and
(c)Occupational exposures associated with working in
the textile, petroleum, paper mill, and shoemaking
industries increase the risk of gallbladder cancer.
(d) Smoking
(e)Exposures through
water pollution (organopesticides, eg,
dichlorodiphenyltrichloroethane and benzene
hexachloride);
heavy metals (eg, cadmium, chromium, lead); and
radiation exposure (eg, radon in miners) are associated with
gallbladder cancer.
PATHOGENESIS

• Gallbladder cancer may arise in the


gallbladder’s fundus (60%), body (30%), or
neck (10%).
• The development of gallbladder cancer is
proposed to occur over a span of 5–15 years,
with tissue alterations including metaplasia,
dysplasia, carcinoma in situ, and invasive
cancer
K. S. Lim, C. C. Peters, A. Kow, and C. H. Tan, “The varying faces of gall bladder carcinoma: pictorial essay,” Acta Radiologica, vol.
53, no. 5, pp. 494–500, 2012.
R. Hundal and E. A. Shaffer, “Gallbladder cancer: epidemiology and outcome,” Clinical Epidemiology, vol. 6, no. 1, pp. 99–109,
2014.
IMAGING
• On sonography, CT, or
MRI, the presence of a
large gallbladder mass
that nearly fills or
replaces the lumen,
often directly invading
the surrounding liver
parenchyma, is highly
suggestive of
gallbladder carcinoma.
Gallbladder Carcinoma Update: Multimodality Imaging Evaluation, Staging, and
Treatment Options. Alessandro Furlan et al American Journal of Roentgenology.
2008;191: 1440-1447
IMAGING
• On sonography,
heterogeneous,
predominantly
hypoechoic tumor fills
much or all of the
gallbladder lumen.

Gallbladder Carcinoma Update: Multimodality Imaging Evaluation, Staging, and


Treatment Options. Alessandro Furlan et al American Journal of Roentgenology.
2008;191: 1440-1447
IMAGING

• The initial detection of


gallbladder carcinoma as
a polypoid lesion occurs
in 15–25% of cases.
• Malignant lesions are
usually larger than 1 cm
in diameter and may
have a thickened
implantation base .

Gallbladder Carcinoma Update: Multimodality Imaging Evaluation, Staging, and


Treatment Options. Alessandro Furlan et al American Journal of Roentgenology.
2008;191: 1440-1447
GB CA vs XGC
IMAGING
Contrast Enhanced US Scan
Upper Left-
Polypoid
Upper Middle-
Thick wall type
Upper Right-
Mass forming
type
Lower Left-
Scattered blood
vessels
Lower Middle-
Linear blood
vessels
Lower Right-
Linear blood
vessels

Contrast-Enhanced Ultrasound in the Diagnosis of Gallbladder Diseases: A Multi-Center


Experience. Lin-Na Liu, Hui-Xiong Xu et al October 31,
http://dx.doi.org/10.1371/journal.pone.0048371
ROLE OF ADJUVANT THERAPY

• Currently (2014), no adjuvant therapy that


has been agreed upon as standard of
care. Williams et al; Defining the role of adjuvant
therapy; cholangiocarcinoma and gall bladder cancer.
Semin Radial Oncol 2014 Apr; 24(2):94-104
PROGNOSIS
• A disease of very poor
prognosis.
• Surgery, the only
curative therapy. (<20%
operable)
• Techniques of early
diagnosis evolving.
• Regional nodal status
and the depth of tumor
invasion (T status) are
the two most important
prognostic factors.

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