CARCINOMA GALL BLADDER

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CARCINOMA GALL BLADDER :

CARCINOMA GALL BLADDER Neeraj Kumar Jain

INTRODUCTION :

INTRODUCTION Cancer of the gallbladder is an aggressive malignancy that occurs predominantly in elderly people . Prognosis for most patients is poor. Series from the Western country have reported 5-year survival rates of only 5% to 38 %. Unfortunately, many of these tumors are unresectable at presentation, and most must be managed nonoperatively . Recently, an aggressive surgical approach for patients with localized gallbladder cancer has produced encouraging results with an acceptable morbidity.

INCIDENCE :

INCIDENCE Gallbladder cancer is the fifth most common gastrointestinal malignancy, with about 5000 new cases diagnosed annually in the United States. Cancer of the gallbladder is two to three times more common in women than men, in part because of the higher incidence of gallstones in women . More than 75% of patients with this malignancy are older than 65 years . The incidence of gallbladder cancer varies considerably with both ethnic background and geographic location.

ETIOLOGY :

ETIOLOGY A strong association has long been noted between gallbladder cancer and cholelithiasis , which is present in 75% to 90% of cases. The incidence of gallstones increases with age, and by age 75, about 35% of women and 20% of men have developed gallstones. The incidence of gallbladder cancer is about seven times more common in the presence of cholelithiasis and chronic cholecystitis than in people without gallstones. In addition, the risk for developing gallbladder cancer is higher in patients with symptomatic gallstones than in patients with asymptomatic gallstones . About 1% of all elective cholecystectomies performed for cholelithiasis harbor an occult gallbladder cancer.

RISK FACTOR FOR CA GALL BLADDER :

RISK FACTOR FOR CA GALL BLADDER Gallstones Porcelain gallbladder Anomalous pancreatobiliary junction Choledochal cysts Adenomatous gallbladder polyps Primary sclerosing cholangitis Salmonella typhi infection

PATHOLOGY :

PATHOLOGY Ninety percent of cancers of the gallbladder are classified as adenocarcinoma . Squamous cell, oat cell, undifferentiated, and adenosquamous cancers and carcinoid tumors are much less frequent. At diagnosis, 25% of cancers are localized to the gallbladder wall, 35% have associated metastases to regional lymph nodes or extension into adjacent organs, and 40% have already metastasized to distant sites. Hepatic involvement with gallbladder cancer can occur by direct invasion through the gallbladder bed, angiolymphatic portal tract invasion, or distant hematogenous spread .

Clinical Presentation :

Clinical Presentation Gallbladder cancer most often presents with right upper quadrant abdominal pain often mimicking cholecystitis and cholelithiasis . Weight loss, anorexia, jaundice, and an abdominal mass are other common presenting symptoms. About 40% of patients present with symptoms of chronic cholecystitis , often with a recent change in the frequency of the painful episodes . Another common presentation is similar to acute cholecystitis , with a short duration of pain associated with vomiting, fever, and tenderness.

Diagnosis:

Diagnosis Ultrasonography It is often the first diagnostic modality used in the evaluation of patients with right upper quadrant abdominal pain. A heterogeneous mass replacing the gallbladder lumen and an irregular gallbladder wall are common sonographic features of gallbladder cancer . The sensitivity of ultrasound in the detection of gallbladder cancer ranges from 70% to 100 %. CT scan CT scan usually demonstrates a mass replacing the gallbladder or extending into adjacent organs . With newer magnetic resonance techniques, gallbladder cancers may be differentiated from the adjacent liver and biliary obstruction or encasement of the portal vein may also be easily visualized .

PowerPoint Presentation:

Cholangiography (MRCP) :- MRCP also may be helpful in diagnosing jaundiced patients with gallbladder cancer. The typical cholangiographic finding in gallbladder cancer is a long stricture of the common hepatic duct . FNAC :- If radiographic studies suggest that the tumor is unresectable (liver or peritoneal metastases, portal vein encasement, or extensive hepatic invasion), FNAC of the tumor is warranted and can be performed under ultrasound or CT guidance.

PowerPoint Presentation:

TNM Staging for Gallbladder Cancer T1 Tumour invades lamina propria (T1a) or muscular (T1b) layer T2 Tumour invades perimuscular connective tissue, no extension beyond the serosa or into the liver T3 Tumour perforates the serosa (visceral peritoneum) and/or directly invades into liver and/or one other adjacent organ or structure such as the stomach, duodenum, colon, pancreas, omentum , or extrahepatic bile ducts T4 Tumour invades main portal vein or hepatic artery or invades multiple extrahepatic organs and/or structures N0 - No lymph node metastases N1 - Regional lymph node metastases M0 - No distant metastases M1 - Distant metastases

STAGING OF CARCINOMA GALLBLADDER:

STAGING OF CARCINOMA GALLBLADDER Nevin’s staging Stage 1 Intramural Stage 2 Spread to muscularis propria Stage 3 Spread to serosa Stage 4 Spread to cystic lymphnode of lund Stage 5 Direct spread to adjacent organs / metastases

Management :

Management The appropriate operative procedure for the patient with localized gallbladder cancer is determined by the pathologic stage . Patients with tumours confined to the gallbladder mucosa or submucosa (T1a) or confined to the gallbladder muscularis (T1b) are usually identified after cholecystectomy for gallstone disease and have an overall 5-year survival rate approaching 100% and 85%, respectively. Therefore , cholecystectomy is adequate therapy for patients with T1 tumours. Recurrent cancer at port sites and peritoneal carcinomatosis have been reported after laparoscopic cholecystectomy , even for patients with in situ disease; therefore, all port sites should be excised if a patient has had a previous laparoscopic cholecystectomy . Patients with preoperatively suspected gallbladder cancer should undergo open cholecystectomy to minimize the chance of bile spillage and tumor dissemination.

m/m cont..:

m/m cont.. Cancer of the gallbladder with invasion beyond (stages II and III) the gallbladder muscularis is associated with an increased incidence of regional lymph node metastases and should be managed with an “extended cholecystectomy .” This includes lymphadenectomy of the cystic duct, pericholedochal , portal, right celiac , and posterior pancreatoduodenal lymph nodes . Extension into the hepatic parenchyma is common, and extended cholecystectomy should incorporate at least a 2-cm margin beyond the palpable or sonographic extent of the tumor . For smaller tumors , this goal can be achieved with a wedge resection of the liver. For larger tumors , an anatomic liver resection (extended right hepatectomy ) may be required to achieve a histologically negative margin.

PowerPoint Presentation:

In most cases , therapy for gallbladder cancer is palliative. If a tissue diagnosis can be established in patients with an unresectable tumour , nonoperative palliation should be considered . Many of these patients have obstructive jaundice that can be managed with either an endoscopic or percutaneously placed biliary stent. Pain is another problem that should be treated aggressively to improve quality of life. Percutaneous celiac ganglion nerve block may reduce the need for narcotics

Role of chemotherapy and radiotherapy :

Role of chemotherapy and radiotherapy The results of chemotherapy in the treatment of patients with gallbladder cancer have been quite poor. External-beam and intraoperative radiation therapy have both been used in the management of patients with gallbladder cancer. Unfortunately , no randomized data have demonstrated improved survival with either chemotherapy or radiation

Survival :

Survival Survival in patients with gallbladder cancer is strongly influenced by the pathologic stage at presentation . Recent advances in surgical technique and aggressiveness of resection for gallbladder cancer have resulted in improved overall survival . Patients with cancer limited to the gallbladder mucosa and lamina propria (T1a) have an excellent prognosis (85-100%) However, most patients with gallbladder cancer have advanced unresectable disease at the time of presentation. As a result, fewer than 15% of all patients with gallbladder cancer are alive after 5 years. The median survival for stage IV patients at the time of presentation is only 1 to 3 months

PowerPoint Presentation:

Thank you ……

Survival :

Survival Survival in patients with gallbladder cancer is strongly influenced by the pathologic stage at presentation . Recent advances in surgical technique and aggressiveness of resection for gallbladder cancer have resulted in improved overall survival . Patients with cancer limited to the gallbladder mucosa and lamina propria (T1a) have an excellent prognosis . Invasion into the muscular wall (T1b) of the gallbladder increases the risk for recurrent cancer after curative resection. However, no difference in 10-year survival has been demonstrated after simple cholecystectomy (100%) and extended cholecystectomy (75%) among patients with T1b gallbladder cancer.

PowerPoint Presentation:

Five-year survival in patients with T2 tumors is improved following extended cholecystectomy with lymphadenectomy and liver resection (59%-61%) compared with simple cholecystectomy (17%-19%) However, most patients with gallbladder cancer have advanced unresectable disease at the time of presentation. As a result, fewer than 15% of all patients with gallbladder cancer are alive after 5 years. The median survival for stage IV patients at the time of presentation is only 1 to 3 months

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