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Gallbladder cancer


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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Vamsikrishna Gunnam M.B.B.S [2]

Synonyms and keywords: Malignant tumour of gallbladder; gallbladder carcinoma; carcinoma of gallbladder

Overview

Overview

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Vamsikrishna Gunnam M.B.B.S [2]

Overview

Gallbladder cancer may be classified according to histology findings into various subtypes and are as follows Adenocarcinoma, Papillary adenocarcinoma, Mucinous adenocarcinoma, Signet ring cell carcinoma, Adenosquamous carcinoma, Squamous cell carcinoma, Neuroendocrine carcinoma, Small cell carcinoma, undifferentiated carcinoma, spindle cell undifferentiated carcinoma, giant cell undifferentiated carcinoma.It is understood that GBC is the result of persistent irritation of the gallbladder mucosa over a period of years which predispose to malignant transformation or act as an enhancer for carcinogenic exposure.The primary mechanism involves cholelithiasis and resultant cholecystitis and appears to be the driving force in most areas of the arena.Chronically inflamed gallbladder may additionally express both pyloric gland and intestinal metaplasia.But, fluke-infested gallbladders more commonly shows intestinal metaplasia and p53 mutations than sporadic gallbladder cancers.Dysplastic lesions have molecular genetic proof that supports progression towards CIS.There are also histologic and molecular differences in GBCs related to anomalous pancreaticobiliary duct junction and in the ones related to gallstones, Providing further proof that two different pathogenetic pathways are involved.Less than 3% of early gallbladder carcinomas have adenomatous remnants, indicating this mechanism has less importance within the carcinogenic pathway.Around 80 t0 95% of biliary tract cancers are gallbladder cancers.Epidemiological research has recognized striking geographic and ethnic difference. An excessive incidence in American Indians and Southeast Asia, but pretty low in the America and the arena.Gallstones, Porcelain gallbladder, Gallbladder polyps, Primary sclerosing cholangitis (PSC) , chronic infection, congenital biliary cysts, pancreaticobiliary maljunction (PBM).There is no screening recommended for gallbladder cancer. According to the National Comprehensive Cancer Network (NCCN) guidelines, gallbladder cancer may be diagnosed as an incidental finding in patients who undergo laparoscopic cholecystectomy.Gallbladder cancer must be differentiated from hepatitis, gallstones, cholecystitis, peptic ulcer, pancreatic cancer and pancreatitis.Depending on the extent of the tumor at the time of diagnosis, the prognosis may vary. However, the prognosis is generally regarded as poor.Most tumors are adenocarcinomas, with a small percent being squamous cell carcinomas. The cancer commonly spreads to the liver, pancreas, stomach and duodenum. The survival rate depends on the extent of cancer at the time of diagnosis with gallbladder cancer and early detection is key for good prognosis.According to the AJCC, there are 4 stages of gallbladder cancer based on the tumor spread.Symptoms of gallbladder cancer include jaundice, pain, fever, burping and weight loss.Laboratory findings consistent with the diagnosis of gallbladder cancer include abnormal liver function tests and elevated CA 19-9 and CEA levels.On abdominal CT scan, gallbladder cancer appears as large heterogeneous mass with areas of necrosis.Palliative therapy in gallbladder cancerinvolves percutaneous transhepatic radiologic catheter bypass or endoscopically placed stents, standard external-beam radiation therapy, palliative surgery or standard chemotherapy.Research suggests that lifestyle factors such as changes in diet, exercise, and maintenance of weight can influence the likelihood of an individual developing gallbladder cancer.Research suggests that lifestyle factors such as changes in diet, exercise, and maintenance of weight can influence the likelihood of an individual developing gallbladder cancer

Historical Perspective

In 1777 Maxmillan de Stol described the gallbladder cancer and since studies have established in the identification of the disease and ineffective treatment of this disease.Gallbladder cancer(GBC) are often clinically asymptomatic and an surprising finding at incision, most commonly detected incidentally on histological examination.GBC is characterised by local invasion, intensive regional lymphoid tissue metastasis and distant metastases. In general, GBC is that the most aggressive of the biliary cancers with the shortest median survival period.

Classification

Gallbladder cancer may be classified according to WHO into various subtypes like adenocarcinoma, papillary adenocarcinoma, mucinous adenocarcinoma, signet ring cell carcinoma, adenosquamous carcinoma, squamous cell carcinoma, neuroendocrine carcinoma, small cell carcinoma, undifferentiated carcinoma, spindle cell undifferentiated carcinoma, giant cell undifferentiated carcinoma.

Pathophysiology

Gallbladder cancer usually develops in the setting of chronic inflammation of the gallbladder.The most common source of chronic inflammation is cholesterol gallstones. The gallbladder cancer risk increases to 4-5% in the presence gallbladder cancer (GBC) is the result of 2 or more different biological pathways based on morphological, genetic, and molecular evidence. Metaplasia is believed to be one of the pathological reason behind the development of gallbladder carcinoma. Although the definite relationship between metaplasia and dysplasia, is not clearly established yet. On gross pathology, fibrosis and thickening of the gallbladder are characteristic findings of the gallbladder cancer. On microscopic histopathological analysis, outer portion is often better differentiated than deeper portion are characteristic findings of gallbladder cancer.

Causes

Definite cause of the gallbladder cancer is not determined, but several risk factors are involved in this cancer, such as gallstones, gallbladder polyps, infections, and Primary sclerosing cholangitis.

Epidemiology and Demographics

Around 80 t0 95% of biliary tract cancers are gallbladder cancers. Epidemiological research has recognized striking geographic and ethnic difference. An excessive incidence in American Indians and Southeast Asia, but pretty low in the America and the arena.

Risk Factors

The most potent risk factor in the development of gallbladder carcinoma is gallstones. Other risk factors include Porcelain gallbladder, gallbladder polyps, Primary sclerosing cholangitis, chronic infection, pancreaticobiliary maljunction (PBM) and biliary cysts.

Screening

According to the National Comprehensive Cancer Network (NCCN) guidelines, gallbladder cancer may be diagnosed as an incidental finding in patients who undergo laparoscopic cholecystectomy.

Differential diagnosis

Gallbladder cancer must be differentiated from hepatocellular carcinoma liver hemangioma, Liver abscess, cirrhosis, inflammatory lesions, cholangiocarcinoma, pancreatic carcinoma, Focal nodular hyperplasia.

Natural History, Prognosis, and Complications

Depending on the extent of the tumor at the time of diagnosis, the prognosis may vary. However, the prognosis is generally regarded as poor.

Diagnosis

Diagnostic Study of Choice

There is no single diagnostic study of choice for the diagnosis of gallbladder cancer. According to Nevin’s staging system and TNM staging system of the American Joint Committee on Cancer there are several stages of gallbladder cancer.

History and Symptoms

The majority of patients with early stages of gallbladder cancer are asymptomatic. Symptoms of gallbladder cancer include jaundice, pain, fever, burping and weight loss.

Physical Exam

Patients with gallbladder cancer usually appear asymptomatic. Physical examination of patients with gallbladder cancer is usually remarkable for nonspecific symptoms that are due to cholelithiasis or cholecystitis. The preoperative diagnosis rate for gallbladder cancer was only 10 to 15 percent.

Laboratory Findings

There are some diagnostic laboratory findings associated with gallbladder cancer, such as alkaline phosphatase, serum bilirubin, carcinoembryonic antigen (CEA), CA 19-9.

Electrocardiogram

There are no electrocardiogram findings associated with gallbladder cancer.

CT scan

CT scan may be helpful in the diagnosis of gallbladder cancer. Findings on CT scan suggestive of gallbladder cancer include invasion of liver and lymphadenopathy, polyps, and mass replacing gallbladder.

MRI

The combination of MRI (magnetic resonance imaging) with MRA (magnetic resonance angiography) is particularly useful in diagnosing the following: Involvement of biliary tract, vascular invasion, involvement of liver, and involvement of lymph nodes.

Ultrasound

According to the NCCN guidelines, screening for gallbladder cancer patients is recommended with endoscopic ultrasonography (EUS).

Other Imaging Findings

Given the rate of high incidence of metastases in gallbladder cancer, FDG(fluorodeoxyglucose), PET(positron emission tomography) scan is particularly useful in identifying metastases. PET scan is useful in diagnosing abnormal lesions and detecting residual disease after cholecystectomy. PET scan has the ability to detect occult metastasis in patients with potentially resectable tumors and changes the management in almost 25% of the patients. Percutaneous transhepatic cholecystoscopy and Percutaneous transhepatic fine needle aspiration are helpful in the evaluation of gallbladder polyps.

Treatment

Medical Therapy

Gallbladder cancer (GBC) is a rare but highly fatal malignancy. The therapy for gallbladder cancer depends largely on the disease progression and the stage of cancer at the time of diagnosis. Palliative therapy in gallbladder cancer involves percutaneous transhepatic radiologic catheter bypass or endoscopically placed stents, standard external-beam radiation therapy, palliative surgery or standard chemotherapy.

Surgical Therapy

Surgery is the only mainstay of treatment for gallbladder cancer. Complete surgical tumour resection is the only curative treatment for the gallbladder cancer.Radicalcholecystectomy and extended radical cholecystectomy are the surgery of choice for gallbladder cancer.

Primary Prevention

Effective measures for the primary prevention of gallbladder cancer include diet, exercise and maintenance of weight.

Secondary Prevention

There are no established measures for the secondary prevention of gallbladder cancer.

References


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Classification

Classification

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Vamsikrishna Gunnam M.B.B.S [2]

Overview

Gallbladder cancer may be classified according to WHO into various subtypes like adenocarcinoma, papillary adenocarcinoma, mucinous adenocarcinoma, signet ring cell carcinoma, adenosquamous carcinoma, squamous cell carcinoma, neuroendocrine carcinoma, small cell carcinoma, undifferentiated carcinoma, spindle cell undifferentiated carcinoma, giant cell undifferentiated carcinoma.

Classification

Gallbladder carcinoma may be classified according to histology into following subtypes.[1]

SUBTYPE HISTOLOGICAL FEATURES
Adenocarcinoma Sheets, cohesive fragments, acini, and mucin
Papillary adenocarcinoma Pleomorphism and papillary fragments with vascular core
Mucinous adenocarcinoma Single cells or cluster and extracellular mucin
Signet ring cell carcinoma Intracellular mucin with signet ring cells
Adenosquamous carcinoma Mixture of glandular and squamous components
Squamous cell carcinoma Necrosis, tadpole cells and atypical keratinized cells
Neuroendocrine carcinoma Salt and pepper chromatin,anisonucleosis and rosettes
Small cell carcinoma Absent cytoplasm, Smudge cells, and mitoses
Undifferentiated carcinoma Pleomorphic cells, abundant necrosis
Spindle cell undifferentiated carcinoma Undifferciated type with prominent spindle cells
Gaint cell undifferentiated carcinoma Undifferentiated type with predominant giant cells

References

  1. ↑ Jain, Deepali; Mathur, SandeepR; Sharma, Atul; Yadav, Rajni; Iyer, VenkateswaranK (2013). “Gallbladder carcinoma: An attempt of WHO histological classification on fine needle aspiration material”. CytoJournal. 10 (1): 12. doi:10.4103/1742-6413.113627. ISSN 1742-6413.


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Historical Perspective

Historical Perspective

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Vamsikrishna Gunnam M.B.B.S [2]

Overview

In 1777 Maxmillan de Stol described the gallbladder cancer and since studies have established in the identification of the disease and ineffective treatment of this disease.Gallbladder cancer(GBC) are often clinically asymptomatic and an surprising finding at incision, most commonly detected incidentally on histological examination.GBC is characterised by local invasion, intensive regional lymphoid tissue metastasis and distant metastases. In general, GBC is that the most aggressive of the biliary cancers with the shortest median survival period.

Historical Perspective

Discovery

References

  1. ↑ Puia IC, Vlad L, Iancu C, Al-Hajjar N, Pop F, Bălă O, Munteanu D (2005). “[Laparoscopic cholecystectomy for porcelain gallbladder]”. Chirurgia (Bucur) (in Romanian). 100 (2): 187–9. PMID 15957463.
  2. ↑ Stephen AE, Berger DL (2001). “Carcinoma in the porcelain gallbladder: a relationship revisited”. Surgery. 129 (6): 699–703. doi:10.1067/msy.2001.113888. PMID 11391368.
  3. ↑ Gómez-López JR, De Andrés-Asenjo B, Ortega-Loubon C (2014). “A porcelain gallbladder and a rapid tumor dissemination”. Ann Med Surg (Lond). 3 (4): 119–22. doi:10.1016/j.amsu.2014.09.002. PMC 4284441. PMID 25568797.
  4. ↑ Schnelldorfer T (2013). “Porcelain gallbladder: a benign process or concern for malignancy?”. J. Gastrointest. Surg. 17 (6): 1161–8. doi:10.1007/s11605-013-2170-0. PMID 23423431.


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Pathophysiology

Pathophysiology


Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Vamsikrishna Gunnam M.B.B.S [2]

Overview

Gallbladder cancer usually develops in the setting of chronic inflammation of the gallbladder.The most common source of chronic inflammation is cholesterol gallstones. The gallbladder cancer risk increases to 4-5% in the presence gallbladder cancer (GBC) is the result of 2 or more different biological pathways based on morphological, genetic, and molecular evidence. Metaplasia is believed to be one of the pathological reason behind the development of gallbladder carcinoma. Although the definite relationship between metaplasia and dysplasia, is not clearly established yet. On gross pathology, fibrosis and thickening of the gallbladder are characteristic findings of the gallbladder cancer. On microscopic histopathological analysis, outer portion is often better differentiated than deeper portion are characteristic findings of gallbladder cancer.

Pathophysiology

Pathogenesis

Theory 1:
Theory 2
  • There are also histologic and molecular differences in GBCs related to anomalous pancreaticobiliary duct junction and in the ones related to gallstones, providing further proof that two different pathogenetic pathways are involved.[4]
  • GBC arising in Japan within the setting of an anomalous pancreaticobiliary duct junction is characterized by means of KRAS mutations and relatively late onset of p53 mutations.[5]
  • By means of comparison, as a minimum in Chilean patients with cholelithiasis and chronic cholecystitis, KRAS mutations are uncommon, while p53 mutations rise up early at some stage in multistage pathogenesis.[6][7]
Theory 3
  • Less than 3% of early gallbladder carcinomas have adenomatous remnants, indicating this mechanism has less importance within the carcinogenic pathway.[8]
  • It’s hard to predict which of those will go through malignant transformation.
  • In contrast to properly-established carcinogenic pathways in colorectal most cancers, it remains debated within the literature whether or not or not adenomas are actual precursors of invasive gallbladder carcinomas.
  • Only 1% of cholecystectomy specimens have adenomatous polyps as preneoplastic lesions.

Genetics

Genes involved in the pathogenesis of gallbladder carcinoma include:

Gross Pathology

  • Most of the times associated with gallstones > 3 cm in diameter.
  • Liver spread is usually evident at time of diagnosis.

Microscopic Pathology

Adeno carcinoma of gallbladder
By:CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=507411


References

  1. ↑ 1.0 1.1 Roa I, de Aretxabala X, Araya JC, Roa J (2006). “Preneoplastic lesions in gallbladder cancer”. J Surg Oncol. 93 (8): 615–23. doi:10.1002/jso.20527. PMID 16724345.
  2. ↑ Wistuba II, Sugio K, Hung J, Kishimoto Y, Virmani AK, Roa I, Albores-Saavedra J, Gazdar AF (1995). “Allele-specific mutations involved in the pathogenesis of endemic gallbladder carcinoma in Chile”. Cancer Res. 55 (12): 2511–5. PMID 7780959.
  3. ↑ Hughes NR, Bhathal PS (2013). “Adenocarcinoma of gallbladder: an immunohistochemical profile and comparison with cholangiocarcinoma”. J. Clin. Pathol. 66 (3): 212–7. doi:10.1136/jclinpath-2012-201146. PMID 23268317.
  4. ↑ Solaini L, Sharma A, Watt J, Iosifidou S, Chin Aleong JA, Kocher HM (2014). “Predictive factors for incidental gallbladder dysplasia and carcinoma”. J. Surg. Res. 189 (1): 17–21. doi:10.1016/j.jss.2014.01.064. PMID 24589178.
  5. ↑ Mano H, Roa I, Araya JC, Ohta T, Yoshida K, Araki K, Kinebuchi H, Ishizu T, Nakadaira H, Endoh K, Yamamoto M, Watanabe H (1996). “Comparison of mutagenic activity of bile between Chilean and Japanese female patients having cholelithiasis”. Mutat. Res. 371 (1–2): 73–7. PMID 8950352.
  6. ↑ Hanada K, Tsuchida A, Iwao T, Eguchi N, Sasaki T, Morinaka K, Matsubara K, Kawasaki Y, Yamamoto S, Kajiyama G (1999). “Gene mutations of K-ras in gallbladder mucosae and gallbladder carcinoma with an anomalous junction of the pancreaticobiliary duct”. Am. J. Gastroenterol. 94 (6): 1638–42. doi:10.1111/j.1572-0241.1999.01155.x. PMID 10364037.
  7. ↑ Hidaka E, Yanagisawa A, Seki M, Takano K, Setoguchi T, Kato Y (2000). “High frequency of K-ras mutations in biliary duct carcinomas of cases with a long common channel in the papilla of Vater”. Cancer Res. 60 (3): 522–4. PMID 10676628.
  8. ↑ Kanthan R, Senger JL, Ahmed S, Kanthan SC (2015). “Gallbladder Cancer in the 21st Century”. J Oncol. 2015: 967472. doi:10.1155/2015/967472. PMC 4569807. PMID 26421012.
Causes

Causes

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Vamsikrishna Gunnam M.B.B.S [2]

Overview

Definite cause of the gallbladder cancer is not determined, but several risk factors are involved in this cancer, such as gallstones, gallbladder polyps, infections, and Primary sclerosing cholangitis.

Causes

Common Causes

Common causes of gallbladder cancer may include:[1][2][3]

Less Common Causes

Less common causes of gallbladder cancer include:

Genetic Causes

References

  1. ↑ Strom BL, Soloway RD, Rios-Dalenz JL, Rodriguez-Martinez HA, West SL, Kinman JL, Polansky M, Berlin JA (1995). “Risk factors for gallbladder cancer. An international collaborative case-control study”. Cancer. 76 (10): 1747–56. PMID 8625043.
  2. ↑ Darby SC, Whitley E, Howe GR, Hutchings SJ, Kusiak RA, Lubin JH, Morrison HI, Tirmarche M, Tomásek L, Radford EP (1995). “Radon and cancers other than lung cancer in underground miners: a collaborative analysis of 11 studies”. J. Natl. Cancer Inst. 87 (5): 378–84. PMID 7853419.
  3. ↑ Lazcano-Ponce EC, Miquel JF, Muñoz N, Herrero R, Ferrecio C, Wistuba II, Alonso de Ruiz P, Aristi Urista G, Nervi F (2001). “Epidemiology and molecular pathology of gallbladder cancer”. CA Cancer J Clin. 51 (6): 349–64. PMID 11760569.
  4. ↑ Mano H, Roa I, Araya JC, Ohta T, Yoshida K, Araki K, Kinebuchi H, Ishizu T, Nakadaira H, Endoh K, Yamamoto M, Watanabe H (1996). “Comparison of mutagenic activity of bile between Chilean and Japanese female patients having cholelithiasis”. Mutat. Res. 371 (1–2): 73–7. PMID 8950352.
  5. ↑ Hidaka E, Yanagisawa A, Seki M, Takano K, Setoguchi T, Kato Y (2000). “High frequency of K-ras mutations in biliary duct carcinomas of cases with a long common channel in the papilla of Vater”. Cancer Res. 60 (3): 522–4. PMID 10676628.


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Epidemiology and Demographics

Epidemiology and Demographics

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Vamsikrishna Gunnam M.B.B.S [2]

Overview

Around 80 t0 95% of biliary tract cancers are gallbladder cancers. Epidemiological research has recognized striking geographic and ethnic difference. An excessive incidence in American Indians and Southeast Asia, but pretty low in the America and the arena.

Epidemiology and Demographics

Incidence

Prevalence

Case-fatality rate/Mortality rate

Age

Gender

Race

  • Gallbladder cancer usually affects individuals of  Chile, Bolivia, Ecuador, India, Pakistan, Japan, and Korea more than the rest of the world.[9]

References

  1. ↑ Sampliner RE, Bennett PH, Comess LJ, Rose FA, Burch TA (1970). “Gallbladder disease in pima indians. Demonstration of high prevalence and early onset by cholecystography”. N Engl J Med. 283 (25): 1358–64. doi:10.1056/NEJM197012172832502. PMID 5481754.
  2. ↑ Miquel JF, Covarrubias C, Villaroel L, Mingrone G, Greco AV, Puglielli L, Carvallo P, Marshall G, Del Pino G, Nervi F (1998). “Genetic epidemiology of cholesterol cholelithiasis among Chilean Hispanics, Amerindians, and Maoris”. Gastroenterology. 115 (4): 937–46. PMID 9753497.
  3. ↑ Miquel JF, Covarrubias C, Villaroel L, Mingrone G, Greco AV, Puglielli L, Carvallo P, Marshall G, Del Pino G, Nervi F (1998). “Genetic epidemiology of cholesterol cholelithiasis among Chilean Hispanics, Amerindians, and Maoris”. Gastroenterology. 115 (4): 937–46. PMID 9753497.
  4. ↑ Stinton LM, Shaffer EA (2012). “Epidemiology of gallbladder disease: cholelithiasis and cancer”. Gut Liver. 6 (2): 172–87. doi:10.5009/gnl.2012.6.2.172. PMC 3343155. PMID 22570746.
  5. ↑ Stinton LM, Shaffer EA (2012). “Epidemiology of gallbladder disease: cholelithiasis and cancer”. Gut Liver. 6 (2): 172–87. doi:10.5009/gnl.2012.6.2.172. PMC 3343155. PMID 22570746.
  6. ↑ Lazcano-Ponce EC, Miquel JF, Muñoz N, Herrero R, Ferrecio C, Wistuba II, Alonso de Ruiz P, Aristi Urista G, Nervi F (2001). “Epidemiology and molecular pathology of gallbladder cancer”. CA Cancer J Clin. 51 (6): 349–64. PMID 11760569.
  7. ↑ Lazcano-Ponce EC, Miquel JF, Muñoz N, Herrero R, Ferrecio C, Wistuba II, Alonso de Ruiz P, Aristi Urista G, Nervi F (2001). “Epidemiology and molecular pathology of gallbladder cancer”. CA Cancer J Clin. 51 (6): 349–64. PMID 11760569.
  8. ↑ Hundal R, Shaffer EA (2014). “Gallbladder cancer: epidemiology and outcome”. Clin Epidemiol. 6: 99–109. doi:10.2147/CLEP.S37357. PMC 3952897. PMID 24634588.
  9. ↑ Strom BL, Soloway RD, Rios-Dalenz JL, Rodriguez-Martinez HA, West SL, Kinman JL, Polansky M, Berlin JA (1995). “Risk factors for gallbladder cancer. An international collaborative case-control study”. Cancer. 76 (10): 1747–56. PMID 8625043.


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Risk Factors

Risk Factors

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Vamsikrishna Gunnam M.B.B.S [2]

Overview

Around 80 t0 95% of biliary tract cancers are gallbladder cancers. Epidemiological research has recognized striking geographic and ethnic difference. An excessive incidence in American Indians and Southeast Asia, but pretty low in the America and the arena.

Epidemiology and Demographics

Incidence

Prevalence

Case-fatality rate/Mortality rate

Age

Gender

Race

  • Gallbladder cancer usually affects individuals of  Chile, Bolivia, Ecuador, India, Pakistan, Japan, and Korea more than the rest of the world.[9]

References

  1. ↑ Sampliner RE, Bennett PH, Comess LJ, Rose FA, Burch TA (1970). “Gallbladder disease in pima indians. Demonstration of high prevalence and early onset by cholecystography”. N Engl J Med. 283 (25): 1358–64. doi:10.1056/NEJM197012172832502. PMID 5481754.
  2. ↑ Miquel JF, Covarrubias C, Villaroel L, Mingrone G, Greco AV, Puglielli L, Carvallo P, Marshall G, Del Pino G, Nervi F (1998). “Genetic epidemiology of cholesterol cholelithiasis among Chilean Hispanics, Amerindians, and Maoris”. Gastroenterology. 115 (4): 937–46. PMID 9753497.
  3. ↑ Miquel JF, Covarrubias C, Villaroel L, Mingrone G, Greco AV, Puglielli L, Carvallo P, Marshall G, Del Pino G, Nervi F (1998). “Genetic epidemiology of cholesterol cholelithiasis among Chilean Hispanics, Amerindians, and Maoris”. Gastroenterology. 115 (4): 937–46. PMID 9753497.
  4. ↑ Stinton LM, Shaffer EA (2012). “Epidemiology of gallbladder disease: cholelithiasis and cancer”. Gut Liver. 6 (2): 172–87. doi:10.5009/gnl.2012.6.2.172. PMC 3343155. PMID 22570746.
  5. ↑ Stinton LM, Shaffer EA (2012). “Epidemiology of gallbladder disease: cholelithiasis and cancer”. Gut Liver. 6 (2): 172–87. doi:10.5009/gnl.2012.6.2.172. PMC 3343155. PMID 22570746.
  6. ↑ Lazcano-Ponce EC, Miquel JF, Muñoz N, Herrero R, Ferrecio C, Wistuba II, Alonso de Ruiz P, Aristi Urista G, Nervi F (2001). “Epidemiology and molecular pathology of gallbladder cancer”. CA Cancer J Clin. 51 (6): 349–64. PMID 11760569.
  7. ↑ Lazcano-Ponce EC, Miquel JF, Muñoz N, Herrero R, Ferrecio C, Wistuba II, Alonso de Ruiz P, Aristi Urista G, Nervi F (2001). “Epidemiology and molecular pathology of gallbladder cancer”. CA Cancer J Clin. 51 (6): 349–64. PMID 11760569.
  8. ↑ Hundal R, Shaffer EA (2014). “Gallbladder cancer: epidemiology and outcome”. Clin Epidemiol. 6: 99–109. doi:10.2147/CLEP.S37357. PMC 3952897. PMID 24634588.
  9. ↑ Strom BL, Soloway RD, Rios-Dalenz JL, Rodriguez-Martinez HA, West SL, Kinman JL, Polansky M, Berlin JA (1995). “Risk factors for gallbladder cancer. An international collaborative case-control study”. Cancer. 76 (10): 1747–56. PMID 8625043.


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Screening

Screening

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Vamsikrishna Gunnam M.B.B.S [2]

Overview

According to the National Comprehensive Cancer Network (NCCN) guidelines, gallbladder cancer may be diagnosed as an incidental finding in patients who undergo laparoscopic cholecystectomy.

Screening

References

  1. ↑ Inui K, Yoshino J, Miyoshi H (2011). “Diagnosis of gallbladder tumors”. Intern. Med. 50 (11): 1133–6. PMID 21628925.


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Differentiating Gallbladder cancer from other Diseases

Differentiating Gallbladder cancer from other Diseases

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Vamsikrishna Gunnam M.B.B.S [2]

Overview

Gallbladder cancer must be differentiated from hepatocellular carcinoma liver hemangioma, Liver abscess, cirrhosis, inflammatory lesions, cholangiocarcinoma, pancreatic carcinoma, focal nodular hyperplasia.

Differentiatiating Gallbladder cancer from other Diseases

Gallbladder cancer must be differentiated from other diseases that causes right upper quadrant pain include followings:[1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21]

Disease Clinical manifestations Diagnosis Comments
Symptoms Signs
Abdominal Pain Fever Rigors and chills Nausea or vomiting Jaundice Constipation Diarrhea Weight loss GI bleeding Hypo-

tension

Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging
Hepatocellular carcinoma/Metastasis RUQ + − − + − − + − − − −
  • Normal
  • Hyperactive if obstruction present
  • US
  • CT
  • Liver biopsy

Other symptoms:

Cholangiocarcinoma Epigastric − − ± ± − + + − − − − N
  • Increased amylase / lipase
  • Increased stool fat content
  • Pancreatic function test
 CT scan
  • Calcification
  • Pseudocyst
  • Dilation of main pancreatic duct
  • Predisposes to pancreatic cancer
Pancreatic carcinoma Epigastric − − + + − + + − − − − N

Skin manifestations may include:

Focal nodular hyperplasia Diffuse ± − − ± − + + + − − − Normal or hyperactive

Extra intestinal findings:

Disease Abdominal Pain Fever Rigors and chills Nausea or vomiting Jaundice Constipation Diarrhea Weight loss GI bleeding Hypo-

tension

Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging Comments
Gallbladder cancer Diffuse ± − − ± − + + − ± − − N Endoscopy is used to confirm diagnosis.

Images used to find complications

Extra intestinal findings:
Liver hemangioma RUQ + − + + − Positive in Hep A and E + − Positive in fulminant hepatitis Positive in acute + N
  • Abnormal LFTs
  • Viral serology
  • US
  • Hep A and E have fecal-oral route of transmission
  • Hep B and C transmits via blood transfusion and sexual contact.
Liver abscess RUQ + + + + − ± + − + + ± Normal or hypoactive
  • US
  • CT
Cirrhosis RUQ − − − + − − + + + − − N US
  • Stigmata of liver disease
  • Cruveilhier- Baumgarten murmur
Inflammatory lesions RUQ − − − + − − + + + − − N US
  • Stigmata of liver disease
  • Cruveilhier- Baumgarten murmur

Abbreviations:RUQ= Right upper quadrant of the abdomen, LUQ= Left upper quadrant, LLQ= Left lower quadrant, RLQ= Right lower quadrant, LFT= Liver function test, SIRS= Systemic inflammatory response syndrome, ERCP= Endoscopic retrograde cholangiopancreatography, IV= Intravenous, N= Normal, AMA= Anti mitochondrial antibodies, LDH= Lactate dehydrogenase, GI= Gastrointestinal, CXR= Chest X ray, IgA= Immunoglobulin A, IgG= Immunoglobulin G, IgM= Immunoglobulin M, CT= Computed tomography, PMN= Polymorphonuclear cells, ESR= Erythrocyte sedimentation rate, CRP= C-reactive protein, TS= Transferrin saturation, SF= Serum Ferritin, SMA= Superior mesenteric artery, SMV= Superior mesenteric vein, ECG= Electrocardiogram

References

  1. ↑ Kim TK, Lee E, Jang HJ (2015). “Imaging findings of mimickers of hepatocellular carcinoma”. Clin Mol Hepatol. 21 (4): 326–43. doi:10.3350/cmh.2015.21.4.326. PMC 4712159. PMID 26770920.
  2. ↑ Ferrell, Linda (2000). “Liver Pathology: Cirrhosis, Hepatitis and Primary Liver Tumors. Update and Diagnostic Problems”. Modern Pathology. 13 (6): 679–704. doi:10.1038/modpathol.3880119. ISSN 0893-3952.
  3. ↑ Kim, Tae Kyoung; Lee, Eunchae; Jang, Hyun-Jung (2015). “Imaging findings of mimickers of hepatocellular carcinoma”. Clinical and Molecular Hepatology. 21 (4): 326. doi:10.3350/cmh.2015.21.4.326. ISSN 2287-2728.
  4. ↑ Kim, Tae Kyoung; Lee, Eunchae; Jang, Hyun-Jung (2015). “Imaging findings of mimickers of hepatocellular carcinoma”. Clinical and Molecular Hepatology. 21 (4): 326. doi:10.3350/cmh.2015.21.4.326. ISSN 2287-2728.
  5. ↑ Alturkistany, Samira; Jang, Hyun-Jung; Yu, Hojun; Lee, Kyoung Ho; Kim, Tae Kyoung (2011). “Fading hepatic hemangiomas on multiphasic CT”. Abdominal Radiology. 37 (5): 775–780. doi:10.1007/s00261-011-9826-6. ISSN 2366-004X.
  6. ↑ Heiken, Jay P. (2007). “Distinguishing benign from malignant liver tumours”. Cancer Imaging. 7 (Special Issue A): S1–S14. doi:10.1102/1470-7330.2007.9084. ISSN 1470-7330.
  7. ↑ Tamada T, Ito K, Yamamoto A, Sone T, Kanki A, Tanaka F, Higashi H (2011). “Hepatic hemangiomas: evaluation of enhancement patterns at dynamic MRI with gadoxetate disodium”. AJR Am J Roentgenol. 196 (4): 824–30. doi:10.2214/AJR.10.5113. PMID 21427331.
  8. ↑ Bhayana, Deepak; Kim, Tae Kyoung; Jang, Hyun-Jung; Burns, Peter N.; Wilson, Stephanie R. (2010). “Hypervascular Liver Masses on Contrast-Enhanced Ultrasound: The Importance of Washout”. American Journal of Roentgenology. 194 (4): 977–983. doi:10.2214/AJR.09.3375. ISSN 0361-803X.
  9. ↑ Bhayana, Deepak; Kim, Tae Kyoung; Jang, Hyun-Jung; Burns, Peter N.; Wilson, Stephanie R. (2010). “Hypervascular Liver Masses on Contrast-Enhanced Ultrasound: The Importance of Washout”. American Journal of Roentgenology. 194 (4): 977–983. doi:10.2214/AJR.09.3375. ISSN 0361-803X.
  10. ↑ Kim, Tae Kyoung; Lee, Kyoung Ho; Jang, Hyun–Jung; Haider, Masoom A.; Jacks, Lindsay M.; Menezes, Ravi J.; Park, Seong Ho; Yazdi, Leyla; Sherman, Morris; Khalili, Korosh (2011). “Analysis of Gadobenate Dimeglumine–enhanced MR Findings for Characterizing Small (1–2-cm) Hepatic Nodules in Patients at High Risk for Hepatocellular Carcinoma”. Radiology. 259 (3): 730–738. doi:10.1148/radiol.11101549. ISSN 0033-8419.
  11. ↑ Kim JH, Kim TK, Kim BS, Eun HW, Kim PN, Lee MG, Ha HK (2002). “Enhancement of hepatic hemangiomas with levovist on coded harmonic angiographic ultrasonography”. J Ultrasound Med. 21 (2): 141–8. PMID 11833870.
  12. ↑ Brannigan, Margot; Burns, Peter N.; Wilson, Stephanie R. (2004). “Blood Flow Patterns in Focal Liver Lesions at Microbubble-enhanced US”. RadioGraphics. 24 (4): 921–935. doi:10.1148/rg.244035158. ISSN 0271-5333.
  13. ↑ Menias, Christine O.; Surabhi, Venkateswar R.; Prasad, Srinivasa R.; Wang, Hanlin L.; Narra, Vamsi R.; Chintapalli, Kedar N. (2008). “Mimics of Cholangiocarcinoma: Spectrum of Disease”. RadioGraphics. 28 (4): 1115–1129. doi:10.1148/rg.284075148. ISSN 0271-5333.
  14. ↑ Syed MA, Kim TK, Jang HJ (2007). “Portal and hepatic vein thrombosis in liver abscess: CT findings”. Eur J Radiol. 61 (3): 513–9. doi:10.1016/j.ejrad.2006.11.022. PMID 17161932.
  15. ↑ Kim TK, Jang HJ, Wilson SR (2006). “Benign liver masses: imaging with microbubble contrast agents”. Ultrasound Q. 22 (1): 31–9. PMID 16641791.
  16. ↑ Kim, Kyoung Won; Choi, Byung Ihn; Park, Seong Ho; Kim, Ah Young; Koh, Young Hwan; Lee, Hyun Ju; Han, Joon Koo (2004). “Pyogenic hepatic abscesses: distinctive features from hypovascular hepatic malignancies on contrast-enhanced ultrasound with SH U 508A; early experience”. Ultrasound in Medicine & Biology. 30 (6): 725–733. doi:10.1016/j.ultrasmedbio.2004.03.006. ISSN 0301-5629.
  17. ↑ Liu GJ, Lu MD, Xie XY, Xu HX, Xu ZF, Zheng YL, Liang JY, Wang W (2008). “Real-time contrast-enhanced ultrasound imaging of infected focal liver lesions”. J Ultrasound Med. 27 (4): 657–66. PMID 18359914.
  18. ↑ Wilson, Stephanie R.; Kim, Tae Kyoung; Jang, Hyun-Jung; Burns, Peter N. (2007). “Enhancement Patterns of Focal Liver Masses: Discordance Between Contrast-Enhanced Sonography and Contrast-Enhanced CT and MRI”. American Journal of Roentgenology. 189 (1): W7–W12. doi:10.2214/AJR.06.1060. ISSN 0361-803X.
  19. ↑ Guo, Le-Hang; Xu, Hui-Xiong (2015). “Contrast-Enhanced Ultrasound in the Diagnosis of Hepatocellular Carcinoma and Intrahepatic Cholangiocarcinoma: Controversy over the ASSLD Guideline”. BioMed Research International. 2015: 1–5. doi:10.1155/2015/349172. ISSN 2314-6133.
  20. ↑ Choi BI, Kim TK, Han JK (1998). “MRI of clonorchiasis and cholangiocarcinoma”. J Magn Reson Imaging. 8 (2): 359–66. PMID 9562062.
  21. ↑ Kim, T K; Choi, B I; Han, J K; Jang, H J; Cho, S G; Han, M C (1997). “Peripheral cholangiocarcinoma of the liver: two-phase spiral CT findings”. Radiology. 204 (2): 539–543. doi:10.1148/radiology.204.2.9240550. ISSN 0033-8419.


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Natural History, Complications and Prognosis

Natural History, Complications and Prognosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Vamsikrishna Gunnam M.B.B.S [2]

Overview

Depending on the extent of the tumor at the time of diagnosis, the prognosis may vary. However, the prognosis is generally regarded as poor.

Natural History, Complications, and Prognosis

Natural History

Complications

Prognosis

  • Gallbladder cancer has an overall 5-year survival rate less than 5%.
  • Advances in perioperative care has markedly improved outcomes.[1]
  • Recent Improvements in surgical techniques have resulted in a decline of both morbidity and mortality of the gallbladder cancer prognosis.
  • 5-year survival rate is seen in patients who undergo R0 curative resection.[2][3]
  • Only 2–8 months survival rate has been noticed by French Surgical Association with T3/T4 tumours.
  • Identified independent predictors such as age, tumour grade,T1 subtype, tumour histology, radiation, and surgery type.
  • The prognosis is not good for most gallbladder cancer patients if the cancer is detected in its late stages. [4]
  • Among all the histological types papillary carcinomas are having one of the best prognosis.[5]
  • Intramural invasion is seen in adenocarcinomas and are associated with worst prognosis, whether or not the tumor can be removed by surgery.[6]
  • The prognosis of the cancer also can depends on the following factors:

References

  1. ↑ Lai CH, Lau WY (2008). “Gallbladder cancer–a comprehensive review”. Surgeon. 6 (2): 101–10. PMID 18488776.
  2. ↑ Murakami Y, Uemura K, Sudo T, Hashimoto Y, Nakashima A, Kondo N, Sakabe R, Kobayashi H, Sueda T (2011). “Prognostic factors of patients with advanced gallbladder carcinoma following aggressive surgical resection”. J. Gastrointest. Surg. 15 (6): 1007–16. doi:10.1007/s11605-011-1479-9. PMID 21547707.
  3. ↑ D’Hondt M, Lapointe R, Benamira Z, Pottel H, Plasse M, Letourneau R, Roy A, Dagenais M, Vandenbroucke-Menu F (2013). “Carcinoma of the gallbladder: patterns of presentation, prognostic factors and survival rate. An 11-year single centre experience”. Eur J Surg Oncol. 39 (6): 548–53. doi:10.1016/j.ejso.2013.02.010. PMID 23522952.
  4. ↑ Kanthan R, Senger JL, Ahmed S, Kanthan SC (2015). “Gallbladder Cancer in the 21st Century”. J Oncol. 2015: 967472. doi:10.1155/2015/967472. PMC 4569807. PMID 26421012.
  5. ↑ Henson DE, Albores-Saavedra J, Corle D (1992). “Carcinoma of the gallbladder. Histologic types, stage of disease, grade, and survival rates”. Cancer. 70 (6): 1493–7. PMID 1516000.
  6. ↑ Kanthan R, Senger JL, Ahmed S, Kanthan SC (2015). “Gallbladder Cancer in the 21st Century”. J Oncol. 2015: 967472. doi:10.1155/2015/967472. PMC 4569807. PMID 26421012.


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Diagnosis

Diagnosis

Diagnostic Study if choice | History and Symptoms | Physical Examination | Laboratory Findings | CT | MRI | Ultrasound | Other Imaging Findings | Other Diagnostic Studies

Treatment

Treatment

Medical Therapy | Surgery | Palliative Treatment | Primary Prevention | Secondary Prevention | Cost-Effectiveness of Therapy | Future or Investigational Therapies

Case Studies

Case Studies

Case#1

External Links

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