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Gall Bladder Cancer

How common is the problem? Who is more likely to be affected?

Gallbladder cancer is very uncommon. Women are more likely to have gall bladder cancer than men. The risk increases with increasing age. It is more common in patients who have stones in the gall bladder, the risk being about 1%. Other diseases of the gall bladder, such as, porcelain (calcified) gallbladder, choledochal (bile duct) cyst and chronic gallbladder infection also increase the risk of gall bladder cancer.

Why does it happen? How does it spread? What are the stages of gall bladder cancer?

It's not clear what causes gallbladder cancer. Most gallbladder cancer begins in the cells that line the inner surface of the gallbladder and is called as adenocarcinoma. Gall bladder cancer tends to spread to nearby organs and tissues such as the liver, bile ducts or small intestine. It also spreads to lymph nodes in the region of the liver. Ultimately, distant organs and lymph nodes can become involved.


The stages of gallbladder cancer are:

Stage I. At this stage, gallbladder cancer is confined to the inner layers of the gallbladder.

Stage II. This stage of gallbladder cancer has grown to invade the outer layer of the gallbladder and may protrude into nearby organs, such as the liver, stomach, intestines or pancreas. This stage of cancer may also include less extensive tumors that have spread to nearby lymph nodes.

Stage III. At this stage, gallbladder cancer has grown to invade more than one of the nearby organs, or it may invade the portal vein or hepatic artery.

Stage IV. The latest stage of gallbladder cancer includes tumors of any size that have spread to distant areas of the body.


What are the signs and symptoms of gall bladder cancer?

Gallbladder cancer is difficult to diagnose because it often causes no signs or symptoms. When present, the symptoms may be non-specific and similar to many other chronic diseases. The relatively hidden nature of the gallbladder probably makes it easier for gallbladder cancer to grow without being detected.

Jaundice (yellowing of the skin and whites of the eyes), itching, bloating, abdominal pain, weight loss, decreasing appetite, fever, nausea & vomiting or an enlarging abdominal mass are all signs that may be attributable to gall bladder cancer. Frequently, jaundice is a late development and the other symptoms have been present for a long time.


Sometimes, it is detected incidentally on the biopsy after cholecystectomy (gallbladder removal operation) for gallstone disease. When diagnosed in this situation, it is generally at a very early stage and the chance for cure is very good.


Which tests are required to diagnose / evaluate this disease?

Very commonly blood tests such as liver function tests are normal in gall bladder cancer. If the tumor causes obstruction of the biliary tract, bilirubin, some liver enzymes (alkaline phosphatase and GGTP) may be raised.

Cancer of the gallbladder produces a tumor marker called carbohydrate antigen 19-9 (CA 19-9), which, if very high helps in the diagnosis of gallbladder cancer


Ultrasound abdomen can detect the tumor and determine the extent of its spread. Involvement of adjoining organs may be indicated by dilatation of the gallbladder or bile ducts.


CT scan (triple phase contrast enhanced) is very useful not only diagnose the tumor, but also determine the extent of involvement of adjacent or distant organs and lymph nodes in the abdomen. It can also be used to visualize the bile ducts, surrounding blood vessels and determine their involvement with the tumor.


Contrast enhanced magnetic resonance imaging (MRI) with MRCP and MR angiogram may be used instead of CT scan to diagnose and determine the stage of the disease.


A biopsy using ultrasound or CT as a guide may be performed only when the diagnosis is doubtful.


Diagnostic laparoscopy (keyhole surgery of the abdomen) may be performed when the extent of the disease (stage of disease) is not very clear on the pre-operative tests or before undertaking any planned major surgery, to be sure about resectability of the tumor (that the tumor has not spread far and wide)


Information from the above tests allows the doctor to determine stage of the disease, plan appropriate treatment and estimate expected outcome.


What is the best treatment for gall bladder cancer?

The only hope of cure lies in surgical removal of the tumor and all involved structures. Unfortunately, in many of the patients the cancer has usually spread too far when the diagnosis is made. When curative treatment is not possible, other therapies may help control the spread of the disease and keep one as comfortable as possible.


Treatment options for gallbladder cancer largely depends on cancer stage at the time of diagnosis and ones overall health.


Surgery:


Radiation may improve survival in patients with residual disease after surgery; however, the use of radiation in the treatment of gallbladder cancer requires further studies. Chemotherapy is not very effective, but may be given in combination with radiation.


In patients with advanced cancer of the gall bladder, the focus of therapy is to improve the quality of remaining life (palliative treatment). Jaundice and blockage of the stomach are common problems faced by patients with extensive disease. These problems can be relieved by putting stents across the blockages, either through endoscopy by the gastroenterologist or by a radiologist. Sometimes, surgery may be required for palliation.

What is the expected prognosis (outlook) after various treatments?

The prognosis depends on the stage and resectability (operatibility) of the tumor. Majority of patients with early stage 1 disease have excellent prognosis whereas those with more advanced stages have considerably worse outcomes. Since most patients are diagnosed with late-stage disease, less than 5% of all patients live longer than 5 years after diagnosis.