Gallbladder Cancer

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What Is Gallbladder Cancer?

Gallbladder cancer is cancer that develops from the tissues of the gallbladder. It is rare cancer and may develop secondary to other conditions that affect the gallbladder. It is a rapidly spreading cancer that spreads via the lymphatic and the circulatory system. The gallbladder is an important organ of the body and it stores the bile juice that is produced by the liver and essential for the proper digestion of fats.

Alternate name

  • Gallbladder carcinoma

Is this condition a medical emergency?

Gallbladder cancer is not a medical emergency, however, early detection, and treatment help to prevent morbidity and mortality.

Types of this condition

Gallbladder cancer may be of the following types:

  • Adenocarcinoma -most common
  • Squamous cell carcinoma- a very small percentage

Causes

While the exact cause of gallbladder cancer is not known, it is believed that chronic inflammation of the gallbladder can predispose to the development of cancer. Also, certain genetic abnormalities and factors have been linked to the development of gallbladder cancer. Reflux of pancreatic juices into the bile ducts and gall bladder due to anatomical defects can lead to inflammation of the gallbladder and may lead to cancer.

Risk factors

Some risk factors for the development of gallbladder cancer include:

  • Gall stones, especially large-sized stones can result in obstruction to the outflow of bile and inflammation of the gallbladder.
  • Porcelain gallbladder - It is formed due to the deposits of calcium secondary to gallstones; it is a high risk for the development of gallbladder cancer.
  • Choledochal cysts - Which form along the bile duct can lead to gallbladder cancer
  • Cholecystoenteric fistula
  • Primary sclerosing cholangitis - There are inflammation and scarring of the bile duct
  • Pancreaticobiliary junction defects
  • Chronic infection with salmonella typhi - Due to the involvement of gallbladder in this infection
  • Obesity - As it predisposes to the formation of gallstones
  • Elderly age group
  • Gender-risk is more in women
  • Medications - Such as oral contraceptives, methyldopa
  • Exposure to pesticides, vinyl chloride, rubber, nitrosamines
  • As an occupational risk in textile, paper, petroleum, shoe manufacturing industries
  • Family history of gallbladder cancer

Symptoms & signs

In a majority of cases, gallbladder cancer is discovered when other conditions are being investigated. It is largely asymptomatic.

The symptoms and signs of gallbladder cancer may include the following:

  • Pain in the abdomen on the upper right side
  • Indigestion
  • Bloating of the stomach
  • Loss of appetite
  • Weight loss
  • Jaundice
  • Nausea and vomiting (may contain bile)

Investigations

Some investigations that may be done for gallbladder cancer include:

  • Laboratory tests-
    • CBP and ESR - Anemia is usually seen in advanced disease.
    • Liver function tests - Alkaline phosphatase and bilirubin levels are increased in advanced stages of the disease.
    • Complete metabolic panel.
    • Carcinoembryonic antigen (CEA) test.
    • CA-19-9 marker test.
  • Imaging tests-
    • Abdominal ultrasound
    • Endoscopic ultrasound
    • CT scan - Useful in the identification of metastasis of cancer outside the gallbladder.
  • MRI scan-
    • MR Cholangiopancreatography (MRCP)
    • MR Angiography
    • PET scan
    • Chest x-ray
  • Procedures-
    • Percutaneous CT guided biopsy  - is useful for gaining access to the parts of the bile tract that may be obstructed by the tumorous growth.
    • Endoscopic retrograde cholangiopancreatography (ERCP) - It is useful for identifying the site of obstruction.

Diagnosis

A diagnosis of gallbladder cancer is established based on medical history, clinical evaluation, and the results of the investigations done.

Course & stages

Staging of gallbladder cancer is done as follows:

  • Stage 0 - Abnormal cells are seen within gallbladder tissue, no lymph node involvement, no metastasis.
  • Stage I  - The tumor invades the muscular layer of the gallbladder, no lymph node involvement, no metastasis,
  • Stage II - The tumor invades the connective tissue next to the muscular layer of the gallbladder but no adjacent organ involvement, no lymph node involvement, no metastasis.
  • Stage III - The tumor may be limited to the muscular layer of the gallbladder or it may have invaded the adjacent structures such as the stomach, or duodenum, liver. The regional lymph nodes are involved, with no distant metastasis.
  • Stage IV - The tumor may or may not have invaded the adjacent structures, lymph nodes may or may not be involved, metastasis to distant organs is seen.

Treatment options

The aim of the treatment of gallbladder cancer is prevention, early detection, proper staging, and appropriate intervention.

A. Medical management

Medical management of gallbladder cancer includes the following:

  • Chemotherapy - Usually with a single agent such as 5-fluorouracil; done as either an adjuvant therapy after surgery or as a palliative treatment.

B. Interventional including surgery and indications for surgery

Surgical intervention is required for the management of gallbladder carcinoma although it may be contraindicated in the following circumstances:

  • Presence of distant metastatic disease.
  • T4 tumor with involvement of the hepatic artery, the portal vein, or multiple adjacent structures.

Surgical intervention is usually done as follows:

  • Cholecystectomy - Removal of the gallbladder
  • Laparoscopic cholecystectomy with lymph node dissection with endoscopic ultrasound guidance.
  • Open cholecystectomy
  • Cholecystectomy with partial liver dissection.

Prophylactic surgical intervention may be done in the following individuals:

  • If there is a presence of a porcelain gallbladder even though the individual is asymptomatic as there is a very high risk of developing gallbladder carcinoma.
  • Presence of gallbladder polyps of size greater than 1cm in individuals older than 50 years.

Other interventional procedures that may be done include:

  • Biliary stenting to relieve any obstruction caused by the tumor.
  • Biliary bypass surgeries to allow for the normal flow of the bile juice.

C. Radiation

Radiotherapy for gallbladder cancer may be done either as palliative therapy or as an adjunct to surgical intervention. Radiotherapy may be done as:

  • External beam radiation therapy
    • 3d conformal radiation therapy
    • Intensity-modulated radiation therapy
    • Chemoradiation therapy is combined with chemotherapy.

D. Role of diet/exercise/lifestyle changes/preventive measures

Some measures that may be taken to reduce the risk of this cancer include:

  • Eating a healthy diet.
  • Maintaining an ideal body weight.
  • Exercising and avoiding a sedentary lifestyle.
  • Avoiding skipping meals.

Complications

Some complications that may be seen with gallbladder cancer and its management include:

  • Distant metastasis
  • Malnutrition
  • Multi-organ failure
  • Death

Prognosis

The prognosis of gallbladder cancer is generally poor as most of them are detected in an advanced stage. The survival rate is very poor. Early detection and appropriate surgical intervention, may result in a better prognosis. It has a poor prognosis and long term survival rate in a majority of the individuals as cancer would have already spread to distant organs at the time of diagnosis.

When to contact the doctor or hospital/How to identify the emergency or complications?

It is advisable to seek medical attention if the signs and symptoms of gallbladder carcinoma are noticed.

Indications for hospitalization if required

Hospitalization will be required for the management and treatment of gallbladder carcinoma.

Screening methods

Individuals with gallbladder disease may benefit from some screening procedures at the time of their regular check-ups to help to identify gallbladder carcinoma at an early stage.

Suggested clinical specialist/Departments to consult for this condition

Gallbladder carcinoma will be treated by specialists from the Department of Hepatology and Gastroenterology.

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