Gallbladder cancer
The gallbladder and biliary system
The Gallbladder
The gallbladder is a pear-shaped organ located just below your liver and behind the right lower ribs. It stores bile, concentrates it and releases it when we eat. Bile is a digestive juice produced by the liver. The gallbladder is connected to the liver and intestine through a thin tube called the common bile duct.
Cancer
Cancer forms when healthy cells develop changes (mutations) in their DNA. These cells begin to grow uncontrolled, don’t die and forms a growing clump called tumour or cancer. Gallbladder cancer begins in the inner layers of the gallbladder. It gradually grows beyond the gallbladder wall and spreads to the liver, bile duct, adjacent lymph nodes and other areas of the body.
Gallbladder cancer is one of the most aggressive cancers of the gastrointestinal tract. India has the highest rate of occurrence of this disease in the world and women are three times more likely to develop gallbladder cancer compared to men.
Risk factors for gall bladder cancer
Risk factors are characteristics which increase the chance of someone developing a disease. The factors which increase the chance of someone developing gallbladder cancer are:
- Gallbladder stones
- Congenital abnormalities of the bile duct such as choledochal cyst
- Biliary-enteric fistula
- Chronic typhoid infection
- Calcified gallbladder wall (porcelain gallbladder)
- Obesity
- Female sex
- Gallbladder polyps
- Primary sclerosing cholangitis
Signs and symptoms of gallbladder cancer
Gallbladder cancer can be asymptomatic in the early stages. Sometimes it is detected while doing routine surgery for gall stones or reported in the final biopsy of the gallbladder removed for stone disease. It is sometimes detected on routine ultrasound of the abdomen, or, when an ultrasound is done for unrelated diseases. When it presents with signs and symptoms, they could be:
- Abdominal pain
- Unexplained weight loss
- Loss of appetite
- Jaundice (yellow eyes, skin and urine)
- Itching
- Nausea and vomiting
- Lump in the abdomen
Diagnosis and Staging (determining the extent of disease)
Diagnosis means identifying a disease. Following tests will help us make the diagnosis and stage the disease.
Physical history and examination: Understanding symptoms and checking for signs by a physician are basics of arriving at a diagnosis.
Blood tests:Complete blood count measures the distinct cells in the blood. Besides, liver and kidney function tests assess the function of these organs.Some patients will have jaundice due to cancer blocking the bile duct. We also check for tumour marker CA 19.9
Computed tomography (CT) scan: CT Scanner acquires images of the inside of our body with the help of x-ray beams. These images are then computer-processed, giving an accurate representation. Contrast injected into the blood enhances these images. A CT scan will show us the tumour and its extent.
Magnetic resonance imaging (MRI): Instead of x-rays, it uses radio waves, and strong magnetic fields.
Positron emission tomography (PET) scan: Cancer cells take up a larger amount of glucose. Here injected radioactive glucose (18F-fluorodeoxyglucose; FDG) binds to the tumour, and the patient is scanned. The images are computer-processed and combined with CT images, giving us a CT image with bright coloured tumours.
Biopsy or cytology: Biopsy means sampling a small piece of the tumour and examining it under a microscope. Biopsy of a gallbladder lesion is done under ultrasound or CT guidance. Since many of these tumours are operated on, biopsy or FNAC is routinely not required. However, in advanced tumours biopsy is always done to confirm the diagnosis before starting chemotherapy/radiotherapy.
Following this work-up, a stage will be assigned to the tumour, which spans from I to IV. It is based on three key elements.
- The extent (size) of the tumor (T): How far has cancer grown into the layers of the gallbladder wall? Has cancer reached nearby structures or organs, such as liver?
- The spread to nearby lymph nodes (N): Has cancer spread to nearby lymph nodes? And to how many?
- The spread (metastasis) to distant sites (M): Has cancer spread to distant lymph nodes or distant organs such as the liver or lungs?
- We also look at the relationship of tumour to nearby critical structures such as bile duct and vessels supplying blood to the liver.
Treatment of gallbladder cancer
Treatment of gallbladder cancer depends on the stage in which it is detected. For treatment purpose, it can be grouped into an early-stage or localized disease and late-stage or unresectable/metastatic disease. Treatment modalities include surgery, chemotherapy, immunotherapy and radiotherapy.
Surgery for cancer entails the removal of the diseased organ along with adjacent healthy tissue and lymph nodes. Chemotherapy is the use of special drugs to kill cancer cells and radiotherapy is the use of high-powered X-ray beams to kill cancer cells.
Treatment of early-stage (localized) disease
If detected early in a stage where it has not spread, gall bladder cancer can be treated by surgery. Surgery for gallbladder cancer is called radical cholecystectomy or extended cholecystectomy. It entails the removal of gall bladder along with adequate removal of its liver bed to the healthy tissue. The lymph nodes in the vicinity are also removed. Sometimes removal of a large part of the liver called hepatectomy is required to completely remove the tumor. The bile duct if involved also needs to be removed.
Following surgery chemotherapy or chemotherapy+radiation is administered in an attempt to further increase the survival. Sometimes chemotherapy/chemoradiotherapy is administered before surgery to downstage the disease when surgery cannot be done immediately but is possible after a decrease in the size of the tumor. The cure rates (5-year survival) of patients with this tumor who are operated is 20%-30%.
Treatments for late-stage (unresectable/metastatic) disease
In some patients the disease is detected at an advanced stage. The gallbladder cancer has either spread to other organs or it has engulfed adjacent critical structures and cannot be surgically removed. In such a scenario we can not aim for cure. We can only prolong the life and make it comfortable. If the patient has jaundice then some procedure is needed to open blocked bile ducts. It could be a percutaneous transhepatic biliary drainage (PTBD) or endoscopic retrograde cholangiopancreatography (ERCP), depending on the level of block. Chemotherapy is given to improve survival and quality of life. Also, the patient is given medicines for pain and to control other symptoms of the disease.
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