1. CANCER GALLBLADDER

2. INCIDENCE
• Increases with age
• 2-6 times common in women
• Common among population in
– Western South America
– Northern India
– North American Indians
– Mexican Americans

3. RISK FACTORS
• Gallstones
• Porcelain gallbladder
• Adenomatous polyps
• Chronic infection with S.typhi
• Carcinogen exposure(miners exposed to
Radon)
• Abnormal PancreaticoBiliary Duct
Junction(APBDJ)

4. APBDJ
• It is more common in Asian countries
• GB cancers with APBDJ
– Tend to occur at an younger age
– Lesser degree of female preponderance
– Asociated less often with cholelithiasis
– High prevalence of K-ras mutations & a late onset
of p-53 mutations
– High prevalence of premalignant epithelial
hyperplasia with a papillary or villous histology.

5. CANCER & CALCULI
• Gallstones are present in 70-90% of patients
diagnosed with GB cancer
• Only 0.5-3% of patients with cholelithiasis will
develop GB cancer
• Risk of GB cancer is increased with increasing
size & duration of cholelithiasis

6. PATHOGENESIS
• Chronic irritation
• Dysplasia-carcinoma in-situ-invasive cancer
• p 53 & K-ras(rare) mutations

7. PATHOLOGY
• 80%-adenocarcinoma
• Others
– Small cell cancer
– Squamous cell cancer
– Lymphoma sarcoma
• Morphologically
– Infiltrative
– Nodular
– Papillary
– Combined pattern
• Staging systems
– Nevin
– TNM

8. CLINICAL PRESENTATION
• Early lesion • Advanced lesion
– Asymptomatic – Weight loss
– Abdomonal pain – Obstructive jaundice
– Anorexia – Duodenal obstruction
– Nausea – Palpable mass
– Vomiting – Hepatomegaly
– ascites

9. INVESTIGATIONS
• Biochemical evidence of obstructive jaundice
• Nonspecific
– Anaemia
– Leucocytosis
– Elevated liver enzymes
– Increased ESR
– Increased CRP
• Tumour markers-CEA/CA 19-9
• USG
• CECT
• MRI/MRCP
• EUS
• ERCP/PTC

10. USG
• Mural thickening
• Mural calcification
• GB mass >1 cm
• Loss of normal GB wall-liver interface
• Gall stones
• Polyps

11. CECT
• Mass protruding into the GB lumen
• Mass completely replacing the GB
• Focal or diffuse thickening of GB wall
• Presence or absence of distant metastasis
• Regional lymph node involvement
• Local invasion into liver & porta hepatis

12. STAGE 0 & 1A
• Carcinoma in situ & T1-cancer that doesnot
extend beyond the GB muscularis
– Simple cholecystectomy

13. STAGE 1B
• T2 lesion- invasion into perimuscular connective
tissue of GB
– Re-exploration revealed residual disease in 40-76%
– Regional lymphnode metastasis in 28-63%
• Exploration with en bloc resection of the GB with
2 cm of adjacent liver(non-anatomoic) with
regional lymphadenectomy of the hepatoduodenal
ligament
• En-bloc resection with anatomic resection of liver
segments 4b & 5

14. STAGE II
• T3 Lesion-locally advanced cancers that
perforate the GB serosa or directly involve the
liver or adjacent organ
• Hepatic resection encompassing segment 4b
& 5 or trisegmentectomy with adjacent organs

15. STAGE III & IV
• Unresectable
• Median survival with unresectable disease is
less than 6 months
• If detected intraoperatively
– Radio-opaque clips
– No data to support debulking cholecystectomy

16. PROGNOSIS
• 5-year survival rate is 5%
• Median survival 12 months(stage IA-III)
• Median survival 5.8 months(stage IV)

17. WHY POOR PROGNOSIS?
• Usually diagnosed at a late stage
• Aggressive nature
• Clinical presentation mimics that of biliary
colic/chronic cholecystitis
• Incidental diagnosis at surgery
• Incidental diagnosis after pathology report

18. SURVIVAL RATE
S.NO STAGE 5 YR.SURVIVAL RATE
1 I 60%
2 II 39%
3 III 15%
4 IV 1%
Median survival 12 months(stage IA-III)
Median survival 5.8 months(stage IV)
NCCN guidelines 2010

19. EXTENT OF LYMPHADENECTOMY