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Epidemiology
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Risk Factors
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Etiology
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'athologic features
Ca gallbladder

Fundus (60%) Body(30%) Neck(10%)

Ca gallbladder

1. Infiltrative 2. Nodular 3. 'apillary 4. Combined form


-Most common type - More distinctive
-polypoid appearance
-causes thickning & - Early invasion
-low invasiveness
induration of gb wall - Easier to control
-much batter prognosis
-difficult to distinguish surgically

from a chronically
inflamed but benign gb
- Tumor to be disseminated
by cholicystectomy
`istopathological classification
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TUMOUR BIOLOGY
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CLINICAL 'RESENTATION
` The symptoms of gallbladder cancer overlap with the symptoms
of gallstones and biliary colic. Abdominal pain may be of a more diffuse
and persistent nature than the classic right upper quadrant pain of
gallstone disease. Jaundice, anorexia, and weight loss often indicate
more advanced disease.
 

‡Jaundice
‡'alpable mass in the right upper quadrant (Courvoisier sign, if this is
due to a palpable gallbladder)
‡'eriumbilical lymphadenopathy (Sister Mary Joseph nodes)
‡Left supraclavicular adenopathy (Virchow node)
‡'elvic seeding: Mass is palpated on digital rectal examination (Blumer
shelf)
INVESTIGATIONS
a  
‡Tumor marker CA 19-9 with 79.4% sensitivity & 79.2% specificity
-CA 19-9 may be significantly elevated in both
cholangiocarcinoma and gallbladder cancer.
-CA 19-9 tests may be helpful in the appropriate situation if the
clinical suspicion for gallbladder cancer is high.
‡Liver function tests: Elevated alkaline phosphatase and bilirubin
levels are often found with more advanced disease.
‡BUN, creatinine, UA: Assess renal function prior to performing an
enhanced CT scan.
‡CBC: Anemia may be an indicator of more advanced disease.
V VV
‡Ultrasonography- is a standard initial study . A mass can be identified in 50-
75% of patients with gallbladder cancer. It also can delineate metastatic
lesions in the liver.
‡Computed tomography- demonstrate tumor invasion outside of the
gallbladder and identify metastatic disease elsewhere in the abdomen or
pelvis. Liver invasion occurs in 60% of cases, and the combination of CT scan
and US provides accurate details of disease extension.
‡Magnetic resonance imaging- useful in examining for disease extension into
other tissues or metastatic disease in the liver. It can provide details of the
vasculature for preoperative planning via magnetic resonance angiogram
(MRA) and bile duct passages via magnetic resonance cholangiogram
(MRC').
‡Cholangiography, via a percutaneous route, or endoscopic retrograde
cholangiography (ERC') may establish the diagnosis of gallbladder cancer by
bile cytology.
‡Endoscopic ultrasonography can be useful to assess regional
lymphadenopathy in conjunction with other studies.
‡Angiography may confirm encasement of the portal vein or hepatic artery, and
assist in preoperative planning for definitive resection.
‡A routine chest radiograph should also be obtained.

‡ERC' can demonstrate the site of the obstruction by direct
retrograde dye injection, as well as excluding ampullary
pathology by endoscopic evaluation. Brush cytology, biopsy,
needle aspiration, and shave biopsies via ERC' can provide
material for histology. 'alliative stenting to relieve biliary
obstruction can be performed at the time of the evaluation.
‡'ercutaneous transhepatic cholangiography ('TC) may
allow access to the proximal biliary tree that has become
obstructed by extensive tumor growth from the gallbladder.
Material for cytology can be obtained and drainage performed
as well.
‡Other methods to obtain tissue include CT or ultrasound
needle aspiration, if a mass lesion is present, and endoscopic
ultrasonographic (EUS) fine-needle aspiration.
V
The AJCC 6th edition guidelines follow the TNM system, with depth of tumor penetration and regional spread defined
pathologically . Survival is correlated directly with stage of disease.
'rimary tumor
‡Category T
TX - 'rimary tumor cannot be assessed
T0 - No evidence of primary tumor
Tis - Carcinoma in situ
T1 - Tumor invades lamina propria or muscle layer
T1a - Tumor invades lamina propria
T1b - Tumor invades muscle layer
T2 - Tumor invades perimuscular connective tissue; no extension beyond serosa or into liver
T3 - Tumor perforates the serosa (visceral peritoneum) and/or directly invades the liver and/or one other adjacent organ
or structure, such as the stomach, duodenum, colon, pancreas, omentum, or extrahepatic bile ducts
T4 - Tumor invades main portal vein or hepatic artery or invades multiple extrahepatic organs or structures
Regional lymph node
‡Category N
NX - Regional lymph nodes cannot be assessed
N0 - No metastases in regional lymph nodes
N1 - Metastases in regional lymph nodes
Distant metastases
‡Category M
MX - 'resence of metastases cannot be assessed
M0 - No distant metastases
M1 - Distant metastases
TNM Groupings by stage
Stage 0 Tis N0 M0
Stage IA - T1 N0 M0
Stage IB - T2 N0 M0
Stage IIA - T3 N0 M0
Stage IIB - T1 N1 M0
T2N1M0
T3N1M0
Stage III - T4 any N M0
Stage IV - any T any N M1
MANAGEMENT
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