Gall Bladder Cancer

About

Dr. Deepak Chhabra

Surgical Oncologist

MS. (Bom), DNB, M.R.C.S. (Edin. UK)

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FAQ

  1. What is cancer
  2. Cancer Risk factors
  3. Stages of Cancer
  4. Early signs of Cancer
  5. Early detection of Cancer

The world knows this man as a consultant oncosurgeon with vast experience in Gastrointestinal and Hepatobiliary-Pancreatic cancers,who specializes in stapled anastomosis for bowel cancers and sphincter saving resections for rectal cancers. In short, he is the person to be contacted for all kinds of cancer related cases.

Richa AgrawalPancreatic Cancer

Thank you Dr Deepak for all you have done for mum, for putting the smile back of her face. I wish you success in all your future endeavors and know that you will continue to touch peoples lives and help them be healthy - the way you have done for my mum….. and me.

Nicola MathiasStomach Cancer

For 67years I've led a very healthy life and thank the "Almighty" for it. However as I said all good things come to an end some time and so be it. Out of the blues was detected the dreadful illness "C" which had shown no signs or symptoms whatsoever..... Time had now come for me to choose a very efficient Oncologist for my treatment.

Patient

My mother was diagnosed of colon cancer, and I was recommended to see Dr Deepak Chhabra for consultation.
The first impression of Dr Chhabra was… he is so young! But after consulting him we realized his level of experience and there was a sense of confidence he spilt over us.We knew we could trust him.....

Neelu GroverColon Cancer
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The Gallbladder

The gallbladder is a small, pear-shaped organ located under the right lobe of the liver. Both the liver and the gallbladder are behind the right lower ribs. The gallbladder is usually about 3 to 4 inches long and normally no wider than 1 inch.

The gallbladder concentrates and stores bile, a fluid made in the liver. Bile helps digest the fats in foods as they pass through the small intestine. Bile may be released from the liver directly into the small intestine, or it may be stored in the gallbladder and released later. When food (especially fatty food) is being digested, the gallbladder contracts and releases bile through a small tube called the cystic duct. The cystic duct joins up with the hepatic duct, which comes from the liver, to form the common bile duct. The common bile duct empties into the small intestine.

The gallbladder is helpful, but you do not need it to live. Many people live normal lives after having their gallbladders removed.

About

What is Gallbladder Cancer?

Cancer of the pancreas develops when healthy cells in the pancreas become abnormal and grow too quickly. The abnormal cells form a mass in the pancreas called a tumor. When a tumor has the ability to spread to other parts of the body, it is called malignant (cancer).

About 9 out of 10 gallbladder cancers are adenocarcinomas. An adenocarcinoma is a cancer that starts in the cells with gland-like properties that line many internal and external surfaces of the body (including the inside the digestive system). There are other types of cancer that can develop in the gallbladder, such as adenosquamous carcinomas, squamous cell carcinomas, small cell carcinomas, and sarcomas, but these are uncommon.

The gallbladder is attached to the under surface of the liver, hence a cancer of the gallbladder has a tendency to spread to the liver at the earliest. Unlike other cancers where spread to the liver is considered as a bad sign, in gallbladder cancers involvement of the liver is a part of the disease process due to its closeness to the gallbladder.

The problem with gallbladder cancer is that it is not usually found until it has become advanced and causes symptoms. Only about 1 out of 5 gallbladder cancers is found in the early stages, where the cancer has not yet spread beyond the gallbladder.

In India, the maximum number of cases of gallbladder cancers is from the northern part of the country.

There are lymph glands around the gallbladder. The lymph nodes are often the first place that cancer cells spread to when they break away from a tumour. So surgeons often remove them during cancer surgery and send them to the lab where a pathologist examines them to see if they contain any cancer cells.

The presence of cancer cells in the lymph nodes is part of the staging of the cancer. The stage is important because it helps the doctor to decide a suitable treatment for you.

Causes

What are the causes of gallbladder cancer?

The exact causes of gallbladder cancers are not known. But some factors can increase your risk of developing them.

A risk factor is anything that affects your chance of getting a disease such as cancer. Different cancers have different risk factors. For example, exposing skin to strong sunlight is a risk factor for skin cancer. Smoking is a risk factor for cancers of the lung, mouth, larynx (voice box), colon, bladder, kidney, and several other organs.

But risk factors don’t tell us everything. Having a risk factor, or even several risk factors, does not necessarily mean that a person will get the disease. And many people who get the disease may not have any known risk factors.

  • Scientists have found several risk factors that make a person more likely to develop gallbladder cancer. Many of these are related in some way to chronic inflammation in the gallbladder.
  • Gallstones: Gallstones are the most common risk factor for gallbladder cancer. Gallstones are hard, rock-like formations of cholesterol and other substances that form in the gallbladder and can cause chronic inflammation. At least 3 out of 4 people with gallbladder cancer have gallstones when they are diagnosed. Gallstones are a very common condition, but gallbladder cancer is quite rare, especially in the United States. Most people with gallstones never develop gallbladder cancer.
  • Porcelain gallbladder: Porcelain gallbladder is a condition in which the wall of the gallbladder becomes covered with calcium deposits. It sometimes occurs after long-term inflammation of the gallbladder. People with this condition may have a higher risk of developing gallbladder cancer (possibly because both conditions can be related to inflammation). Still, not all studies have found such a link.
  • Gallbladder polyps: A gallbladder polyp is a growth that bulges out from the surface of the inner gallbladder wall. Some polyps are formed by cholesterol deposits in the gallbladder wall. Others may be small tumors (either cancerous or benign) or may be caused by inflammation. Polyps larger than 1 centimeter (almost a half inch) are more likely to be cancerous, so doctors often advise removing the gallbladder in patients with gallbladder polyps that size or larger.
  • Obesity: Patients with gallbladder cancer are more often overweight or obese than people without this disease. Obesity is also a risk factor for gallstones, which may help explain this link.
  • Ethnicity and geography: In India, the risk of developing gallbladder cancer is highest among North Indians. They are also more likely to have gallstones. Worldwide, gallbladder cancer is much more common in Asian, Eastern European and South American countries.
  • Choledochal cysts: Choledochal cysts are bile-filled sacs that are connected to the common bile duct, the tube that carries bile from the liver and gallbladder to the small intestine. (Choledochal means having to do with the common bile duct.) The cysts can grow over time and may contain as much as 1 to 2 quarts of bile. The cells lining the sac often have areas of pre-cancerous changes, which increase a person’s risk for developing gallbladder cancer.
  • Industrial and environmental chemicals: It is not clear if exposure to certain chemicals in the workplace or the environment increases the risk of gallbladder cancer. More research is needed in this area to confirm or refute these possible links.

Symptoms

What are the common symptoms of gall bladder cancer?

Some gallbladder cancers are found incidentally after a gallbladder has been removed to treat gallstones or chronic (long-term) gallbladder inflammation. Gallbladders removed for those reasons are always looked at under a microscope by a pathologist (a doctor specializing in lab tests) to see if they contain cancer cells.
Signs and symptoms are usually not present until the later stages of gallbladder cancer, but in some cases they may lead to an early diagnosis. If you go to your doctor when you first notice symptoms, your cancer might be diagnosed at an earlier stage, when treatment may be more effective. Some of the most common symptoms of gallbladder cancer are:

  • Abdominal pain: Most people with gallbladder cancer have abdominal (stomach area) pain when they are first diagnosed. Most often this is in the upper right part of the abdomen.
  • Nausea and/or vomiting: At the time of their diagnosis, many people with gallbladder cancer report vomiting as a symptom.
  • Jaundice: Jaundice is a condition that gives a yellowish colour to the skin and the white part of the eyes. This can happen when bile from the liver is unable to drain into the intestines because the cancer blocks the bile duct. Bilirubin, a chemical in bile that gives it a yellow colour, may build up in the blood and settle in different parts of the body. This can cause the colour changes seen in the skin and eyes. Some patients with gallbladder cancer have jaundice when they are diagnosed.
  • Gallbladder enlargement: If the cancer blocks the bile duct, bile can also build up in the gallbladder, causing it to become larger than usual. The enlarged gallbladder can sometimes be felt by the doctor during a physical exam. It can also be detected by imaging tests such as ultrasound.
  • Other symptoms: Less common symptoms include loss of appetite, weight loss, abdominal
  • These are symptoms and signs of gallbladder cancer, but it is important to remember that they are more likely to be caused by non-cancerous diseases. For example, people with gallstones may have many of these same symptoms. There are many causes of abdominal pain that are far more common than gallbladder cancer. And hepatitis (inflamed liver most often caused by infection with a virus) is a much more common cause of jaundice. Still, if you have any of these problems, it’s important to see your doctor right away so the cause can be found and treated, if needed.

Tests

What tests are carried out to diagnose Gallbladder cancers?

This section lists common tests that may be performed and it is not necessary for all the tests to be performed for a patient. Your doctor will select the tests that will assist him /her to have the maximum information about the tumor/ disease.

Blood Tests

Tests of liver and gallbladder function: The doctor may order lab tests to find out how much bilirubin is in the blood. Bilirubin is the chemical that causes jaundice. Problems in the bile duct, gallbladder, or liver may cause too much bilirubin to remain in the blood. A high bilirubin count tells the doctor that there may be problems with the bile duct, gallbladder, or liver.

The doctor may also order tests for other substances in your blood, such as albumin, alkaline phosphatase, AST, ALT, and GGT. These are sometimes called liver enzymes or liver function tests. They can also give an indication of bile duct, gallbladder, or liver disease. Higher levels of these substances may point to blockage of the bile duct, but they cannot show if it is due to cancer or some other reason.

Tumor markers: Tumor markers are substances made by cancer cells that can sometimes be found in the blood. People with gallbladder cancer may have high blood levels of the carcinoembryonic antigen (CEA) and CA 19-9 tumor markers. Usually the blood levels of these markers are high only when the cancer is in an advanced stage. These markers are not specific for gallbladder cancer — that is, high levels can also be caused by other cancers or even some other health conditions.

Ultrasound

Ultrasound (US or ultrasonography) is often the first imaging test done in people who have symptoms such as jaundice or pain in the right upper part of their abdomen. On the basis of results of this ultrasound the doctor may decide for the next best investigation.

Computerised tomography (CT) scan

A CT scan is a type of x-ray that gives a picture of organs and other structures (including any tumours) in your body. It is used to see more details of a cancer and its relation to the surrounding organs in your body. It also gives information related to cancer spread into the lymph nodes, liver or lungs.

Magnetic resonance imaging (MRI)

This test is like a CT scan, but it uses magnetism instead of x-rays to build up pictures of the organs in your abdomen. Like a CT scan, MRI is painless and the magnetism is harmless. MRI scan may be used to see the extent of blockage of bile duct and in case the patient is allergic to contrast dye injection used for CT scans. MRI scans provide a great deal of detail and can be very helpful in looking at the gallbladder, bile ducts and nearby organs. Sometimes they can help tell a benign tumor from a malignant one.

Endoscopic ultrasound scan (EUS)

This involves a special endoscope equipped with an ultrasound probe and a small needle at the end. The scope is placed through the mouth into the oesophagus (food pipe) and the first portion of the small intestine for more detailed information about the local spread of the tumor. If there is a tumor, ultrasound may help the doctor tell if and how far it has invaded the gallbladder wall, which helps in planning for surgery. Ultrasound may be able to show if nearby lymph nodes are enlarged, which may be a sign that cancer has reached them. It may also be used to guide a needle into a suspicious node so that cells can be removed (biopsied) and viewed under a microscope.

Positron emission tomography (PET) scan

This test is combined with a CT scan by injecting a radioactive material in the body to highlight all areas where the tumor has or can spread. This test may be used to build up more information after an MRI or CT scan. PET-CT scan is not necessary for all patients. Your doctor will decide if you need to undergo this scan.

Biopsy

Imaging tests can suggest that a bile duct cancer is likely to be present, but in many cases a sample of bile duct cells or tissue is removed (biopsied) and looked at under a microscope to be sure of the diagnosis.

But when gallbladder cancer is likely, a biopsy may not always be done before surgery to remove the tumor. Doctors are often concerned that sticking a needle into the tumor or otherwise disturbing it without completely removing it might allow cancer cells to spread to other areas.

If imaging tests (ultrasound, CT or MRI scans, cholangiography, etc.) suggest there is a tumor in the gallbladder and there are no obvious signs of distant spread, the doctor may decide to proceed directly to surgery and to treat it as a gallbladder cancer. (See the section,”Surgery.”) In these cases, the gallbladder tissue is looked at under a microscope after the gallbladder is removed.

In other cases, a doctor may feel that a biopsy of a suspicious area in the gallbladder is the best approach to know for certain that it is gallbladder cancer. For example, imaging tests may show that a tumor has spread or grown too large to be completely removed by surgery. Unfortunately, many gallbladder cancers are not removable by the time they are first found.

Treatment

What is the treatment of Gallbladder cancer?

Many years of treating cancer patients and testing treatments in clinical trials has helped doctors know what is likely to work for a particular type and stage of cancer. You will be advised on the best treatment for your cancer. This will depend on the type of cancer you have, where it is and how far it has spread and your general health.

Nearly all doctors agree that surgery offers the only real chance for curing people with gallbladder cancer. But there are differences of opinion about how advanced a gallbladder cancer can be and still be treatable with surgery. The surgery needed for gallbladder cancer is often complex

In general, some cancers that have not spread far beyond the gallbladder may still be treatable by surgery, unless the cancer has spread into major blood vessels. For instance, if the cancer has invaded the liver – but only in one area and not too deeply – it may be possible to remove all of the cancer by surgery. On the other hand, if the cancer has spread to both sides of the liver, to the lining of the abdominal cavity, to organs far away from the gallbladder, or if it surrounds a major blood vessel, surgery is unlikely to remove it all.

Surgery

Surgery For GallBladder cancer

If the tumor is resectable, surgery is usually the main type of treatment for gallbladder cancer, as it offers the only reasonable chance to cure the cancer. Chemotherapy and / or Radiation therapy may be added after surgery in some cases, or they may be used instead of surgery if the cancer cannot be entirely removed.

Though cancer surgeries are extensive and take longer hours; with advanced medical care, surgeries have become safer and better equipments are now available to perform surgeries. Improved techniques of anaesthesia and post-operative monitoring have significantly contributed to overall safety of surgical procedures for cancers.

There are 2 general types of surgical treatment for gallbladder cancer — potentially curative surgery and palliative surgery.

Potentially curative surgery is used when imaging tests indicate a good chance that the surgeon will be able to remove all of the cancer. Doctors may use the term resectable to describe cancers they believe can be removed completely (by potentially curative surgery) and unresectable to describe those they think have spread too far or are in too difficult a place to be entirely removed by surgery. Unfortunately, only a small portion of bile duct cancers are resectable at the time they are first found.

Palliative surgery may be performed to relieve symptoms or treat (or even prevent) complications, such as blockage of the bile ducts. This type of surgery is performed when the tumor is too widespread to be completely removed. Palliative surgery is not expected to cure the cancer, but it can sometimes help someone feel better and sometimes can even help them live longer.

Staging laparoscopy

Often, when gallbladder cancer is suspected, the surgeon will do a laparoscopy before any other surgery. This is done to help determine the extent of the cancer and whether it may be resectable or not. Laparoscopy may let the surgeon see areas of cancer that were not detected with imaging tests. In this procedure, a small cut is made so that a long, lighted tube called a laparoscope can be inserted into the abdomen. The doctor uses the laparoscope to look around the abdominal cavity for signs of cancer spread. If the cancer is resectable, laparoscopy can also help in planning the operation to remove it.

Cholecystectomy (simple cholecystectomy)

The operation to remove the gallbladder is called a cholecystectomy. If only the gallbladder is removed, the operation may be called simple cholecystectomy. This operation is often used to remove the gallbladder for other reasons such as gallstones, but it is not done if gallbladder cancer is known or suspected (a more extensive operation is done instead).

Gallbladder cancers are sometimes found incidentally (by accident) after a person has a cholecystectomy for another reason, such as gallstones. If the cancer is found to be at a very early stage (T1a) and is thought to have been completely removed, no further surgery may be needed. If there’s a chance the cancer may have spread beyond the gallbladder, more extensive surgery may be advised.

Extended (radical) cholecystectomy

Because of the risk that the cancer will come back if just the gallbladder is removed, a more extensive operation, known as an extended (or radical) cholecystectomy, is done in most cases of gallbladder cancer. This can be an involved, complex operation, and it is best done by a surgeon who is experienced in treating gallbladder cancer.

The extent of the surgery depends on where the cancer is located and how far it might have spread. At a minimum, an extended cholecystectomy removes:

  • The gallbladder
  • About an inch or more of liver tissue next to the gallbladder
  • All of the lymph nodes in the region

If the surgeon feels it is needed and the patient is healthy enough, the operation may also include one or more of the following:

  • Removing more of the liver, ranging from a wedge-shaped section of the liver close to the gallbladder (wedge resection) to a whole lobe of the liver (hepatic lobectomy)
  • Removing the common bile duct
  • Removing part or all of the ligament that runs between the liver and the intestines
  • Removing lymph nodes around the pancreas, around the major blood vessels leading to the liver (the portal vein and hepatic artery), and around the artery that brings blood to most of the small intestine and to the pancreas
  • Removing the pancreas
  • Removing the duodenum (the first part of the small intestine into which the bile duct drains)
  • Removing any other areas of organs to which cancer has spread

Palliative therapy is treatment that is given to help control or reduce symptoms caused by advanced cancer. It is not meant to be a curative treatment. If the cancer has spread too far to be completely removed by surgery, doctors may focus on palliative operations, palliative radiation, and other palliative therapies. Because these cancers tend to advance quickly, doctors try to use palliative therapies that are less likely to affect a person’s quality of life, when possible.

Palliative surgery: In some cases a doctor may think that a cancer is resectable based on the information available (imaging tests, laparoscopy, etc.), but once the surgery is started it becomes clear that the cancer is too advanced to be removed completely. At this point the surgeon may do a biliary bypass to allow the bile to flow into the intestines to reduce symptoms such as jaundice or itching.

In this palliative procedure, the surgeon creates a bypass around the tumor blocking the bile duct by connecting part of the bile duct before the blockage with a part of the intestine.

If a bypass can’t be done, the surgeon may simply ask for a plastic or expandable metal tube (called a stent) to be placed through the bile duct to keep it open.

Biliary stent or biliary catheter:

If cancer is blocking a duct that carries bile from the gallbladder to the small intestine, it can lead to jaundice and other problems. The doctor may insert a small tube (either a stent or a catheter) into the bile duct or the gallbladder to help the bile drain out. This may be done as part of a cholangiography procedure such as PTC or ERCP.

A stent is a small metal or plastic tube that keeps the duct open to allow the bile to drain into the small intestine. A catheter is a thin, flexible tube that drains into a bag outside the body through a small hole in the skin of the abdomen. The bag can be emptied when needed. If you have a catheter, your doctor or nurse will teach you how to care for it.

The stent or catheter may need to be replaced every few months to reduce the risk of it becoming blocked, which could lead to jaundice or gallbladder inflammation.

For gallbladder cancers that are resectable, chemotherapy may be used after surgery to try to lower the risk that the cancer will return. This is known as adjuvant chemo. Some doctors may use it before surgery for borderline resectable cancers to try to improve the odds that surgery will be successful. This is called neoadjuvant treatment. Chemotherapy may also be used (with or without radiation therapy) for more advanced cancers. With newer drugs available, there are good responses to chemotherapy for gallbladder cancers and patients can be offered surgery after a confirmation of response to treatment with chemotherapy.

Radiation therapy is treatment with high-energy rays or particles that destroy cancer cells. There are different kinds of radiation therapy.

Nevertheless radiation therapy has not been a standardised treatment for gallbladder cancers and almost 9 out of 10 doctors dealing with gallbladder cancer will not recommend radiation as a part of treatment for gallbladder cancers.