Gallbladder Cancer : Diagnosis and treatment

Although being the most common and viscous malignancy of the biliary tract, gallbladder cancer is fairly uncommon in the United States. It is estimated that there are 2 cases per 100,000 population in the United States, which has decreased over the last 30 years.1 This disease has the shortest median survival from the time of diagnosis and is mainly due to its aggressive nature, anatomic position of the gallbladder, and the vagueness and non-specificity of symptoms.  Due to its vague and broad symptoms, gallbladder disease is usually diagnosed at an advanced stage. Only 10% of patients with diagnosed gallbladder cancer are candidates for surgery with a curative intent. Even when patients are eligible for curative surgery, the structural complexity of the biliary hepatic system, the high risk associated with liver resection, as well as the risks of metastatic spread secondary to manipulation potentiate a high mortality rate. The majority of gallbladder cancer cases are found incidentally in patients being evaluated for cholelithiasis; which a tumor will be found in about 2% of such cases.1 Due to the disease being extremely problematic with an extremely high risk of morbidity and mortality, it is essential to identify the cancer early in its course to improve prognosis.

Know about Gallbladder Cancer

Gallbladder cancer may develop in the gallbladder’s fundus, body, or neck; with the fundus being the most common. This development usually does not happen suddenly and is over a span of 5-15 years. The most common form of direct spread from the disease is to the liver, mainly due to the lack of submucosa of the gallbladder and no serosal membrane present where the gallbladder attaches to the liver. The reason this disease poses such a high morbidity and mortality risk is because it tends to spread to other organ systems within the body. This spread can occur by four different mechanisms: local invasion of the liver or nearby structures, lymphatic dissemination, peritoneal spread, and hematogenous spread.2

Risk Factors

Some individuals are at a greater risk of developing gallbladder cancer than others. Certain demographic factors that can potentially put an individual at greater risk include advanced age, female gender, obesity, geography (South American, India, Japanese, Korean), ethnicity (Caucasians, Mexican Americans, Native Americans, Asian), and particular genetic predispositions. Medical conditions and pathologies also play a role in gallbladder cancer. These include cholelithiasis, gallstone disease, porcelain gallbladder, gallbladder polyps, congenital biliary cysts, and possibly diabetes. Exposures to heavy metals, certain medications (methyldopa, oral contraceptives, isoniazid, and estrogen), and smoking may also place an individual at a higher risk. Lastly, infections by specific pathogens have been linked to increasing the risk of gallbladder disease. These organisms include Salmonella and Helicobacter species. Individuals need to strive to avoid modifiable risk factors in order to lower the risk of developing the carcinoma.2

Diagnosis

Patients with early invasive gallbladder cancer most often present asymptomatically, or they have symptoms not specific to the disease. These symptoms usually correlate with cholelithiasis or cholecystitis, making it difficult to identify the cancer. In symptomatic patients, the most common complaint is pain in the right upper quadrant, which is usually followed by anorexia, nausea, and vomiting. Advanced gallbladder symptoms generally differ from that of the more common biliary colic. These symptoms are more suggestive of malignant disease and include weight loss and malaise. Individuals may also present with obstructive jaundice. This occurs from direct invasion of the biliary tree or from metastatic disease to the hepatoduodenal ligament region. Invasion of the tumor into the porta hepatis may also result in duodenal obstruction and this condition is unresectable.2

As mentioned earlier, gallbladder cancer is commonly diagnosed incidentally after routine cholecystectomy or through evaluating another diagnosis. This raises importance of screening patients with symptomatic biliary tract disease for the possibility of co-existing gallbladder cancer. The initial diagnostic study used for high risk patients is ultrasound imaging. Some findings that are suggestive of gallbladder cancer, but not diagnostic, are mural thickening or calcification, a mass protruding into the lumen, a fixed mass in the gallbladder, loss of the interface between the gallbladder and liver, or direct liver infiltration. If these suspicious findings are present upon ultrasound imaging, cross-sectional imaging with a CT scan or MRI/MRCP is needed in order to determine confirmatory diagnosis. For proper diagnosis of gallbladder cancer, then you can ask a doctor online by visiting our website: https://justhealthexperts.com/ 

Treatment

The only curative treatment for gallbladder cancer is complete surgical tumor resection. This is often challenging due to anatomy of the gallbladder region, as it is neighboring vital organ systems. It is also challenging due to the disease’s tendency for hepatic invasion with early lymphatic metastases. If a patient is eligible for surgical resection, it may range from simple cholecystectomy to being combined with partial hepatectomy, with or without regional lymph node dissection. At a minimum, definitive surgery includes removal of involved liver parenchyma as well as regional lymph nodes. The extent of surgery is usually estimated by using the TNM staging system for gallbladder cancer. If the cancer spread cannot be removed, other options are available that may relieve symptoms, which include biliary bypass, endoscopic stent, and percutaneous transhepatic biliary drainage.2

If patients are not eligible for surgery, pharmacotherapy is used in curative and palliative settings. For localized disease that is staged past T1 or is node positive, the treatment includes adjuvant chemotherapy with or without radiation therapy. Adjuvant chemotherapy at this stage includes IV mitomycin and 5-fluorouracil, followed by maintenance therapy of oral 5-fluorouracil. In the setting of locally advanced disease, the treatment includes gemcitabine-based chemotherapy with or without radiation therapy. Lastly, for advanced disease the chemotherapy is once again gemcitabine based. This setting includes metastatic disease and the most effective regimens to improve patient survival include gemcitabine plus cisplatin, oxaliplatin, or capecitabine.2 The combination of gemcitabine with the oral prodrug of 5-fluorouracil, capecitabine, has showed the best improvement in patient survival thus far in this particular patient population. To learn more about natural approaches to aiding gallbladder cancer, please visit this following link: natural approaches to gallbladder problems  

Conclusion

 Gallbladder cancer is a fairly uncommon condition with a high rate of fatality and a low 5-year survival probability. There are many risk factors that can influence the disease and place an individual at a higher risk. Most gallbladder cancers, unfortunately, are incidentally diagnosed through routine cholecystectomy or are at an advanced stage upon presentation. Although a patient’s past medical history and physical exam can help determine the presence gallbladder cancer, it is often difficult to accurately assess the disease due to patients’ presenting asymptomatically or with symptoms similar to cholelithiasis. In order to correctly diagnose the disease, imaging studies need to be undertaken. When a patient does have a confirmatory diagnosis, the treatment options include complete surgical resection or systemic chemotherapy with or without radiation. The decision on which treatment modality is best is based on patient specific factors as well as the status of the disease. In order for improved success in the management of this rare disease, the future must be directed towards more specific and sensitive screening methods in order to tackle the disease early in its course.

 References

  1. Carriaga MT, Henson DE. Liver, gallbladder, extrahepatic bile ducts, and pancreas. Cancer. 1995;75(1 Suppl):171‐190. doi:10.1002/1097-0142(19950101)75:1+<171::aid-cncr2820751306>3.0.co;2-2 
  2. Kanthan R, Senger JL, Ahmed S, Kanthan SC. Gallbladder Cancer in the 21st Century. J Oncol. 2015;2015:967472. doi:10.1155/2015/967472
  3. Knox J. J., Hedley D., Oza A., et al. Combining gemcitabine and capecitabine in patients with advanced biliary cancer: a phase II trial. Journal of Clinical Oncology. 2005;23(10):2332–2338. doi: 10.1200/jco.2005.51.008.

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