An In-Depth Guide to Understanding Gallbladder Carcinoma 

A serious health risk is associated with gall bladder carcinoma (CaGB), a malignant biliary illness that is more common in some areas of the world, such as Pakistan and India. The goal of this blog is to present a thorough review of CaGB, including information on its prognosis, staging, investigations, pathology, clinical features, risk factors, and occurrence.

Incidence and Demographics

Gall bladder cancer is more common in India and Pakistan, and it strikes more women in their sixth or seventh decade of life. Large gallstones (>3 cm), which occur in 0.3 to 3% of gallstone-afflicted patients, and cholelithiasis, which affects 75–98% of patients, are important risk factors.

Pathology and Genetics

Adenocarcinoma is the most prevalent histological form of carcinoma of gall bladder. For staging purposes, the Nevin Classification is employed, and it is common to see gene mutations for K-RAS, BRAF, and p53. The most frequent location is the fundus (60%) and is followed by the torso (30%) and neck (10%).

Risk Factors

Choledochal cysts, gallstones (>3 cm), obesity, adenomatous polyps, porcelain gallbladder, primary sclerosis cholangitis (PSC), and chronic typhoid carriers are among the risk factors that lead to the development of carcinoma of gall bladder.

Pathology

The most common gross appearance in carcinoma of gall bladder. histology is adenocarcinoma, which can take many different forms, including diffuse infiltrative, nodular or mass-forming, and papillary kinds. Hepatic dissemination is the most frequent mode of transmission, followed by lymphatic and perineural pathways.

Clinical Features

Patients frequently have systemic symptoms, such as early-stage right upper quadrant (RUQ) pain that mimics cholecystitis. Jaundice, weight loss, abdominal mass, persistent epigastric pain, early satiety, and a full feeling are possible latter stage symptoms.

Investigations

The first line of treatment for RUQ discomfort is ultrasonography, which can detect thicker gallbladder walls, heterogeneous masses, gallstones, and irregularly shaped lesions. The gold standard for diagnosis is contrast-enhanced CT (CECT), which can reveal vascular involvement, lymphadenopathy, and metastases to the liver and peritoneum.

8th AJCC TNM Classification

The TNM classification aids in staging carcinoma of gall bladder. based on tumor (T), node involvement (N), and metastases (M).

Treatment

Stage Ia (T1a) involves a lap cholecystectomy. A prolonged cholecystectomy is performed between stages Ib and IIIb. Extended right hepatectomy and extended cholecystectomy are performed during IVa. Palliation is recommended with chemotherapy in stage IVb.

Treatment For Various Presentation Subgroups:

1. Gall Bladder Polyp Patients:
   • Adenomatous polyps have a considerable risk of harboring cancer and have the potential to become malignant. The most reliable indicators of malignancy are solitary polyps larger than one centimeter. Patients older than 50 years old are more likely to experience it. Physicians prescribe lap cholecystectomy if the polyp size is more than 1 cm, and surveillance if it is less than 1 cm.
2. Gall Bladder Cancer After Cholecystectomy
   • Following cholecystectomy, 85–100% of patients with GB cancer have cholecystectomy (Lap) if the tumor is T1a. The prevalence of nodal illness is less than 3% of people. 
   • A negative cystic duct margin is ideal. If margins are not negative, CBD resection should be performed to get them to be negative. There is a larger chance of nodal illness if the tumor is T1b. Patients who meet the criteria for extended cholecystectomy are those who have tumors classified as T1b or higher and are medically fit.
   • Port size excision
     • Because port size excision seldom occurs in isolation and is typically associated with an aggressive disease, it is a controversial treatment.
3. Patients suspected of having Carcinoma Gall Bladder pre-operatively
   • A diagnostic laparoscopy is performed to detect liver or peritoneal metastases with a limited volume.  Palliation (non-operative techniques to alleviate symptoms) in metastatic disease (stage IVB) 
4. Patients with advanced disease of presentation
   • It is preferable to palliate.  Typical signs that call for palliation include:
     • Jaundice: biliary stenting via endoscopy is performed
     • Pain: In a hospice environment, parenteral opioids or oral narcotics may be administered.  Percutaneous celiac ganglion neurolysis.
     • Intestinal obstruction: duodenum and pylorus involvement causes gastric outlet obstruction (GOO). Stents for the duodenum are used endoscopically.

Adjuvant Therapy

Patients with high-risk lesions, such as T4 tumors, undergo this procedure. 
• Positive involvement of lymph nodes
• R1 resection (resection having positive microscopic margins)
• Gemcitabine and cisplatin are used as part of an adjuvant treatment chemotherapy regimen.

The Following Independent Variables Impact Survival:

1. T-status (prognosis excellent if T1a lesion)
2. The level of node involvement
3. Histological differentiation
4. Involvement with CBD
5. R0 resection: good prognosis due to resection with negative margin.

Survival Down The Lane In 5 Years:

• T2 lesion patients had a 60% chance of surviving for five years after diagnosis.
• T3 lesions in patients: fewer than 20%
• Lesions on T4: Most likely months
• 13 months is the median survival time for metastatic illness at presentation.
• 5 year survival overall: less than 15% 

Also read: High-Yield GIT, Hepatobiliary and Pancreatic Surgery Questions

Hope you found this blog helpful for your GIT, Hepatobiliary and Pancreatic Surgery preparation. For more informative and interesting posts like these, keep reading PrepLadder’s blogs.