Transcript GALLBLADDER TUMORS

GALLBLADDER TUMORS
Aswad H. Al.Obeidy
FICMS, FICMS GE&Hep
Kirkuk General Hospital
MALIGNANT TUMORS
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The incidence of gallbladder carcinoma in
the United States is 2.5 cases per 100,000
population
More than 6950 new cases diagnosed per
year
Gallbladder carcinoma is the sixth most
common carcinoma of the digestive tract
It accounts for 3% to 4% of all
gastrointestinal tumorsis
The most common carcinoma of the
biliary tree
Epidemiology
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Gallbladder carcinoma occurs primarily in the
elderly
Three to four times as common in women as in
men
The association between gallbladder cancer and
gallstones is well established
At least 80% of patients with gallbladder cancer
have gallstones
However, gallbladder cancer develops in less
than 0.5% of patients with gallstones
Risk factors for gallbladder carcinoma
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The risk that gallbladder cancer will develop in
patients with gallstones over 20 years is less than
0.5% for the overall population and 1.5% for highrisk groups. The association is probably related to
chronic inflammation of the gallbladder; larger
stones (>3 cm) are associated with a 10-fold
higher risk of cancer than smaller stones
Other risk factors for gallbladder carcinoma are a
calcified gallbladder
A long common channel formed by the union of
the pancreatic and common bile ducts
The chronic typhoid carrier state
Histological subtypes
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Histologically, approximately 80% of gallbladder
carcinomas are adenocarcinomas
Histologic subtypes include papillary, nodular,
and tubular adenocarcinomas
Papillary tumors, which grow predominantly
intraluminally, have a better prognosis than the
other subtypes
Less common types of gallbladder carcinoma
include squamous cell carcinoma,
cystadenocarcinoma, small cell carcinoma, and
adenoacanthoma
Metastases
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Gallbladder carcinoma spreads via both lymphatic
and venous vessels
Because the cholecystic veins drain directly into the
liver, gallbladder cancers frequently extend directly
into the hepatic parenchyma, usually segments IV
and V
Lymphatic spread occurs first to the cystic duct
(Calot's) lymph node, then to pericholedochal and
hilar nodes, and finally to peripancreatic, duodenal,
periportal, celiac, or superior mesenteric nodes
Often the nodal disease of the porta hepatis leads to
biliary obstruction and presentation with jaundice
Not surprisingly, presentation with jaundice is
associated with a dismal prognosis, even if the
patient is otherwise asymptomatic
Clinical presentation
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The clinical presentation of gallbladder carcinoma ranges from an
incidental finding to a rapidly progressive disease that affords little
opportunity for effective treatment
Symptoms and signs associated with gallbladder cancer are
commonly nonspecific and include abdominal pain, nausea, fatty
food intolerance, anorexia, weight loss, fever, and chills
The most common presenting symptom is right upper quadrant
pain, which is present in more than 80% of patients
As the disease advances, the pain often becomes continuous;
obstruction of the common bile duct with jaundice may occur in up
to 30% of patients
Physical findings in advanced cases include right upper quadrant
tenderness, a palpable mass, hepatomegaly, and ascites
Laboratory findings are often unremarkable until obstructive
jaundice develops
There are no reliable tumor markers for early detection of this
disease
Diagnosis
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Abdominal ultrasonography is usually the initial diagnostic procedure
Thickening of the gallbladder wall or a polypoid mass should raise the
suspicion of a gallbladder neoplasm
Computed tomography (CT) is more sensitive than ultrasonography,
delineates a gallbladder mass with sensitivity and specificity rates of
nearly 90%
Is critical for determining resectability, the extent of local disease, and
the presence or absence of lymphadenopathy, hepatic metastases, and
invasion of the portal vein and hepatic artery by tumor
Magnetic resonance imaging (MRI), specifically magnetic resonance
cholangiopancreatography (MRCP), permits noninvasive assessment
of the hepatic parenchyma, biliary tree, vasculature, and lymph nodes
Endoscopic ultrasonography is also useful, especially for
demonstrating the extent of tumor invasion and lymph node
metastases
In patients who present with obstructive jaundice, either endoscopic
retrograde cholangiopancreatography (ERCP) or percutaneous
transhepatic cholangiography (THC) can identify the level and extent of
biliary obstruction
Diagnosis
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The tumor is typically detected in one of
the following three ways:
(1) as an incidental finding during or after
cholecystectomy for suspected benign
disease
(2) as a suspected or confirmed neoplasm
that appears to be resectable after
preoperative evaluation
(3) as an advanced, unresectable intraabdominal malignancy
American Joint Committee on Cancer Staging of
Gallbladder Carcinoma
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Primary Tumor (T stage)
T1Tumor invades lamina propria or muscle layer
T1a: Tumor invades lamina propria
T1b: Tumor invades muscle layer
T2Tumor invades perimuscular connective tissue
T3Tumor perforates serosa or directly invades one adjacent organ
(extension £2 cm into liver)
T4Tumor extends ≥2 cm into liver and/or into two or more adjacent
Regional Lymph Nodes (N Stage)
N0No regional lymph node metastasis
N1Metastasis in cystic ductal, pericholedochal, and/or hilar lymph
nodes
N2Metastasis in peripancreatic, periduodenal, periportal, celiac,
and/or superior mesenteric lymph nodes
Distant Metastasis (M Stage)
M0No distant metastasis
M1Distant metastasis
TNM Stage Grouping
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Stage I T1
Stage II T2
Stage III T3
T1-3
Stage IVAT4
Stage IVBT1-4
N0
N0
N0
N1
N0-2
N0-2
M0
M0
M0 or
M0
M0
M1
Surgical Resection
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If preoperative evaluation suggests gallbladder
carcinoma, laparoscopic cholecystectomy should be
avoided, because it may worsen the prognosis through
incomplete excision of the tumor and spillage of bile
More commonly, carcinoma is not suspected
preoperatively, and the cancer is found at the time of
laparoscopy for cholelithiasis , in this case, biopsy of
the gallbladder mass should be avoided, and conversion
to open laparotomy should be performed
If cancer is diagnosed on histologic examination of the
gallbladder after laparoscopic resection, further
management is based on the stage of the tumor
If reoperation is performed, all trochar sites should be
excised in their entirety
Surgical Resection
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In patients with stage I gallbladder cancer (TIN0M0), disease is
confined to the gallbladder wall, and a simple cholecystectomy is
adequate provided that the cystic duct margin is negative for
tumor. In most series, simple cholecystectomy is associated with
a survival rate of nearly 100%
The management of patients with T2 and T3 lesions is generally
accepted to involve extended or radical cholecystectomy, which
consists of en bloc resection of the gallbladder and nonanatomic
wedge resection of the gallbladder bed (segments IV and V of the
liver), with at least a 3- to 4-cm margin of normal liver parenchyma.
Regional lymphadenectomy of the choledochal, periportal, hilar,
and high pancreatic lymph nodes should be performed
The management of T4 lesions remains controversial. Several
series have demonstrated that radical resections for gallbladder
cancer can be performed with mortality rates of less than 4%. In
these series, at least 50% of patients had advanced T-stage
disease (T3 and T4), and 5-year survival rates ranged from 31% to
65%
Palliation
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If unresectable local disease is found at the time of
exploration, a biliary bypass (hepaticojejunostomy)
can be performed to relieve extrahepatic biliary
obstruction and the associated pruritus, jaundice,
and progressive liver dysfunction
If disseminated disease is found at laparotomy, at
laparoscopy, or preoperatively, biliary drainage can
be achieved with placement of either a percutaneous
or endoscopic stent
Placement of an expandable metal stent can provide
permanent internal decompression of biliary
obstruction in patients with a life expectancy of only
a few months
Chemotherapy and Radiation Therapy
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Gallbladder carcinoma is believed to be resistant to most
standard chemoradiation regimens in the neoadjuvant
(preoperative), adjuvant (postoperative), and palliative settings
The most commonly used chemotherapeutic agent has been 5fluorouracil (5-FU), with associated response rates ranging from
5% to 30% in most series
In the adjuvant setting, radiation therapy is used to control
microscopic residual foci of carcinoma in the tumor bed.
Approaches have included standard external-beam radiation
therapy, intraoperative external-beam radiation therapy (IORT),
and brachytherapy
The benefit of radiation in the palliative setting is modest. The
median survival is 6 months after palliative surgery and 2
months after biopsy of the tumor alone without treatment. The
addition of palliative radiation therapy increases the median
survival to 4 months after biopsy without surgery and to 8
months after palliative surgery
Prognosis
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The overall 5-year survival rate for patients with
gallbladder carcinoma is less than 5%, with a
median survival of less than 6 months
The overall survival rate in series of patients
who have undergone resection and whose
tumors have been staged according to the AJCC
system is nearly 100% for stage I and nearly 50%
for node-negative stage II and stage III disease
Although aggressive surgical resection in large
centers has offered some improvement in these
results, most patients still present with
advanced disease that is unlikely to be
amenable to cure
BENIGN TUMORS
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Benign tumors of the gallbladder manifest most commonly as
polyps or polypoid lesions. Polyps can be adenomas,
pseudotumors, or hyperplastic inflammatory lesions
Adenomas of the gallbladder are rare and can be sessile or
polypoid, they may be premalignant
Cholesterolosis, or pseudotumors, is manifested by yellow spots
visible on the surface of the gallbladder mucosa that give the
appearance of a “strawberry gallbladder
Inflammatory polyps are composed of a vascular connective tissue
stalk with a single layer of columnar epithelial cells
Adenomyomatosis of the gallbladder is characterized by the
proliferation of the mucosa and hypertrophy of the underlying
muscular layers
The management of a benign gallbladder tumor depends on the size
of the lesion. Because polyps larger than 1 cm have the greatest
malignant potential, even asymptomatic patients with such polyps
should undergo cholecystectomy
Tumors smaller than 1 cm have been shown not to progress to
carcinoma; therefore, routine follow-up cholecystectomy is not
warranted