Cancer gallbladder

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  • 1. CANCER GALLBLADDER

2. INCIDENCE Increases with age 2-6 times common in women Common among population in Western South America Northern India North American Indians Mexican Americans 3. RISK FACTORS Gallstones Porcelain gallbladder Adenomatous polyps Chronic infection with S.typhi Carcinogen exposure(miners exposed toRadon) Abnormal PancreaticoBiliary DuctJunction(APBDJ) 4. APBDJ It is more common in Asian countries GB cancers with APBDJ Tend to occur at an younger age Lesser degree of female preponderance Asociated less often with cholelithiasis High prevalence of K-ras mutations & a late onsetof p-53 mutations High prevalence of premalignant epithelialhyperplasia with a papillary or villous histology. 5. CANCER & CALCULI Gallstones are present in 70-90% of patientsdiagnosed with GB cancer Only 0.5-3% of patients with cholelithiasis willdevelop GB cancer Risk of GB cancer is increased with increasingsize & duration of cholelithiasis 6. PATHOGENESIS Chronic irritation Dysplasia-carcinoma in-situ-invasive cancer p 53 & K-ras(rare) mutations 7. PATHOLOGY 80%-adenocarcinoma Others Small cell cancer Squamous cell cancer Lymphoma sarcoma Morphologically Infiltrative Nodular Papillary Combined pattern Staging systems Nevin TNM 8. CLINICAL PRESENTATION Early lesion Advanced lesion Asymptomatic Weight loss Abdomonal pain Obstructive jaundice Anorexia Duodenal obstruction Nausea Palpable mass Vomiting Hepatomegaly ascites 9. INVESTIGATIONS Biochemical evidence of obstructive jaundice Nonspecific Anaemia Leucocytosis Elevated liver enzymes Increased ESR Increased CRP Tumour markers-CEA/CA 19-9 USG CECT MRI/MRCP EUS ERCP/PTC 10. USG Mural thickening Mural calcification GB mass >1 cm Loss of normal GB wall-liver interface Gall stones Polyps 11. CECT Mass protruding into the GB lumen Mass completely replacing the GB Focal or diffuse thickening of GB wall Presence or absence of distant metastasis Regional lymph node involvement Local invasion into liver & porta hepatis 12. STAGE 0 & 1A Carcinoma in situ & T1-cancer that doesnotextend beyond the GB muscularis Simple cholecystectomy 13. STAGE 1B T2 lesion- invasion into perimuscular connectivetissue of GB Re-exploration revealed residual disease in 40-76% Regional lymphnode metastasis in 28-63% Exploration with en bloc resection of the GB with2 cm of adjacent liver(non-anatomoic) withregional lymphadenectomy of the hepatoduodenalligament En-bloc resection with anatomic resection of liversegments 4b & 5 14. STAGE II T3 Lesion-locally advanced cancers thatperforate the GB serosa or directly involve theliver or adjacent organ Hepatic resection encompassing segment 4b& 5 or trisegmentectomy with adjacent organs 15. STAGE III & IV Unresectable Median survival with unresectable disease isless than 6 months If detected intraoperatively Radio-opaque clips No data to support debulking cholecystectomy 16. PROGNOSIS 5-year survival rate is 5% Median survival 12 months(stage IA-III) Median survival 5.8 months(stage IV) 17. WHY POOR PROGNOSIS? Usually diagnosed at a late stage Aggressive nature Clinical presentation mimics that of biliarycolic/chronic cholecystitis Incidental diagnosis at surgery Incidental diagnosis after pathology report 18. SURVIVAL RATES.NOSTAGE5 YR.SURVIVAL RATE1 I60%2 II 39%3 III15%4 IV 1% Median survival 12 months(stage IA-III) Median survival 5.8 months(stage IV)NCCN guidelines 2010 19. EXTENT OF LYMPHADENECTOMY