What is Gallbladder Carcinoma?
Gallbladder cancer is not very common, but it accounts for almost half of all cancers in the biliary tract, which is the pathway your body uses to move bile. This type of cancer is known to be extremely deadly, with only about 17.6% of patients living for 5 years after their diagnosis between 2007 and 2013. Gallbladder cancer is often diagnosed at a late stage because it grows rapidly, it’s hard to detect due to its complicated location in the body, and its symptoms appear at advanced stages. If the cancer has already spread locally or to distant parts of the body, the main form of treatment is relief-centered chemotherapy. However, if found at an early stage, it can potentially be cured through surgery and follow-up treatments.
What Causes Gallbladder Carcinoma?
Chronic inflammation is a major risk factor for gallbladder cancer. The chances of getting gallbladder cancer are highest in people who’ve had gallstones in the past. The risk increases if the gallstones were large, if they’ve been present for a long time, and if they caused numerous symptoms.
“Porcelain gallbladder” is a condition where the gallbladder becomes hard due to the presence of gallstones for an extended period. This condition is typically found during imaging tests for other health issues. In most cases, it leads to the removal of the gallbladder (cholecystectomy) to prevent further complications.
Other risks for gallbladder cancer include having gallbladder polyps, or growths; congenital biliary cysts, or cysts present from birth in the gallbladder; and unusual anatomical structure of the areas connecting the pancreas and the gallbladder, which all result in chronic inflammation and may culminate in gallbladder cancer.
In certain regions where bacteria like salmonella typhi and helicobacter are common, there is a higher risk of gallbladder cancer. Long-term carriers of these bacteria, even if they don’t show symptoms, are at a higher risk.
Certain drugs, substances from certain jobs, and lifestyle choices have all been linked to gallbladder cancer. These include drugs like methyldopa and isoniazid; exposure to substances like methylcellulose and radon at work; and lifestyle-related factors like cigarette smoking, obesity, and high carbohydrate intake. Chronic primary sclerosing cholangitis, a disease that causes inflammation and scarring of bile ducts, and inflammatory bowel diseases can also increase the risk of gallbladder cancer.
Risk Factors and Frequency for Gallbladder Carcinoma
Gallbladder cancer is more prevalent in certain areas outside the United States, such as South America, India, Pakistan, Japan, and Korea. This is largely due to the high number of people with gallstones and chronic gallbladder infections in these regions. The American Cancer Society estimated that, in 2017, there were about 11,740 new cases of gallbladder cancer and 3,830 deaths in the United States, with more cases in women. However, the overall occurrence of gallbladder cancer has dropped in people over the age of 50, but it has risen in the young population. The disease is seen more frequently in Whites, Southwestern Native Americans, and Mexican Americans, while it is less common in African Americans.
Signs and Symptoms of Gallbladder Carcinoma
Gallbladder cancer is often found by chance during imaging tests or after surgery. It’s usually spotted during a review of the surgical specimen after a gallbladder removal surgery.
People with gallbladder cancer often do not show any symptoms initially. Symptoms that do arise can be quite vague and can easily be mistaken for inflammation of the gallbladder. They may experience belly pain, feel nauseous or vomit, suffer from indigestion, feel weak, lose their appetite, lose weight, and might show signs of jaundice. When the cancer causes a blockage in the bile duct, it leads to jaundice, light-colored stools, dark-colored urine, and itchy skin. One of the syndromes that’s associated with gallbladder cancer is Mirizzi syndrome. It occurs when a gallstone blocks the common bile duct and is often accompanied by a poor prognosis because the cancer is usually advanced and cannot be removed surgically. Other general symptoms of advanced cancer, like weight loss and a feeling of tiredness, can also occur.
During a physical examination, doctors might discover signs of jaundice, pain in the upper right part of the abdomen, or Courvoisier sign (which is a swollen, yet not tender, gallbladder with jaundice). The latter usually happens as a result of a blockage caused by the growing cancer, rather than an occasional gallstone blockage. If the doctor feels an enlarged liver, a mass in the abdomen, fluid in the abdomen, or signs of a bowel blockage during the physical examination, it usually means the cancer is in an advanced stage and has spread to other areas.
Testing for Gallbladder Carcinoma
If you have symptoms indicating obstructive jaundice, your doctor will need to run particular tests. These include a complete blood count, a basic chemistry panel, and a liver function test. The results may expose a non-specific pattern caused by blockage of bile, a fluid that helps digest fat. This situation would necessitate bile decompression.
Two common tools for visualizing what’s going on inside your body are an ultrasound and a CT scan. However, a more accurate test could be an endoscopic ultrasound (EUS) which uses a small probe passed down your throat to create images. EUS has proven very effective (97%) in spotting cancerous cells accurately and can provide crucial information on the stage of a tumor by determining its depth and any swollen lymph nodes.
CT scans sometimes struggle to differentiate between benign (non-cancerous) or malignant (cancerous) conditions. To overcome this, doctors can use dynamic magnetic resonance (MR) or MR cholangiopancreatography (MRCP). These imaging tests offer a more comprehensive understanding of the extent of the disease. They can identify patients where surgical treatment may not be possible due to the tumor involving vital structures such as the blood vessels or lymph nodes.
Some gallbladder cancers show up in a scan called a PET/CT that uses a small amount of a radioactive drug to show potential cancer. This test helps to spot hidden and advanced-stage diseases and can prevent unneeded surgery.
While tumor markers like carcinoembryonic antigen and carbohydrate antigen 19-9 are frequently high, their lack of specificity and sensitivity means they can’t be directly used to diagnose cancer. However, regular monitoring can track response to therapy. The American Joint Committee on Cancer 2010’s TNM system is typically preferred for staging a tumor. The system ranks the cancer from 0 to IV, with corresponding survival rates at five years ranging from 81% (stage 0) to 2-3% (stage IV).
Treatment Options for Gallbladder Carcinoma
Neoadjuvant therapy, which is treatment given before primary treatment like surgery, is usually not considered for gallbladder cancer since it’s often quite advanced when diagnosed. However, in cases that are treatable by surgery, surgery is the only way to cure patients with Stage II or less of the disease.
The surgery usually includes removing the gallbladder along with part of the liver and neighbouring lymph nodes, or the common bile duct if the cancer has spread. If a pathology test of a removed gallbladder inadvertently discovers cancer that’s stage T2 or higher, further surgery may be required.
After surgery, patients should be offered chemotherapy within 8 to 12 weeks. This treatment is especially recommended for patients whose pathology report shows that their cancer is T2 or higher, has spread to lymph nodes, or if the tumor was not completely removed in surgery. The chemotherapy typically lasts six months or alternatively, could be four months if combined with radiation therapy.
For this kind of post-surgical chemotherapy, commonly used drugs are gemcitabine or 5-FU (fluoropyrimidine). Another chemotherapy regimen includes capecitabine combined with gemcitabine. Last of all, yet another regimen is combining 5-FU-based chemotherapy with radiation therapy.
For follow-up care, it is suggested that patients get imaged every six months for two years then annually up to five years. Doctors might also monitor liver function and tumor markers every three to four months for two years then every six months up to five years.
For gallbladder cancer that can’t be surgically removed or has spread, palliative care can help manage symptoms. Patients may undergo radiation therapy, which is usually combined with 5-FU. For those physically fit enough, another type of chemotherapy involving gemcitabine and cisplatin might be explored. Other first-line treatment combinations are also available. As gallbladder cancer varies widely from patient to patient, it is recommended that patients with advanced, inoperable disease consider participating in clinical trials.
What else can Gallbladder Carcinoma be?
Here are some potential conditions that could be diagnosed:
- Acalculous cholecystitis (inflammation of the gallbladder without gallstones)
- Acalculous cholecystopathy (gallbladder disease without gallstones)
- Ampullary carcinoma (a type of cancer located where the bile duct and pancreatic duct join and empty into the small intestine)
- Bile duct strictures (narrowing of the bile ducts)
- Bile duct tumors (cancerous growths in the bile ducts)
- Biliary colic (severe pain in the abdomen caused by gallstones)
- Biliary disease (any disease involving the system that creates, stores, and releases bile into the intestines for digestion)
- Biliary obstruction (a blockage of the bile ducts)
- Cholangitis (inflammation of the bile ducts)
- Cholecystitis (inflammation of the gallbladder)
What to expect with Gallbladder Carcinoma
As mentioned earlier, the outlook for gallbladder cancer is usually unfavorable. The outcome can be influenced by several factors including how advanced the cancer is at the time it’s discovered, the specific location of the tumor, whether it’s able to be removed through surgery or respond to chemotherapy, and whether it has spread and if so, where. Gallbladder cancer often comes back after treatment and most people diagnosed with this condition don’t survive more than 5 years.
Possible Complications When Diagnosed with Gallbladder Carcinoma
The negative effects of the disease might be a relapse of the tumor, which can lead to severe abdominal pain due to the involvement of the internal abdominal organs. Sometimes, a tumor can reappear in the same area, causing obstructive jaundice, a condition where the flow of bile is blocked causing yellowing of the skin. If a patient starts experiencing unexplained weight loss, obstructive jaundice, or growing pain in the abdomen, it could indicate the disease has returned.
Potential Complications:
- Tumor recurrence
- Severe abdominal pain linked to the internal abdominal organs
- Obstructive jaundice due to the tumor blocking bile flow
- Unexplainable weight loss
- Increasingly intense intra-abdominal pain
Preventing Gallbladder Carcinoma
Patients should be given advice that aligns with the phase of their illness. It’s really important to understand what the probable results could be, whether the cancer is detected early or diagnosed in a late, untreatable stage. Emotional support is necessary throughout all phases of dealing with this illness. Doctors will typically provide these supportive services to the patients and their families.