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Gallbladder Cancer

Anatomical facts:

Bile is a fluid that contains enzymes needed to digest fat. It is secreted by the liver and stored in the gallbladder, a small organ located underneath the liver. Bile is released and delivered from the gallbladder to the small intestine when a person eats.

A complex system of hollow tubes, called ducts, delivers bile from the liver to the gallbladder and from the gallbladder to the duodenum, which is the first section of the small intestine. This system is referred to as the biliary tract. The part of the system located inside the liver is called the intra-hepatic bile duct, and the part located outside the liver is called the extra-hepatic bile duct.

Bile duct cancers:

About 9,000 people in the United States are diagnosed with extra-hepatic bile duct cancer or gallbladder cancer each year. Most biliary tract cancers are discovered in late stages, when cure is difficult to achieve. The five-year survival rate for both gallbladder cancer and extra-hepatic bile duct cancer is about 15,010.

Bile duct cancer is more common in men, and most patients are diagnosed between the ages of 50 and 70. Gallbladder cancer, on the other hand, is more common in women because one of the risk factors for this disease is gallstones, which are more frequent in women. Gallbladder cancer has a higher incidence among the Native American population in New Mexico and Alaska. Most patients are diagnosed after age 70. Bile duct cancer has a higher incidence in the Middle East and Asia because a parasite infection common in those parts of the world is one of the causes of this disease.

Types of cancers:

The majority of tumors that develop in the biliary tract are adenocarcinomas. Cholangiocarcinoma is a synonym for an adenocarcinoma that grows in the biliary tract. Cholangiocarcinomas also grow in the intrahepatic bile duct, and although these tumors are counted as liver cancer, their treatment and behavior are similar to those for cholangiocarcinomas that grow in the extra-hepatic biliary tract. Some information sources present separate sections for gallbladder and bile duct cancer, but others present the information together.

A rare subtype of cholangiocarcinomas, papillary cholangiocarcinoma, is less invasive and carries a better prognosis. Other tumors that may appear in the biliary tract are neuroendocrine carcinoma, adenosquamous carcinoma, melanoma, and lymphoma. These tumors are treated differently than cholangiocarcinomas.

Treatment for biliary tract cancers:

Surgery is the only treatment that has the potential for the cure of biliary tract cancer. The type and extent of the surgery depends on the location of the tumor. A number of surgical procedures may be used with the goal of removing the diseased section of the biliary tract and reconnecting the tubes to the small intestine. If the disease has spread, parts of other organs, such as the pancreas, the small intestine and the liver also are removed.

Cancers that are confined to the intrahepatic bile duct are treated with removing part of the liver (partial hepatectomy). Surgery in the biliary tract area is complicated, requires a long recovery period, and has significant side effects, some of which may be long term. Radiation therapy and chemotherapy are used to alleviate symptoms and improve the quality of life of patients’ whose disease is inoperable or has metastasized to distant organs.

Treatment for gallbladder cancer depends on many factors that include the stage of your cancer, your overall health and your preferences.

Surgery

Surgery is usually done on patients to remove the gallbladder if the cancer has not spread throughout the body. This kind of surgery is potentially curative. If the cancer has spread, then the cancer is not resectable, and surgery is done only to relieve the symptoms. This kind of surgery is called palliative surgery. Unfortunately, only a small portion of gallbladder cancers are resectable when they are first detected. Surgery to remove gallbladder cancer can have significant side effects and, depending on how extensive it is, may require several weeks for recovery.

Curative surgery can be done in the following ways:

Staging laparoscopy

This refers to the use of a laporoscope to determine the stage of the cancer. The laporoscope is a flexible tube like instrument with a camera and light at its end. It is inserted slowly through an incision made in the abdomen of the patient. With the help of this instrument, the doctor gets a proper view of the cancer. Surgery is planned based on the condition of the cancer (resectable or unresectable).

Simple cholecystectomy

In this operation, the surgeon removes the gallbladder completely. Early stage cancer patients can be cured by this surgery. Lymph nodes are also removed if required.

A simple cholecystectomy may be done in 2 ways:

Laparoscopic cholecystectomy: A laporoscope is inserted through a small incision on the abdomen. Surgical tools are inserted through several small openings to help the surgeon to remove the gallbladder while viewing the images on a screen. This kind of surgery can be performed only if the cancer is localized within the gallbladder. It is not possible to have a good view of the other organs where the cancer may have spread. It is minimally invasive and, therefore, the patient recovers quickly.

Open cholecystectomy: It involves removal of the gallbladder by making a larger incision in the abdomen.

Extended (radical) cholecystectomy: This surgical procedure involves removal of gallbladder along with adjacent tissues to which the cancer may have spread.This operation is preferred over simple cholecystectomy since it reduces the chances of recurrence of cancer. The extent of the surgery depends on the extent of metastasis from the gallbladder. Some parts of liver, pancreas, duodenum, the common bile duct, lymph nodes and some other tissues may be removed in this surgery.

Palliative surgery can be done in the following ways:

Surgical biliary bypass: This procedure is applied when the tumor blocks the small intestine which causes accumulation of bile in the gallbladder. A new passage for bile is created by cutting and re-joining the bile duct with the small intestine.

Placement of endoscopic stent: This surgical procedure is also performed to overcome bile duct blockage. A thin tube or stent is surgically placed through a catheter to remove the bile in the gallbladder or the stent may bypass the blocked zone and let the bile drain into the intestine.

Percutaneous transhepatic biliary drainage: This surgical procedure is applied when the above two processes to drain bile cannot be performed. The blocked zone can be determined from X-ray images. The ultra sound imaging technique is then used by the surgeon to place the stent in such a way that it remains in the liver to allow the drainage of bile either outside the body in a bag or into the small intestine.

Radiation therapy

Radiation therapy refers to the use of high-energy rays to reduce the size of gallbladder tumors by destroying cancer cells. This can be done in two ways:

External radiation therapy: A beam of radiation from a machine is aimed at the affected site of the patient’s body from outside the body.

Internal radiation therapy or brachytherapy: Radioactive substance put inside a needle or wire is placed near the affected region. Cancer cells are killed by the radiations emitted from the radioactive substances.

Several side effects accompany radiation therapy of gallbladder cancer.

When radiation is given after surgery, then the treatment is called adjuvant radiation therapy. This helps in reducing the chances of recurrence of the cancer. Radiation may also be used to reduce pain or increase the life span of a patient when diagnosed at an advanced stage.

Radiation therapy may also be used in combination with chemotherapy to improve the effect of either treatment.

The role of radiotherapy for carcinoma of the gallbladder is not yet clear. However, it has been shown that life span of advanced stage patients increases if radiation is given after surgery.

Chemotherapy

Chemotherapy is the use of drugs for the treatment of cancer.Chemotherapy may be given alone or in combination with surgery or radiation. When drugs are administered through a vein or by mouth, then this kind of chemotherapy is called systemic chemotherapy. This form of chemotherapy is used when cancer has spread all throughout the body and surgery is not possible. Direct administration of the chemotherapeutic agent to the target organ is called regional chemotherapy.

Clinical trials are going on to improve the status of chemotherapy for gallbladder cancer. The drug 5-FU can be used in combination with radiation therapy. Adjuvant chemotherapy can be given with single agent gemcitabine or a fluorpyrimidine-based agent. Another drug, Gemcitabine is normally used for treatment of patients with unresectable recurrent or metastatic disease. It may be used in combination with cisplatin or capecitabine for better effects.

Clinical trials

Clinical trials are treatments that are under development. Patients may participate in clinical trials to improve the standard of treatment, but cure cannot be guaranteed. Side effects related to these trials are also a cause of concern.

References

Jayaraman S, Jarnagin WR. Management of gallbladder cancer. Gastroenterol Clin North Am. 2010 Jun; 39(2):331-42, x. Review.

Zhu AX, Hong TS, Hezel AF, Kooby DA. Current management of gallbladder carcinoma. Oncologist. 2010; 15(2):168-81. Epub 2010 Feb 10.

Hueman MT, Vollmer CM Jr, Pawlik TM. Evolving treatment strategies for gallbladder cancer. Ann Surg Oncol. 2009 Aug; 16(8):2101-15.

This article was originally published on 7/12/2014 and last revision and update of it was 9/14/2015.