Definition
Gallbladder carcinoma is a malignant disease usually originating in the epithelium lining. Its cause is unknown, but the high incidence of associated cholesterol gallstones (>75%) creates an etiological link between the two diseases.
Tumors of the biliary system are found mostly in the elderly in the seventh decade of life and are 3-4 times as common in women as in men. It is strongly associated with gallstones, but while nearly 80% of those with carcinoma have concomitant gallstones, less than 0.5% of all patients with gallstones will develop carcinoma. Porcelain gallbladder predisposes to the development of carcinoma.(25% incidence)
Structurally it can present with focal thickening of the wall, polypoid lesion, or a mass, and is most common in the fundus (60%) , followed by the body 30%, and then the neck (10%).
Functional impairment is limited and it is for this reason that presentation is late and prognosis is poor.
Complications include early spread to the regional nodes and direct invasion into the liver through the gallbladder fossa.
Clinically the patient usually presents late in the disease with symptoms similar to that of cholelithiasis. RUQ pain, jaundice, and nausea with vomiting. Occasionally this results in a palpable gallbladder before invasion into the adjacent structures. Still, it is rarely found at a time when surgical resection is possible, and thus has a 5-year survival rate of ~1%.
The diagnosis is rarely suspected given the above symptoms, and is often only found incidentally on resection of a gallbladader for symptomatic cholelithiasis.
From an imaging standpoint, ultrasonography will often reveal a thickened wall or polypoid masses, though these features may not specific for carcinoma. A polyp that is larger than 1cms is suspicious for carcinoma. CT may also identify a mass or thickening within the gallbladder, but the diagnosis is usually suggested when spread to the liver adjacent to the gallbladder fossa is identified or when regional adenopathy is present. Magnetic resonance cholangiopancreatogrphy may also help visualize the liver, biliary treee and neighboring lymph nodes but offers no clinical advantages over CT scan.
Surgical treatment is provides the only opportunity for cure but only a minority of patients are candidates. Patients who have a porcelain gall;bladdder should have elective cholecystectomy because of the high incidence of gallbladder cancer. The role of adjuvant chemotherapy following surgery is to control microscopic disease. Role of radiation therapy is unclear.
Carcinoma Thickening and Granular Appearance |
This is a resected gallbladder cut longitudinally and opened like a book. You are looking into the lumen in the two halves created by the cut. The cystic duct is over the left side of the label, and the fundus of the gallbladder is over the right side. The tumor is in the fundus as tan-white tissue thickening the wall, and causing a granular appearance in the mucosa. There is a separate, 0.8 cm mucosal nodule nearby. The rest of the mucosal surface is normal appearing with small ridges, and a green-brown color. The wall is only about 1 – 2 mm thick. This carcinoma was found incidentally in this gallbladder, which was removed for gallstone. Unfortunately many gallbladder carcinomas are not diagnosed early. They are either found incidentally, like this one, or they are detected after they spread, when it is too late for effective therapy.
11951c01.8s gallbadder carcinoma grosspathology Courtesy Barbara Banner MD |
Most exophytic carcinoma occurs in the fundus and the neck of the gallbladder.
gallbladder dx cholelithiasis grosspathology Courtesy Barbara Banner MD |
Morphology of gallbladder carcinoma may be infitrating or exophytic. The infiltrating pattern is more common, and is characterized by deep ulcerations of the wall. These may occasionally lead to fistulous tracts forming with adjacent visceral structures, most often the liver.
82755c01.8s |
82755c01.8s 68 M gallbladder prone supine fundus Phrygian cap normal fundus and body are exposed to the concentrated bile normal anatomy pathophysiology Copyright 2008 Courteesy Ashley Davidoff MD |
04500c01 porcelain gallbladder premalignant plain film plain X-ray calcification calcified wall Courtesy Ashley Davidoff MD copyright 2008 |
47683c01 gallbladder fx calcification in wall calcified wall dx porcelain gallbladder CTscan Davidoff MD |
76225c01 gallbladder wall calcification calcified porcelain gallbladder premalignant CTscan Courtesy Ashley Davidoff MD |
In the exophytic patterin illustrated above, the neoplasm remains within the wall, taking on a characteristic cauliflower like appearance. The luminal portion can be necrotic, hemmorrhagic and ulcerated.
11949bs gallbadder carcinoma grosspathology Courtesy Barbara Banner MD |
Carcinoma – Restricted to the Gallbladder
16228c03.8s gallbladder wall submucosal tumor = orange mucosal tumor = pink lumen = green thickened mucosa and submucosa carcinoma of the gallbladder CTscan Courtesy Ashley DAvidoff MD copyright 2008 |
Carcinoma – Extending into the Liver via the Gallbladder Fossa
16254c03.8s gallbladder anterior wall liver invasion space occupatopn obstruction bile ducts aggressive gallbladder carcinoma complicated by direct invasion metastasis liver windows narroe windws tumor settings gallbladder fossa GBF CTscan Courtesy Ashley Davidoff copyright 2008 |
24404c.8s 75 female gallbladder calcification adjacent mass in the liver local invasion into the gallbladder fossa dystrophic calcification probably mucinous adenocarcinoma of the gallbladder carcinoma stones cholelithiasis hydronephrosis |
Carcinoma – Extending into the Liver via the Gallbladder Fossa and Additional Metastases
17280c02b01.8s gallbladder liver mass local invasion cholelithiasis metastasis carcinoma primary gallbladder gallbladder fossa Courtesy Ashley Davidoff MD copyright 2008 |
Disease Extension Beyond the Liver
40018c02b.8s elderly female cholelithiasis obstructive jaundice common bile duct stricture dilated intrahepatic ducts irregular enhancing thickening of the gallbladder wall stent gallbladder carcinoma with extension into the CBD or CBD carcinoma with extension into the wall of the gallbladder CTscan USscan ultrasound ERCP Courtesy Ashley DAvidoff MD copyright 2008 |
16254c05 gallbladder space occupation gallbladder carcinoma by CT it appears as a low density centrally and enhancing soft tissue peripherally by USscan looks like the whole lumen is filled with soft tissue tumor question of delayed tumor enhancement vs necrosis CTscan USscan ultrasound Courtesy Ashley Davidoff copyright 2008 |
16254c01b02.8s gallbladder thickened irregular wall air anterior wall small fluid collection gallbladder carcinoma complicated by perforation and abscess formation CTscan Courtesy Ashley Davidoff copyright 2008 |
Conclusion
From the anatomical point of view it is interesting to note that gallbladder cancer occurs most commonly in the fundus, and from the pathophysiological point of view it is so frequently associated with gallstones. It is attractive to consider the fact that in the “day” position of the gallbladder, the most dependant, concentrated bile is in contact with the mucosa, and similalrly stones will be in contact with the fundal mucosa for the longest time. In the prone position (if the person sleeps in prone position) stones will be in contact with the anteriorly positioned fundus as well. hence chronoic contact, chronic irritation of the fundus and aberrant chemical environments such as excessive bile salts, or cholesterol make a fertile environment for the evolution of the mucosa to dysplasia and carcinoma.
Gallbladder Cancer and Stones |
The greenpepper sectioned in long axis has a mass like base, and remnant seeds reminiscent of the combination of fundal carcinoma in the presence of cholelithiasis.
11528b.8 gallbladder food in the body green pepper cancer carcinoma gall stones cholelithiasis Davidoff art Davidoff photography copyright |
References
Denshaw-Burke Mary Denshaw-Burke, MD, Gallbladder Cancer eMedicine 2008
Szarnecki Gregory M Szarnecki, MD, Gallbladder, Carcinoma e Medicine 2007
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