indiacancer.org - Gall Bladder Cancer

	Gall Bladder Cancer

		What is the Gallbladder?
		What is cancer of the Gallbladder?
		How does cancer of the Gallbladder present?
		How is cancer of the Gallbladder detected?
		What are staging and grading?
		How is cancer of the Gallbladder treated?
		What are the side effects of treatment for Gall bladder Cancer?
		What is the importance of follow up?

What is the Gallbladder?

The gallbladder is a globular or pear-shaped organ hanging from the undersurface of the liver, on the right side of the upper abdomen. It is a storage organ for bile which is a fluid produced by the liver. Bile is a fluid used to break down and digest fats, which are produced from food broken down in the stomach and the intestines.

As the food is being digested in the stomach and the intestines, bile is released from the gallbladder through a tube called the common bile duct that connects the gallbladder and the liver to the first part of the small intestine, which is known as the duodenum. The common bile duct opens into the second part of the duodenum on its inner or left surface.

The Gall Bladder and the Bile Duct

What is cancer of the Gallbladder?

Gall Bladder Cancer

Cancer of the gallbladder is a cancer originating from the gallbladder. The slight difference between other cancers and cancer of the gall bladder is usually the fact that cancer of the gallbladder is more common in women than in men.

It is also more common in people who have developed gallstones, which are hardened clusters of material inspissated and found clogging the gallbladder.

How does cancer of the Gallbladder present?

	Cancer of the gallbladder is always a diagnostic dilemma, because the gallbladder is hidden so far behind other organs in the abdomen. The symptoms of cancer of the gallbladder may be just like any other benign disease or condition of the gallbladder such as gallstones or infection and there may be no symptoms at all in the early stages of the disease. Unfortunately, when abdominal findings do appear, such as the appearance of a hard lump just beneath the right rib cage, it is often already an advanced disease. There may have been symptoms of flatulent dyspepsia, or 'indigestion with gas', pain in the right upper abdomen, or even an attack of jaundice or yellowish discoloration of skin in the past.

How is cancer of the Gallbladder detected?

If the above symptoms are present, the doctor may order a series of imaging investigations and other tests to find out the problem. Usually, it is still difficult to find out cancer of the gallbladder unless the patient undergoes a surgery.

The first basic investigation which is ordered is an ultrasound which uses sound waves to bounce off tumors and normal tissues in order to diagnose what is abnormal and differentiates it from the normal.

A more definitive investigation is in the form of a CT scan or a CAT scan which is a special kind of x-ray in which very thin radiographic images are taken and are then integrated and interpreted with the help of a computer.

Sometimes the CT may be able to tell an experienced surgeon about the presence of a gallbladder cancer by the thickness or change in thickness of the gallbladder wall. But many a times this may be missed. Especially so, if gallstones are associated with the problem and the gallstones being easily detectable, the patient is considered to be suffering from gallstone disease. The gallbladder is removed for gallstones and only when the final tissue diagnosis comes, is it realized that there was a coexisting gallbladder cancer and the patient has actually undergone a sub-optimal treatment.

In case the cancer is not at all picked up by investigations but the doctor still suspects that it could be a gallbladder cancer, especially if the walls are thickened without presence of a stone, then the abdomen may be opened and the gallbladder and other nearby organs and tissues may be examined. This procedure is called an exploratory laparotomy.

What are staging and grading?

These are terms with which you must become familiar, if you are dealing with any form of cancer.

When we stage a cancer, we try to establish carefully degree of spread of the cancer and if indeed there is spread, to what extent and involving which organs.

The grading of a cancer is a microscopic issue, in which the pathologist lets you know how aggressive this particular type of cancer is ; well differentiated means less aggressive, moderately differentiated intermediately aggressive and poorly differentiated more aggressive.

Both grading and staging help your clinician to establish the prognosis or how serious your disease is and what is going to be the likely outcome.

Staging may require additional imaging tests such as CT Scan, MRI, Sonography of the abdomen, IVU, Bone scan or chest X-ray.

A working staging system for cancer of the gallbladder is as follows:

Localized cancer of the gallbladder is found only in the tissues which are making the wall of the gallbladder and can be removed in toto during surgery.

Unresectable cancer of the gallbladder is that which has spread to tissues beyond the gallbladder such as the liver, pancreas, stomach or small intestine and into the lymph nodes in the area (Lymph nodes are small bean-shaped structures, which act as stations for drainage of lymph, a clear watery fluid, which courses through out the body in transparent, thin tubes called lymph channels or lymphatics, from various organs). This type of cancer is not amenable to surgery.

Recurrent
This is a disease which has come back after the primary therapy for the Gall bladder Cancer is over. It may recur in the gall bladder itself or in other parts of the body.

How is cancer of the Gallbladder treated?

A lot depends on the patient's constitution, the grade of her disease and its staging. Patients are usually treated by a team of specialists which utilizes a multipronged approach. This includes an oncosurgeon and a radiotherapist. The plan of treatment is tailored to fit a patient's requirements. If necessary, chemotherapy may become an add on.

Treatment strategies

The bastion of treatment for cancer of the gallbladder is surgery. Although radiation and chemotherapy have also been tried out, usually cancer of the gallbladder is not very amenable to these other modalities of treatment.

The ideal treatment for localized gallbladder cancer is an operation called a radical cholecystectomy. In radical cholecystectomy, the gallbladder is removed (this procedure is known as a cholecystectomy) along with a section of the liver, which forms the gallbladder bed or that part of the liver which houses the gallbladder, along with the associated lymph nodes draining that particular area.

If the gallbladder has already been removed for other possible diagnoses such as gallstones and the cancer has been detected incidentally by the histopathologist, then the person may have to undergo a re-surgery and the gallbladder bed and the surrounding nodes may have to be removed in order to complete the procedure.

This is often quite a difficult undertaking because most tissues will be stuck out there (due to the previous surgical intervention) and all the planes of dissection will be lost for the second procedure.

In case the cancer of the gallbladder is unresectable and has spread to surrounding tissues, then a surgery may be performed to relieve the patient of symptoms of obstructed bile. This procedure is known as a biliary bypass.

In this procedure, the gallbladder or the common bile duct is cut open and is sewn directly to a segment of the second part of the small intestine called the jejunum. If the gallbladder is joined with the small intestine, then the procedure is known as a cholecystojejunostomy, and if the common bile duct is joined with the jejunum, then it is known as a choledochojejunostomy.

The alternative local therapy to surgery is radiation therapy. This involves the use of high energy, penetrative rays to destroy cancer cells. It affects cancer cells only in the zone treated. Radiation therapy is also employed for palliation i.e. control of symptoms alone in an advanced cancer.

Radiation therapy can also be used in adjunct to surgery or chemotherapy, either before or after.

Teletherapy or external radiation is given via a machine remote from the body while brachytherapy or internal radiation is given by implanting a radioactive source within the involved tissues. Patients may or may not require both modalities of radiation.

Radiotherapy, after initial planning, usually takes just 5 to 10 minutes per day, 5 days a week for about 6 weeks. This time period is flexible depending upon the modality of radiation used.

Besides local therapy, the best attempt to control cancer cells circulating in the body and lodged at places other than the gall bladder is by using systemic therapy (therapy which affects the entire systems of the body) which is in the form of injections or oral drugs. This form of treatment is called chemotherapy.

This form of treatment is given in a cyclical manner (each set of drugs is repeated usually after every 3-4 weeks.)

Chemotherapy can also be used in combination with surgery, radiotherapy or both, either before or after.

What are the side effects of treatment for Gall bladder Cancer?

	Surgery for Gall bladder Cancer should be undertaken only in institutes which are experienced in this kind of surgery. The surgery can be very morbid in the wrong hands and it is one of the technically more difficult surgeries to perform. Often the result of surgery may not be favorable if done by inexperienced hands. Unfortunately treatment for cancer does cause damage to the healthy tissues. Please ask the clinician about any possible side effects before any form of treatment commences. The effects of radiation depend upon the dose of radiation, the size of the area radiated, and the number and size of each fraction. The commonest side effect is extreme fatigue. Although bed rest is good, most radiotherapists advise the patient to be as mobile as possible. Another common problem is that of radiation dermatitis in which the skin covering the radiated area becomes red, dry, itchy, and may show signs of scaling off. This will slowly settle down after radiation ceases, but there may be a permanent 'bronzing' of the skin. It is important to note here that this skin problem is associated only with teletherapy or external radiation therapy. Radiation also may cause nausea and vomiting, diarrhea, urinary discomfort. There may also be a fall in the white blood cells, which are needed by humans to fight infection. Usually the radiotherapist can suggest the drugs and diet necessary to alleviate such problems. The various drugs in chemotherapy cause a varied spectrum of side effects. The severity and variability of these symptoms are very individualistic, changing from patient to patient. Some of the common side effects are:
		Skin rashes.
		Loss of hair.
		Diarrhea.
		Vomiting.
		Tingling and numbness in the fingers and toes.
		Hearing loss.
	Most are temporary and recede after therapy is over. Hair growth gradually starts after cessation of chemotherapy.
	The medical oncologist will usually be able to reduce the severity and spectrum of these side effects.
	The psychology of the patient is very important during therapy. Better psychologically prepared the patient is, better are her chances of having decreased side effects. The patient should drink large quantities of water while the therapy is in progress, and preferably avoid uncooked or raw food. Water should be filtered or boiled. Any relative or person who has any sort of infection such as common cold should be asked to desist from coming close to the patient.

What is the importance of follow up?

The importance of followup cannot be overemphasized. It is a fatal fallacy to assume on the patient's part that once the primary or the first phase of treatment is over, then he or she is cured. It must be stressed here that cancer has a notorious proclivity of coming back again and again. The only way to fight this is to pick up any problem when it is still early, so that it can be nipped in the bud. And the only way to do this is to follow up when the doctor calls you for the next visit. Each such visit will include a detailed history, a physical examination (including an internal i.e. a rectal or vaginal examination ), a chest x-ray, an ultrasonography or a CT scan, and various other blood studies as indicated.