Gall Bladder Cancer

1. What is the gallbladder?

The gallbladder is a pear-shaped organ that lies just below the liver in the upper abdomen. The purpose of the gallbladder is to store bile, a juice made by the liver to digest fat. When food is being digested in the stomach and intestines, bile is released by the gallbladder through a tube called the common bile duct, which connects the gallbladder and liver to the duodenum (first part of the small intestine).

2. What is gallbladder cancer?

Gallbladder cancers occurs when normal cells in the gallbladder change and grow uncontrollably, forming a mass called a tumor. A tumor can be benign (noncancerous) such as a polyp, or malignant (cancerous). Over time, a benign mass/polyp has the potential to become malignant. Such as occurrence has been demonstrated amongst Indians or people living in the west who are of Indian origin. Malignant tumours can spread to other parts of the body. Primary gallbladder cancer is cancer that starts in the gallbladder, as opposed to cancer that begins somewhere else in the body and spreads to the gallbladder.

3. Is there a reason I have developed gallbladder cancer ?

It is not yet what exactly causes gallbladder cancer. The following factors can raise a person's risk of developing gallbladder cancer.
Gallstones- These are tiny stones made up of cholesterol and bile salts that occur in the gallbladder. While gallstones have been found in 75-90 of people with gallbladder cancer, only a very small proportion of people with gallstones actually develop gallbladder cancer.
Gallbladder polyps- These growths sometimes form when small gallstones are embedded in the gallbladder wall or may develop because of inflammation. Polyps larger than one centimeter are more likely to be cancerous.
Age- The risk of gallbladder cancer increase with age.
Gender- Women are about twice as likely to develop gallbladder cancer as men.
Geographical factors- Women are about twice as likely to develop gallbladder cancer as men.
Geographical factors- The incidence of gallbladder cancer is much greater in the northern and north eastern regions compared to other parts of India.
Smoking- Tobacco use increases the risk of gallbladder cancer. Other gallbladder diseases and conditions-Porcelain gallbladder, choledochal cyst, and chronic gallbladder infections are conditions that increase the risk of developing gallbladder cancer.
4. What are the symptoms of gallbladder cancer ?

Unfortunately, gallbladder cancer is usually not discovered at an early stage. Gallbladder cancer can be difficult to detect during routine physical examinations. Sometimes, gallbladder for other reasons, such as gallstones. When symptoms do occur, they include jaundice(yellowing of the skin and whites of the eyes), abdominal pain, nausea and vomiting, bloating, lumps in the abdomen, and fever.

5. What tests will I be required to undergo?

  • Blood tests such as liver function tests and tumour markers (Serum CEA, Serum CA 19.9) are useful in patients with gallbladder cancer. It is important to realize that even in patients with gallbladder cancer, these tumour marker levels may be normal. If elevated, they help to support the possibility of cancer. These tests are also useful in the follow-up of patients with gallbladder cancer. If the levels after surgery suddenly begin to rise on follow-up, this could alert the doctor to the possibility that the cancer may have come back.
  • Imaging techniques in the form of ultrasound, CT scan, MRI scan, and/or PFT scan can provide valuable information regarding the cancer and whether it has spread (Stage of the cancer).
  • Endoscopic retrograde Cholangio-Pancreaticography (ERCP) with stenting (a tube is inserted into the bile duct through an endoscope which is inserted through the mouth) is planned if jaundice is present. If an ERCP is not possible and jaundice is present, a Percutaneous Transhepatic Biliary Drainage (PTBD) may be performed (a tube is placed into the bile duct through the skin by interventional readiologists). Jaundice is not a good sign and relieving of jaundice is preferable before any definitive treatment is started.
  • Biopsy is often required if an operation is not being planned immediately. If the cancer was only detected after your gallbladder was removed, a review of the slides and/or blocks of the gallbladder biopsy specimen, by our own specialized pathologists, is performed to confirm the diagnosis and also acquire additional information if possible.

6. How will my treatment be decided ?

After confirmation of the diagnosis and the essential tests are completed, a fair idea about the stage of the disease can be obtained. Treatment planning is performed by a multidisciplinary team which consists of a surgeon, gastroenterologist, radiation oncologist, intervention radiologist, medical oncologist, and pathologist. Treatment options and recommendations depend, on various factors, including the type and stage of cancer, possible side-effects, and the patient's preferences and overall health.

If the gallbladder has already been removed (laparoscopic / open cholecystectomy) and the tumor is limited to the innermost lining (lamina propria) of the gallbladder, no further treatment is required and regular observation is sufficient. If the tumour extends beyond this layer, another larger operation is usually required. If the tumour has extended beyond the gallbladder and an operation is not feasible, chemotherapy or chemoradiotherapy if sufficient tumour shrinkage takes place. This situation is often dealt with in the setting of a possible clinical trial.

7. What type of operation will be performed ?

Complete removal of the cancer is the best and only possibility of a cure. In the event that this is the first operation being performed on the gallbladder, it is called a radical cholecystectomy. If the operation is being performed after the gallbladder has already been removed, it is called a radical re-revision surgery. The operation essentially includes removal of the gallbladder (if not already removed) along with a pari of the adjacent liver as well as the surrounding lymphnodes that drain the gallbladder with or without the removal of the bile duct.

8. If I am to undergo surgery how do I prepare myself for it ?

Preparation for gallbladder surgery is similar to preparation for any major surgery. From the perspective of the patient, breathing exercises should be practiced as instructed. Smoking should be stopped. A nutritious diet should be implemented. Follow the anaesthiologist's instructions regarding your regular medications. Necessary arrangements regarding the admission and other logistical issues related to the hospital stay for 10-14 days after the operation, or even longer in the event of any complication, should be made.

9. What are the risk involved if I get operated ?

There is a possibility that during the operation (either open surgery or laparoscopy), it is found that the tumour has spread beyond that was previously thought or seen on preoperative imaging. In such an event, a major operation is not advisable and other options of treatment such as chemotherapy may be recommended. This unpleasant situation can be encountered in spite of adequate and best possible preoperative evaluation. IN addition, as is the case with all major operations no matter how well done, there is a minimal but definite risk of complications associated with the surgery. There is almost a 10% chance that the recovery after the operation may be affected due to complications such as leakage of bile or bleeding. If complications do occur, adequate and timely intervention will solve such problems in the vast majority of cases. Up to 1% of patients are at risk of death during or immediately after surgery. These risks should be understood by the patient and relatives. This risk is acceptable even in the best centers world wide.

10. Will I need further treatment after surgery?

Whether or not you will benefit from further treatment in the form of chemotherapy or chemo-radiotherapy will be decided after the operation. Selected patients will benefit from such treatment. This decision will be made taking into consideration the final biopsy report.

11. How long can I expect to live after treatment?

Some patients may went to know the survival statistics of patients in similar situations. Others may not find the numbers helpful, or even might not want to know. It is up to you whether you want to read about the survival statistics in patient with gallbladder cancer. These figures are at best a rough estimate of your life-span after treatment.

As with many other types of cancer, the outcome depends on how advanced your cancer is when it is diagnosed. Sadly, for most people cancer of the gallbladder does not have a very good outlook. By the time it is diagnosed, it is often in the later stages and treatment is unlikely to cure it. Of all the people diagnosed with cancer of the gallbladder, only around 1 out of 10 (10%) will live for more than 5 years. However, in the earlier stages of these cancers 5-8 out of 10 people (50-80%) will live for more than 5 years. This long term outcomes are further improved when complete radical surgery is performed. Chemotherapy and chemo-radiotherapy after surgery is also believed to improve survival by most experts. Keep in mind that every person's situation is unique and statistics cannot predict exactly what will happen in your case.

12. Is there any chance of the cancer coming back?

Despite optimal treatment, there remains a risk of the cancer returning. The likelihood of tumor recurrence is highly subjective. After completion of treatment, reporting for regular check-ups as advised is the best way to detect and treat any tumour that has come back at an early stage.

13. How often do I have to come back to the hospital for routine check-ups after the completion of treatment?

In the absence of significant symptoms, routine check-ups is performed every 3-4 months for 2 years after that, and annually thereafter. The check-ups includes a few questions regarding any problem you might be facing, a physical examination, blood tests, including liver functions and tumour markers, as well as ultrasound. Further tests may be required if any problem is suspected.

14. Will I be able to adjust to this disease well?

Each patient's experience with gallbladder cancer is different. Once you undergo an operation, you will be able to return to regular activity within a mouth of surgery. This will be with little or no dietary/lifestyle restrictions. Completing treatment can be noth stressful and exciting. It may help to know that many cancer survivors have learnt to liver with the uncertainty of the future and are leading full lives.