Gallbladder Cancer

What is Gallbladder Cancer Or Gallbladder Carcinoma?

It is a form of cancer that occurs when cancerous or cancer-causing cells are found in the gallbladder, an organ around the liver that stores bile.

Extent and Statistics:

It is the 22nd most common cancer worldwide.

Gallbladder Cancer is typically seen to be rather curable if discovered in the early stages. However, we have also observed cases where late-stage gallbladder cancer is incurable. Or in cases where people do survive, life becomes very difficult.

Gallbladder cancer is rather hard to detect due to it having symptoms that can be similar to what we experience on a daily basis.

Types of Gallbladder Cancer:

• Adenocarcinoma: Nearly 90% of cancers worldwide are adenocarcinomas. It starts in gland cells (which typically produce mucus) in the gallbladder lining.
  • Adenocarcinomas can be further divided into three types:
    • Non-papillary adenocarcinoma
    • Papillary adenocarcinoma: They occur in the connective tissue which holds the gallbladder. These are less likely to spread to the liver or places like the lymph nodes. The prognosis in this case is typically better.
    • Mucinous adenocarcinoma: As the name suggests, mucinous adenocarcinomas are often found in pools of mucus.
• Squamous cell cancer: Very similar to adenocarcinomas, these too typically start in the gland cells or the epidermis lining the gallbladder.
• Adenosquamous cancer: These typically have both cancer cells of the gland cells and the squamous cells. It is treated similarly to the cancers mentioned above.
• Sarcoma: It affects the connective tissues. However, it is different from adenocarcinoma, as here, the cancer starts in the muscle cells of the gallbladder, and then spreads to connective tissues.
• Lymphoma: It is an extremely rare form of gallbladder cancer and is typically treated with chemotherapy and radiotherapy.
• Small cell neuroendocrine tumours: This type of gallbladder cancer is very rare and rather malignant. It is also very difficult to detect, since the symptoms are quite “usual”, or what we typically ignore—such as vomiting, dizziness, and nausea.

As a result when these are discovered they are typically in the advanced stages. It can sometimes get large enough to compress the duodenum and invade the mucus lining of the stomach.

• There is no proper cure for this type of cancer yet. However, after tumour removal (if possible), anti-tumour therapy is seen to be useful.

Symptoms:

Though it may vary from person to person, this is a compilation of what we (typically) see in someone suffering from gallbladder cancer of any kind:

• Bloating, particularly in the upper belly.8
• Pain near the gallbladder, which is the upper right side of the abdomen.9
• Feeling a hard lesion through the skin on the upper right side of the abdomen.10
• Rapid loss of weight inactively.
• Extreme temperature, feeling very hot or very cold.
• Pain after eating.
• Constantly feeling “sick”—vomiting, nausea et cetera.
• Whites of the eyes, patches on the skin, turning yellow. This is called jaundice, and typically happens whenever the gallbladder cancer is very advanced.
• Itchy skin
• Darker urine
• Difficulty in excretion—conditions such as constipation or diarrhea.
  • Stool is typically also lighter and/or lumpier.

Stages:

Stage 0, or carcinoma in situ (CIS):

Earliest stage of gallbladder cancer.18 It is very unlikely for a cancer in the gallbladder to be found in this stage as the cancer cells are still only in the lining of the gallbladder and very few in number. If a patient has had a gallbladder stone removed or any surgery regarding the gallbladder, it is possible that it will be discovered even at this stage, but it is too early of a stage for a medical advisor to start working on it.

Stage 1

• The cancer is only in the inner layers of the tissues lining the gallbladder. So it has not spread to nearby lymph nodes, organs or cells or tissues for that matter.
• Though there is an unlikely chance that the cancer will be discovered here, it is arguably easier to recover from the after effects if it is discovered and treated from this stage.

Stage 2

• This stage of the cancer typically signifies that the cancer cells have not yet spread to the other cells—but have spread to the nearby connective tissues.
• It is an indication that you should seek help at this stage. It is only a matter of time before the issue gets grave as the cancer cells are starting to penetrate other parts of the body.

Stage 3

The stages are divided to 3A and 3B

• 3A: The cancer is growing through the gallbladder wall and spreading but has not obstructed or acted on any major lymph nodes yet.
• 3B: The cancerous cells have spread to nearby major lymph nodes.

Stage 4

This stage is an indication that the cancer is very advanced. It has most likely spread to other parts of the body and in most cases isn't possible to recover from. However there is still hope, given proper treatment and living conditions. This stage is divided into 4A and 4B

• 4A: Before we get into this, it is essential to reinstate that after the nutrients from the food are absorbed into the blood by the small intestine, they first reach the liver through the hepatic portal. It is needless to say that if this system is damaged in any way shape or form it will be detrimental to one's health. This stage means that the cancer has spread to one of the major blood arteries or veins that are leading to the liver, or into multiple organs outside the liver. It will thus cause a problem with nutrient absorption. The cancer might have spread to nearby lymph nodes as well.
• 4B: This stage is very hard to map; it can mean that the cancer is either near the affected site (here, the gallbladder) or very far away from it. One thing certain here is that the cancerous cells have definitely affected some of the lymph nodes, whether it be near or far from the gallbladder. As for organs, the cancer may/may not have spread to very distant organs. It might still be fairly localized and only affect nearby organs.

TNM stages:

Apart from stages 1-4, cancer can also be divided through the TNM stages.

• T: Signifies the size and spread of the cancer.
  • T1: Same as stage 0, all the cancer cells are concentrated in the lining of the gallbladder. It is divided to:
    • T1a: the cancer has grown into the immediate connective tissue layer underneath the lining of the gallbladder.
    • T1b: It means that the cancer has spread to the muscle tissue underneath the previous layer made of connective tissue.
  • T2: It means that the cancer has fully broken through the lining and entered the connective tissue.
    • T2a: it means that the cancer has spread to the side of the connective tissue that is not proximal to the liver.
    • T2b: it means that the cancer has spread to the side of the connective tissue that is facing the liver, but not spread into the liver yet.
  • T3: It means that the cancer has spread out of the gallbladder wall fully, most likely spreading into the liver first. However it might also spread to the stomach, intestines, pancreas et cetera organs that are relatively nearer.
  • T4: It means that the cancer has spread to a major blood vessel such as the hepatic portal vein or the hepatic artery; or multiple organs outside the liver.
• N: Signifies whether it has spread to lymph nodes.
  • N0: The cancer hasn't spread to any nearby lymph nodes yet.
  • N1: The cancer has spread to at least one lymph node. Typically, it can be along something major such as the bile duct, or the hepatic portal vein or hepatic artery.
  • N2: Cancer has spread to 4+ lymph nodes.
• M: Metastasis, or spreading of the cancer to another part of the body.
  • M0: It means that the cancer MIGHT have spread, but even so to nearby organs or ducts or structures. Just places proximal to the gallbladder might be affected.
  • M1: The cancer has spread to organs far from the gallbladder. It typically signifies that the cancer is very advanced. It might spread to the kidneys, lungs et cetera at this point.
• Correlating stages (0-4) with TNM stages:
  • Stage 1: T1N0M0
  • Stage 2: T2N0M0
  • Stage 3: a) T3N0M0, b) T(1-3)N1M0
  • Stage 4: a) T4N(0-1)M0, b)T(1-4)N(0-1)M1

★ Note: Correlations can be different for different stages depending on the individual. Consult your medical advisor.

Risk Factor and Causes:

• Age: It is typically seen that the risk of Gallbladder cancer increases with increasing age. Usually, people in their 80s or 70s are prone to getting it. Though it is a rare cancer, and even rarer in the younger generation, it can’t be entirely ruled out.
• Sex: Gallbladder cancers are more common in women than men. 71% of the cases reported are of women.
• A history of gallbladder related to problems, like gallstones, or inflammation: Again, this is very rare, even in people who do have a history of gallstones. Yet, compared to people who have never had gallstones, they have a chance of 4-5 times more in developing this cancer.
• Genetics and Family History: Very rare, but if people in your family have had gallbladder cancer, you do have a slightly higher chance of developing it.
• Calcium deposits in gallbladder: People with high calcium deposits in the gallbladder have a higher risk of developing gallbladder cancer, due to it being inflamed over and over. In such a case, to prevent cancer, surgeons might advise that the gallbladder be taken out.
• Abnormalities in the bile duct or a region/duct close to the gallbladder: It is likely that these conditions are hereditary. In such a case, pancreatic juices and enzymes can go back up into the common bile duct, which irritates and inflames it over time, causing a higher risk of cancer.
• Smoking increases the risk of developing cancers (any kind).
• Alcohol increases your risk of developing cancers (any kind).
• Diabetes increases your risk of developing cancers (any kind).
• Being overweight: It affects your hormones. This disbalance puts you at a higher risk of Gallbladder cancer. It also means you're more likely to develop gallstones which can increase your risk of cancer.
• Polyps: These aren't usually cancerous but can turn cancerous over time. These are small outgrowths on the lining of your gallbladder.
• Ethnicity: People from Latin America and Asia have a higher risk of developing gallbladder cancer.

Prevention:

• Keep your weight in check: Try to move as much as you can. Exercise is key to keeping a healthy weight. However, don't resort to extreme measures to lose weight in case you are overweight. Instead, focus on losing weight with a healthy diet and regular exercise.
• Avoid alcohol: Alcohol is a leading cause of Gallbladder cancer. Try to limit your alcohol intake to as much as possible. Start with one drink a day, then one drink every 3 days, then 5 days, then a week.
• Avoid processed foods and artificial sweeteners: Though a piece of salami and a sweet treat every once in a while is completely okay, try to stick to fresh fruits and vegetables on a daily basis. Whole grains and lean meat is also very helpful. Try to avoid red meat too.
• Avoid smoking: Smoking is a cause of Gallbladder cancer. Try to smoke as little as you can. If need be, resort to chewing gums for a limited time period in moderation.
• Removal of gallstones: Gallstones are fairly common; gallbladder cancer isn't. And, chances are, if you do have gallbladder cancer or are about to develop it but are unaware, a gallstone/gallbladder cancer will ensure that you're completely risk free. However, this still isn't recommended as much since gallbladder cancers are very rare and typically gallstones don't always take a turn to gallbladder cancer. The complications outweigh the benefits in this case.
• Maintain a healthy lifestyle overall:
  • Exercise
  • Eat healthy (see the third point)
  • Get adequate sleep
  • Try to be calm and collected in all situations. Your mental health does affect your body for the better or for the worse based on how you treat it.

Diagnosis:

• Blood tests: These will show how well your liver is working.46 Since the gallbladder and liver are very proximal and the liver produces bile which the gallbladder stores in a duct, if the liver has complications; chances are the gallbladder will have it too.
• Imaging tests: To really find the extent of the cancer and stage your cancer accordingly, your healthcare adviser might suggest scans and tests like CT scan and MRI scan of the abdomen. Apart from this, to check the functioning of the very crucial bile duct, they might suggest an imaging test that involves putting dye into the bile duct. It is then recorded where the dye goes. These tests can show if the bile ducts are blocked.
• Laproscopy: It is almost an experimental procedure to check where (and if) the cancer has spread to parts other than the gallbladder. Your doctor will make a small incision on your abdomen area and put in a small camera for observation and diagnostic purposes.
• Abdominal ultrasound: These are carried to check the extent of the cancer, and how far the cancer has spread. Usually, a needle might also be stuck THROUGH the skin to extract the cells and look at them under a microscope for careful examination. This is known as ultrasound guided needle biopsy.
• MRI scans: Uses radio waves and strong magnetic fields, and is very helpful and coherent to detect the cancer and its condition along with the extent to the other bile ducts.
  • These also include:
    • MR cholangiopancreatography (MRCP): can be used to look at the bile ducts.
    • MR angiography (MRA): looks at blood vessels.
• Angiography: A thin plastic tube called a catheter is threaded into an artery and a small amount of contrast dye is injected to outline blood vessels. Then x-rays are taken. This helps us to detect if the blood flow is being obstructed anywhere due to presence of any tumours; or if the cancer has grown beyond the blood vessels.
  • It helps your surgeon to decide whether the cancer can be eliminated by virtue of surgery or not.
• Endoscopic retrograde cholangiopancreatography (ERCP): A flexible tube is inserted through the patient's throat and passes through the stomach and holds to the small intestine. This is an endoscope. It is inserted after anaesthesia or sedation. A small amount of contrast dye is injected through the catheter, which is passed through the endoscope. The dye helps outline the bile ducts and pancreatic duct as x-rays are taken.

Treatment, Side Effects and Maintenance:

• Surgery: The most viable and reliable method to get rid of any kind of cancer is of course surgery. However the cancer might have become so advanced that surgery cannot eliminate it.
  • In case the surgery is small enough to be eliminated by surgery, you can go for:
    • Surgery to scrap the gallbladder: If the cancer is still in the beginning stages, then you can go for a process called cholecystectomy, which involves removing the gallbladder as a whole.
    • Surgery to scrap the gallbladder and certain parts of the liver: If the cancer has reached the liver and the bile duct, you can opt for this kind of surgery. It will remove the gallbladder and parts of the liver and bile ducts proximal to the gallbladder.
• Radiation Therapy: It uses powerful energy beams to target the cancerous cells.
  • However, there is still a slight risk of it affecting the healthy cells adversely.
  • It can also be used after surgery if your doctor feels that all the cancer cells couldn't be safely removed.
• Chemotherapy: It is typically used when the cancer is so intensive and we'll spread that surgery isn't reliable. In such a case, very strong medications targeted for the cancer cells are inserted through the vein into the bloodstream.
  • Like radiotherapy, it can also be used after surgery.
• Palliative care: This is also used when the cancer is well developed, but can be preferably used through any stage of the cancer development. It is aimed at making you feel better rather than intensively curing cancer.
  • It involves taking medication for nausea and vomiting, et cetera. However if discomfort still persists, doctors typically prescribe:
    • Biliary stent or biliary catheter: As discussed before gallbladder cancer often ends up taking a toll on the bile ducts and liver as well, which might cause yellowing of the skin called jaundice. To prevent this doctors will insert a stent, which keeps the duct open to allow the bile to drain into the small intestine for proper digestion. Otherwise, a catheter can also be installed to let the bile drain into a bag. The bag can be emptied when needed.
    • It is needless to say that these stents and catheters have to be frequently changed to prevent bile buildup and clogging. This can, in turn, inflame the gallbladder more and cause discomfort and/or an infection.
    • Replacing the stents/ catheters every few months is recommended.
    • Biliary bypass: If the cancer obstructs the bile duct the doctor can join the part of the unblocked bile duct with either the intestine directly or with another part of an unblocked bile duct. A biliary bypass can often give longer-lasting relief than a stent.
    • In both these procedures, however, it is necessary to ensure that your health is in optimal condition and a healthy diet and lifestyle. Post operative care is extremely important; it is also necessary to ensure that you are free of (especially) fevers and jaundice before any surgery to avoid any complications.
• Targeted therapy: Targeted therapy is more focused on cancer cells, minimizing damage to normal tissues. Unlike chemotherapy or radiotherapy which pose a significant risk to healthy cells, targeted therapy is quite localized and uses special medications to fight against cancer cells.

FAQs:

Q) What are the risks involved after surgery if I get it done?

• Certain risks you should be aware of are:
  • Problems with digestion of fats: The gallbladder stores the bile that the liver secretes, which helps in the emulsification of fats. It is thus needless to say that tampering with the gallbladder will cause problems when digesting large amounts of fat based foods.
  • Bile leakage: Typically results if there was any tampering with the bile ducts during the operation.58
  • Infections: Not sterilizing medical equipment can result in this.
  • Pneumonia and blood clots: Can result from heavy exertion and improper rest after the surgery.
  • Having problems with digestion.
  • Anesthesia working improperly.

Q) How do I minimize these risks?

• You can start by ensuring and cross checking the qualifications of your surgeon, making sure that they have a clean record and that they understand your needs and discomforts.
• Try to ensure that your surgeon is either highly qualified or has a high success rate and experience of performing these surgeries.
• Try to avoid surgery on the whole as it may lead to infections even with the slightest bit of neglect after the operation.
• If your surgeon recommends surgery at the first go, get a second opinion.
• Ensure that the cancer is staged properly by cross checking from various sources before seeking surgery.

Q) What are the typical symptoms for gallbladder cancer?

• Bloating
• Upper right abdominal pain
• Itchiness
• Fever
• Having a general distaste towards food
• Sudden unexplained weight loss
• Vomiting
• Jaundice

Q) What is the survival rate for gallbladder cancer?

• Since this kind of cancer is very rare and isn't typically diagnosed within the very early stages, people often don't realise that they have gallbladder cancer until it's very late.
• As a result only about 2% of people with metastasised gallbladder cancer survive.
• However if the cancer is localised (concentrated only around the gallbladder) the survival rate is higher—nearly 65%.
• That being said, 80% of gallbladder cancers are discovered when it's very late for surgery and the cancer has fully metastised. Thus it is essential to consult your doctor at the earliest if you see any symptoms—since the cancer is quite curable if discovered in the early stages.

Q) How do I care for myself after a gallbladder cancer diagnosis?

• Seek palliative care after consulting your medical adviser. Palliative care is effective no matter which stage or kind of cancer you have.
• Inquire about your prognosis to your healthcare adviser.
• Maintain a healthy diet and try to avoid fat-rich foods.
• Move your body as much as you can but do not over exert yourself.
• Get adequate sleep and try to avoid taking unnecessary stress.

Q) If my mother and father had gallbladder cancer, would I get it too?

• There is no definite ‘yes’ or ‘no’ to this question—you might get it, you might not.
• However, you do have a higher risk of developing this cancer compared to the average person.

Q) Do only women get gallbladder cancer?

• Though the risk is higher for women—no, it isn't a cancer that happens only in women.
• Men can develop this cancer as well.