PDQ® Treatment Health Professionals
Cancer that arises in the gallbladder is uncommon. In patients whose superficial cancer is discovered on pathological examination of tissue after gallbladder removal for other reasons, the disease is often cured without further therapy. Even in patients who present with symptoms, the tumor is rarely diagnosed preoperatively. In such cases, the tumor often cannot be removed completely by surgery and is incurable, although palliative measures may benefit these patients. Cholelithiasis is an associated finding in the majority of cases, but fewer than 1% of patients with cholelithiasis develop this cancer. The most common symptoms caused by gallbladder cancers are jaundice, pain, and fever.
The histologic types of gallbladder cancer include the following. Some histologic types have a better prognosis than others; papillary carcinomas have the best prognosis.
The American Joint Committee on Cancer (AJCC) has designated staging by the TNM classification as follows:
-- TNM definitions -- Primary tumor (T) TX: Primary tumor cannot be assessed T0: No evidence of primary tumor Tis: Carcinoma in situ T1: Tumor invades lamina propria or muscle layer T1a: Tumor invades lamina propria T1b: Tumor invades the muscle layer T2: Tumor invades the perimuscular connective tissue; no extension beyond the serosa or into the liver T3: Tumor perforates the serosa (visceral peritoneum) or directly invades one adjacent organ, or both (extension 2 cm or less into the liver) T4: Tumor extends more than 2 cm into the liver, and/or into two or more adjacent organs (stomach, duodenum, colon, pancreas, omentum, extrahepatic bile ducts, any involvement of the liver) Regional lymph nodes (N) NX: Regional lymph nodes cannot be assessed N0: No regional lymph node metastasis N1: Metastasis in cystic duct, pericholedochal, and/or hilar lymph nodes (i.e., in the hepatoduodenal ligament) N2: Metastasis in peripancreatic (head only), periduodenal, periportal, celiac, and/or superior mesenteric lymph nodes Distant metastasis (M) MX: Distant metastasis cannot be assessed M0: No distant metastasis M1: Distant metastasis
These patients have cancer confined to the gallbladder wall that can be completely resected. They represent a minority of cases of gallbladder cancer. Patients with muscular invasion or beyond have a survival of less than 15%. Regional lymphatics and lymph nodes should be removed along with the gallbladder.
With the exception of patients with T1 N1 M0 or T2 N2 M0 disease, these patients have cancer that cannot be completely resected. They represent the majority of cases of gallbladder cancer. Often the cancer invades directly into adjacent liver or biliary lymph nodes or has disseminated throughout the peritoneal cavity. Spread to distant parts of the body is uncommon. At this stage, standard therapy is directed at palliation. Because of its rarity, no specific clinical trials exist; however, such patients can be included in trials aimed at improving local control by combining radiation therapy with radiosensitizer drugs.
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Some citations in the text of this section are followed by a level of evidence. The PDQ editorial boards use a formal ranking system to help the reader judge the strength of evidence linked to the reported results of a therapeutic strategy. Refer to the PDQ levels of evidence summary for more information.
(Tis, T1a or b, selected T2, rare T3; N0; M0)
When gallbladder cancer is previously unsuspected and is discovered in the mucosa of the gallbladder at pathologic examination, it is curable in more than 80% of cases. However, gallbladder cancer suspected before surgery because of symptoms usually penetrates the muscularis and serosa and is curable in fewer than 5% of patients.
Tsukada et al. have reported on patterns of lymph node spread from gallbladder cancer and outcomes of patients with metastases to lymph nodes in 111 consecutive surgical patients in a single institution from 1981-1995.[Level of evidence: 3iiiA] The standard surgical procedure was removal of the gallbladder, a wedge resection of the liver, resection of the extrahepatic bile duct, and resection of the regional (N1 and N2) lymph nodes. Kaplan-Meier estimates of the 5-year survival for node negative tumors pathologically staged as T2-T4 were 42.5% plus or minus 6.5% and for similar node positive tumors, 31% plus or minus 6.2%.
Implantation of the carcinoma at all port sites (including the camera site) after laparoscopic removal of an unsuspected cancer is a problem. Even for stage I cancers, the port sites must be excised completely.
2. External-beam irradiation: The use of external-beam irradiation with or without chemotherapy as a primary treatment has been reported in small groups of patients to produce short-term control. Similar benefits have been reported for radiation therapy with or without chemotherapy administered following resection.[6,7]
(any T, N1, M0; any T, N0 or N1, M1; most T3, N0, M0; T4, N0, M0)
These patients are not curable. Significant symptomatic benefit can often be achieved with relief of biliary obstruction. A few patients have very slow-growing tumors and may live several years.
2. An alternative approach to biliary obstruction is percutaneous transhepatic radiologic catheter bypass or endoscopically placed stents.
3. Standard external-beam radiation therapy can, on occasion, alleviate biliary obstruction in some patients and may supplement bypass procedures.
The prognosis for any treated cancer patient with progressing or recurrent gallbladder cancer is poor. The question and selection of further treatment depends on many factors: tumor burden, prior treatment, site of recurrence, and individual patient considerations. Patients may have portal hypertension caused by portal vein compression by the tumor. Transperitoneal and intrahepatic metastases are not uncommon. Clinical trials are appropriate and should be considered when possible.
Date Last Modified: 05/1999