Malignant Biliary Disease

What is Gall Bladder

• Gall bladder is located beneath the liver on the right side of the abdomen
• The gall bladder stores bile, a digestive fluid produced by your liver.

Whom does gall bladder cancer affect?

• Gall bladder cancer is common in India, especially in the Northern parts.
• Gall bladder cancer often develops in between 60 and 80 years of an individuals life and is 2-3 times more common in women.

What are the signs and symptoms?

• Abdominal pain, particularly in the upper right portion of the abdomen
• Abdominal bloating
• Fever
• Nausea
• Yellowing of the skin and eyes (jaundice)
• Itching all over the body

What are the Risk Factor for gall bladder cancer?

• Female gender
• Old age
• Porcelain Gall Bladder
• Gall stones
• Gall bladder polyps
• Exposure to carcinogen
• Obesity

How is gall bladder cancer diagnosed?

Physical examination:

Your doctor will examine your abdomen to look for any lump in the upper abdomen on the right side. Your eyes and skin will be examined to look for signs of jaundice

Laboratory investigations

• Blood investigations Complete blood count, Liver function test, Coagulation profile, CA19-9, RFT
• Radiological imaging: USG Abdomen, Triple phase CT scan of the abdomen & pelvis, MRCP (if the tumour is invading the bile ducts), PET-CT scan
• Biopsy USG guided biopsy
• Diagnostic laparoscopy for patients undergoing surgical resection.

What are the treatment options?:

A) Surgery for gall bladder cancer depends on the stage of cancer.

• Radical cholecystectomy with wedge resection of the liver with portal lymphadenectomy with or without bile duct resection based on the extent of disease.
• Major hepatectomy If there is a major infiltration into the liver.
• Revision surgery - Some patients may be diagnosed with gall bladder cancer after undergoing laparoscopic cholecystectomy for the gallstones. This is defined as incidental gall bladder cancer. These patients may undergo resurgery after complete investigations.

B) Chemotherapy and radiotherapy: Patients with potentially unresectable gall bladder cancer or gall bladder cancer with widespread metastasis or technically resectable gall bladder cancer but are not a candidate for major surgical resection are the ones considered for chemotherapy and radiotherapy. Patients who undergo surgery are offered Adjuvant Chemotherapy based on final Histopathology report.

C) Palliative care: Palliative care is considered for patients who are not a candidate for surgical resection patients. ERCP and Stent placement or PTBD is done to relieve the symptoms of obstructive jaundice.

Nanavati-Max Super Speciality Hospital is one of the few centres in the country that offer major and aggressive surgical resections for gall bladder cancer with a good success rate.

Also Read About Radiation Therapy for Breast Cancer

Hilar cholangiocarcinom

Hilar cholangiocarcinoma (Klatskin's tumour) is cancer involving the confluence of the right and left hepatic ducts. Most patients are greater than 65 years of age.

What are the signs and symptoms of Hilar Cholangiocarcinoma?

• Jaundice (yellowish discolouration of eyes and skin)
• Pain abdomen
• Loss of weight and appetite
• Fever with chills and rigour in case of cholangitis
• Fatigue

What are risk factors for Hilar Cholangiocarcinoma?

• Primary sclerosing cholangitis
• Age more than 50 years
• Parasitic infection (clonorchis sinensis & opisthorchis viverrini)
• Chronic liver disease
• Smoking
• Choledochal cysts
• Congenital hepatic fibrosis
• Hepatitis B and Hepatitis C infection
• Obesity and diabetes

How is Hilar cholangiocarcinoma diagnosed?

A) Physical examination: Your doctor will examine your abdomen to look for any lump in the upper abdomen on the right side. Your eyes and skin will be examined to look for signs of jaundice

B) Blood investigations: Complete blood count, Liver function test, HIV, HBV and HCV testing, coagulation profile, CA19-9, CEA, RFT

C) Radiological imaging: USG Abdomen, Triple phase CT scan of the abdomen, MRCP (if the tumour is invading the bile ducts), PET-CT scan

D) Biopsy: USG guided biopsy or brush cytology during ERCP.

What are the treatment options for Hilar Cholangiocarcinoma?

A) Surgery: Major hepatectomy combined with extra hepatic bile duct resection is standard therapy.

B) Chemotherapy and radiotherapy: chemotherapy and radiotherapy for unresectable hilar cholangiocarcinoma.

C) Palliative care: If the patient is having an unresectable hilar cholangiocarcinoma and surgical resection cannot be performed, then ERCP and Stent placement or PTBD is done

FAQs

1) Do gallstones cause gallbladder cancer?

Ans) Gallstones are one of the risk factors for gallbladder cancer. Quite a few patients with gallbladder cancer have gallstones at the time of diagnosis. A stone size of more than 3cm increases the risk of gall bladder cancer.

2) What do I expect after a surgery for gall bladder cancer?

Ans) Patients who undergo radical cholecystectomy with wedge resection of the liver will have a hospital stay of 4-5 days after surgery. Oral feeds are started after 48 hours. If the patient requires a more aggressive surgery in the form of major hepatectomy, then the hospital stay could be extended by few days depending on the recovery

3) Will I require chemotherapy or radiotherapy after surgery?

Ans) Patients with advanced gall bladder cancer or hilar cholangiocarcinoma will require multidisciplinary treatment modalities.

4) What are the side effects of of chemotherapy and radiotherapy?

Ans) Radiation therapy may cause patients to become very tired as treatment continues. In addition, when patients receive radiation therapy, the skin in the treated area may sometimes become red, dry, and tender. Radiation therapy to the abdomen may cause nausea, vomiting, diarrhoea, or other problems with digestion. For most patients, the side effects of radiation therapy go away when treatment is over.

Patients who undergo chemotherapy may also be more likely to get infections, bruise, or bleed easily, and may have less energy. Other side effects are poor appetite, nausea and vomiting, diarrhoea, or mouth sores. Usually, these side effects go away gradually during the recovery periods between treatments or after treatment is over.

5) What is the survival rate in Hilar Cholangiocarcinoma?

Ans) Survival depends on the stage of cancer at the time of diagnosis. Most of the patients are diagnosed in advanced stages. 5-year survival in node-negative

disease its 50%. In node-positive disease, its 35% and in inoperable cases, the prognosis is very poor with 5-year survival rate of less than 5%

6) What are the complications of surgery for gall bladder and bile duct cancers?

Ans) Bile leak, abdominal collections, wound infection, and pneumonia. All these complications are managed conservatively. Rare complications include intraabdominal haemorrhage, which may require surgery.

7) What is the follow up period after surgery?

Ans) In the first year, its every 3 months and after 1 year its every 6 months

8) What is the survival rate in gall bladder cancer?

Ans) 5-year survival rate for resectable node-negative disease is around 40% and node-positive disease is 25%. Inoperable cases have an extremely poor prognosis.

Download Brochure