GALL BLADDER CANCER 2015/4/25 一般外科郭禎明醫師
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1 GALL BLADDER CANCER 2015/4/25 一般外科郭禎明醫師
2 BACKGROUND Cancers of the biliary tract include cholangiocarcinoma (cancers arising from the bile duct epithelium), ampulla of Vater cancer, and gallbladder cancer All subtypes of biliary tract cancers are rare and have an overall poor prognosis Difficult to diagnose Gallbladder cancer is the 5 th most common GI cancer and the most common hepatobiliary cancer in US Gallbladder cancer accounts for 46% of the biliary tract cancers in US
3 PATHOPHYSIOLOGY CAUSES OF GALL BLADDER CANCER Chronic inflammation Gall stones >75%, cholesterol gall stones The presence of gallstones increases the risk of gallbladder cancer 4- to 5-fold Primary sclerosing cholangitis, ulcerative colitis, liver flukes, chronic Salmonella typhi and paratyphi infections, and Helicobacter infection Ingestion of certain medications (eg, oral contraceptives, INH, methyldopa) can increase the risk of gallbladder cancer Certain chemical exposures (eg, pesticides, rubber, vinyl chloride 氯乙烯 )
4 PATHOPHYSIOLOGY CAUSES OF GALL BLADDER CANCER Occupational exposures Textile, petroleum, paper mill, and shoemaking Exposures through water pollution (organopesticides, eg, dichlorodiphenyltrichloroethane-ddt and benzene hexachloride 林丹 ); heavy metals (eg, cadmium 鎘, chromium 鉻, lead); and radiation exposure (eg, radon 氡 in miners) Obesity Association with gallstones, increased endogenous estrogens, or through the ability of fat cells to secrete a large number of inflammatory mediators
5 PATHOPHYSIOLOGY CAUSES OF GALL BLADDER CANCER Hereditary syndromes Gardner syndrome, neurofibromatosis type I, and hereditary nonpolyposis colon cancer Oncogenic mutations polymorphism of the cytochrome P450 1A1 gene (CYP1A1), encodes a protein involved in catalyzing the synthesis of cholesterol and other lipids Polymorphisms within the apolipoprotein B gene Overexpression of alpha-methylacyl coenzyme A racemase (AMACR) Abnormal anatomy Congenital defects with anomalous pancreaticobiliary duct junctions Choledochal cysts
6 PATHOPHYSIOLOGY RELATIVE RISK
7 FREQUENCY UNITED STATES 10,000 new cases of gallbladder cancer and other biliary cancers are predicted in 2013 according to the American Cancer Society 2013 statistic projections Gallbladder cancer is more common in women The incidence of gallbladder cancer rises with age 75% with gallbladder cancer > 64 years
8 FREQUENCY WORLD WIDE Incidence of gallbladder cancer worldwide (From National Cancer Institute. Surveillance, Epidemiology and End Results (SEER) Program)
9 FREQUENCY WORLD WIDE Incidence varies substantially with racial and ethnic group and sex Gallbladder cancer rates are the highest among American Indians/Alaska Natives and among white Hispanic ( 西班牙血統 ) peoples Areas with the highest incidence rates India, Korea, Japan, Czech Republic 捷克, Slovakia 斯洛伐克, Spain, Columbia, Chile, Peru, Bolivia 玻利維亞, and Ecuador 厄瓜多爾 The United Kingdom, Denmark, and Norway have the lowest international incidence rates (<2/100,000)
10 CLINICAL PRESENTATION HISTORY Overlap with the symptoms of gallstones and biliary colic Abdominal pain may be of a more diffuse and persistent nature than the classic right upper quadrant pain of gallstone disease Jaundice, anorexia, and weight loss often indicate more advanced disease
11 CLINICAL PRESENTATION SIGNS AND SYMPTOMS Usually not present until the later stages of gallbladder cancer Jaundice Pain above the stomach Fever Nausea and vomiting Bloating Lumps in the abdomen Jaundice, anorexia, and weight loss often indicate more advanced disease
12 CLINICAL PRESENTATION SIGNS AND SYMPTOMS Palpable mass in the right upper quadrant (Courvoisier sign, if this is due to a palpable gallbladder) Periumbilical lymphadenopathy (Sister Mary Joseph nodes) Left supraclavicular adenopathy (Virchow node) Pelvic seeding: Mass is palpated on digital rectal examination (Blumer shelf)
13 DIFFERENTIAL DIAGNOSES Biliary Colic Acalculous cholecystitis Acalculous cholecystopathy Ampullary carcinoma Bile duct stricture Bile duct tumors Biliary disease Biliary obstruction Carcinoma of ampulla Vater Cholangiocarcinoma Cholangitis Cholecystitis Choledochal cysts Cholecholithiasis Cholelithiasis Clostriadial cholecystitis Gall bladder mucocele Gall bladder volvulus Hepatic carcinoma, primary Liver abscess Pancreatic cancer Primary biliary cirrhosis Primary sclerosing cholangitis
14 WORKUP LABORATORY STUDIES Tumor marker CA 19-9 CA 19-9 may be significantly elevated in both cholangiocarcinoma and gallbladder cancer CA 19-9 tests may be helpful in the appropriate situation if the clinical suspicion for gallbladder cancer is high Liver function tests: Elevated alkaline phosphatase and bilirubin levels are often found with more advanced disease CBC: Anemia may be an indicator of more advanced disease
15 WORKUP IMAGE STUDIES Ultrasonography (US) Standard initial study in patients with right upper quadrant pain A mass can be identified in 50-75% of patients with gallbladder cancer Also can delineate metastatic lesions in the liver Computed tomography (CT) scans Can demonstrate tumor invasion outside of the gallbladder and identify metastatic disease elsewhere in the abdomen or pelvis Liver invasion occurs in 60% of cases, and the combination of CT scan and US provides accurate details of disease extension
16 WORKUP IMAGE STUDIES Magnetic resonance imaging (MRI) Useful in examining this region for disease extension into other tissues or metastatic disease in the liver Provide details of the vasculature for preoperative planning via magnetic resonance angiogram (MRA) and bile duct passages via magnetic resonance cholangiogram (MRCP)
17 WORKUP IMAGE STUDIES Cholangiography Via a percutaneous route, or endoscopic retrograde cholangiography (ERCP) May establish the diagnosis of gallbladder cancer by bile cytology Endoscopic ultrasonography Useful to assess regional lymphadenopathy and depth of tumor invasion into the wall of the gallbladder Angiography May be used to confirm encasement of the portal vein or hepatic artery and may assist in preoperative planning for definitive resection
18 TNM STAGING (AJCC, 7 TH ED)
19 PROGNOSIS SURVIVAL RATE
20 TREATMENT SURGERY Curative surgery Cholecystectomy Extended cholecystectomy with lymphadenectomy Palliative surgery Biliary bypass Endoscopic stent placement Percutaneous transhepatic biliary drainage
21 TREATMENT ADJUVANT THERAPY Radiotherapy External beam Internal beam (brachytherapy) Chemotherapy Gemcitabine, Capecitabine, Oxaliplatin, 5-Flurouracil and Cisplatin
22 TREATMENT ACCORDING TO STAGES Stage Treatment 1 Cholecystectomy alone 2 Extended cholecystectomy CCRT 3 Extended cholecystectomy R/T, CCRT 4 Palliative therapy with R/T, C/T Stents
23 THE EXTENT OF LYMPHADENECTOMY FOR GALLBLADDER CANCER
24 Thank you
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