Gall Bladder Cancer

63 year old gentleman presented with right upper abdominal pain, loss of appetite, loss of weight & a USG report showing a gall bladder mass involving liver. Patient was thoroughly investigated. Investigations (PET-CT scan,MRI & tumor marker CA19-9 were highly in favour of a gall bladder cancer which could be completely removed. Hence immediate surgery was conducted without any preoperative biopsy to avoid any tumor spillage. An intraoperative controlled biopsy (Frozen section) confirmed the malignancy. The tumor was removed in toto along with portion of attached liver and draining lymph nodes. Patient recovered well in 5 days and was discharged. He was recommended postoperative chemotherapy based on the histopathology (adjuvant chemotherapy) A chemoport was inserted for the ease of delivering chemotherapy in a safe and painless manner. Patient was put on a strict follow up protocol.

Important points in the management of Gall bladder mass / cancer of gall bladder

1. It is vital that patient is properly investigated using PET-CT scan, MRI, Liver function tests & tumor marker CA19-9.
2. A percutaneous (USG / CT guided) biopsy should be avoided in patients having a clear malignant resectable mass with elevated tumor markers & patient is operable. An intraoperative biopsy with frozen section examination may be done in such situations. Percutaneous biopsy has risk of tumor spillage / dissemination / spread in the abdomen.
3. However biopsy is needed when a metastatic (spread) disease is suspected, is evident, patient is not operable / resectable & any chemotherapy is planned.
4. Diseases like xanthogranulomatous cholecystitis and IgG4 disease may mimic a malignancy.
5. Operable and resectable patients may need (depending on the extent of disease) a radical cholecystectomy with or without liver resection / pancreatoduodenectomy / vascular resection with reconstruction and even some bowel resection.
6. Patient’s having a locally advanced disease are often downstaged using chemotherapy and later operated.
7. Patients often present with jaundice and need biliary drainage (using endoscopically or percutaneously inserted stents) and may or may not undergo a surgery later.
8. The fact remains that most patients with gall bladder cancer present late with advanced disease and hence cannot be cured. They are treated with palliative measures like painkillers, stents for jaundice and chemotherapy where feasible.
9. In Indian patients gall stone disease has shown clear association with gall bladder cancer and some authors from India recommend a prophylactic cholecystectomy in Indian patients with gall stones; even when a patient is not symptomatic for gall stones.
10. Often gall bladder cancer is picked up as an accidental finding in patient who has undergone a cholecystectomy for gall stones. These patients need another surgery depending on the stage of disease.

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