Gall bladder carcinoma.03

CARCINOMA ESOPHAGUS - DR ZAHID IQBAL MIR

Dr. Zahid Iqbal Mir, MBBS MS (General Surgery), DNB (General Surgery) has done his MBBS and masters in General Surgery from the prestigious Govt Medical College Jammu and DNB in General Surgery from NBEMS New Delhi. He is a passionate surgeon, earlier practising at Government Medical College, Jammu as Registrar in Department of General Surgery. Nowadays working as Senior Resident in Department of General Surgery, Government Medical College & Hospital, Sector 32, Chandigarh and a rising name in field of surgery.

He is an enthusiastic, enigmatic and dedicated teacher as well. He is not just a resolute learner, but also an awe inspiring guiding light for his juniors, which makes him the most loveable and respected senior.

Currently he is running “LOVE FOR SCALPEL” for PGMEE aspirants on most of the social platforms, which is gaining immense popularity among residents, medical graduates and undergraduates.

1. DIAGNOSTIC EVALUATION & STAGING
GALL BLADDER
CARCINOMA
SAMBHAVI JOSHI, 79, 2K17
Dr. ZAHID IQBAL MIR (SENIOR RESIDENT)
MBBS,MSSurgery,DNBSurgery

2. DIAGNOSTIC EVALUATION

3. PATIENTS WITH SYMPTOMATIC CHOLELITHIASIS
Screening–Ultrasound
Additionalcross-sectionalimaging[CT,MRI/MRCP]in
patientswhohaveconcerningfindingsonUS
•Calcification
•amassprotrudingintothelumen
•lossofinterfacebetweengallbladderandliver
•directliverinfiltration
•gallbladderpolyps≥10mm
•thickenedgallbladderwallnotexplainedby
cholecystitis

4. USG
vInitialdiagnosticstudyforpresumedgallbladder
disease
vOverallaccuracyofUSGforstagingofGBCis
limited

5. USGFINDINGS -MALIGNANCY
üMural thickening
ücalcification
ümass protruding into lumen
üfixed mass in GB
üloss of interface between gband liver
üdirect liver infiltration

6. ØPolyp over 1 cm in diameter -invasive
§FNAC (cholesterolosis/GBC)
§Adenoma/GBC –less accurate
§CT/MRI required
ØPolyp less than 1 cm
§adenoma/ papilloma/ cholesterosis/ GBC less likely
COLOR DOPPLER -VASCULARITY
•pulsatile flow -seen in most cases
•continuous flow pattern
•Doppler sensitivity is mandatory for diagnosis of GBC in stage T 1 a

7. Ultrasoundimage showing intraluminal
polypoidgallbladderwallmass(arrow)but
withoutextraluminalextension.
Ultrasoundimageofgallbladdermass
withlossofcontinuityofgallbladderwall
(arrow),suggestingextraluminalgrowth.

8. Asymmetric gallbladder wall thickening (arrow) in a patient with GBC

9. SUSPICIOUS ULTRASOUND FINDINGS OR INCIDENTAL
GALLBLADDER CANCER AT CHOLECYSTECTOMY
üPatientswhohaveconcerningfindingsonUS-
Evaluationofpotentialresectabilityisthekeyfactor
üIncidentallydiagnosedGBCfollowingsimple
cholecystectomy -Apropriateimaging (and
detailedhistopathologicanalysis)isneededto
decidewhetherfurtherresectionisnecessary

10. CECT
•CT is more useful than US for detecting lymph node
involvement, adjacent organ invasion, and distant
metastasis.
INDICATIONS
•USGdetectedgallbladderlesionthatmay
representGBC
•IncidentallydiagnosedGBCfollowingsimple
cholecystectomy.

11. CT FINDINGS -GBC
üPolypoid mass protruding into the lumen/ filling it
üFocal or diffuse thickening of gallbladder wall.
üMass in gallbladder fossa
üLiver invasion
üNodal involvement
üDistant metastasis
GBC vscholecystitis
Higherfrequencyof
•lymphnodeenlargement
•moreextensivewallthickness
•focalirregularity
•lessdistension

12. LIMITATIONS
•Less helpful in differentiating between benign and
malignant polyps.
Computed tomography scan showing
gallbladder cancer with invasion into the
duodenum and liver parenchyma.
Computed tomography scan showing
gallbladder mass with local invasion into
portal vein (arrow).

13. MRI
•USG findings are confirmed on MRI.
MRI/MRCP –differentiate benign from malignant GB
lesions
•GBC is typically T1 hypointenseand T2 hyperintense
compared with the surrounding liver parenchyma.
INDICATIONS –AS CECT

14. üMoreaccurateforimagingGBthanextracorporeal
transabdominalUS
üDetectionanddifferentialdiagnosisofgallbladder
polypsandinstagingtumorextent
üToassessthedepthoftumorinvasionintothewallof
thegallbladderandfordefininglymphnode
involvementintheportahepatisorperipancreatic
regions.
üMeansofobtainingbileforcytologicanalysisand
EUS-guidedFNA
ENDOSCOPIC ULTRASOUND

15. üCholangiography,ERCPand
percutaneous transhepatic
cholangiopancreatography
areoflittleuse
üIncaseswithjaundice,ERCP
may benecessary for
definitionoftheextentof
biliaryinvolvement,aswellas
forstentplacement.
CHOLANGIOGRAPHY
ERCP in an adult with obstructive jaundice
demonstrates an APBDJ with malignant stricture
replacing the cystic duct insertion

16. üCECTCHEST–recommended
•Dstantmetastasescanaffectthelungsandpleura
üPET/PETCT–notrecommend
COMPLETING THE STAGING EVALUATION

17. •Generallynondiagnostic
•ElevatedALPorserumbilirubin-bileductobstruction.
•Serumtumormarkers–CEAorCA19-9areoftenelevated-
lackspecificityandsensitivity.
If a tumor marker is found to be elevated preoperatively, serial assay after
resection might aid in the diagnosis of persistent or recurrent disease.
LABORATORY INVESTIGATIONS
Other non specific findings :
1.anemia
2.leukocytosis
3.transaminases elevation
4.ESR elevation
5.CRP Elevation

18. PATHOLOGY
INVASIVEADENOCARCINOMA PRESENTINGAS
MULTIFOCAL,NODULAR,PAPILLARYPROLIFERATION
INTHEFUNDUS&BODYOFGB
ADENOCARCINOMA PRESENTINGASDIFFUSE
THICKENINGOFGBWALL

19. Incidentalgallbladderadenocarcinoma
detectedinagallbladderwithfocal
thickening. A well differentiated
morphology.
Invasivepapillaryadenocarcinoma arisingin
thebackground ofanintracholecystic
papillaryneoplasm.
HISTOPATHOLOGY

20. Gall Bladder Cancer–Incidental
Incidental
on
Histology

22. STAGING

23. GALL BLADDER CANCER -GROUPS
üObvious clinical
üSuspected imaging
üUnsuspected at operation
üIncidental at histology
üMissed at follow up
Kapoor. J HBP Surg 2007;14:366-73

24. PRIMARY TUMOURSTAGING
T stageT criteria
Tx Primary tumour cannot be assesed
T0 No evidence of primary tumour
T-is Carcinoma insitu
T 1 Tumourinvades the lamina propriaor muscular layer
T1a Tumourinvades the lamina propria
T1b Tumour invades the muscular layer
T 2 Tumourinvades the perimuscularconnective tissue
T2 aTumourinvades the peri-muscular tissue on the peritoneal side
without involvement of the serosa(visceral peritoneum).
T2 bTumour invades the perimusculartissue on the hepatic side
without extension into the liver.
T3 Tumour perforatesthe serosa (visceral peritoneum) and/or
directly invades the liver and/or one other adjacent organ or
structures
T4 Tumour invades the main portal vein or hepatic artery or
invades two or more extra hepatic organs or structures.

26. REGIONAL NODE STAGING
Nstage N criteria
Nx Regionallymph nodes cannot be
assessed
N0 No regional lymphnode
metastasized
N1 Metastasis to 1 –3 regional lymph
nodes
N2 Metastasisto 4 or more regional
lymph nodes.
METASTASIS
M stage M criteria
M0 No distant metastasis
M1 Distant metastasis

27. PROGNOSIS STAGE GROUP
T N M STAGE
Tis N0 M0 0
T1 N0 M0 I
T2a N0 M0 IIA
T2b N0 M0 IIB
T3 N0 M0 IIIA
T1-3 N1 M0 IIIB
T4 N0-1 M0 IVA
anyT N2 M0 IVB
anyT anyN M1 IVB

28. REFRENCES