The gall bladder is a small, pear-shaped structure just beneath the liver on the right side of the abdomen. It stores a digestive fluid, called bile, which is produced in the liver. Gall bladder cancer is relatively rare. In India in 2018, there were 25,999 new cases and 19,676 deaths.
TYPES OF GALLBLADDER CANCER
Almost all gallbladder cancers are adenocarcinomas, in which the cancer cells originate from gland-like cells in the digestive tract. Other types of gallbladder cancers are much rarer and may include adenosquamous carcinomas, squamous cell carcinomas, small cell carcinomas and sarcomas.
These are diagnosed by the pathologist based on the sample taken during surgery or endoscopy.
STAGING OF GALLBLADDER CANCER
If you are diagnosed with gallbladder cancer, your doctor will run more tests to determine the extent (stage) of your cancer. The stage of your cancer is based on the size and spread of the tumour and helps your doctor decide which treatments are optimum.
- Stage 0 (Carcinoma in Situ): Abnormal cells are found only in the innermost layer of the gallbladder Stage I: The cancer has formed in the innermost layer of the gallbladder wall and may have spread to the muscle layer of the gallbladder.
- Stage II: Divided into two stages. Stage IIA (Cancer has spread through the muscle layer to the layer just beyond it.) Stage IIB (Cancer has spread through the muscle layer on the same side as the liver but has not spread to the liver.)
- Stage III: Divided into two stages. Stage IIIA (Cancer has spread through the connective tissue layer of the gallbladder wall and has spread to the layer of tissue that covers the gallbladder or has spread to the liver, stomach, small intestine, colon or pancreas). Stage IIIB (cancer has formed in the innermost layer of the gallbladder wall and may have spread to the muscle or to the tissue that covers the gallbladder. The cancer may have spread to the liver or to one nearby organ or structure (such as the stomach, small intestine, colon, pancreas, or the bile ducts but has spread to one to three lymph nodes.)
- Stage IV: It is divided into two stages. Stage IVA (Cancer has spread to the blood vessels in and around the gall bladder or to two or more organs other than the liver) Stage IVB (Cancer has spread to nearby organs or structures and four or more nearby lymph nodes).
Sources: Mayo Clinic; India Against Cancer; Cancer treatment centers of America; National Cancer Institute;
DIAGNOSTIC TESTS FOR GALLBLADDER CANCER
- Clinical History and examination: The doctor will ask for symptoms such as pain in the abdomen, bloating, fever, weight loss, nausea and jaundice as well as do an abdominal examination.
- Biopsy: A biopsy is a tissue sample removed from the suspicious area and analysed under a microscope. It can confirm the presence or absence of cancer as well as provide key insights for the clinical team to decide the best path forward. The tissue sample could be retrieved during surgery itself, with a fine-needle guided by a CT scan or ultrasound scan or with an endoscope (a thin, lighted, flexible tube) through the mouth.
- Endoscopic retrograde cholangiopancreatography (ERCP): This procedure allows the gastroenterologist to look inside the gut. The patient is sedated, and an endoscope is passed through the mouth, down the esophagus, stomach and into the small bowel. A smaller tube is then passed through the endoscope and into the bile ducts to inject a dye. Post this, an x-ray is taken that reveals whether a tumour is present in the area.
- Percutaneous cholangiography: A thin needle is inserted through the skin and into the gallbladder area to inject the dye for X-ray visualisation. The clinician will use these films to be able to confirm a gall bladder tumour.
- Laparoscopy: This procedure uses an endoscope to look at the gallbladder and other internal organs by passing them through a small incision in the abdomen.
- Blood tests: The patient’s blood is collected to check for specific markers of liver or gall bladder related complications. These are chemicals include bilirubin. Bilirubin is a chemical that reaches a high level in gallbladder cancer due to blockage of the ducts by a tumour. Your doctor may also order carcinoembryonic antigen - CEA test or CA19-9 test.
- Radiological tests: Computed tomography (CT scan): A CT scan creates takes pictures of the inside of the body using x-rays and combines these images into a detailed, 3D image. Sometimes, a special dye is given before the scan to provide better detail on the image. It is used to measure the tumour size. Magnetic resonance imaging (MRI): An MRI uses magnetic fields, not X-rays, to produce detailed images of the body and can be used to find out whether the cancer has spread outside the gallbladder. MRI can be used to measure the tumour’s size. A special dye called a contrast medium is given before the scan to create a clearer picture. This dye can be injected into a patient’s vein or given as a pill or liquid to swallow. A specialized MRI used for the gallbladder is called MRI cholangiopancreatography. A contrast medium may be given before the MRI to create a clearer picture. Ultrasound: Ultrasound uses sound waves to create a picture of the internal organs and is used by a radiologist to detect a tumour or a suspicious mass inside the body. Positron emission tomography (PET) scan: A PET scan allows the visualisation of organs and tissues inside the body using a small amount of a radioactive sugar-like substance. This substance is taken up by active cells which are detected when scanned. Tumour cells tend to take up this substance and hence is useful to detect spread (metastasis).
- Endoscopic ultrasonography: A long flexible endoscope, is inserted through the mouth and reaches the stomach and some of the intestine. It has an ultrasound probe at the end that can be used to look for tumours through an internal ultrasound.
TREATMENT OF GALLBLADDER CANCER
The management of cancer depends on various factors, including the stage of the cancer, additional health issues, age etc. Surgery, radiation or chemotherapy may be used.
- Surgery: Gallbladder cancer can be treated surgically, and patients may receive a cholecystectomy, in which the gallbladder and surrounding tissue with the lymph nodes are removed. There are two broad types of cholecystectomy: Simple (only the gall bladder is removed) and Radical (Removes the gall bladder, an inch or more of liver tissue next to the gallbladder, all of the lymph nodes in the region). Sometimes a surgeon may offer patients laparoscopic surgery in cases of simple cholecystectomy in which a video camera and inserted in a small incision along with surgical instruments leading to lesser hospitalisation time and less scarring. However, there is a risk that the cancer cells can spread to these small incisions. as they can be complex. In cases in which the cancer has spread, palliative surgery may be considered. These may include Biliary bypass (removing the tumour blocking the bile duct leading to the collection of bile), Endoscopic stent placement (a thin tube is inserted in cases in which the tumour is blocking the bile duct to drain the bile), Percutaneous transhepatic biliary drainage (When stenting is not possible this procedure connects the liver to a drain bile into the small intestine or a collection bag outside the body.) It is especially advisable to choose surgeons who have expertise in these types of surgeries (cholecystectomy, pre-op biliary drainage, bile duct excision). Side effects: Pain, infection, liver failure, bile leakage into the abdomen, problems with digestion etc.
- Radiotherapy: Radiotherapy destroys tumour cells using ionizing irradiation and may be used alone or in combination with chemotherapy, especially prior to surgery or post-surgery in selected patients. Radiotherapy may be external source radiotherapy or internal radiation, which involves injecting tiny microspheres or radioactive material into arteries that supply the tumour. Radiotherapy may be used post-surgery (to kill any cancer that might have been left after surgery) as the main therapy in advanced cancers, or as palliative therapy to help relieve symptoms if the cancer is too advanced to be cured. Side effects: Redness, blisters, nausea, vomiting, diarrhoea, fatigue, liver damage.
- Chemotherapy: This form of treatment that uses drugs to stop the growth of cancer cells and may be taken by mouth or injected into a vein. When the drugs enter the bloodstream and reach cancer cells throughout the body, it is known as systemic chemotherapy. When chemotherapy agent is placed directly into an organ, it affects cancer cells in those areas and is known as regional chemotherapy.
- Palliative care: In patients in whom the cancer has spread too far to be removed by surgery, the management focuses on palliative treatments which deal with the symptoms of the cancer and the side effects of treatment. It also helps patients deal with the anxiety of the cancer prognosis and prepares for end-of-life care.
Sources: National Cancer Institute ; American Cancer Society;
MULTI-DISCIPLINARY TEAM (MDT): Unlike most other diseases, cancer treatment requires an integrated approach from several specialists, each with their own expertise. This team of specialists who would work together on your cancer, is referred to as the Multi-Disciplinary Team (MDT). Many global organisations have recognized the importance of a MDT for cancer treatment, as it improves coordinated care to you, as a patient. Your MDT would include specialists from the following:
- Gastroenterologist: Specialist dealing with diseases of the gastrointestinal tract. Performs the endoscopic procedures.
- Surgeon or surgical oncologist: Specialist in operating on various types of cancer
- Medical oncologist: Specialist who decides the optimum schedule and agent for chemotherapy
- Radiation oncologist: Specialist in administering radiation therapy to treat cancer
- Pathologist: Examines biopsies and other samples under the microscope
- Radiologist: Specializes in using imaging tests to diagnose diseases such as gall bladder cancer
- Palliative care specialist: Specialist in palliative and end-of-life care
- Nutritionists: To customize diet during treatments.
Some hospitals that take an organ-based approach to cancer, have a separate department for Hepatobiliary Cancers (Liver, Gall bladder and also pancreas). These teams comprise of specialists who have dedicated training in cancers of the Hepatobiliary system.
TUMOR BOARD: A tumor board is a meeting where a Multi-Disciplinary Team discusses cancer cases and share knowledge. The board’s goal is to determine the best possible cancer treatment and care plan for an individual patient. Having fresh perspectives from other doctors makes it much easier to come up with that plan.
In some hospitals, all cancer cases are discussed at the Tumor Board, while in other hospitals the Tumor Board focuses on cases where a doctor seeks inputs from other specialists on the patient's case. It’s OK to ask your doctor if or why your case was discussed at a tumor board. Or if it wasn’t, why not? In some cases, a patient’s treatment plan is very straightforward using standard treatment guidelines, and the doctor may feel a tumor board review isn’t needed. However, you can request that one be done.
SUPPORT GROUPS: These are offline or online groups that connect patients suffering from cancer. Do find out about a support group around you. The hospital where you are being treated may have a support group that you could join.
Sources: Mayo Clinic;
Choosing your oncologist and hospital is a very important decision, we recommend you make the time to research your options. We profile doctors and hospitals based on their range of services to treat gallbladder cancer. Use our search tools to find a suitable medical provider. You may call us for assistance to find a medical provider or make a booking.
If you’ve been diagnosed with cancer, you need to find an oncologist to begin your treatment. An oncologist is a doctor who specializes in treating cancer. For gallbladder cancer, you can start by visiting a surgical oncologist or a medical oncologist. Choose someone you are not only confident about but also comfortable with.
TIPS TO FIND AN ONCOLOGIST
- Look for Specialists: Look for doctors who treat your specific type of cancer - gallbladder cancer or hepatobiliary cancers (liver, gallbladder, bile ducts and pancreas). You may need to work with more than one type of oncologists – surgical, medical or radiation oncologists.
- Gather Feedback: Discuss with friends and family, especially those who’ve taken similar treatment before. Online communities are a quick way to get feedback from others who’ve experienced your type of cancer before.
- Check the doctor’s credentials: Find out if the doctor has received any advanced training. There may be super-specialists available for hepatobiliary cancers, who have received dedicated training on treating gallbladder If doctor’s credentials are not available easily, you have the right to ask for it from the doctor directly.
- Review doctor’s experience: Check how long the doctor has been practicing after completion of formal oncology education. How many patients with your type of cancer – gallbladder cancer – does the doctor see every year? In case of surgeons, studies have proven that higher volumes of surgeries lead to better outcomes. Organ-specific surgeons are also available in some hospitals, they have advance training and experience in operating cancers in specific organs.
- Find out hospital affiliations: Which hospitals does the doctor practice in? The availability of a multiple types of doctors at the hospital where you get treated is important. Find out what support staff is available at the hospital e.g. dietitian, counselor, home healthcare facilities etc.
TIPS TO FIND A HOSPITAL
- Lookout for hospitals with lot of experts: Look for hospitals that offer a multi-disciplinary approach to hepatobiliary cancer treatment. This means each you receive inputs from many cancer experts. You will be helped by specialists including surgeons, medical oncologists, radiation oncologists, oncology nurses and other supporting staff. Find out if the hospital has surgeons with dedicated training for hepatobiliary cancers? Does the hospital have Tumor Board reviews – how often are they conducted and will your case be discussed there if you wish?
- Work with a major cancer hospital, even if it is far: Most experts in high-volume centers are willing to work with your local doctors. Usually, part of the treatment (for example, surgery) can be executed in the major center and the post-surgery treatment is executed locally.
- Research hospital’s Hepatobiliary Cancer volumes: How many cases of hepatobiliary cancer are treated in the hospital every year? High volume centers with multiple specialists available for hepatobiliary cancers may have better expertise and specialized medical infrastructure required.
- Consider Clinical Trials Availability: Ask whether the doctor or hospital has access to clinical trials and if you are eligible for any. Clinical trials are research studies that test new ways to treat cancer that you can be involved with. By being involved, you can help improve treatments and outcomes for future patients.
- Insurance Acceptance: Check if the hospital accepts your insurance. Check if the hospital has a desk that can assist you with claims.
Sources: Rogel Cancer Center; Cancer.Net