Types of Gall-bladder Cancer and Treatment

Summary

The Gall-bladder is a tiny organ located in the abdomen, and plays a significant role in digestion of food. Like any other part of the body, the gall-bladder too is vulnerable to cancer. Compared to other cancers, Gall-Bladder Cancer is a rare condition. If detected early, it can be treated effectively. However, more often than not, it is detected when it is at an advanced stage. Treatment options include Chemotherapy, Radiation and Surgery.

Introduction to Gall-Bladder

The gall-bladder is a small, pear-shaped organ that sits below the right lobe of the liver, in the upper-right quadrant of the abdomen. Its function is to store the bile secreted by the liver. The bile is a semi-liquid that helps break down fats in the food consumed by us. The bile stored by the gall-bladder is released into the digestive tract through a series of pipes called bile ducts which together with bile ducts coming from the liver form a biliary tract network. Every time the person consumes a meal, the bile gets emptied out of the gall-bladder, which causes the gall-bladder to shrink (like a deflated balloon). Soon afterwards, the bile starts filling up again in the gall-bladder, and this cycle repeats again and again, every day of our lives.

Cancer in general is caused when there is unwanted mutation in the body’s cells. The DNA in our body cells carry the code that determines the rate at which body cells are destroyed and new cells generated in their place. Unwanted mutations in the DNA can cause rapid multiplication and division of the body-cells leading to unhealthy growths of tissues at that spot. Such growths are called tumours and the overall condition as cancer. This can happen anywhere in the body and when it happens in the gall-bladder, we call that as gall-bladder cancer.

Gall-bladder cancer is generally hard to detect because not every patient shows clear signs and symptoms. Further, the almost hidden position of the organ, compared to other organs in the digestive system, makes it difficult to spot a gall-bladder cancer at quick glance. This is one of the reasons, gall-bladder cancer is generally detected when its already in an advanced stage.  Thankfully, the condition is quite rare compared to cancer in other parts of the body.

Risk Factors for Gall-bladder Cancer

• Gender: Being a woman or AFAB (assigned female at birth)
• Race: Being native American Indian, Mexican-American or Alaskan increases the risk
• Age: Being over age 65 years of age
• Having gallstones currently, or a history of gallstones
• Any blockage in the bile ducts
• Gallbladder polyps, which are benign (non-cancerous) growths
• Chronic or long-term inflammation in the gall-bladder (called cholecystitis)
• Chronic or long-term infection from the bacteria Salmonella typhi (which causes typhoid)
• Calcium deposits in the gall-bladder (the condition being called ‘porcelain gallbladder’)
• Chronic or long-term inflammation in the bile ducts (condition being called ‘primary sclerosing cholangitis’)
• Cysts in the common-bile-duct (condition being called ‘choledochal cysts’)
• Obesity or being overweight
• Smoking tobacco in any form (cigarette, beedi, cheroot, cigar, pipe)
• Exposure to certain chemicals that are used in the textile and rubber industries

Symptoms of Gall-bladder Cancer

• Pain in the upper right quadrant of the abdomen
• Bloating in the abdomen
• Unexplained weight-loss
• Jaundice (yellowing of the skin and eye-whites)
• Lumps in the abdomen
• Nausea and vomiting
• Fever

Types of Gall-bladder Cancer

Adenocarcinoma

The most common type of gallbladder cancer, with nearly 90% of all gall-bladder cancers being of this type. In this type, the cancerous growth originates in the gland cells that line the inside of the gall-bladder. Such cells produce mucus and are said to form the mucosal lining.

This again is of 3 types:

• Papillary adenocarcinoma: This develops in the connective tissues that hold the gallbladder in place. This type generally does not spread to the liver or lymph nodes in the vicinity. This makes it the least harmful type of gall-bladder cancer, and one that responds favourably to treatment.
• Mucinous adenocarcinoma: Here, the cancer cells are found in pools of mucus.
• Non-papillary adenocarcinoma: When its neither of the above two types.

Squamous cell cancer

This is the next most common type with nearly 5% of all gall-bladder cancers being of this type. Here, the cancer develops in certain types of cells that line the bladder (skin-like cells) as well as the glandular cells of the gall-bladder. Treatment options are very similar to that of adenocarcinomas.

Adenosquamous cancer

In this type, there are two kinds of cancer cells – squamous and glandular (or mixed histology). Treatment options are very similar to that of adenocarcinomas.

Small cell cancer

Also called oat cell carcinomas because of their characteristic oat-like shape.

Sarcoma

This affects the connective tissues in the gall-bladder. Connective tissues are all those tissues that perform a supporting or protective role, and examples include nerves, muscles and blood-vessels. So, a sarcoma of the gall-bladder implies the cancer has originated in the muscle layers of the gallbladder.

Neuroendocrine tumour

These are rare tumours that develop in the hormone-producing tissues of the digestive system. The most common type is carcinoid neuroendocrine tumour.

Lymphoma and melanoma

These are the rarest types of gall-bladder cancer. They are treated differently compared to the other types of gall-bladder cancer. For example, surgery may not be required, and the condition may respond well to radiation or chemotherapy.

Stages of Gall-bladder Cancer

• Stage 0 or ‘Carcinoma in situ’. Here, abnormal, precancerous cells are found in the inner or mucosal layer of the gall-bladder.
• Stage 1: In this, the cancer cells are present in the mucosal layer and possibly have spread to the muscle-wall of the gall-bladder.
• Stage 2: Here, the cancer has spread from the muscle layer to connective-tissue layers of the gallbladder.
• Stage 3: Here, the cancer has spread to the outer layer of the gall-bladder, possibly to the lymph nodes, and nearby organs such as the liver
• Stage 4: Here, the cancer has spread to more than 3 lymph nodes in the vicinity as well as blood-vessels and organs that are distant from the gall-bladder.

Stages 0 and 1 are relatively easier to treat, while stages 2 through 4 are a little more challenging to treat.

Diagnosis

Lab tests

These look for substances in the blood that indicate signs of cancer.

• Liver function test: Measures levels of certain substances released by the liver which can indicate if cancer has spread to the liver
• Carcinoembryonic antigen (CEA) assay: CEA is a tumour-marker that is released by healthy as well as cancerous cells. Their levels are measured, and high levels may indicate gall-bladder cancer.
• CA 19-9 assay: CA 19-9 is another tumour marker found in the blood. Their levels are measured, and high levels may indicate gall-bladder or pancreatic cancer.

Imaging tests

These locate the cancer and look for signs of it spreading.

• Abdominal ultrasound: this uses ultrasound waves to create images of the organs in the abdomen. If any suspicious growth is detected in this test, the doctor will order for CT or MRI scans.
• CT (computed tomography) scan: This uses a type of X-ray to create images of the internal organs.
• MRI (magnetic resonance imaging): This uses a large magnetic field, radio waves and a computer screen to create images of the internal organs.
• Endoscopic ultrasound: Here, a long thin tube called endoscope fitted with a camera and lens at the tip is inserted into the digestive tract, to capture images of the same.
• Endoscopic retrograde cholangiopancreatography (ERCP): This captures X-ray images of the bile ducts. A narrowed bile duct is indicative of gall-bladder cancer.

Surgeries

These allow the doctors to directly access the tissue that contains cancer cells.

• Biopsy: A long, thin and fine needle is used to invade the gall-bladder at the spot of suspicious growth, and a sample of the tissue is extracted. The sample is then examined under a microscope to confirm or rule out cancer diagnosis.
• Laparoscopy: The laparoscope is similar to the endoscope and carries a light and camera at the end. This is inserted into the abdomen to look into the digestive tract, more specifically the gall-bladder and surrounding tissues. Images are relayed by the laparoscope onto a computer screen and these can be examined slowly and in detail, to either confirm or rule out a gall-bladder diagnosis.

Treatment

• Surgery: Cholecystectomy is a surgery undertaken to remove the gall-bladder altogether if the cancer is in an advanced stage. In a simple cholecystectomy, only the gallbladder is removed. In an extended cholecystectomy, in addition to the gall-bladder, the surgeon will remove lymph nodes or a part of the liver that is affected by cancer.
• Radiation therapy: In this, the source of radiation is a machine that is kept outside the body. This directs radiation to the spot of the cancer. This helps kill the cancer cells or slow down their spread, while ensuring no damage happens to healthy cells in the vicinity. Quite often, this is done along with surgery explained above, in order to destroy any remaining cancer cells at the spot.
• Chemotherapy: As the name implies, chemicals are used to kill the cancer cells or slow down their spread, while ensuring no damage happens to healthy cells in the vicinity. Like Radiation, Chemotherapy is also used as an adjuvant therapy to surgery. Sometimes all the three are undertaken.
• Targeted therapy: This targets cancer cells that are marked by specific gene mutations.
• Immunotherapy: This aims to boost the immune system so that it can fight the cancer cells effectively.
• Radiosensitizers: This makes cancer cells more receptive to radiation therapy.

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