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BILIARY MALIGNANCIES. Dr Sanjay De Bakshi MS(Cal.);FRCS (Eng Edin.). GALL BLADDER CANCER -Incidence. States of Uttar Pradesh, Bihar, West Bengal & Assam Delhi Madhya Pradesh; Bhopal have the highest incidence of Gall Bladder Cancer. AETIOLOGY.

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BILIARY MALIGNANCIES

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BILIARY MALIGNANCIES

Dr Sanjay De Bakshi

MS(Cal.);FRCS (Eng Edin.).


GALL BLADDER CANCER-Incidence.

  • States of

    • Uttar Pradesh,

    • Bihar,

    • West Bengal &

    • Assam

    • Delhi

    • Madhya Pradesh; Bhopal

  • have the highest incidence of

  • Gall Bladder

  • Cancer.


AETIOLOGY

  • Cholelithiasis-directly proportional to the size of the stone;(Risk 2.4 for those with stones 2.0 to 2.9cm. in size; 10.1 for those with stones >3cm.) Metaplasia Dysplasia Carcinoma.

  • Papillary and non-papillary adenomas have pre-malignant potential, (in particular polyps >10mm in size).

  • Carcinogens-breakdown products from bile acids.

  • Anomalous connection between the CBD and Pancreatic ducts.

  • Porcelain Gall Bladder pathological finding of a brittle gallbladder with a bluish tinge. Diffuse (Type I)less prone than Selective mucosal calcification (Type II and III) Stephen et al 2001


AETIOLOGY

  • Occupational – possibly in the rubber industry.

  • Mustard oil loaded with impurities (Hai et al 1994).

  • Infections – Salmonella typhi, Helicobacter bilis and hepaticus and Esch. Coli implicated though the proof of relationship nebulous (Nath et al 2010) {Chronic inflammation and genotoxic toxin (cytotoxic distending toxin- CdtB)}

PATHOBIOLOGY OF GALLBLADDER CANCER. Sunita Singh et al Journal of Scientific Research; Banaras Hindu University, Varanasi; Vol. 56, 2012 : 35-45


RISK FACTORS

  • Race

  • Obesity

  • Multiparity

  • Smoking

  • Chronic infections with S typhi and paratyphi

  • Porcelain Gall Bladder

  • Certain diet patterns.


STAGING OF GALL BLADDER CANCER

Nevin et al 1976.


STAGING OF GALL BLADDER CANCER

Donohue modification of Nevin classification 1990


STAGING OF GALL BLADDER CANCER

AJCC/TMN 6th Edition


T STAGING7th Edition


STAGING OF GALL BLADDER CANCER

M

N

0

No lymph node involvement

0

No distant mets

AJCC/TMN 6th Edition

1

Distant mets incl. interaortocaval nodes

1

Any lymph node involvement


N STAGING7TH Edition

M STAGING7TH Edition


STAGING OF GALL BLADDER CANCER


STAGING OF GALL BLADDER CARCINOMA7th Edition AJCC


Characteristics of a Gall Bladder Cancer

  • Spread principally by direct extension.

  • Spreads also by lymphatic, vascular,neural, intraperitoneal and intraductal routes.

  • Anatomically straddles the junction between the IVB and V lobe of the liver.


Lymphatic drainage of the Gall Bladder

  • Cholecysto-retropancreatic

  • Cholecysto-coeliac.

  • Cholecysto-mesenteric


Presentation of Gall Bladder Carcinoma.

  • Histological surprise

  • Lump abdomen without jaundice.

  • Lump abdomen with jaundice.

  • From secondaries.


OLDER TRADITIONAL VIEW.

Nevin Stage I or II, cured by cholecystectomy ALONE.

RECENT VIEWS-

Tumours with Tis and T1a staging with clear resection margin, no further treatment needed.

For patients with T2 or advanced GB cancer, a completion second radical operation is only chance of cure.

Histological Surprise- what to do?

VERSUS


Histological Surprise- what to do?

EARLY RE-EXLORATION BUT AFTER FOUR STEPS

  • Pathology reviewed regarding staging and status of cystic duct.

  • Staging with adequate preoperative imaging.

  • Assessment for fitness for another major surgery.

  • Counselling of patient and family.


Patient presents with a lump-without jaundice,- what to do?

?

  • NEED TO RULE OUT SPREAD TO

  • N2 NODAL COMPARTMENT AND

  • TO PERITONEUM


Patient presents with a lump -with jaundice-What to do?

?


BILE DUCT CANCERAetiology

  • Prolonged cholestasis, inflammation and infection.

  • Choledochal cyst, Caroli’s disease, Congenital hepatic fibrosis and Polycystic disease.

  • After choledocho-enteric anastomosis and other previous biliary surgery(In the Lahey clinic series-50% had had cholecystectomy and 25% other types of biliary surgery.)


BILE DUCT CANCER


BILE DUCT CANCER


PERIPHERAL CHOLANGIOCAs

  • In most peripheral cholangiocarcinomas, hard, compact, and grayish-white massive or nodular lesions are found in the liver.

  • PET Sensitive.


BILE DUCT CANCERAetiology

  • Infection with liver flukes(Round worms?)

  • Chronic typhoid carrier states(x6 times)

  • Ulcerative colitis.

  • Solitary adenomas & biliary papillomas.


Pathology of the Bile Duct Cancer

  • TYPE-almost always adenocarcinomas

  • Sclerosing-70%.

  • Papillary-20%.

  • Nodular-10%.

  • SITE:-

%


AJCC STAGING


BISMUTH STAGING OF CHOLANGIOCARCINOMAS


Bismuth-Corlette Type I tumor


Bismuth Corlette type II tumour


Bismuth Corlette type IIIatumor.


Bismuth Corlette type IIIbtumor


Bismuth Corlette type-IV tumor


THE PROBLEM OF STAGING SYSYTEMS FOR BILE DUCT CARCINOMA

  • NONE ASSESS FOR RESECTABILITY

  • Most large series (for hilar tumours)-

    • 32% unresectable

    • 29% found to have secondaries at exploration

  • Therefore, a staging system has been proposed.

  • Based on Staging Laparoscopy (with Ultrasound).

Janargin WR et al 2001


HILAR CARCINOMAS

Janargin WR et al 2001


HILAR CARCINOMAS

CRITERIA FOR NONRESECTABILITY

  • PATIENT FACTOR

    • Medically unfit

    • Cirrhosis/portal hypertension

  • LOCAL FACTORS

    • Hepatic duct involvement upto secondary radicles bilaterally

    • Encasement/occlusionof main portal vein proximal to its bifurcation

    • Atrophy of one lobe with encasement of contralateral portal vein branch

    • Atrophy of one lobe with contralateral secondary biliaryradicles involved

  • DISTANT DISEASE

    • Metastases to lymph node groups beyond hepatoduodenal ligament(Coeliac, Paraaortic, Retroduodenal – histo +ve)

    • Liver lung or peritoneum – histo +ve)

Janargin WR et al 2001


DISTAL TUMOURS

  • Usually needs pancreatico-duodenectomy -

    • Longitudinal spread (less than pancreatic tumours)

    • True mid CBD tumours difficult to define

  • Lymph node status only independent predictor of long time survival.


INTRAHEPATIC (PERIPHERAL) DUCTAL TUMOURS

  • Often a diagnosis of exclusion.

  • Liver mass, cytologically an adenocarcinoma and extensive search for primaries – unrewarding.

(Nakanuma et al 1985)

(Ohashi et al 1994)

(Yamamoto et al 1998)


Bile Duct Cancer -What to do?

FROZEN-SECTION OF DUCT ENDS A MUST TO EXCLUDE LONGITUDINAL SPREAD.


Scope of Adjuvant Therapy


THANK YOU

ACCESS THE PRESENTATION AT

www.drsanjaydebakshi.org


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