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.

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BILIARY MALIGNANCIES

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Biliary malignancies

BILIARY MALIGNANCIES

Dr Sanjay De Bakshi

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


Gall bladder cancer incidence

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

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


Aetiology1

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

RISK FACTORS

  • Race

  • Obesity

  • Multiparity

  • Smoking

  • Chronic infections with S typhi and paratyphi

  • Porcelain Gall Bladder

  • Certain diet patterns.


Staging of gall bladder cancer

STAGING OF GALL BLADDER CANCER

Nevin et al 1976.


Staging of gall bladder cancer1

STAGING OF GALL BLADDER CANCER

Donohue modification of Nevin classification 1990


Staging of gall bladder cancer2

STAGING OF GALL BLADDER CANCER

AJCC/TMN 6th Edition


T staging 7 th edition

T STAGING7th Edition


Staging of gall bladder cancer3

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 staging 7 th edition

N STAGING7TH Edition

M STAGING7TH Edition


Staging of gall bladder cancer4

STAGING OF GALL BLADDER CANCER


Staging of gall bladder carcinoma 7 th edition ajcc

STAGING OF GALL BLADDER CARCINOMA7th Edition AJCC


Characteristics of a gall bladder cancer

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

Lymphatic drainage of the Gall Bladder

  • Cholecysto-retropancreatic

  • Cholecysto-coeliac.

  • Cholecysto-mesenteric


Presentation of gall bladder carcinoma

Presentation of Gall Bladder Carcinoma.

  • Histological surprise

  • Lump abdomen without jaundice.

  • Lump abdomen with jaundice.

  • From secondaries.


Histological surprise what to do

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 do1

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

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

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

?


Bile duct cancer aetiology

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


Bile duct cancer1

BILE DUCT CANCER


Peripheral cholangiocas

PERIPHERAL CHOLANGIOCAs

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

  • PET Sensitive.


Bile duct cancer aetiology1

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

Pathology of the Bile Duct Cancer

  • TYPE-almost always adenocarcinomas

  • Sclerosing-70%.

  • Papillary-20%.

  • Nodular-10%.

  • SITE:-

%


Ajcc staging

AJCC STAGING


Bismuth staging of cholangiocarcinomas

BISMUTH STAGING OF CHOLANGIOCARCINOMAS


Bismuth corlette type i tumor

Bismuth-Corlette Type I tumor


Bismuth corlette type ii tumour

Bismuth Corlette type II tumour


Bismuth corlette type iiia tumor

Bismuth Corlette type IIIatumor.


Bismuth corlette type iiib tumor

Bismuth Corlette type IIIbtumor


Bismuth corlette type iv tumor

Bismuth Corlette type-IV tumor


The problem of staging sysytems for bile duct carcinoma

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

HILAR CARCINOMAS

Janargin WR et al 2001


Hilar carcinomas1

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

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

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

Bile Duct Cancer -What to do?

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


Scope of adjuvant therapy

Scope of Adjuvant Therapy


Thank you

THANK YOU

ACCESS THE PRESENTATION AT

www.drsanjaydebakshi.org


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