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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

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 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

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

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
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.)
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:-

%

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.

thank you
THANK YOU

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www.drsanjaydebakshi.org

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