European Gastroenterology & Hepatology Review, 2005:23-24
Longer version of article from Reference Section:
Carcinoma of gall bladder (CaGB) is extremely rare, affecting 7,100 people in the US per year. In the UK in 2002, only 394 new cases of CaGB were registered, with a rate of 1.5 per 100,000 population. Women are more commonly affected than men. The peak incidence is for people in their 60s, but the disease age range is from 29 to 90 years of age and there is great geographic and ethnic variation.1 CaGB is one of the five most common malignancies of the gastrointestinal (GI) tract and the most common biliary malignancy.
Association of Ca GB with Benign Diseases
There is a direct link between gall stones and CaGB. In patients with CaGB, the incidence of cholelithiasis ranges from 54% to 97%.2,3 CaGB is more common in patients with Mirizzi’s syndrome,4 and typhoid carriers are a high-risk group. Moreover, porcelain (calcified) gall bladder has a high malignant potential and large, sessile polyps (more than 10mm) are more likely to be malignant than multiple, small, pedunculated ones.5,6 The incidence of CaGB increases 14.7-fold 20 years after surgery for gastric ulcer.7
Pathology
The adenocarcinoma is the most common histological type (approximately 80%) of CaGB, but histology varies. Cases of undifferentiated carcinoma occur in 6% and squamous carcinoma in 3%. Cases of adenosquamous, carcinosarcoma and spindle-cell sarcoma of gall bladder have also been reported. A variety of other lesions, including carcinoid tumours, sarcoma, melanoma and lymphomas, have also been found.8–10
Symptoms
CaGB either remains asymptomatic for a long time or presents with very non-specific symptoms. Commonly, symptoms are related to associated gall stones and include (in descending order of frequency) pain, anorexia and weight loss, jaundice, pruritis, fever, vomiting, gall bladder mass, enlarged liver and ascites.
Investigations
Abnormal serum alkaline phosphatase and gamma glutamyl transferase may be elevated in the absence of jaundice. An ultrasound (U/S) scan may show irregular thickening of the gall bladder wall, polypoidal lesion protruding into the gall bladder lumen and a mass in the gall bladder fossa replacing the gall bladder.11 A U/S scan may give a false positive result as patients with acute cholecystitis may have an inflammatory mass that could be mistaken for the CaGB.
Computed tomography (CT) is better at detecting lesions than U/S. CT has a low sensitivity for detecting lymph node metastasis, although its positive predictive value is more than 90%.12 Both US and CT may fail to show local GI and omental infiltration and peritoneal deposits.
Cholangiography, both percutaneous (PTC) or endoscopic (ERC), may not be helpful in diagnosis of CaGB at an early stage. ERC or PTC may detect obstruction due to external compression on the bile duct caused by either direct infiltration from CaGB or enlarged metastatic lymph nodes.
Fine needle aspiration cytology (FNAC) provides 90% sensitivity, 100% specificity and 90% accuracy in the presence of a gall bladder mass.13 Endoscopic ultrasonography (EUS) may detect early lesion and better assess local infiltration. Laparoscopy, laparoscopic U/S and FNAC may prevent unnecessary laparotomy.
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