Does gallbladder cancer divide India?

Indian Journal of Gastroenterology, Jan 2010

Anu Behari, Vinay K. Kapoor

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Does gallbladder cancer divide India?

Anu Behari 0 Vinay K. Kapoor 0 A. Behari 0 V. K. Kapoor 0 0 Department of Surgical Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences , Lucknow 226 014, India 1 Springer - abnormalities, to save costs and reduce workloads. We would like to introduce a strong note of caution in accepting this recommendation across all geographical areas. GBC is the most common cancer of the biliary tract worldwide.2 The overall prognosis remains grim with 5-year survival of less than 5-10%.3 Potentially curative resection of the tumor and its loco-regional spread provides the only hope of long-term cure and survival. The extent of such resection may range from a simple cholecystectomy, through an extended cholecystectomy with a 2-cm nonanatomic wedge of liver in the GB bed in segments IVb+V and lymphadenectomy, to an extended right hepatectomy and pancreatico-duodenectomy, depending upon the location and spread of the tumor. Curative resection is possible in only those few patients who have a tumor that is limited to the GB wall without involvement of the lymph nodes or adjacent structures in the hepato-duodenal ligament.4 A highly select sub-group of patients with locally advanced, but non-metastatic, disease may benefit from extensive resections including hepatopancreatico-duodenectomy.5,6 However, in most patients, the disease is diagnosed at an advanced stage when curative resection is not possible; in these cases, radiotherapy, with or without chemotherapy, has little impact on survival.7 GBC diagnosed for the first time on histology of GB removed with a presumed diagnosis of gallstone disease is known as incidental GBC (IGBC). The term IGBC should not be used when GBC is suspected either on pre-operative imaging (ultrasonography [US] or CT scan), during surgery or on opening the GB specimen. Management of IGBC is primarily guided by the extent of transmural spread (T stage) of the tumor. The chances of lymph node involvement and residual disease in the GB fossa increase with increasing T stage. While simple cholecystectomy without lymphadenectomy, which has already been done, is considered sufficient for tumors limited to the GB mucosa (T1a), a re-operation with liver resection and lymph node clearance (completion extended cholecystectomy) is recommended for tumors extending to the muscle coat (T1b) and beyond. Significant survival benefit of re-resection has been well-documented for tumors reaching the peri-muscular connective tissue (T2).8-10 Some prolongation of survival has also been reported for selected T3 tumors.8,11 Re-resection may also be required in patients with node-positive disease; this requires histological examination of the cystic lymph node in addition to the GB. Early stage tumors, which are most likely to benefit from surgical resection, are difficult to diagnose pre-operatively.12 This is especially true when GB contains stones, which make it difficult to detect a small area of thickening or small mass lesions on abdominal US. Long-standing gallstone disease with GB wall thickening due to chronic cholecystitis and xantho-granulomatous cholecystitis (XGC) (a variant of chronic cholecystitis) may make this detection even more difficult.13 Many of these lesions are not apparent even on gross examination of the GB. Thus, in various reports, IGBC forms a significant percentage of resected GBCs.14,15 Since there are no clinical pointers to early GBC, these patients are usually subjected to a cholecystectomy for the associated gallstone disease and the cancer is discovered for the first time on histological examination of the removed GB. With the easy availability of US and ever-increasing popularity of laparoscopic cholecystectomy, there is a perception that an increasing number of early stage GBCs are being picked up.16 This may, however, merely reflect increasing number of cholecystectomies. One of the unique features of GBC is the striking gender, geographic and ethnic variation in worldwide incidence, suggesting a strong influence of genetic and environmental factors. GBC is rare in most of Northern Europe and North America.2 The highest rates of GBC are found in northern India and Pakistan, East Asia (Korea and Japan), Eastern Europe (Slovakia, Poland, and Czech Republic), and South America (Columbia and Chile). Rates may vary even within a region or a country. Incidence of GBC in women in northern India is as high as 9 per 100,000 per year as compared to as low as 1 per 100,000 per year in southern India.17 In areas of high prevalence, GBC is one of the most common gastrointestinal cancers, especially in women. The association between gallstones and GBC continues to mystify clinicians. The parallels in epidemiology between the two are striking. The risk of GBC increases with increasing size and number of gallstones, especially if the stones occupy a significant volume of the GB.18 Progressive changes in GB walls from chronic cholecystitis, hyperplasia, metaplasia, (...truncated)


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Anu Behari, Vinay K. Kapoor. Does gallbladder cancer divide India?, Indian Journal of Gastroenterology, 2010, pp. 9-13, Volume 29, Issue 1, DOI: 10.1007/s12664-010-8001-2