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
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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)