Gallbladder Tumors Workup

Author: Thomas J VanderMeer, MD; Chief Editor: John Geibel, MD, DSc, MA more...

Updated: Aug 10, 2011

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Laboratory Studies
Imaging Studies
Diagnostic Procedures
Histologic Findings
Staging
TNM Definitions
AJCC Stage Groupings
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Laboratory Studies

Laboratory studies are generally not very nonspecific for gallbladder cancer.

In the later stages, liver function enzyme levels may be slightly elevated. These levels are generally not elevated in stages I and II.

An elevated bilirubin or alkaline phosphate level generally indicates advanced or obstructive disease.

Elevated carbohydrate antigen 19-9 (CA19-9) is 79.4% sensitive and 79.5% specific for gallbladder cancer. Elevated carcinoembryonic antigen (CEA) is also associated with gallbladder cancer and is 93% specific and 50% sensitive.

Imaging Studies

Ultrasonography is a very useful tool in the workup of gallbladder cancer. Polypoid lesions need to be at least 5 mm in size to be detected by ultrasonography. Cholesterol polyps generally appear as pedunculated lesions attached to the gallbladder wall.

Ultrasonographic findings that indicate possible malignancy or the need for further workup are a thick gallbladder wall, vascular polyp, a mass projecting into the lumen or invading the wall, multiple masses or a fixed mass in the gallbladder, a porcelain gallbladder, and an extracholecystic mass. Invasion of the liver can also be seen on ultrasonograms. (See image below.)

Sagittal ultrasonogram in a 71-year-old woman. This image demonstrates heterogeneous thickening of the gallbladder wall (arrows). The diagnosis was primary papillary adenocarcinoma of the gallbladder.

Displacement of a stone to one side of the gallbladder is also suggestive of possible malignancy.

Computed tomography (CT) scanning and magnetic resonance imaging (MRI) are useful in evaluating the extent of invasion and resectability of gall bladder tumors. CT scan results suggestive of gallbladder cancer include asymmetrical wall thickening or gallbladder mass with or without invasion into the liver. CT scanning of the chest, abdomen, and pelvis is a common staging modality that can determine the presence of distant metastases and give reliable information about involvement of other organs and vascular structures.

A porcelain gallbladder has been commonly associated with gallbladder cancer; however, studies have shown that the type of calcification is more important in determining the risk for malignancy. Selective mucosal calcifications have an increased risk when compared to diffuse intramural wall calcification. (See image below.)

A transaxial enhanced computed tomography (CT) scan of a 60-year-old man with right upper quadrant pain shows a partially calcified gallbladder (arrow). At laparotomy and histology, an infiltrating adenocarcinoma of the gallbladder was confirmed.

Computed tomography (CT) scan in a 65-year-old man. This image depicts squamous cell carcinoma of the gallbladder and invasion of the liver.

Positron emission tomography (PET) scanning has a sensitivity of 75% and a specificity of 88% in gallbladder cancer but is not used routinely in the preoperative staging or postoperative surveillance of the disease.

Diagnostic Procedures

Percutaneous CT scan – guided biopsy is avoided in patients considered resectable based on preoperative imaging. Because of the substantial risk of peritoneal seeding, percutaneous biopsy and diagnostic cholecystectomy are not necessary in the patient suspected of having gallbladder cancer. In these patients, exploration with curative intent is planned based on preoperative imaging alone.

Percutaneous CT scan – guided biopsy is a useful diagnostic tool in patients who appear to have a nonresectable tumor. Tissue diagnosis is necessary for palliative treatment.

Endoscopic ultrasonography with fine-needle aspiration can be used to evaluate for peripancreatic and periportal lymphadenopathy.

Histologic Findings

The vast majority of gallbladder cancers are adenocarcinomas. Papillary adenocarcinomas have a better prognosis, because they tend to be well-differentiated and less invasive. A number of other histologic subtypes have been described, but the prognostic implications are unknown. Some authors have described metaplastic and nonmetaplastic subtypes and have suggested that metaplastic tumors have a more favorable prognosis. Unfortunately, most gallbladder cancers are poorly differentiated and present at an advanced stage, limiting the prognostic importance of histologic subtypes.

Staging

The American Joint Committee on Cancer (AJCC) has designated staging by the TNM (primary t umor, regional lymph n odes, distant m etastasis) classification as follows^[10]:

Primary tumor (T)

TX - Primary tumor cannot be assessed
T0 - No evidence of primary tumor
Tis - Carcinoma in situ
T1 - Tumor invades lamina propria or muscle layer
- T1a - Tumor invades lamina propria
- T1b - Tumor invades the muscularis
T2 - Tumor invades the perimuscular connective tissue; no extension beyond the serosa or into the liver
T3 - Tumor perforates the serosa (visceral peritoneum) and/or directly invades the liver and/or 1 other adjacent organ or structure, such as the stomach, duodenum, colon, pancreas, omentum, or extrahepatic bile ducts
T4 - Tumor invades the main portal vein or hepatic artery or invades multiple extrahepatic organs or structures

Regional lymph nodes (N)

NX - Regional lymph nodes cannot be assessed
N0 - No regional lymph node metastasis
N1 - Portal lymph node metastasis
N2 - Distant lymph node metastasis such as periaortic, pericaval, superior mesenteric artery, or celiac artery

Distant metastasis (M)

MX - Distant metastasis cannot be assessed
M0 - No distant metastasis
M1 - Distant metastasis

Stage 0: Tis, N0, M0
Stage I: T1 (a or b), N0, M0
Stage II: T2, N0, M0
Stage IIIA: T3, N0, M0
Stage IIIB: T1 to T3, N1, M0
Stage IVA: T4, N0 or N1, M0
Stage IVB: Any T, N2, M0, OR Any T, any N, M1

Proceed to Treatment & Management

Contributor Information and Disclosures

Author

Thomas J VanderMeer, MD Assistant Professor of Surgery, SUNY Upstate Medical University; Program Director, General Surgery Residency; Chief, Section of General Surgery, Guthrie Health; Sayre, PA

Thomas J VanderMeer, MD is a member of the following medical societies: American College of Surgeons, American College of Surgeons Oncology Group, American Hepato-Pancreato-Biliary Association, Association for Surgical Education, Association of Program Directors in Surgery, and Society for Surgery of the Alimentary Tract

Disclosure: Nothing to disclose.

Coauthor(s)

Michael K McLeod, MD, FACE, FACS Professor of Surgery and Program Director, Integrated General Surgery Program, Department of Surgery, Michigan State University College of Human Medicine

Michael K McLeod, MD, FACE, FACS is a member of the following medical societies: American Association of Clinical Endocrinologists, American Association of Endocrine Surgeons, American College of Surgeons, American Medical Association, Association for Academic Surgery, Central Surgical Association, International Association of Endocrine Surgeons, Michigan State Medical Society, Midwest Surgical Association, National Medical Association, Society of American Gastrointestinal and Endoscopic Surgeons, and Western Surgical Association

Disclosure: Nothing to disclose.

Tara Mancl, MD Staff Physician, Department of Surgery, Michigan State University, Kalamazoo Center for Medical Studies

Tara Mancl, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Family Physicians, American College of Surgeons, and American Medical Student Association/Foundation

Disclosure: Nothing to disclose.

Michel M Murr, MD Professor, Department of Surgery, Director of Bariatric Surgery, University of South Florida

Michel M Murr, MD is a member of the following medical societies: American College of Surgeons, American Hepato-Pancreato-Biliary Association, American Society for Metabolic and Bariatric Surgery, Association for Academic Surgery, International College of Surgeons US Section, Society for Surgery of the Alimentary Tract, and Southeastern Surgical Congress

Disclosure: Covidien Consulting fee Consulting; Elsevier Consulting fee Board membership; Endocore Consulting fee Consulting

Specialty Editor Board

Alex Jacocks, MD Program Director, Professor, Department of Surgery, University of Oklahoma School of Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Michael A Grosso, MD Consulting Staff, Department of Cardiothoracic Surgery, St Francis Hospital

Michael A Grosso, MD is a member of the following medical societies: American College of Surgeons, Society of Thoracic Surgeons, and Society of University Surgeons

Disclosure: Nothing to disclose.

Paolo Zamboni, MD Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy

Paolo Zamboni, MD is a member of the following medical societies: American Venous Forum and New York Academy of Sciences

Disclosure: Nothing to disclose.

Chief Editor

John Geibel, MD, DSc, MA Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director, Surgical Research, Department of Surgery, Yale-New Haven Hospital

John Geibel, MD, DSc, MA is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, and Society for Surgery of the Alimentary Tract

Disclosure: AMGEN Royalty Consulting; ARdelyx Ownership interest Board membership

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