Gallbladder Cancer Workup

  • Author: Mary Denshaw-Burke, MD, FACP; Chief Editor: Jules E Harris, MD   more...
 
Updated: Apr 23, 2012
 

Laboratory Studies

  • Tumor marker CA 19-9
    • CA 19-9 may be significantly elevated in both cholangiocarcinoma and gallbladder cancer.
    • CA 19-9 tests may be helpful in the appropriate situation if the clinical suspicion for gallbladder cancer is high.
    • CA 19-9 can be useful in conjunction with CEA.
  • Liver function tests: Elevated alkaline phosphatase and bilirubin levels are often found with more advanced disease.
  • BUN, creatinine, urinalysis: Assess renal function prior to performing an enhanced CT scan.
  • CBC: Anemia may be an indicator of more advanced disease.
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Imaging Studies

  • Ultrasonography (US) is a standard initial study in patients with right upper quadrant pain. A mass can be identified in 50-75% of patients with gallbladder cancer. It also can delineate metastatic lesions in the liver.
  • Computed tomography (CT) scans also may be useful in patients with upper abdominal pain and can demonstrate tumor invasion outside of the gallbladder and identify metastatic disease elsewhere in the abdomen or pelvis. Liver invasion occurs in 60% of cases, and the combination of CT scan and US provides accurate details of disease extension.
  • Magnetic resonance imaging (MRI) has been useful in examining this region for disease extension into other tissues or metastatic disease in the liver. It can provide details of the vasculature for preoperative planning via magnetic resonance angiogram (MRA) and bile duct passages via magnetic resonance cholangiogram (MRCP).
  • Cholangiography, via a percutaneous route, or endoscopic retrograde cholangiography (ERCP) may establish the diagnosis of gallbladder cancer by bile cytology.
  • Endoscopic ultrasonography can be useful to assess regional lymphadenopathy and depth of tumor invasion into the wall of the gallbladder. In conjunction with other studies, it also can provide a means of obtaining bile for cytologic analysis, which has a sensitivity of 73% for the diagnosis of gallbladder cancer.[15]
  • Angiography may be used to confirm encasement of the portal vein or hepatic artery and may assist in preoperative planning for definitive resection.
  • A routine chest radiograph should also be obtained.
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Procedures

  • ERCP can demonstrate the site of the obstruction by direct retrograde dye injection, as well as exclude ampullary pathology by endoscopic evaluation. Brush cytology, biopsy, needle aspiration, and shave biopsies via ERCP can provide material for histology. Palliative stenting to relieve biliary obstruction can be performed at the time of the evaluation.
  • Percutaneous transhepatic cholangiography (PTC) may allow access to the proximal biliary tree that has become obstructed by extensive tumor growth from the gallbladder. Material for cytology can be obtained and drainage performed as well.
  • Other methods to obtain tissue include CT or ultrasound needle aspiration if a mass lesion is present and endoscopic ultrasonographic (EUS) fine-needle aspiration.
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Histologic Findings

Adenocarcinoma is the primary histologic finding in 80-85% of gallbladder carcinomas, with several histologic subtypes, including papillary, nodular, and infiltrative. The papillary type appears to be less aggressive and more often localized and has a better prognosis than the other forms. Additional rare histologic types of gallbladder cancer exist. These include squamous cell cancer, sarcomas, carcinoid, lymphoma, and melanoma.

Grade is also important, with poorly differentiated tumors associated with a poorer prognosis than the typically less infiltrative, better differentiated tumors with metaplasia.

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Staging

Staging of tumor extent is essential in selection of the appropriate treatment approach.

The AJCC 6th edition guidelines follow the TNM system, with depth of tumor penetration and regional spread defined pathologically.[14] Survival is correlated directly with stage of disease.

Primary tumor

  • Category 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 muscle layer
    • T2 - Tumor invades perimuscular connective tissue; no extension beyond serosa or into liver
    • T3 - Tumor perforates the serosa (visceral peritoneum) and/or directly invades the liver and/or one other adjacent organ or structure, such as the stomach, duodenum, colon, pancreas, omentum, or extrahepatic bile ducts
    • T4 - Tumor invades main portal vein or hepatic artery or invades multiple extrahepatic organs or structures
    • Regional lymph node
  • Category N
    • NX - Regional lymph nodes cannot be assessed
    • N0 - No metastases in regional lymph nodes
    • N1 - Metastases to regional lymph nodes along the cystic duct, common bile duct, hepatic artery, and/or portal vein
    • N2 - Metastases to periaortic, pericaval, superior mesenteric artery, and/or celiac artery lymph nodes
  • Category M
    • MX - Presence of metastases cannot be assessed
    • M0 - No distant metastases
    • M1 - Distant metastases
  • TNM groupings by stage
    • Stage 0- Tis N0 M0
    • Stage I - T1 N0 M0
    • Stage II - T2 N0 M0
    • Stage IIIA - T3 N0 M0
    • Stage IIIB - T1-3 N1 M0
    • Stage IVA - T4 N0-1 M0
    • Stage IVB - Any T N2 M0 any T any N M1
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Contributor Information and Disclosures
Author

Mary Denshaw-Burke, MD, FACP  Clinical Assistant Professor of Medicine, Jefferson Medical College of Thomas Jefferson University; Clinical Assistant Professor, Affiliated Clinical Faculty of the Lankenau Institute for Medical Research; Program Director of Hematology/Oncology Fellowship, Education Coordinator for Oncology, Lankenau Medical Center

Mary Denshaw-Burke, MD, FACP is a member of the following medical societies: American College of Physicians and Pennsylvania Medical Society

Disclosure: Novartis Pharmaceuticals Honoraria Speaking and teaching

Coauthor(s)

Jessica B Katz, MD, PhD, FACP  Associate Director, Discovery Medicine Clinical Pharmacology, Oncology Division, Bristol Myers Squibb

Jessica B Katz, MD, PhD, FACP is a member of the following medical societies: American College of Physicians, American Society of Clinical Oncology, and Phi Beta Kappa

Disclosure: BMS Salary Employment

Andrew Scott Kennedy, MD  Co-Medical Director, Wake Radiology Oncology

Andrew Scott Kennedy, MD is a member of the following medical societies: Alpha Omega Alpha, American Association for Cancer Research, American Hepato-Pancreato-Biliary Association, American Society for Therapeutic Radiology and Oncology, American Society of Clinical Oncology, and Radiological Society of North America

Disclosure: Nothing to disclose.

Specialty Editor Board

Michael Perry, MD, MS, MACP  Nellie B Smith Chair of Oncology Emeritus, Director, Division of Hematology and Medical Oncology, Deputy Director, Ellis Fischel Cancer Center, University of Missouri-Columbia School of Medicine

Michael Perry, MD, MS, MACP is a member of the following medical societies: Alpha Omega Alpha, American Association for Cancer Research, American College of Physicians, American College of Physicians-American Society of Internal Medicine, American Medical Association, American Society of Clinical Oncology, American Society of Hematology, International Association for the Study of Lung Cancer, and Missouri State Medical Association

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

Benjamin Movsas, MD  Vice-Chairman, Department of Radiation Oncology, Fox Chase Cancer Center

Benjamin Movsas, MD is a member of the following medical societies: American College of Radiology, American Radium Society, and American Society for Therapeutic Radiology and Oncology

Disclosure: Nothing to disclose.

Rajalaxmi McKenna, MD, FACP  Southwest Medical Consultants, SC, Department of Medicine, Good Samaritan Hospital, Advocate Health Systems

Rajalaxmi McKenna, MD, FACP is a member of the following medical societies: American Society of Clinical Oncology, American Society of Hematology, and International Society on Thrombosis and Haemostasis

Disclosure: Nothing to disclose.

Chief Editor

Jules E Harris, MD  Clinical Professor of Medicine, Section of Hematology/Oncology, University of Arizona College of Medicine, Arizona Cancer Center

Jules E Harris, MD is a member of the following medical societies: American Association for Cancer Research, American Association for the Advancement of Science, American Association of Immunologists, American Society of Hematology, and Central Society for Clinical Research

Disclosure: GlobeImmune Salary Consulting

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