More than 2,000 years ago, the Yellow Emperor’s Classic of Internal Medicine proposed that “the top doctor treats the untreated disease, the middle doctor treats the desired disease, and the bottom doctor treats the existing disease”, which means that the most skilled doctor is not the one who is good at treating disease, but the one who can prevent it. Gallbladder cancer is the most common malignant tumor of biliary tract, which has always been of great concern to the surgeons for its extremely poor prognosis and low survival rate. In recent years, the incidence of primary gallbladder cancer has been on the rise in some regions of China. The incidence of primary gallbladder cancer is insidious, with no special symptoms and signs, and the early diagnosis rate is only 19.1%, and once found, it is mostly in the middle and late stages. The 5-year survival rate after surgery is less than 5%. Here I will discuss with you some questions that are often asked by patients in clinical work about primary gallbladder cancer diagnosis and treatment.
1.Where is the incidence of primary gallbladder cancer high?
The most obvious feature of gallbladder cancer incidence is its geographical difference, both globally and within a country. In China, the incidence is higher in the northwest and northeast than in the south of Yangtze River, and the incidence is higher in rural areas than in cities.
2.Are older women more likely to develop primary gallbladder cancer?
There is an obvious gender difference in the epidemiological distribution of primary gallbladder cancer, with women being significantly higher than men. The reason for this difference in incidence rate between the two genders is still not clear. Some studies have found that multiple pregnancies and multiple births in women can significantly increase the risk of gallbladder cancer, which may be related to the increase of progesterone and endogenous estrogen levels in women’s bodies during pregnancy. The age distribution of primary gallbladder cancer in mainland China ranges from 25 to 87 years old, with an average of 57 years old, and 70% to 80% of those above 50 years old, with the peak age group of incidence being 50 to 70 years old. The peak age of incidence is 50-70 years old, especially around 60 years old.
3.Is primary gallbladder cancer related to occupation?
Many surveys show that the incidence of gallbladder cancer is higher among people in oil refining, paper making, chemical, shoe making and textile industries, but due to the small number of cases and the lack of relevant studies to further verify, the connection between occupation and gallbladder cancer still needs further study.
4.I have been suffering from cholecystitis and gallbladder stone disease for many years, will it lead to gallbladder cancer?
There is a basic consensus on the risk factors for the development of primary gallbladder cancer.
① Gallbladder stones disease duration greater than 5 years.
②Female gallbladder stone patients over 50 years of age.
③B ultrasound suggesting limited thickening of the gallbladder wall.
④ embedded stones in the gallbladder neck.
⑤Stone diameter greater than 2.0 cm.
(6) atrophy of the gallbladder or significant thickening of the cyst wall
(vii) porcelain-like gallbladder.
⑧ Combined with polypoid lesions of the gallbladder.
⑨ combined with abnormal biliopancreatic duct connection.
(⑩Persons who have undergone cholecystostomy in the past. If patients with the above high-risk factors are encountered clinically, more active diagnostic and treatment measures should be taken to improve the early diagnosis rate of primary gallbladder cancer.
5.Many people are found to have gallbladder polyps in physical examination, why do doctors only recommend surgery for some of them? Is there any relationship between gallbladder polyps and gallbladder cancer?
Most of the patients with gallbladder polyps found in physical examination have no obvious clinical symptoms. Given that a few gallbladder polyps may be early-stage gallbladder cancer or may become cancerous. The possibility of cancer and the need for surgical treatment depend on the polyp form. The more recognized indications for surgery are: a single lesion with a diameter of more than 25 px, age over 50 years, a tendency for polyps to increase in size on serial ultrasound examinations, adenomatous polyps or a wide base, combined gallbladder stones or thickened gallbladder wall.
6.In daily life, what symptoms indicate the possibility of primary gallbladder cancer?
Clinical manifestations of primary gallbladder cancer may have different symptoms according to the location and depth of the lesion. In the early stage, there are no specific symptoms, such as abdominal pain, nausea and vomiting, abdominal pressure pain caused by chronic cholecystitis or gallbladder stones, etc. Some patients accidentally discover gallbladder cancer through pathological examination of gallbladder resection specimens. When the tumor invades into the plasma membrane or gallbladder bed, localization symptoms will appear, most commonly right upper abdominal pain, which can radiate to the back of shoulder, appetite can be decreased, and the enlarged gallbladder can be palpated when the gallbladder duct is blocked. When the right upper abdominal swelling can be palpated, it is often in advanced stage, often accompanied by abdominal distension, weight loss or wasting, poor appetite, anemia, large liver, and even gangrene, ascites, and systemic failure.
7.After the ultrasound found to have gallbladder-occupying lesions, why did the doctor recommend many other tests, and are these tests useful?
Before talking about this issue, we should first clarify the concept of “accidental gallbladder cancer”. Accidental gallbladder cancer refers to the diagnosis of gallbladder cancer after cholecystectomy with clinical diagnosis of benign gallbladder disease, which is confirmed by pathological examination during or after surgery. Unexpected gallbladder cancer is very common in the diagnosis and treatment of gallbladder cancer. The key to solve this problem lies in how to turn accidental gallbladder cancer into preoperative diagnosed gallbladder cancer as much as possible, so that appropriate surgery can be performed in one operation to meet the requirements of pathological staging and avoid the second operation to bring harm to patients. Therefore, it is very important to try to clarify the diagnosis of gallbladder cancer in high-risk group before surgery.
Among various imaging examinations, ultrasound examination has a high diagnostic rate and is the first choice of instrumental examination for its simplicity, non-invasiveness and repeatability. The diagnostic conformity rate for gallbladder cancer can reach more than 80%, but the diagnostic rate for early stage gallbladder cancer is low, not very helpful for qualitative diagnosis and staging, and easily interfered by obesity and gastrointestinal gas.
Ultrasound endoscopy examination is of high value for confirming the diagnosis of microscopic lesions and differential diagnosis of benign and malignant tumors. Because ultrasound is easily affected by abdominal wall hypertrophy and intestinal pneumatization, early gallbladder cancer is more difficult to detect. Ultrasound endoscopy, on the other hand, uses a high-frequency probe to scan the gallbladder only through the stomach or duodenal wall, which can further improve the detection rate of gallbladder cancer, especially for early-stage gallbladder cancer, and can also assess the infiltration range of gallbladder cancer, which is of guiding significance for clinical staging.
CT is better than B ultrasound in characterizing gallbladder cancer, and its diagnosis rate is higher than that of B ultrasound, and it can clarify the infiltration range of gallbladder cancer and whether there is hepatic artery and portal vein infiltration. Enhanced CT can clarify the relationship between tumor and surrounding blood vessels.
In recent years, magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) are also used for the diagnosis of gallbladder cancer. MRI combined with MRA can show vascular infiltration, bile duct infiltration, liver infiltration and lymph node metastasis|.
With the wide development of positron emission tomography (PET), PET can better identify benign and malignant gallbladder polyp-like lesions that cannot be identified by CT and B ultrasound. More importantly, PET has a high diagnostic value for residual gallbladder cancer, recurrence and distant metastasis of gallbladder cancer after cholecystectomy or radical cholecystectomy.
In terms of laboratory tests, recent studies have shown that CA-242 has high diagnostic value among specific tumor markers for gallbladder cancer, with a diagnostic sensitivity of 84%, which is significantly better than CEA, CA-19-9 and CA-125. fine needle aspiration of gallbladder bile for tumor marker examination has more diagnostic significance.
With the development of molecular biology technology, it is now possible to directly detect and identify the defective genes, so that the diagnosis of gallbladder cancer has risen from traditional morphological diagnosis to genetic diagnosis. At present, the oncogenes related to gallbladder cancer that have been studied more frequently include K-ras, survivin, cerbB-2, hcl-2, c-mvc, bax, etc., and oncogenes such as p53, PTEN, p27, Rb gene, etc. Detection of the above genetic changes can provide more important auxiliary means for early diagnosis of gallbladder cancer.
8.Laparoscopic cholecystectomy was performed for chronic cholecystitis and gallbladder stones, but after the operation, the doctor told that the postoperative pathology was gallbladder cancer and a second operation was needed, is this reasonable?
LC (laparoscopic cholecystectomy) has become a routine and alternative to traditional surgical treatment for benign gallbladder disease. Due to the widespread availability of LC and the difficulty of diagnosing gallbladder cancer before surgery, the number of unexpected gallbladder cancers detected intraoperatively or postoperatively by LC is gradually increasing. However, the management of unexpected gallbladder cancer in the absence of well-established guidelines is a challenge. Whether, when, and how to perform reoperation for unexpected gallbladder cancer and the effectiveness of reexcision for gallbladder cancer at different pathological stages have been controversial. Surgical resection is currently the only effective treatment for gallbladder cancer, and most scholars believe that the treatment of gallbladder cancer is determined by the stage of gallbladder cancer. In gallbladder cancer detected after simple LC surgery for benign disease, in order to improve the prognosis, the tumor and gallbladder margins should be retrieved and analyzed to determine the stage of the tumor, and if the initial surgery cannot achieve radical surgery, secondary radical surgery is necessary. It has been reported in the literature that a second radical surgery is recommended for patients with stage T2 (cancer infiltrating the entire cyst wall without lymph nodes and distant metastases) gallbladder cancer or more advanced stages.
Here we can only briefly popularize the knowledge about primary gallbladder cancer through the preliminary answers to some questions, and hope to give you some help through this. Gallbladder cancer may be far away from you or very close to you, but please don’t be paralyzed and don’t panic. Cherish your life, prevention is the main focus!