Advances in the treatment of gallbladder cancer
It is one of the common malignant tumors of the biliary system. It accounts for about 1% of the total number of all cancers. There are significant regional, age and gender differences in incidence. The incidence of gallbladder cancer accounts for 2.9% in India and 4% in the United States. It is 2 to 4 times more common in women than men. It is mostly seen in 50-70 years old, and 90% of the cases are above 50 years old. The literature reports that the misdiagnosis rate of gallbladder cancer is as high as 79.5%. The following factors should be highly suspected in clinical practice:
1, female gallbladder stone patients over 50 years of age.
2, Gallstones of >5 years duration or diameter >50px.
3, ultrasound suggesting limited thickening or atrophy of the gallbladder wall.
4, embedded stones in the neck of the gallbladder.
7, porcelain-like gallbladder.
8, combined with gallbladder polyp-like lesions or abnormal pancreaticobiliary duct connections.
9, previous cholecystostomy.
Patients suspected of gallbladder cancer should routinely undergo rapid cryopathological examination during surgery to assist in diagnosis.
I. Symptoms of gallbladder cancer
1.Pain in the right upper abdomen (84%)
2.Majority of gastrointestinal symptoms (90%)
3.Jaundice (36, 5%)
4.Fever (25, 9%)
5.Mass in the right upper abdomen (54, 5%)
Physical signs of gallbladder cancer
1.Jaundice is mostly obstructive; once jaundice appears, the lesion has mostly reached advanced stage.
2.Mass in right upper abdomen.
3.Signs caused by metastasis Some cases have metastasis of supraclavicular lymph nodes.
III. Laboratory tests
CA19-9 and CEA have a certain positive rate in gallbladder cancer cases, and the degree of elevation is related to the stage of disease.
Instrument examination
1.Ultrasound examination
The preferred method for early detection of gallbladder cancer
2.CT
The sensitivity is 50%. Gallbladder cancer is divided into three types
1.Gallbladder wall thickening type
2.Nodular type
3.Mass type.
3.MRI
It is especially suitable for determining the invasion of hepatoduodenal ligament and portal vein and lymph node metastasis by gallbladder cancer.
4.PTC
The application of PTC is easy to operate and has high diagnostic value when extrahepatic bile duct obstruction is caused by gallbladder cancer. The value of PTC for early diagnosis is to obtain bile test.
V. Treatment
Nevin stage
Stage I: cancerous tissue is limited to the mucosa, i.e. carcinoma in situ.
Stage II: Invasion to the muscular layer.
Stage III: cancerous tissue invades the whole layer of gallbladder wall.
Stage IV: Invasion of the entire wall of the gallbladder combined with metastasis to the surrounding lymph nodes.
Stage V: direct invasion of liver or metastasis to other organs or distant metastasis.
1.Surgery
(1) Simple cholecystectomy: it is applicable to early gallbladder patients, i.e. Nevin stage I and II or TNM stage 0 and I. However, clinically, patients with early gallbladder cancer can be treated with the same surgery. However, clinically it is difficult to diagnose early-stage gallbladder cancer patients before surgery, and most of them are diagnosed by intraoperative freezing or postoperative pathology.
Do we need to perform radical surgery again?
Radical surgery should be performed if the diagnosis of gallbladder cancer is confirmed before surgery
If gallbladder cancer is found unexpectedly after pathological examination due to benign lesions, it is not necessary to operate again if it is Nevin stage I. If it is Nevin stage II, it is necessary to operate again to remove regional lymph nodes and wedge part of the liver.
(2) Radical surgery for gallbladder cancer: applicable to pT2 stage patients, it refers to complete total gallbladder resection, appropriate resection of liver tissue in the gallbladder bed, and whole resection of paracolic lymph nodes of hepatoduodenal ligament and posterior duodenal lymph nodes of hepatic artery.
The depth of wedge resection of the liver remains controversial, with some authors suggesting 50 px from the tumor.
Most resectable gallbladder cancers should be cleared of lymph nodes in the hepatoduodenal ligament and, if necessary, of lymph nodes in the superior pancreaticoduodenum and posterior pancreatic head.
(3) Extended radical surgery for gallbladder cancer is suitable for patients with T3 and T4 stages, i.e., in addition to resection of gallbladder, it mainly includes hepatectomy, hepatoduodenectomy, lymph node dissection of the para-aortic lymph nodes, portal vein and hepatic artery resection with reconstruction.
Lymph node metastasis can occur very early in gallbladder cancer, and the main difficulty of this procedure is not the difficulty of resection of the locally invaded organs, but the complete clearance of the involved lymph nodes, and if there is distant lymph node metastasis, it cannot be called radical surgery.
However, only a small number of patients can survive for a long time after extended radical surgery, and the complications and mortality of extended radical surgery are high, so it should be chosen carefully.
(4) Palliative surgery for advanced gallbladder cancer: The more prominent problem of advanced gallbladder cancer is obstructive yellow bile caused by cancer invading the biliary system. Internal drainage should be considered as much as possible for surgery. The methods of internal drainage include bile duct jejunostomy and so on.
For cases with very poor systemic condition, external drainage can also be performed.
Hepatic artery chemoembolization via femoral artery puncture, percutaneous ultrasound-guided anhydrous alcohol injection, etc. can also be performed.
2.Radiation and chemotherapy
Gallbladder cancer has certain sensitivity to radiotherapy, so surgery plus radiotherapy can prolong life and improve life quality.
1.Intraoperative internal irradiation: For Nevein stage V, intraoperative internal irradiation therapy is performed during palliative surgery, and BOSSee reported that radiation therapy can relieve pain and reduce jaundice.
2.Postoperative external irradiation
It is suitable for those who can’t be resected after radical surgery or palliative resection of gallbladder cancer and surgery.
If jaundice deepens, or persistent pain, or the lesion develops more than before by ultrasound, radiation therapy is considered ineffective.
Interventional chemotherapy – hepatic artery embolization and perfusion chemotherapy (HAE) mainly with epi-amycin and 5-FU intrahepatic arterial perfusion
systemic chemotherapy – fluorouracil-based agents with a combination regimen of epi-amycin, mitomycin, etc.
Intraperitoneal perfusion chemotherapy – the drug is mainly cisplatin
3.Chinese medicine treatment.
The empirically effective formula for gallbladder cancer uses precious wild plants from Yunnan and Sichuan, which have unique killing effect on cancer cells. It has made breakthrough progress in the treatment of gallbladder cancer.
4.Immunotherapy
Immunotherapy is still an exploratory stage in the treatment of gallbladder cancer.
The general immune drugs are interferon, LAK cells, lysozyme and immune ribonucleic acid.