Gallbladder Cancer

Although highly lethal, gallbladder cancer is extremely rare. The annual incidence in the United States is less than 7000 cases, and it is the fifth most common malignancy of the gastrointestinal (GI) tract. When the diagnosis of carcinoma of the gallbladder is incidental on routine cholecystectomy for gallstone disease, the prognosis is excellent. Incidental carcinoma of the gallbladder is noted in 1% to 3% of cholecystectomy specimens and 0.5% to 7.4% of autopsies.

Risk factors for gallbladder carcinoma include gallstones, history of chronic cholecystitis, and porcelain gallbladder (more in patchy type of porcelain gallbladder than in the diffuse type). Adenomas of the gallbladder may progress to cancer, the risk is associated with older age, single lesion, sessile shape and polyps greater than 10 mm in size. The risk is related to the size of the polyp. Polyps smaller than 1 cm seldom undergo malignant changes. Other risk factors are anomalous drainage of the pancreatic duct into the common bile duct (CBD), congenital biliary cysts, and Salmonella infection (chronic gallbladder infection).

In contrast to the general US population, gallbladder cancer is the most common GI malignancy in Native Americans who live in the southwest and in Mexican Americans. Worldwide, the incidence of carcinoma of the gallbladder is highest in Chile, Bolivia, and northern regions of India. The risk is higher in women and elderly populations.

Although gallstones are frequently associated with carcinoma, the incidence of carcinoma in patients with gallstone disease is extremely low. Symptomatic gallstone disease—large size of the stones (>2.5 cm) and long duration of gallstone disease (notably >40 years)—are other observed risk factors. Another risk factor for gallbladder carcinoma involves an anomalous pancreatobiliary duct junction. A strong association of Salmonella infection and its carrier state has been shown in many studies. Most gallbladder carcinomas are adenocarcinomas, but squamous cell tumors, mixed tumors, and adenoepidermoid tumors occasionally develop.

Clinical Picture

Most patients have nonspecific findings of right upper quadrant pain, malaise, weight loss, jaundice, anorexia, and vomiting mimicking symptomatic gallstone disease. Few patients have acute cholecystitis. At diagnosis, most patients have tumors that have invaded adjacent organs, local lymph node metastasis, or even distinct metastasis ( Fig. 141.1 ). The 5-year survival rate is less than 5%, except when the diagnosis is incidental on routine cholecystectomy.