Gall Bladder Cancer and Cholangiocarcinoma

Question 1

Is gall bladder cancer common?

Answer 1

• no
• 23rd most common cancer with incidence of 1.2/100,000

Question 2

All of the following are risk factors for gall bladder cancer, but which one is the most common?

1 - obesity
2 - advancing age
3 - ethnicity (black and asian)
4 - family history of GB cancer
5 - gallstones
6 - gall bladder polyps
7 - porcelain gall bladder (calcified)
8 - abnormal anatomy

Answer 2

5 - gallstones

• 90% of patients with gall bladder cancer will have gallstones
• commonly associated with old age

Question 3

Patients do not typically present clinical with early gall bladder cancer. However, they do present with late onset of symptoms. Which of the following is NOT a common clinical presentation in patients with gall bladder cancer?

1 - left hypochondriac pain
2 - nausea and vomiting
3 - bloating
4 - jaundice
5 - fever

Answer 3

1 - left hypochondriac pain

• pain is typically in the right hypochondriac area.

Question 4

If a patient has the following, they should be monitored for gall bladder cancer?

1 - gall bladder polyps
2 - gallstones
3 - bile stones
4 - cholangitis

Answer 4

1 - gall bladder polyps

Question 5

Although there are a number of biochemical markers that can be used to identify if a patient is at risk of gall bladder cancer, along with their clinical presentation, which one has the better sensitivity?

1 - AST
2 - ALT
3 - ALP
4 - GGT

Answer 5

2 - ALT

• used for jaundice which can be common
• there are no specific tumour markers for gall bladder cancer

Question 6

Which of the following is normally the first line imaging modality for a patient with suspected hepatobiliary symptoms due to gall bladder cancer?

1 - ultrasound
2 - CT
3 - MRI
4 - FDG-PET/CT

Answer 6

1 - ultrasound

Question 7

Which of the following is normally the first line imaging modality for staging a patient with gall bladder cancer?

CAP = chest, abdomen and pelvis

1 - ultrasound
2 - CT for CAP
3 - MRI
4 - FDG-PET/CT

Answer 7

2 - CT for CAP

Question 8

What is the only curative treatment for gall bladder cancer?

1 - chemotherapy
2 - surgery
3 - radiotherapy
4 - immunotherapy

Answer 8

2 - surgery
- requires local resection so a cholecystectomy
- radical resection includes partial liver
- can also include adjuvant therapy with chemo and radiotherapy

Question 9

If curative treatment is not an option, patients can have palliative care. Which of the following do patients have during palliative care?

1 - stents
2 - drainage
3 - artificial fistula
4 - parental feeding

Answer 9

1 - stents
2 - drainage

• both ensure the gall bladder continues to function

Question 10

5 year survival of gall bladder cancer:

• disease localised to GB = 65%
• GB and lymph nodes = 28%
• distant metastasis = 2%

Question 11

Cholangiocarcinoma is a tumour in the biliary tree. It is rare in the UK with 1200 new cases/year, but where does it have a high incidence?

1 - North America
2 - South America
3 - Asia
4 - Sastern European

Answer 11

3 - Asia

Question 12

What condition of the biliary tree is commonly associated with cholangiocarcinoma?

1 - secondary sclerosing cholangitis
2 - primary sclerosing cholangitis
3 - cholecystitis
4 - cholelithiasis

Answer 12

2 - primary sclerosing cholangitis

• with or without the presence of ulcerative colitis

Question 13

Which of the following is NOT a risk factor for cholangiocarcinoma?

1 - choledochal cyst
2 - bile duct stones
3 -primary sclerosing cholangitis
4 - liver fluke
5 - gastritis

Answer 13

5 - gastritis

Question 14

Courvoisier’s sign can be used in cholangiocarcinoma. Which of the following is NOT part of Courvoisier’s sign?

1 - painful gall bladder
2 - jaundice
3 - palpable gall bladder
4 - no presence of gallstones

Answer 14

1 - painful gall bladder

• it is normally pain free
• jaundice is due to malignant obstruction of biliary tree
• can be tumour in common bile duct

Question 15

Patients with cholangiocarcinoma can present with jaundice. What affect can cholangiocarcinoma have on stool and urine?

1 - darker stool and urine
2 - lighter stool and urine
3 - pale stool and dark urine
4 - dark stool and pale urine

Answer 15

3 - pale stool and dark urine

• no bile being secreted so no stercobilin
• conjugated bile moves into blood and out through urine

Question 16

Which of the following is NOT one of the key clinical presentations of cholangiocarcinoma?

1 - weight gain
2 - epigastric pain
3 - nausea
4 - jaundice

Answer 16

1 - weight gain

• normally weight loss

Question 17

Cholangiocarcinoma is normally identified as an incidental finding when investigating a patients symptoms or with biliary surveillance. Are there any useful tumour markers for cholangiocarcinoma?

Answer 17

• no
• low sensitivity and specificity

Question 18

Although ultrasound can commonly be used to identify Cholangiocarcinoma, which method is more accurate and generally used for staging?

1 - ultrasound
2 - CT
3 - MRI
4 - FDG-PET/CT

Answer 18

2 - CT

• MRCP is optimal though

Question 19

Although not always performed or available, what method can be used to diagnosis Cholangiocarcinoma based histology?

1 - ERCP
2 - CT
3 - MRCP
4 - FDG-PET/CT

Answer 19

1 - ERCP

• can increase the risk of infection though

Question 20

Surgery in Cholangiocarcinoma is often not curable, why is this?

1 - difficult to operate on
2 - previous surgery makes it difficult
3 - progressive stage of cancer makes surgery risky
4 - presentation is late and therefore disease has typically spread

Answer 20

4 - presentation is late and therefore disease has typically spread

Question 21

Surgery in Cholangiocarcinoma could include the following:

• local resection of bile ducts
• partial liver resection
• whipple
• liver transplantation

Answer 21

Patients can also receive:

• chemotherapy
• radiotherapy
• stents or drains palliatively

Question 22

At presentation what % of patients are eligible for potentially curative treatment?

1 - 10%
2 - 22%
3 - 33%
4 - 60%

Answer 22

3 - 33%

Question 23

What is the 5 year survival of patients who are eligible for potentially curative treatment?

1 - 1-7%
2 - 10-20%
3 - 15-25%
4 - 11-42%

Answer 23

4 - 11-42%

• lymphatic involvement has an 8% 5 year survival
• distant metastatic disease has a 2% 5 year survival

Question 24

What is the main risk factor for Cholangiocarcinoma in ASIA?

1 - alcohol
2 - smoking
3 - liver fluke
4 - medications

Answer 24

3 - liver fluke

• parasites in fish, common in undercooked fish
• increases Asian incidence to 100 / 100,000