Gallbladder neoplasms Flashcards
What are the 4 types of benign gallbladder neoplasms?
- cholesterol polyps 2. inflammatory polyps 3. adenomas 4. adenomyomatosis
Describe cholesterol polyps
smaller than 1 cm multiple associated with vesicular cholesterolosis no risk of cancer
Describe inflammatory polyps
smaller than 1 cm made of inflammatory cells secondary to chronic inflammation and cholestasis no risk of cancer
Describe adenomas
0.5 to 2 cm Pedunculated 3 types associated with gallstones
What are the three types of adenomas?
tubular papillary mixed types
Describe adenomyomatosis
solitary hyperplastic mucosal lesions near the fundus rarely associated with cancer
Which benign gallbladder lesions are associated with cancer?
Adenomas Adenomyomatosis
Are the majority of malignant gallbladder lesions primary or metastatic?
primary
what is the MC histological subtype of malignant gallbladder lesion?
adenocarcinoma
What are the subtypes of adenocarcinoma?
papillary nonpapillary mucinous
What other primary malignant lesions can be found in the gallbladder?
squamous cell adenosquamous neuroendocrine small cell sarcomatous
what are the mc metastatic lesions to the gallbladder?
melanoma lymphoma RCC HCC
where do the majority of cholangiocarcinoma form?
perihilar region (60-70%)
What bismuth classification for cholangiocarcinoma?
Type I
What bismuth classification for cholangiocarcinoma?
Type II
What bismuth classification for cholangiocarcinoma?
Type IIIa
What bismuth classification for cholangiocarcinoma?
Type IIIb
What bismuth classification for cholangiocarcinoma?
Type IV
Are polyps more common in males or females?
males
Is gallbladder cancer more likely in men or women?
women
Which ethinicities are more prone to gallbladder cancer?
mexican
native american
south america
southest asian
japanese
What are some risk factos for gallbladder cancer?
- obesity
- large stones >3 cm
- large polyps >1.0 cm
- segmental mucosa calcification
- PSC
- anomalous pancreaticobiliary junction (choledochal cysts)
What are some risk factors for cholangiocarcinoma?
- PSC
- choledochal cysts
- parasitic infection
- hepatolithiasis
- hepatitis C
What parasitic infections increase risk for cholangiocarcinoma?
- Chlonorchisis sinesis
- opisthorchis
How to cholesterol polyps look on US?
hyperechoic compared to the liver
How to adenomas look on US?
isoechoic
solitary
homogenous
smooth
How does adenomyomatosis look on US?
focal gallbladder wall thickening with diffuse/segmental round anechoic foci
How does adenocarcinoma look on US?
homogenous/hetergenous
isoechoic
solitary
How do adenomas and adenocarcinoma look different on US?
adenomas are usually smooth and homogenous
What is the staging work up for gallbladder cancer?
- Liver protocol CT or MRI if contraindicated
- CT chest and pelvis
- endoscopic U/S if CT equivocal
- Don’t need routine PET
- Elevated CA 19-9 and CEA may be suggestive of GB cancer but not diagnostic
What is the staging work up for gallbladder cancer found incidentally during surgery?
- Frozen section plus any suspicious lymph nodes
- CT liver protocol + CT chest, MRI if CI
- If resectable: radical cholecystectomy with resection of segments IVB and V, lymphadenectomy, and hepatic/biliary resection as needed
- If unresectable: get microsatellite/mismatch repair testing and tumor mutational burden testing
What is the staging work up for gallbladder cancer found incidentally on pathology that is T1a?
Observe
What is the staging work up for gallbladder cancer found incidentally on pathology that is T1b or greater?
- Liver protocol CT, CT chest
- Consider staging laparoscopy
- if resectable do radical cholecystectomy with hepatic resection + lymphadenectomy +/- bild duct excision for malignant involvement
- if unresectable get MSI/MMR and TMB testing
What is the staging work up for intrahepatic cholangiocarcinoma?
- Liver protocol CT, CT chest
- Consider CEA and CA 19-9, AFP
- LFT
- consider viral hepatitis serologies
- EGD and colonoscopy
- Biopsy
What is the treatment for resetable intrahepatic cholangiocarcinoma?
staging laparoscopy then resection with regional lymphadenectomy
What is the treatment for unresectable intrahepatic cholangiocarcinoma or metastatic disease?
Get MSI/MMR, TMB testing then consider systemic therapy
What is the work up for extrahepatic cholangiocarcinoma?
- Liver protocol CT and CT chest
- cholangiography
- LFT
- consider CEA, CA 19-9
- consider EUS after surgical consultation
- consider serum IgG4 to rule out autoimmune cholangitis
What is the primary treatment for resectable extrahepatic cholangiocarcinoma?
- surgical exploration/staging laparoscopy
- consider preop drainage
- multidisciplinary review
- resection
- Adjuvant therapy with capacitabine
What is the primary treatment for unresectable extrahepatic cholangiocarcinoma?
- Biliary drainage if indicated
- biopsy (only after determining transplant status)
- get MSI/MMR/TMB testing
- Systemic treatment with Capecitabine
What layer is gallbladder cancer T1a?
limited to lamina propria
What layer is T2a in gallbladder cancer?
The cancer has grown through the muscle layer into the fibrous tissue on the side of the peritoneum (the lining of the abdominal cavity) (T2a).
What layer is gallbladder cancer T1b?
started to grow into the muscular layer
simple cholecystectomy no longer sufficient
When is it okay to do simple cholecystectomy for polyp?
When size is 1.0 cm to 1.9 cm
