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BILIARY MALIGNANCIES

BILIARY MALIGNANCIES. Dr Sanjay De Bakshi MS(Cal.);FRCS (Eng Edin.). GALL BLADDER CANCER -Incidence. States of Uttar Pradesh, Bihar, West Bengal & Assam Delhi Madhya Pradesh; Bhopal have the highest incidence of Gall Bladder Cancer. AETIOLOGY.

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BILIARY MALIGNANCIES

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  1. BILIARY MALIGNANCIES Dr Sanjay De Bakshi MS(Cal.);FRCS (Eng Edin.).

  2. GALL BLADDER CANCER-Incidence. • States of • Uttar Pradesh, • Bihar, • West Bengal & • Assam • Delhi • Madhya Pradesh; Bhopal • have the highest incidence of • Gall Bladder • Cancer.

  3. AETIOLOGY • Cholelithiasis-directly proportional to the size of the stone;(Risk 2.4 for those with stones 2.0 to 2.9cm. in size; 10.1 for those with stones >3cm.) Metaplasia Dysplasia Carcinoma. • Papillary and non-papillary adenomas have pre-malignant potential, (in particular polyps >10mm in size). • Carcinogens-breakdown products from bile acids. • Anomalous connection between the CBD and Pancreatic ducts. • Porcelain Gall Bladder pathological finding of a brittle gallbladder with a bluish tinge. Diffuse (Type I)less prone than Selective mucosal calcification (Type II and III) Stephen et al 2001

  4. AETIOLOGY • Occupational – possibly in the rubber industry. • Mustard oil loaded with impurities (Hai et al 1994). • Infections – Salmonella typhi, Helicobacter bilis and hepaticus and Esch. Coli implicated though the proof of relationship nebulous (Nath et al 2010) {Chronic inflammation and genotoxic toxin (cytotoxic distending toxin- CdtB)} PATHOBIOLOGY OF GALLBLADDER CANCER. Sunita Singh et al Journal of Scientific Research; Banaras Hindu University, Varanasi; Vol. 56, 2012 : 35-45

  5. RISK FACTORS • Race • Obesity • Multiparity • Smoking • Chronic infections with S typhi and paratyphi • Porcelain Gall Bladder • Certain diet patterns.

  6. STAGING OF GALL BLADDER CANCER Nevin et al 1976.

  7. STAGING OF GALL BLADDER CANCER Donohue modification of Nevin classification 1990

  8. STAGING OF GALL BLADDER CANCER AJCC/TMN 6th Edition

  9. T STAGING7th Edition

  10. STAGING OF GALL BLADDER CANCER M N 0 No lymph node involvement 0 No distant mets AJCC/TMN 6th Edition 1 Distant mets incl. interaortocaval nodes 1 Any lymph node involvement

  11. N STAGING7TH Edition M STAGING7TH Edition

  12. STAGING OF GALL BLADDER CANCER

  13. STAGING OF GALL BLADDER CARCINOMA7th Edition AJCC

  14. Characteristics of a Gall Bladder Cancer • Spread principally by direct extension. • Spreads also by lymphatic, vascular,neural, intraperitoneal and intraductal routes. • Anatomically straddles the junction between the IVB and V lobe of the liver.

  15. Lymphatic drainage of the Gall Bladder • Cholecysto-retropancreatic • Cholecysto-coeliac. • Cholecysto-mesenteric

  16. Presentation of Gall Bladder Carcinoma. • Histological surprise • Lump abdomen without jaundice. • Lump abdomen with jaundice. • From secondaries.

  17. OLDER TRADITIONAL VIEW. Nevin Stage I or II, cured by cholecystectomy ALONE. RECENT VIEWS- Tumours with Tis and T1a staging with clear resection margin, no further treatment needed. For patients with T2 or advanced GB cancer, a completion second radical operation is only chance of cure. Histological Surprise- what to do? VERSUS

  18. Histological Surprise- what to do? EARLY RE-EXLORATION BUT AFTER FOUR STEPS • Pathology reviewed regarding staging and status of cystic duct. • Staging with adequate preoperative imaging. • Assessment for fitness for another major surgery. • Counselling of patient and family.

  19. Patient presents with a lump-without jaundice,- what to do? ? • NEED TO RULE OUT SPREAD TO • N2 NODAL COMPARTMENT AND • TO PERITONEUM

  20. Patient presents with a lump -with jaundice-What to do? ?

  21. BILE DUCT CANCERAetiology • Prolonged cholestasis, inflammation and infection. • Choledochal cyst, Caroli’s disease, Congenital hepatic fibrosis and Polycystic disease. • After choledocho-enteric anastomosis and other previous biliary surgery(In the Lahey clinic series-50% had had cholecystectomy and 25% other types of biliary surgery.)

  22. BILE DUCT CANCER

  23. BILE DUCT CANCER

  24. PERIPHERAL CHOLANGIOCAs • In most peripheral cholangiocarcinomas, hard, compact, and grayish-white massive or nodular lesions are found in the liver. • PET Sensitive.

  25. BILE DUCT CANCERAetiology • Infection with liver flukes(Round worms?) • Chronic typhoid carrier states(x6 times) • Ulcerative colitis. • Solitary adenomas & biliary papillomas.

  26. Pathology of the Bile Duct Cancer • TYPE-almost always adenocarcinomas • Sclerosing-70%. • Papillary-20%. • Nodular-10%. • SITE:- %

  27. AJCC STAGING

  28. BISMUTH STAGING OF CHOLANGIOCARCINOMAS

  29. Bismuth-Corlette Type I tumor

  30. Bismuth Corlette type II tumour

  31. Bismuth Corlette type IIIatumor.

  32. Bismuth Corlette type IIIbtumor

  33. Bismuth Corlette type-IV tumor

  34. THE PROBLEM OF STAGING SYSYTEMS FOR BILE DUCT CARCINOMA • NONE ASSESS FOR RESECTABILITY • Most large series (for hilar tumours)- • 32% unresectable • 29% found to have secondaries at exploration • Therefore, a staging system has been proposed. • Based on Staging Laparoscopy (with Ultrasound). Janargin WR et al 2001

  35. HILAR CARCINOMAS Janargin WR et al 2001

  36. HILAR CARCINOMAS CRITERIA FOR NONRESECTABILITY • PATIENT FACTOR • Medically unfit • Cirrhosis/portal hypertension • LOCAL FACTORS • Hepatic duct involvement upto secondary radicles bilaterally • Encasement/occlusionof main portal vein proximal to its bifurcation • Atrophy of one lobe with encasement of contralateral portal vein branch • Atrophy of one lobe with contralateral secondary biliaryradicles involved • DISTANT DISEASE • Metastases to lymph node groups beyond hepatoduodenal ligament(Coeliac, Paraaortic, Retroduodenal – histo +ve) • Liver lung or peritoneum – histo +ve) Janargin WR et al 2001

  37. DISTAL TUMOURS • Usually needs pancreatico-duodenectomy - • Longitudinal spread (less than pancreatic tumours) • True mid CBD tumours difficult to define • Lymph node status only independent predictor of long time survival.

  38. INTRAHEPATIC (PERIPHERAL) DUCTAL TUMOURS • Often a diagnosis of exclusion. • Liver mass, cytologically an adenocarcinoma and extensive search for primaries – unrewarding. (Nakanuma et al 1985) (Ohashi et al 1994) (Yamamoto et al 1998)

  39. Bile Duct Cancer -What to do? FROZEN-SECTION OF DUCT ENDS A MUST TO EXCLUDE LONGITUDINAL SPREAD.

  40. Scope of Adjuvant Therapy

  41. THANK YOU ACCESS THE PRESENTATION AT www.drsanjaydebakshi.org

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