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 Table of Contents  
REVIEW ARTICLE
Year : 2012  |  Volume : 4  |  Issue : 7  |  Page : 293-299

Diagnosis and management of gallbladder cancer


Department of Surgery, Karolinska Institute at Karolinska University Hospital, Huddinge, Stockholm, Sweden

Date of Web Publication17-Jul-2012

Correspondence Address:
Åke Andrén-Sandberg
Department of Surgery, Karolinska Institute at Karolinska University Hospital, Huddinge, S-141 86, Stockholm
Sweden
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1947-2714.98586

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  Abstract 

Gallbladder cancer (GBC) is a rather uncommon disease, but at the time when it gives symptoms it has usually reached no longer curable stage. Therefore, all attempts must be made to make the diagnosis earlier to have better opportunity for cure. The author searched PubMed, and reviewed literatures on diagnoses and treatment of GBC.

Keywords: Diagnosis, Gallbladder cancer, Incidence, Metastases, Risk factors, Staging, Treatment


How to cite this article:
Andrén-Sandberg Å. Diagnosis and management of gallbladder cancer. North Am J Med Sci 2012;4:293-9

How to cite this URL:
Andrén-Sandberg Å. Diagnosis and management of gallbladder cancer. North Am J Med Sci [serial online] 2012 [cited 2023 Feb 4];4:293-9. Available from: https://www.najms.org/text.asp?2012/4/7/293/98586


  Introduction Top


Since the first description of the gallbladder carcinoma by Maxmillan de Stol in 1777, studies have established a characteristic pattern of late diagnosis and ineffective treatment of this disease. [1] Gallbladder cancer (GBC) can be clinically obvious, an unexpected finding at laparotomy, detected incidentally on histologic examination or may be missed only to present with recurrence during follow-up. [2] GBC is characterized by local invasion, extensive regional lymph node metastasis, vascular encasement, and distant metastases. In general, GBC is the most aggressive of the biliary cancers with the shortest median survival duration.

Resection is the most effective and only potentially curative treatment. Early-stage tumors are often curable with a proper resection; however, many patients present late in the course of the disease when surgical intervention is no longer effective. [3] Patients with unresectable or metastatic GBC have a poor prognosis. In patients with suspected GBC, an open surgical resection is advocated. Adjuvant combination chemotherapy and molecular targeted therapy are emerging as effective therapeutic options in those with advanced GBC. Endoscopic palliation of biliary and gastric outlet obstruction with metallic stents has improved the quality of life. [4],[5]

In this article, by searching the publications on PubMed, the author has summarized the current status and key issues in the diagnosis and management of GBC, and hopes to improve diagnosis, treatment, and survival of patients with GBC.

Risk factors of gallbladder cancer

Many factors are associated with the development of GBC. The routine histopathology examination of the gallbladder, particularly in cases of empyema and patient's older than 60 years, is of value for identifying unsuspected conditions requiring further postoperative management. [6] The risk of GBC is increased in anomalous pancreaticobiliary duct junction, gall stones, xanthogranulomatus cholecystitis, calcified or porcelain gallbladder, cholelithiasis with typhoid carriers, gallbladder adenoma, red meat consumption, and tobacco uses. [7] Predisposing risk factors for GBC include cholelithiasis, chronic biliary infections (Opisthorchis viverrini,  Salmonella More Details typhi), primary sclerosing cholangitis (PSC), and porcelain gallbladder. [8],[9],[10] The presence of large gallstone is also one of the major risk factors. A stone size of more than 3 cm, a family history of GBC, and the duration of cholelithiasis are potential risk factors for developing GBC. [9],[11]

Gallbladder polyps are associated with a risk of malignancy. [12] Choledochal cysts, [13] porcelain gallbladder, and chronic gallbladder infection has been implicated as a risk factor for malignant degeneration. [11],[14],[15],[16],[17] Pancreaticobiliary maljunction is a risk factor for GBC and bile duct cancer. [11],[18],[19] PSC is a risk factor for cholangiocarcinoma. [20],[21],[22] Patients with PSC often develop advanced cholangiocarcinoma with a poor prognosis. In patients with PSC, therefore, strict follow-up should be recommended. Adenoma and dysplasia have been regarded as precancerous lesions of GBC. A polypoid lesion of the gallbladder that is sessile, has a diameter greater than 10 mm, and/or grows rapidly, is highly likely to be cancerous and should be resected. With respect to ampullary carcinoma, adenoma of the ampulla is considered to be a precancerous lesion. [11]

Patients with cholesterolosis were less likely to have cancer than those who did not have cholesterolosis. Therefore, cholesterolosis has a strong negative association with GBC. [23] Occult pancreaticobiliary reflux is associated with precancerous mucosal changes in the gallbladder, and can lead to inflammatory changes of the biliary epithelium and progress toward the development of precancerous mucosal changes and GBC. [24] Pancreaticobiliary maljunction is associated with an increased frequency of gallbladder malignancy. Intestinal metaplasia is often observed in gallbladder disease and is a risk factor for gallbladder carcinoma in adults. The hyperplasia-dysplasia-carcinoma progression is one of the possible mechanisms involved in biliary carcinogenesis. [25],[26]

Diabetes is a risk factor for GBC, [27] and GBC risk may be reduced by controlling diabetes, stones, and high-density lipoprotein levels. [28],[29] Certain genetic variants involved in the regulation of obesity-related insulin sensitivity may increase susceptibility to bile duct cancer and gallstones. [30] Obesity and overweight are associated with a risk for GBC. [31],[32],[33],[34],[35] Comparable factors include lifestyle, dietary habits, religion, education, family income, chewing of tobacco, as well as smoking, which play an important role in carcinogenesis. [36],[37]

Symptoms and signs of gallbladder carcinoma

The clinical presentation of GBC is often vague or delayed relative to pathologic progression, contributing to advanced staging and dismal prognosis at the time of diagnosis. The clinical presentation is nonspecific, may include abdominal pain, weight loss, fever, and jaundice, and any of these can be seen in cholecystitis and other benign gallbladder conditions as well as in other abdominal malignancies. [8],[38]

It is important to differentiate at an early stage. Ultrasound, computed tomography (CT), and magnetic resonance imaging (MRI) have improved the possibility of differentiating and choosing the correct treatment. [39] Mass occupying lesion may be present in 40%-65% of patients with GBC at initial detection. The presence of a large gallbladder mass that nearly fills or replaces the lumen, often directly invading the surrounding liver parenchyma, is highly suggestive of GBC. [8] GBC may present as focal or diffuse asymmetric wall thickening, which can have an expansive differential diagnosis, including acute and chronic cholecystitis, xanthogranulomatous cholecystitis, and adenomyomatosis, as well as diffuse hepatic or systemic diseases, such as acute hepatitis, portal hypertension, and congestive heart failure. Conventional cross-sectional imaging may be limited in differentiating gallbladder carcinoma from chronic cholecystitis; however, at contrast-enhanced CT and MRI, diffuse symmetric wall thickening suggests a nonneoplastic process, whereas asymmetric, irregular, or extensive thickening, which may have marked enhancement during the arterial phase that persists or becomes isodense or isointense to the liver during the portal venous phase should heighten suspicion of GBC. GBC may arise as a nidus in pre-existing background chronic cholecystitis, which can obscure or delay the diagnosis of cancer. [8]

Acute cholecystitis

GBC may manifest as acute cholecystitis. For elderly patients, especially women, presenting with acute cholecystitis and abnormal liver function, CT demonstration of focal gallbladder wall thickening, intraluminal masses, small gallbladder with diffuse wall thickening, and enlarged regional lymph nodes are suggestive of concurrent GBC. [40],[41]

Acute lithiasic cholecystitis

GBC may present as acute lithiasic cholecystitis that leads to severe septic complications. Severe septic complications in elderly patients with a long-standing history of gallbladder stones may coexist with primary carcinoma of the gallbladder. [42]

Mirizzi syndrome

Mirizzi syndrome has a low incidence in patients with gallbladder disease. The coexistence of GBC seems to be more frequent in patients with Mirizzi syndrome than in those with gallstones only. [43] There were no clinical features to differentiate these patients with GBC from those with Mirizzi syndrome alone, except that they were a decade older and had longer duration of symptoms. The diagnosis of GBC was made on final histology after cholecystectomy. [44],[45]

Other diseases

GBC presenting as gallstone ileus, [46] gallbladder perforation, [47] duodenal ulcus, [48] gastroduodenal dysmotility, [49] malnutrition, [50] venous thromboembolism, [51] gynecologic symptoms, [52] skin disorders, [53] paraneoplastic symptoms, [54] and even neuropathy [55] have been reported.


  Diagnostics and Staging Top


In the diagnosis of GBC, differential diagnosis and determination of the local extension of tumor are important. For these purposes, imaging modalities such as endoscopic ultrasonography (EUS), CT, MRI, and magnetic resonance cholangiopancreatography(MRCP) are useful. EUS has good sensitivity in differentiating benign gallbladder diseases from GBC. [56]

Most of the gallbladder tumors are benign. Adenoma, cholesterol polyps, or adenomyomatosis are most frequently typical on ultrasonographic images. It may be difficult to identify precancerous or malignant lesion. All symptomatic lesions must be considered as indications for surgery. Polyps over 1 cm are indication for preventive cholecystectomy. In case of suspicious polyp or suspicious wall thickening, EUS can be helpful to evaluate local tumoral spread and eliminate differential diagnosis. CT and MRI examinations are useful for local and metastatic staging. [57]

Ultrasound image studies

Ultrasonography (US), a useful initial modality when exploring the background of jaundice or nonspecific gastrointestinal complaints, sensitively reveals bile duct obstruction in particular. [58],[59] In unclear cases, or if US suggests a resectable biliary malignancy, CT, MRI with magnetic resonance cholangiography (MRC) and/or traditional cholangiography often provide additional information, and imaging-guided fine-needle biopsy or an endoscopic brush sample may verify the malignant nature of the tumor. [60] Complementary modalities are usually needed for accurate staging, and traditional cholangiography is often performed for therapeutic purposes as well. [61]

The poor prognosis of GBC is related to its dissemination capacity and usually late diagnosis due to its nonspecific clinical appearance. The first step in an early diagnosis is to identify patients in the appropriate epidemiologic setting (eg, incidental finding, chronic cholecystitis) for the correct interpretation of test results. It is desirable to enhance the sensitivity of the initial US examination by use of the appropriate technology in skilled specialist hands. When GBC is suggested by US findings, fluorodeoxyglucose-positron emission tomography (FDG-PET) can be considered complementary to establish the benign/malignant nature of the lesion and to obtain a primary staging study. If GBC is confirmed, thin-slice spiral CT can contribute valuable information on local spread. [56],[62],[63] Although CT is inferior to ultrasound in depicting mucosal irregularity, mural thickening, and cholelithiasis, it is superior for evaluating the thickness of portions of the gallbladder wall that are obscured by gallstones or mural calcification on ultrasound. CT may show focal or irregular mural thickening; the images should be carefully inspected for bile duct dilation, local invasion, metastases, and adenopathy. [8],[59] Recent hybrid PET-CT systems provide structural and functional information simultaneously, and may offer early and accurate staging with an improved specificity. [64],[65],[66],[67],[68],[69]

On MRI, GBC usually shows hypo- to isointense signal characteristics. An all-in-one protocol supplementing MRI with cholangiographic (MR cholangiopancreatography) and contrast-enhanced arterial and portal phase 3D angiographic (MR angiography) images may be up to 100% sensitive for bile duct and vascular invasion, yet sensitivity falls to 67% for hepatic invasion and 56% for lymph node metastases. [8] Dynamic MRI with MRCP is an accurate and a reliable method of showing GBC and in assessing its local and regional extent as part of preoperative assessment. [70]

Cytology

A carcinoma at early stages can be overlooked, and the diagnosis would then be made only after microscopic examination of paraffin-embedded tissue. Imprint cytology of the gallbladder mucosa is an easy, rapid, and high-quality method for detecting GBC. [71] Ultrasound-guided fine-needle aspiration cytology is also a safe diagnostic modality for GBC. [72] Endoscopic retrograde cholangiopancreaticography of biliary tree and GBC is highly specific and should be considered for evaluation of clinically suspicious lesions. [73]

Tumor markers

Tumor markers have an increasing significance in the diagnosis and evaluation of GBC. Assay of CA242, CA15-3, CA19-9, and CA 125 are fairly good markers for discriminating patients of carcinoma of the gallbladder from cholelithiasis. CA242 and CA125 when used together achieved best sensitivity and specificity. Serum markers seem to be less sensitive when used individually in carcinoma of the gallbladder but may prove useful in combination. [74]

Electrophoretic pattern of proteins

Electrophoretic analysis of serum protein has revealed protein bands in patients with carcinoma of the gallbladder as compared with electrophoretic pattern in cholelithiasis. [75]

Gallbladder membrane lipids

Fourier transform infrared (FTIR) spectroscopy is sensitive to the molecular composition of tissue, and has the potential to identify premalignant tissue. Lipids were increased in the plasma membrane during carcinogenesis of the gallbladder; the ratio of intensity could be a marker to diagnose cancer by FTIR. [76]


  Surgical Technical Aspects Top


GBC is characterized as an aggressive and highly lethal disease, and surgery is the only option for the treatment. [77] A more aggressive surgical approach, including resection of the gallbladder, liver, and regional lymph nodes, is advisable for patients with T1b to T4 tumors. Aggressive resection is necessary because a patient's GBC stage determines the outcome, not the surgery itself. Therefore, major resections should be offered to appropriately selected patients. Patients with advanced tumors or metastatic disease are not candidates for radical resection and thus should be directed to more suitable palliation. [78],[79]

Complete surgical resection remains the only potentially curative treatment for primary adenocarcinoma of the gallbladder. Several basic concepts of surgical management of this illness are straightforward, whereas others remain controversial. Aggressive surgical therapy of GBC is becoming more common as large institutional series demonstrate longer survival times from more extensive resections. [80] Long-term survival is possible in early stage of gallbladder carcinoma. Surgery for gallbladder carcinoma has the potential to be curative only in local or regional disease. [81],[82]

Today's recommended routine surgery

The majority of patients present with advanced-stage tumors (stage IV), and are not amenable to surgical resection. A small percentage of patients present with stage I disease, and may be cured by cholecystectomy. The role for surgery in patients with stage II and III disease remains controversial, but most hepatobiliary surgeons believe that an aggressive surgical approach improves survival for these patients. However, the extent of hepatic and lymph node resection, the need for resection of the extrahepatic ducts in nonjaundiced patients, the role of vascular resection, and the advisability of hepatopancreatoduodenectomy remain a matter of debate. Although no data from prospective, randomized studies are available, resection of the gallbladder and adjacent liver with or without the extrahepatic bile ducts and with a regional lymph node dissection is the operative approach recommended for selected patients with GBC. [83]

For patients with T1b, T2, and T3 incidental GBC, re-resection is generally recommended. At re-exploration, many patients with incidental GBC will have residual disease. Definitive oncologic management requires re-resection of the liver, portal lymphadenectomy, and attention to the common bile duct. The extent of the hepatic resection should be dictated by the ability to achieve a microscopically negative (R0) margin. Routine resection of the common bile duct is unnecessary, but should be undertaken in the setting of a positive cystic duct margin. [84]

In patients with a preoperative diagnosis of GBC, it is imperative that the patient be treated with a cholecystectomy with en-bloc hepatic resection with lymphadenectomy with or without bile duct resection. The extent of the hepatic resection varies from a wedge of the gallbladder bed to major right lobe of liver resections. [85] The rationale for including a bile duct resection should be based on the cause of the GBC, with routine excision of the bile duct performed for patients with anomalous pancreatic bile duct junctions. The excision of the bile duct should be performed only when involved or when surgically indicated. [85]

Prophylactic cholecystectomy

Since there is a strong association between long-standing gallstone disease and the development of GBC, a study from India has indicated that prophylactic cholecystectomy is recommended in populations with high incidence of GBC. [86] Data from the West, however, indicate that the risk of GBC in persons with asymptomatic gallstone is very small and does not warrant prophylactic cholecystectomy. Not all persons with asymptomatic GS require cholecystectomy. Type of stone, tumor markers, and genetic markers need to be investigated to identify those with asymptomatic GS who are at the highest risk of developing GBC so that they can selectively be offered pre-emptive cholecystectomy to prevent GBC. [87]

 
  References Top

1.Abi-Rached B, Neugut AI. Diagnostic and management issues in gallbladder carcinoma. Oncology 1995;9:19-30.   Back to cited text no. 1
[PUBMED]    
2.Kapoor VK. Gallbladder cancer: A global perspective. J Surg Oncol 2006;93:607-9.  Back to cited text no. 2
[PUBMED]  [FULLTEXT]  
3.Miller G, Jarnagin WR. Gallbladder carcinoma. Eur J Surg Oncol 2008; 34:306-12.  Back to cited text no. 3
[PUBMED]  [FULLTEXT]  
4.Dutta U. Gallbladder cancer: Can newer insights improve the outcome? J Gastroenterol Hepatol.2012;27:642-53.  Back to cited text no. 4
[PUBMED]  [FULLTEXT]  
5.van der Hoeven J, Busch O, Bijnen C, Gouma D, van Gulik T. Diagnosis and treatment of carcinoma of the gall bladder. Ned Tijdschr Geneeskd 2010;154:A355. (in Dutch).  Back to cited text no. 5
    
6.Lohsiriwat V, Vongjirad A, Lohsiriwat D. Value of routine histopathologic examination of three common surgical specimens: Appendix, gallbladder, and hemorrhoid. World J Surg 2009;33:2189-93.  Back to cited text no. 6
[PUBMED]  [FULLTEXT]  
7.Kang CM, Kim KS, Choi JS, Lee WJ, Kim BR. Gallbladder carcinoma associated with anomalous pancreaticobiliary duct junction. Can J Gastroenterol 2007;21:383-7.  Back to cited text no. 7
[PUBMED]  [FULLTEXT]  
8.Furlan A, Ferris JV, Hosseinzadeh K, Borhani AA. Gallbladder carcinoma update: Multimodality imaging evaluation, staging, and treatment options. Am J Roentgenol 2008;191:1440-7.  Back to cited text no. 8
[PUBMED]  [FULLTEXT]  
9.Hsing AW, Bai Y, Andreotti G, Rashid A, Deng J, Chen J, et al. Family history of gallstones and the risk of biliary tract cancer and gallstones: A population-based study in Shanghai, China. Int J Cancer 2007;121:832-8.  Back to cited text no. 9
[PUBMED]  [FULLTEXT]  
10.Venniyoor A. Cholesterol gallstones and cancer of gallbladder (CAGB): Molecular links. Med Hypotheses 2008;70:646-53.  Back to cited text no. 10
[PUBMED]  [FULLTEXT]  
11.Miyazaki M, Takada T, Miyakawa S, Tsukada K, Nagino M, Kondo S, et al. Risk factors for biliary tract and ampullary carcinomas and prophylactic surgery for these factors. J Hepatobiliary Pancreat Surg 2008;15:15-24.  Back to cited text no. 11
    
12.Kwon W, Jang JY, Lee SE, Hwang DW, Kim SW. Clinicopathologic features of polypoid lesions of the gallbladder and risk factors of gallbladder cancer. J Korean Med Sci 2009;24:481-7.  Back to cited text no. 12
[PUBMED]  [FULLTEXT]  
13.Lee SE, Jang JY, Lee YJ, Choi DW, Lee WJ, Cho BH, et al. Choledochal cyst and associated malignant tumors in adults: A multicenter survey in South Korea. Arch Surg 2011;146:1178-84.  Back to cited text no. 13
    
14.Kianmanesh R, Scaringi S, Castel B, Flamant Y, Msika S. Precancerous lesions of the gallbladder. J Chir (Paris) 2007;144:278-86. (in French).  Back to cited text no. 14
    
15.Khan ZS, Livingston EH, Huerta S. Reassessing the need for prophylactic surgery in patients with porcelain gallbladder: Case series and systematic review of the literature. Arch Surg 2011;146:1143-7.  Back to cited text no. 15
[PUBMED]  [FULLTEXT]  
16.Palermo M, Núñez M, Duza GE, Giménez Dixon M, Bruno MO, Tarsitano FJ. Porcelain gallbladder: A clinical case and a review of the literature. Cir Esp 2011;89:213-7. (in Spanish).  Back to cited text no. 16
    
17.Kim JH, Kim WH, Yoo BM, Kim JH, Kim MW. Should we perform surgical management in all patients with suspected porcelain gallbladder? Hepatogastroenterology 2009;56:943-5.  Back to cited text no. 17
    
18.Inui K, Yoshino J, Miyoshi H. Diagnosis of gallbladder tumors. Intern Med 2011;50:1133-6.  Back to cited text no. 18
[PUBMED]  [FULLTEXT]  
19.Roukounakis N, Manolakopoulos S, Tzourmakliotis D, Bethanis S, McCarty TM, Cuhn J. Biliary tract malignancy and abnormal pancreaticobiliary junction in a Western population. J Gastroenterol Hepatol 2007;22:1949-52.  Back to cited text no. 19
[PUBMED]  [FULLTEXT]  
20.Ishii N, Suzuki S, Fujitani S, Tsukamoto M, Arai M, Iizuka Y, et al. A case of recurrent gall bladder cancer responding to chemotherapy with gemcitabine after endoscopic metallic biliary stent implantation. Gan To Kagaku Ryoho 2008;35:1403-5.  Back to cited text no. 20
    
21.Lewis JT, Talwalkar JA, Rosen CB, Smyrk TC, Abraham SC. Prevalence and risk factors for gallbladder neoplasia in patients with primary sclerosing cholangitis: Evidence for a metaplasia-dysplasia-carcinoma sequence. Am J Surg Pathol 2007;31:907-13.  Back to cited text no. 21
[PUBMED]  [FULLTEXT]  
22.Agrawal V, Goel A, Krishnani N, Pandey R, Agrawal S, Kapoor VK. p53, carcinoembryonic antigen and carbohydrate antigen 19.9 expression in gall bladder cancer, precursor epithelial lesions and xanthogranulomatous cholecystitis. J Postgrad Med 2010;56:262-6.  Back to cited text no. 22
[PUBMED]  Medknow Journal  
23.Roa I, de Aretxabala X, Ibacache G, Muñoz S. Association between cholesterolosis and gallbladder cancer. Rev Med Chil 2010;138:804-8.  Back to cited text no. 23
    
24.Beltrán MA, Vracko J, Cumsille MA, Cruces KS, Almonacid J, Danilova T. Occult pancreaticobiliary reflux in gallbladder cancer and benign gallbladder diseases. J Surg Oncol 2007;96:26-31.  Back to cited text no. 24
    
25.Ono S, Fumino S, Iwai N. Implications of intestinal metaplasia of the gallbladder in children with pancreaticobiliary maljunction. Pediatr Surg Int 2011;27:237-40.  Back to cited text no. 25
    
26.Ali AE, Blythe AI, Ford WD. Chronic inflammatory changes seen in gallbladders of patients with pancreatico-biliary malunion years after transduodenal sphincterotomy: Is it a precursor for gallbladder carcinoma? Pediatr Surg Int 2008;24:1005-8.  Back to cited text no. 26
    
27.Ren HB, Yu T, Liu C, Li YQ. Diabetes mellitus and increased risk of biliary tract cancer: Systematic review and meta-analysis. Cancer Causes Control 2011;22:837-47.  Back to cited text no. 27
    
28.Shebl FM, Andreotti G, Rashid A, Gao YT, Yu K, Shen MC, et al. Diabetes in relation to biliary tract cancer and stones: A population-based study in Shanghai, China. Br J Cancer 2010;103:115-9.  Back to cited text no. 28
    
29.Rapp K, Schroeder J, Klenk J, Ulmer H, Concin H, Diem G, et al. Fasting blood glucose and cancer risk in a cohort of more than 140,000 adults in Austria. Diabetologia 2006;49:945-52.  Back to cited text no. 29
    
30.Chang SC, Rashid A, Gao YT, Andreotti G, Shen MC, Wang BS, et al. Polymorphism of genes related to insulin sensitivity and the risk of biliary tract cancer and biliary stone: A population-based case-control study in Shanghai, China. Carcinogenesis 2008;29:944-8.  Back to cited text no. 30
    
31.Hemminki K, Li X, Sundquist J, Sundquist K. Obesity and familial obesity and risk of cancer. Eur J Cancer Prev 2011;20:438-43.  Back to cited text no. 31
    
32.Samanic C, Chow WH, Gridley G, Jarvholm B, Fraumeni JF Jr. Relation of body mass index to cancer risk in 362, 552 Swedish men. Cancer Causes Control 2006;17:901-9.  Back to cited text no. 32
    
33.Wolin KY, Carson K, Colditz GA. Obesity and cancer. Oncologist 2010;15:556-65.  Back to cited text no. 33
    
34.Yagyu K, Kikuchi S, Obata Y, Lin Y, Ishibashi T, Kurosawa M, et al.; JACC Study Group. Cigarette smoking, alcohol drinking and the risk of gallbladder cancer death: A prospective cohort study in Japan. Int J Cancer 2008;122:924-9.  Back to cited text no. 34
    
35.Ozasa K. Alcohol use and mortality in the Japan Collaborative Cohort Study for Evaluation of Cancer (JACC). Asian Pac J Cancer Prev 2007;8 suppl:81-8.  Back to cited text no. 35
    
36.Shukla VK, Chauhan VS, Mishra RN, Basu S. Lifestyle, reproductive factors and risk of gallbladder cancer. Singapore Med J 2008;49:912-5.  Back to cited text no. 36
    
37.Ozasa K. Smoking and mortality in the Japan collaborative cohort study for evaluation of cancer (JACC). Asian Pac J Cancer Prev 2007;8 suppl:89-96.  Back to cited text no. 37
    
38.van der Horst MP, Hendriks ER, Blok P, Brouwers MA, Steup WH. Diversity of complaints in manifesting carcinoma of the gallbladder. Ned Tijdschr Geneeskd 2007;151:1083-6.  Back to cited text no. 38
    
39.von Meyenfeldt EM, Mantel SF, Gouma DJ, van Gulik TM. Tumors in the gallbladder: A possible differentiation between malignant and benign tumours. Ned Tijdschr Geneeskd 2007;151:1049-54.  Back to cited text no. 39
    
40.Liang JL, Chen MC, Huang HY, Ng SH, Sheen-Chen SM, Liu PP, et al. Gallbladder carcinoma manifesting as acute cholecystitis: Clinical and computed tomographic features. Surgery 2009;146:861-8.  Back to cited text no. 40
    
41.Tanaka S, Kubota D, Lee SH, Oba K, Yamamoto T, Ikebe T, et al. Latent gallbladder carcinoma in a young adult patient with acute cholecystitis: Report of a case. Surg Today 2007;37:713-5.  Back to cited text no. 41
    
42.Charalampopoulos A, Lazaris A, Misiakos E, Liakakos S, Macheras A, Peschos D, et al. Acute septic cholelithiasic cholecystitis and adenocarcinoma of the gallbladder; an interesting association. Acta Gastroenterol Belg 2007;70:267-70.  Back to cited text no. 42
    
43.Ramia JM, Villar J, Muffak K, Mansilla A, Garrote D, Ferron JA. Mirizzi syndrome and gallbladder cancer. Cir Esp 2007;81:105-6.  Back to cited text no. 43
    
44.Prasad TL, Kumar A, Sikora SS, Saxena R, Kapoor VK. Mirizzi syndrome and gallbladder cancer. J Hepatobiliary Pancreat Surg 2006;13:323-6.  Back to cited text no. 44
    
45.Lai EC, Lau WY. Mirizzi syndrome: History, present and future development. ANZ J Surg 2006;76:251-7.  Back to cited text no. 45
    
46.Zissin R, Osadchy A, Klein E, Konikoff F. Consecutive instances of gallstone ileus due to obstruction first at the ileum and then at the duodenum complicating a gallbladder carcinoma: A case report. Emerg Radiol 2006;12:108-10.  Back to cited text no. 46
    
47.Hori T, Wagata T, Takemoto K, Shigeta T, Takuwa H, Hata K, et al. Spontaneous necrosis of solid gallbladder adenocarcinoma accompanied with pancreaticobiliary maljunction. World J Gastroenterol 2008;14:5933-7.  Back to cited text no. 47
    
48.Tsai TJ, Lai KH, Hsu PI, Tsai CC, Fu TY. Gallbladder cancer manifesting as recurrent common bile duct stone and duodenal ulcer bleeding. J Chin Med Assoc 2009;72:434-7.  Back to cited text no. 48
    
49.Sachdeva S, Ghoshal UC, Saraswat VA, Das K, Misra A. Gastroduodenal dysmotility in patients with gallbladder carcinoma: Frequency of occurrence and clinical importance. Natl Med J India 2006;19:4-9.  Back to cited text no. 49
    
50.Rai A, Tewari M, Mohapatra SC, Shukla HS. Correlation of nutritional parameters of gallbladder cancer patients. J Surg Oncol 2006;93:705-8.  Back to cited text no. 50
    
51.Ögren M, Bergqvist D, Wåhlander K, Eriksson H, Sternby NH. Trousseau's syndrome - what is the evidence? A population-based autopsy study. Thromb Haemost 2006;95:541-5.  Back to cited text no. 51
    
52.Triolo O, Antico F, Mancuso A, Salimbeni V, Nicotina PA. Postmenopausal bleeding and vaginal nodules as the first presenting sign of adenocarcinoma of the gallbladder. Eur J Gynaecol Oncol 2005;26:543-4.  Back to cited text no. 52
    
53.Umekoji A, Tsuruta D, Inoue T, Nishimori T, Ishii M. Bullous pemphigoid as a dermadrome associated with spindle cell carcinoma of the gallbladder. J Dermatol 2010;37:251-4.  Back to cited text no. 53
    
54.Ng ES, Venkateswaran K, Ganpathi SI, Chuah BY. Small cell gallbladder carcinoma complicated by paraneoplastic hyponatremia: A case report and literature review. J Gastrointest Cancer 2010;41:264-8.  Back to cited text no. 54
    
55.Uribe-Uribe NO, Jimenez-Garduño AM, Henson DE, Albores-Saavedra J. Paraneoplastic sensory neuropathy associated with small cell carcinoma of the gallbladder. Ann Diagn Pathol 2009;13:124-6.  Back to cited text no. 55
    
56.Miyakawa S, Ishihara S, Takada T, Miyazaki M, Tsukada K, Nagino M, et al.; Japanese Association of Biliary Surgery; Japanese Society of Hepato-Biliary-Pancreatic Surgery; Japan Society of Clinical Oncology. Flowcharts for the management of biliary tract and ampullary carcinomas. J Hepatobiliary Pancreat Surg 2008;15:7-14.  Back to cited text no. 56
    
57.Vialle R, Velasco S, Milin S, Bricot V, Richer JP, Levillain PM, et al. Imaging in the diagnosis and the staging of gallbladder tumors. Gastroenterol Clin Biol 2008;32:931-41.  Back to cited text no. 57
    
58.Samad A. Gall bladder carcinoma in patients undergoing cholecystectomy for cholelithiasis. J Pak Med Assoc 2005;55:497-9.  Back to cited text no. 58
    
59.Gore RM, Shelhamer RP. Biliary tract neoplasms: Diagnosis and staging. Cancer Imaging 2007;7:S15-23.  Back to cited text no. 59
    
60.Matsubara S, Arizumi T, Togawa O, Sasaki T, Yamamoto N, Nakai Y, et al. Endoscopic transpapillary approach to the gallbladder for diagnosing gallbladder cancer. Can J Gastroenterol 2007;21:809-13.  Back to cited text no. 60
    
61.Oikarinen H. Diagnostic imaging of carcinomas of the gallbladder and the bile ducts. Acta Radiol 2006;47:345-58.  Back to cited text no. 61
    
62.Ching BH, Yeh BM, Westphalen AC, Joe BN, Qayyum A, Coakley FV. CT differentiation of adenomyomatosis and gallbladder cancer. AJR Am J Roentgenol 2007;189:62-6.  Back to cited text no. 62
    
63.Maldjian PD, Ghesani N, Ahmed S, Liu Y. Adenomyomatosis of the gallbladder: Another cause for a "hot" gallbladder on 18F-FDG PET. AJR Am J Roentgenol 2007;189:W36-8.  Back to cited text no. 63
    
64.Rodríguez-Fernández A, Gómez-Río M, Medina-Benítez A, Moral JV, Ramos-Font C, Ramia-Angel JM, et al. Application of modern imaging methods in diagnosis of gallbladder cancer. J Surg Oncol 2006;93:650-64.  Back to cited text no. 64
    
65.Ben Farhat L, Askri A, Jeribi R, Daly N, Hendaoui L. CT evaluation of locoregional spread of carcinoma of the gallbladder. J Chir (Paris) 2009;146:34-9.  Back to cited text no. 65
    
66.Kalra N, Suri S, Gupta R, Natarajan SK, Khandelwal N, Wig JD, et al. MDCT in the staging of gallbladder carcinoma. AJR Am J Roentgenol 2006;186:758-62.  Back to cited text no. 66
    
67.Ramos-Font C, Gómez Río M, Rodríguez-Fernández A, Sánchez Sánchez R, Llamas Elvira JM. Positron tomography with 18F-fluorodeoxyglucose in the preoperative evaluation of gall bladder lesions suspicious of malignancy. Diagnostic utility and clinical impact. Rev Esp Med Nucl 2011;30:267-75.  Back to cited text no. 67
    
68.Achong DM. Pericholecystic rim sign on PET/CT secondary to locally invasive gallbladder carcinoma. Clin Nucl Med 2010;35:720-1.  Back to cited text no. 68
    
69.Nishiyama Y, Yamamoto Y, Fukunaga K, Kimura N, Miki A, Sasakawa Y, et al. Dual-time-point 18F-FDG PET for the evaluation of gallbladder carcinoma. J Nucl Med 2006;47:633-8.  Back to cited text no. 69
    
70.Kaza RK, Gulati M, Wig JD, Chawla YK. Evaluation of gall bladder carcinoma with dynamic magnetic resonance imaging and magnetic resonance cholangiopancreatography. Australas Radiol 2006;50:212-7.  Back to cited text no. 70
    
71.Otero JC, Proske A, Vallilengua C, Luján M, Poletto L, Otero JR, et al. Gallbladder carcinoma: Intraoperative imprint cytology, a helpful and valuable screening procedure. J Hepatobiliary Pancreat Surg 2008;15:157-60.  Back to cited text no. 71
    
72.Iqbal M, Gondal KM, Qureshi AU, Tayyab M. Comparative study of ultrasound guided fine needle aspiration cytology with open/laparoscopic biopsy for diagnosis of carcinoma gallbladder. J Coll Physicians Surg Pak 2009;19:17-20.  Back to cited text no. 72
    
73.Meara RS, Jhala D, Eloubeidi MA, Eltoum I, Chhieng DC, Crowe DR, et al. Endoscopic ultrasound-guided FNA biopsy of bile duct and gallbladder: Analysis of 53 cases. Cytopathology 2006;17:42-9.  Back to cited text no. 73
    
74.Shukla VK, Gurubachan, Sharma D, Dixit VK, Usha. Diagnostic value of serum CA242, CA 19-9, CA 15-3 and CA 125 in patients with carcinoma of the gallbladder. Trop Gastroenterol 2006;27:160-5.  Back to cited text no. 74
    
75.Shukla VK, Goel S, Trigun SK, Sharma D. Electrophoretic pattern of proteins in carcinoma of the gallbladder. Eur J Cancer Prev 2008;17:9-12.  Back to cited text no. 75
    
76.Wang J, Zhang J, Wu W, Duan X, Wang S, Zhang M, et al. Evaluation of gallbladder lipid level during carcinogenesis by an infrared spectroscopic method. Dig Dis Sci 2010;55:2670-5.  Back to cited text no. 76
    
77.Mastoraki A, Papanikolaou IS, Konstandiadou I, Sakorafas G, Safioleas M. Facing the challenge of treating gallbladder carcinoma. Review of the literature. Hepatogastroenterology 2010;57:215-9.  Back to cited text no. 77
    
78.Jayaraman S, Jarnagin WR. Management of gallbladder cancer. Gastroenterol Clin North Am 2010;39:331-4.  Back to cited text no. 78
    
79.Kondo S, Takada T, Miyazaki M, Miyakawa S, Tsukada K, Nagino M, et al. Guidelines for the management of biliary tract and ampullary carcinomas: Surgical treatment. J Hepatobiliary Pancreat Surg 2008;15:41-54.  Back to cited text no. 79
    
80.Zhu AX, Hong TS, Hezel AF, Kooby DA. Current management of gallbladder carcinoma. Oncologist 2010;15:168-81.  Back to cited text no. 80
    
81.Sikora SS, Singh RK. Surgical strategies in patients with gallbladder cancer: Nihilism to optimism. J Surg Oncol 2006;93:670-81.  Back to cited text no. 81
    
82.Sicklick JK, Choti MA. Controversies in the surgical management of cholangiocarcinoma and gallbladder cancer. Semin Oncol 2005;32 (6 suppl 9):S112-7.  Back to cited text no. 82
    
83.Pitt HA, Nakeeb A. Operative approach to gallbladder cancer. Curr Gastroenterol Rep 2006;8:161-7.  Back to cited text no. 83
    
84.Hueman MT, Vollmer CM Jr, Pawlik TM. Evolving treatment strategies for gallbladder cancer. Ann Surg Oncol 2009;16:2101-15.  Back to cited text no. 84
    
85.Shukla PJ, Barreto SG. Gallbladder cancer: We need to do better! Ann Surg Oncol 2009;16:2084-5.  Back to cited text no. 85
    
86.Mohandas KM, Patil PS. Cholecystectomy for asymptomatic gallstones can reduce gall bladder cancer mortality in northern Indian women. Indian J Gastroenterol 2006;25:147-51.  Back to cited text no. 86
    
87.Kapoor VK. Cholecystectomy in patients with asymptomatic gallstones to prevent gall bladder cancer - the case against. Indian J Gastroenterol 2006;25:152-4.  Back to cited text no. 87
    



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