Gallbladder cancer treatment

Gallbladder cancer occurs in 8% of cases of malignant neoplasms of the liver and bile ducts. Most often the disease develops in women between 50 and 70 years of age. This is a fairly rare pathology. However, it runs practically asymptomatic and is diagnosed at late stages. The main treatment of gallbladder cancer is radical removal followed by chemotherapy and radiation therapy. There are oncology centers in Germany, where unique methods of therapy are carried out.

Types of gallbladder cancer

The gallbladder as well as the bile ducts are lined with epithelium. Usually a malignant neoplasm begins to form from its superficial layer, as well as from the glandular epithelium located in the neck of the organ.

The process begins with dysplasia of the epithelium, and further transformation into cancer takes about 10-15 years. There are several classifications of pathology:

• on macroscopic analysis;
• histologically;
• process localization.

Macroscopically, the masses are of three types:

• Diffuse-infiltrative — the most frequent variant, the disease spreads to the liver, intestine, mesentery. The affected organ may have different sizes. The boundaries of the tumor are not clearly defined.
• Nodular form — the neoplasm usually extends into the lumen. The boundaries are quite clearly defined.
• The papillary form is a rare variant. The papillary form of the mass grows inside the organ.

In addition, there may be a mixed form according to macroscopic features.

On histologic analysis, several varieties of the mass are distinguished:

• adenocarcinoma;
• squamous cell variant;
• undifferentiated type.

The first two variants refer to highly and low-differentiated carcinomas.

The gallbladder consists of three sections: body, neck and bottom. Depending on where the mass is located, it will be of three types:

• in the fundus occurs in up to 60% of all carcinomas. This is quite a favorable variant, as the formation in this case grows long enough and it takes a long time to spread to other structures of the hepato-biliary system.
• about 30% of carcinomas are localized in the body.
• 10% occupy formations in the neck, which has the worst prognosis, as carcinoma quickly and intensively sprouts into neighboring organs, liver, intestine, mesentery. In this case, a large number of complications develop, and the carcinoma quickly becomes unresectable.

Metastases spread through the lymph and blood vessels. The liver is affected first, followed by the peritoneum, lungs and pleura.

Stages of gallbladder cancer

Every patient is different and carcinoma forms and spreads in everyone depending on genetics and body condition. However, the general principles are the same for all patients. The stages of cancer characterize the volume of the mass, the degree of sprouting into other organs, as well as the treatment and prognosis of the disease.

Cancer is classified according to the international system TNM, where T is the size and extent of the tumor, N— lymph node involvement, M — presence of metastases. The prevalence of carcinoma is determined by the lesion of different layers of the organ, which is revealed by biopsy and subsequent histologic analysis. The bladder wall consists of the following layers:

• epithelials;
• your own plate;
• muscle layer;
• surrounding muscle fibrous tissue;
• serous membrane.

After diagnosing the stage of the disease according to the classification TNM the results are combined into groups. According to the American Joint Committee on Cancer Research, there are 4 stages.

Stage 0 — pathology in situ — the earliest stage, when the carcinoma is just forming and does not go beyond the affected organ. The formation is localized only in the epithelium.

• Stage 1 corresponds to T1N0M0. The mass grows through its own lamina or reaches the muscle layer. It does not spread to the lymph nodes.
• Stage 2 is subdivided into two substages:

2A: the mass sprouts through the muscle tissue into the fibrous sheath on the peritoneal side.

2B: sprouting from the side of the liver, but without damaging it.

• Stage 3 also has two substages:

3A: the mass has invaded all layers of the wall, but there is no lymph node involvement

3B: the pathologic process also grows through all layers, and there is an affection of the nearest lymph nodes.

• Stage 4 is characterized by the lesion of more than 3 lymph nodes, and the presence of metastases.

Symptoms

In most cases, the disease is recognized at stage 3-4 of the process. However, there are symptoms and signs that can help in early diagnosis.

1. The main symptom is pain in the abdomen. Most often it is localized in the right subcostal region. At later stages, when the carcinoma is large enough, it can be palpated.
2. Quite often patients experience nausea and vomiting.
3. Jaundice. If the carcinoma blocks the bile ducts, bile does not pass into the intestine from the liver and is carried to the tissues through the vessels, which gives a yellow color to the skin and mucous membranes.
4. Urine may become dark and feces may become light colored.

Also, these symptoms are characteristic of cholecystitis (inflammation) in the stage of exacerbation.

It is very important that the specialist, after suspecting cholecystitis, refer the patient to perform an ultrasound or MRI.

In addition to specific symptoms, the patient may have general signs of tumorigenesis:

• weight loss without the use of strict diets;
• apathy;
• fatigue;
• depression;
• increased fatigue and others.

Diagnosis of gallbladder cancer

Some cancers are detected after removal of the organ due to cholecystitis. The removed gallbladder is viewed under a microscope and cancer cells are identified using various methods of histologic and cytologic analysis.

In all other cases, diagnosis begins with the patient’s visit to the doctor. The specialist interviews and examines the patient. The gastroenterologist will determine the presence of risk factors. The examination usually focuses on the abdominal cavity. The doctor will perform palpation to rule out any large masses, and will also test for right subcostal pain. He will then examine the skin and visible mucous membranes for jaundice. In addition, if the process has spread to the lymph nodes, the doctor will also determine their enlargement.

If carcinoma is suspected, the following diagnostic measures will be ordered:

1. Blood tests to evaluate the function of the hepatobiliary organs. Bilirubin, ALT, AST, alkaline phosphatase levels show changes in the functioning of the hepatobiliary organs.
2. Tumor markers. Malignant cells produce various substances that help in the diagnosis of pathology. These include CEA and CA 19-9. These markers indicate the presence of cancer in the body, when the carcinoma is already large enough, its decay occurs and chemicals enter the blood. More often than not, the level of markers is an indicator of the success of therapy.
3. Instrumental diagnostic methods (ultrasound, CT, MRI and others). These methods are necessary to make a diagnosis, to determine the size of the carcinoma, its localization. This information is necessary for surgical intervention and biopsy.

Instrumental methods

1. Ultrasound of the abdominal organs can identify various structures in the liver, gallbladder, and bile ducts. If the tumor is sufficiently well visualized, ultrasound helps the doctor guide the needle for biopsy.

1. 1. Endoscopic or laparoscopic ultrasound. A transducer is placed on the end of the endoscope, which allows you to see nearby organs and tissues. This method can give information about the focus in other projections, in which conventional ultrasound will not help. Laparoscopic examination is performed through a small puncture in the anterior abdominal wall. It allows you to see even smaller changes compared to other methods.
2. Thanks to CT and MRI scans, the doctor can see the damage to the organ, the spread of the process to nearby lymph nodes, and the presence or absence of metastases to other tissues. In addition, computed tomography (CT( is used to perform biopsies. The body is scanned as long as the doctor advances the needle to the pathologic focus and takes a tissue sample.
3. Laparoscopy and biopsy. Laparoscopic techniques are used when there are contraindications to other techniques, or when it is not possible to obtain a tissue sample or assess the extent of tumor spread using other techniques.

On a side note! In German clinics, CT-angiography is performed to assess the spread of carcinoma to the blood vessels. These data are taken into account when choosing a surgical method of therapy.

MRI helps in early diagnosis, and special MRI scans can assess the malignancy of the pathology. During MRI, the doctor injects a special substance into the patient’s vein and during the scan all structures of the affected organ, as well as nearby organs and tissues, become visible. There are several variants of the study:

• MR angiography — used to assess vessel patency and involvement of vessels in the tumor.
• MR-cholangiopancreatography — is performed to evaluate the bile ducts and the presence of tumor in them. For this method, contrast is not used, and there is no possibility to take a tissue sample. But often the method is used to develop a scheme of surgical intervention.
• Endoscopic retrograde cholangiopancreatography. Under local anesthesia with the help of an endoscope, a contrast agent is injected into the area of bile ducts, and then images are taken. This makes it possible to assess the patency of the bile ducts. This method is considered invasive, however, it is possible to perform a biopsy of the necessary tissues. In addition, it is used to perform stenting of narrowed ducts.

Gallbladder cancer treatment in Germany

The following methods are emphasized in cancer therapy:

• surgical removal of the mass;
• radiation and chemotherapy;
• targeted therapy;
• immunotherapy;
• palliative care techniques.

During the laparoscopy, the doctor determines the size of the tumor and the possibilities for its removal. Therefore, all surgical techniques will be different for resectable and non-resectable tumors.

If the tumor can be removed, the doctor performs a conventional (gallbladder removal) or extended cholecystectomy (removal of the gallbladder, part of the liver, and affected lymph nodes).

In case of an unresectable tumor, surgeons usually perform ductal stenting. That is, if the tumor has grown through the bile ducts and is blocking the secretion of bile, the doctor places a special tube along the duct through the tumor to allow the bile to flow out.

Radiation therapy can be of several types:

• three-dimensional conformal radiation therapy. Using computer technology, the localization of the tumor is precisely determined and radiation beams are directed strictly at it. Healthy tissues are practically not damaged.
• Intensity modulated radiation therapy. This is an extended version of the treatment of the previous method. During the procedure, the device delivering the radiation is constantly moving around the person’s body, and when it passes healthy areas, the radiation dose is reduced, and when it passes a tumor, the dose is increased. In this way, the tumor is exposed to stronger radiation.
• chemoradiation. When radiation treatment is given along with chemotherapy. There are more side effects from this method, but research shows that patients live longer after this type of treatment.

On a side note! Clinics in Germany have centers for the development of various drugs for targeted treatment and immunotherapy, which show good results in the treatment of gallbladder cancer.

Cost of treatment

The cost of treatment in German clinics is influenced by several aspects: the stage of cancer, the general somatic status of the patient, the presence of concomitant pathology, as well as the wishes of the patient.

Name of service	Price, €	Optional
Diagnostics	1750	5 days, outpatient
Diagnostics with chemotherapy	38150	8 days, outpatient
Cholangiopancreatography  (ЭERCPG ) with bouching and stenting	7000 – 9000	9 days, inpatient
Partial hepatectomy	19000	10 days, inpatient

Choosing the right clinic is the key to successful treatment

German medicine is considered to be one of the best, with treatment of oncological diseases being a priority. The clinics are staffed by oncology specialists who have undergone, in addition to classical training, various internships and courses in different countries of the world. Surgeons in Germany have extensive experience in treating the most complex and neglected forms of cancer. The peculiarity of treatment in Germany is multidisciplinary approach. In this case, the patient has an attending physician, who after consultations c with colleagues of related specialties, gives a general opinion on the implementation of the necessary therapy. In addition, he will explain in detail the regimen, side effects, and alternatives before starting therapy.

There are a lot of clinics that treat gallbladder pathology. Therefore, for the right choice, our expert doctors under the guidance of the head of the center «Clinics of Germany» Rykov Maxim Sergeevich will conduct a thorough analysis of your situation and present the clinic and the leading specialist who treats your disease and has a great practical experience in this field.

Thus, gallbladder masses are a serious medical problem, which often proceeds without pronounced symptoms and requires immediate therapy. Therefore, early diagnosis — the key to success in the fight against the disease.