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Staging and grading of gall bladder cancer
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Staging

The stage of a cancer describes its size and whether it has spread beyond its original site. Knowing the particular type and stage of the cancer helps the doctors to decide on the most appropriate treatment.

Cancer can spread in the body, either in the bloodstream or through the lymphatic system. The lymphatic system is part of the body’s defence against infection and disease. It is made up of a network of lymph nodes that are linked by fine tubes (lymph vessels). Doctors will usually look at the nearby lymph nodes to find the stage of the cancer.

There are four stages of cancer of the gall bladder:

Stage 1

The cancer affects only the wall of the gall bladder. Approximately 1 in 4 cancers are at this stage when they are diagnosed.

Stage 2

The cancer has spread through the full thickness of the wall of the gall bladder, but has not spread to nearby lymph nodes or surrounding organs.

Stage 3

The cancer has spread to lymph nodes close to the gall bladder or has spread to the liver, stomach, colon or the small bowel.

Stage 4

The cancer has spread very deeply into two or more organs close to the gall bladder or has spread to distant lymph nodes or organs, such the lungs. This is known as metastatic or secondary cancer.

A different system called the TNM staging system is sometimes used, in which:
• T describes the size of the tumour.
• N describes whether the cancer has spread to the lymph nodes.
• M describes whether the cancer has spread to another part of the body, such as the liver (secondary or metastatic cancer).

This system is more complex and gives more precise information about the tumour stage.

If the cancer comes back after initial treatment it is known as recurrent cancer.

Grading

Grading refers to the appearance of cancer cells under a microscope and gives an idea of how quickly a cancer may develop.

Low-grade means the cancer cells look very much like normal cells; they are usually slow-growing and are less likely to spread. In high-grade tumours the cells look very abnormal, are likely to grow more quickly and are more likely to spread.

Treatment of gall bladder cancer
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The treatment you have depends on a number of factors including your general health, the position and size of the cancer in the gall bladder and whether the cancer has spread to other areas of the body.

Giving your consent

Before you have any treatment, your doctor will give you full information about what it involves and explain its aims. They will ask you to sign a form saying that you give permission (consent) for the hospital staff to give you the treatment. No medical treatment can be given without your consent.

Benefits and disadvantages of treatment

Treatment can be given for different reasons and the potential benefits will vary for each person. If you've been offered treatment that aims to cure your cancer, deciding whether to have the treatment may not be difficult. However, if a cure is not possible and the treatment is to control the cancer for a period of time, it may be more difficult to decide whether or not to go ahead.

If you feel that you can't make a decision about treatment when it’s first explained to you, you can always ask for more time to decide.

You are free to choose not to have the treatment and the staff can explain what may happen if you don't have it. You don't have to give a reason for not wanting treatment, but it can be helpful to let the staff know your concerns so that they can give you the best advice.

Surgery

Surgery is an important treatment for gall bladder cancer. If you have early gall bladder cancer, it may be removed using an open cholecystectomy or a laparotomy.

If the cancer has spread beyond the gall bladder, a radical cholecystectomy may be done. This is a major operation which removes the gall bladder, the surrounding tissues, lymph nodes and parts of other organs that may be affected by cancer.

After your operation you may stay in an intensive-care ward for the first couple of days. You will then be moved to a general ward until you recover. Most people need to be in hospital for about two weeks after this type of operation.

If a cure isn't possible, surgery may still be used to help improve a person's symptoms by removing as much of the cancer as possible.

Whether surgery is possible or not depends on the results of the investigations described here. You may be referred to a surgeon who is a specialist in this rare cancer.

Radiotherapy

Radiotherapy treats cancer by using high-energy x-rays to destroy the cancer cells, while doing as little harm as possible to normal cells. It’s occasionally used for cancer of the gall bladder.

It can either be given externally from a radiotherapy machine or internally by placing radioactive material close to the tumour (brachytherapy).

Chemotherapy

Chemotherapy is the use of anti-cancer (cytotoxic) drugs to destroy the cancer cells. Chemotherapy may occasionally be used after surgery if all the cancer couldn't be removed by the operation. It may also be used if an operation isn't possible or if the cancer has come back (recurred) after initial treatment. The aim of chemotherapy treatment is to try to shrink or slow down the growth of the cancer and to relieve symptoms. The drugs cisplatin and gemcitabine (Gemzar®) can be used in combination to treat gall bladder cancer.

Stent insertion

If cancer in the gall bladder is causing a blockage in the bile duct, it may be possible for the doctor to insert a small tube (stent) during the ERCP. This can help to relieve jaundice without a surgical operation.

The stent is about 5–10cm long and is as thick as a ballpoint pen refill. The stent clears a passage through the bile duct to allow the bile to drain away. The preparation and procedure is the same as for an ERCP. By looking at the x-ray image the doctor will be able to see the narrowing in the bile duct. The narrowing can be stretched using inflatable balloons (dilators), and the stent can be inserted through the endoscope to enable the bile to drain.

The stent usually needs to be replaced every 3–4 months to prevent it becoming blocked. If it does become blocked, you may become jaundiced and have high temperatures. It's important to tell your specialist about these symptoms as early as possible. You may need antibiotics and your specialist might advise that the stent be exchanged for a new one. For most people this procedure can be done quite easily.

ERCP (endoscopic retrograde cholangio-pancreatography)

This may be used to take an x-ray picture of the pancreatic duct and bile duct. It can also be used to unblock the bile duct if necessary.

You'll be asked not to eat or drink anything for about six hours before the test, so that the stomach and first part of the small bowel (the duodenum) are both empty. You'll be given a tablet or injection to make you relax (a sedative) and a local anaesthetic spray will be used to numb your throat. The doctor will then pass a thin flexible tube called an endoscope through your mouth, into your stomach and the small bowel just beyond it.

Looking down the endoscope, the doctor can find the openings where the bile duct and the duct of the pancreas drain into the duodenum. A dye, which can be seen on x-rays, can be injected into these ducts so the doctor can see whether there are any abnormalities or blockages.

EUS (endoscopic ultrasound)

This scan is similar to an ERCP but involves an ultrasound probe being passed down the endoscope to take an ultrasound scan of the gall bladder and surrounding structures.

Angiogram

This is a test to look at blood vessels. The bile duct is very close to large blood vessels that carry blood to and from the liver. An angiogram may be used to check whether any of these blood vessels are affected by the cancer.

Angiograms are carried out in the x-ray department. A fine tube is put into a blood vessel (artery) in your groin. A dye is then injected up the tube. The dye circulates in the arteries so that they show up on x-ray.

Laparoscopy

This is a small operation that allows the doctors to look at the gall bladder, the liver and other internal organs in the area around the gall bladder. It’s done under a general anaesthetic and will mean a short stay in hospital.

While you are under anaesthetic the doctor makes a small cut (incision) in your abdomen and inserts a thin flexible tube containing a light and camera (laparoscope). The doctor looks at the gall bladder and may take a small sample of tissue (biopsy) for examination under a microscope.

Sometimes the gall bladder may be removed during a laparoscopy, to treat gallstones or chronic inflammation of the gall bladder. This operation is called a laparoscopic cholecystectomy.

If gall bladder cancer is found or suspected during this operation, the surgeon will

change the operation to an open cholecystectomy. This is when the gall bladder and surrounding tissues are removed through a larger cut in the abdomen. It makes it easier to remove all of the cancer.

After the laparoscopy you will have one or two stitches in your abdomen. You may have uncomfortable wind and/or shoulder pains for several days after the operation. The pain can often be eased by walking or taking sips of peppermint water.

Laparotomy

If the doctor can't make a diagnosis using these tests, a procedure called a laparotomy may be done under a general anaesthetic. This involves making a cut (incision) in your abdomen so the surgeon can examine the gall bladder, and the tissue around it, for cancer. If a cancer is found, but looks as though it has not spread to surrounding tissues, the surgeon may be able to remove the cancer or relieve any blockages it might be causing.

Signs and symptoms of gall bladder cancer
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Early gall bladder cancer often causes no symptoms and is usually discovered unexpectedly when someone has surgery to remove gallstones. About 1 in 5 gall bladder cancers are found in this way.

Most tumours are only discovered at an advanced stage. They can cause a variety of symptoms including sickness, high temperatures, weight loss and pain in the tummy (abdomen).

If the cancer blocks the bile duct it may stop the flow of bile from the gall bladder into the small bowel. This causes bile to flow back into the blood and body tissues, and leads to the skin and whites of the eyes becoming yellow (known as jaundice).

The urine also becomes a dark yellow colour and stools (bowel motions) are pale. The skin may become itchy.

These symptoms may be caused by other problems such as gallstones or an infection of the gall bladder, but it's important to get them checked by your doctor.

How gall bladder cancer is diagnosed
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Usually you begin by seeing your GP who will examine you. They will refer you to a hospital specialist for any tests that may be necessary and for expert advice and treatment.

At the hospital, the doctor will ask you about your general health and any previous medical problems. They will then examine you and take blood samples to check your general health and that your liver is working properly. There are a number of commonly used tests to diagnose gall bladder cancer.

Ultrasound scan

This uses sound waves to build up a picture of the gall bladder and surrounding organs. You'll usually be asked not to eat or drink anything for at least six hours before the scan. Once you are lying comfortably on your back, a gel is spread onto your abdomen. A small device that produces sound waves is then rubbed over the area. The sound waves produce a picture on a computer. The test is painless and only takes a few minutes.

CT (computerised tomography) scan

A CT scan takes a series of x-rays that build up a three-dimensional picture of the inside of the body. The scan is painless and takes 10–30 minutes. CT scans use small amounts of radiation, which are very unlikely to hurt you or anyone you come into contact with.

You will be asked not to eat or drink for at least four hours before the scan.

You may be given a drink or injection of a dye that allows particular areas to be seen more clearly. For a few minutes, this may make you feel hot all over. If you are allergic to iodine or have asthma you could have a more serious reaction to the injection, so it's important to let your doctor know beforehand.

Spiral CT scan

In this test the x-ray machine rotates continuously around the body, to make cross-sectional pictures of the body.

MRI (magnetic resonance imaging) scan

This test is similar to a CT scan but uses magnetism instead of x-rays to build up a detailed picture of areas of your body. Before the scan you may be asked to complete and sign a checklist. This is to make sure it’s safe for you to have an MRI scan.

Before having the scan, you’ll be asked to remove any metal belongings including jewellery. Some people are given an injection of dye into a vein in the arm. This is called a contrast medium and can help the images from the scan to show up more clearly.

During the test you’ll be asked to lie very still on a couch inside a long cylinder (tube) for about 30 minutes. It's painless but can be slightly uncomfortable, and some people feel a bit claustrophobic during the scan. It’s also noisy, but you’ll be given earplugs or headphones. You will be able to hear and speak to the person operating the scanner.

Gall bladder cancer

Gall bladder cancer is rare, with around 670 new cases in the UK each year. It's very rare in people under 50 and is most often seen in people over 70. It's more common in women than men.

On this page
•The gall bladder
•Causes and risk factors of gall bladder cancer
•Signs and symptoms of gall bladder cancer
•How gall bladder cancer is diagnosed
•Staging and grading of gall bladder cancer
•Treatment of gall bladder cancer
•Clinical trials for gall bladder cancer
•Your feelings about gall bladder cancer
•References and thanks

Most cancers of the gall bladder are a type of cancer called adenocarcinoma. They start in the lining of the gall bladder.

We hope this information answers your questions. If you have any further questions, you can ask your doctor or nurse at the hospital where you are having treatment.

The gall bladder
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The gall bladder is a small pouch that stores and concentrates bile. Bile is a fluid that helps us to digest food. Its main function is to break down fats in food. Bile is made by the liver and stored in the gall bladder. The gall bladder is connected to the small intestine and the liver by the bile ducts.

The position of the gall bladder
The position of the gall bladder

View a large copy of the position of the gall bladder image

The gall bladder and the bile ducts are known as the biliary system. We have separate information about cancer of the bile duct.

Causes and risk factors of gall bladder cancer
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The cause of most gall bladder cancers is unknown. There are a number of risk factors that may increase your chances of developing this type of cancer. These include:

Gall stones and inflammation

Gall bladder cancer is more likely to occur in people who have a history of gallstones or in people who have inflammation of the gall bladder (cholecystitis). However, most people who have gallstones or an inflamed gall bladder won't develop gall bladder cancer.

Polyps

These are non-cancerous (benign) tumours of the gall bladder that increase the risk of developing gall bladder cancer.

Abnormal bile ducts

Gall bladder cancer is slightly more common in people who are born with (congenital) abnormalities of the bile ducts.

Porcelain gall bladder

People who have a condition called porcelain gall bladder, in which calcium forms in the wall of the gall bladder, also have a slightly increased risk of this type of cancer.

Smoking

Some evidence suggests that people who smoke ci******es are more likely to develop gall bladder cancer.

Family history

People who have a close relative (parent, brother or sister) with gall bladder cancer have a slightly higher risk of developing this type of cancer.

Obesity

Being very overweight increases your risk of developing gall bladder cancer.

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