1. Gallbladder Cancer Reham Khalilieh 4 th year Medical Student Surgical Round- Shaare Zedek Medical Center, Jerusalem

2. Anatomy (Reminder)

3. Introduction and Epidemiology ^ Uncommon ^ Aggressive Malignancy ^ Poor Prognosis ^ Age ^ Women > Men ^ Caucasians > Blacks ^ South American Countries, India, Pakistan, Japan

4. Risk Factors ^ Gallstone Disease- porcelain gallbladder ^ Gallbladder Polyps ^ Chronic Infection- Salmonella, Helicobacter ^ Abnormal pancreaticobiliary duct junction ^ Medications- Methyldopa, Isoniazid ^ Carcinogen Exposure- oil, paper, radon ^ Obesity ^ Diabetes

5. Abnormal pancreaticobiliary duct junction

6. Pathogenesis and Staging ^ Metaplasia-Dysplasia > CIS >Invasive Adenocarcinoma ^ TNM staging system

7. American Joint Committee on Cancer Staging of Gallbladder Carcinoma Primary Tumor (T stage) T1Tumor invades lamina propria or muscle layer T1a: Tumor invades lamina propria T1b: Tumor invades muscle layer T2Tumor invades perimuscular connective tissue T3Tumor perforates serosa or directly invades one adjacent organ (extension £2 cm into liver) T4Tumor extends ≥2 cm into liver and/or into two or more adjacent Regional Lymph Nodes (N Stage) N0No regional lymph node metastasis N1Metastasis in cystic ductal, pericholedochal, and/or hilar lymph nodes N2Metastasis in peripancreatic, periduodenal, periportal, celiac, and/or superior mesenteric lymph nodes Distant Metastasis (M Stage) M0No distant metastasis M1Distant metastasis

8. TNM Stage Grouping Stage I T1 N0 M0 Stage II T2 N0 M0 Stage III T3 N0 M0 or T1-3 N1 M0 Stage IVA T4 N0-2 M0 Stage IVB T1-4 N0-2 M1

9. Metastases ^ GBC spreads via both lymphatic and venous vessels ^ GBC frequently extend directly into the hepatic parenchyma ^ Lymphatic spread: Calot's lymph node >> pericholedochal and hilar nodes >> peripancreatic, duodenal, periportal, celiac, superior mesenteric nodes

11. Clinical Presentation ^ Early invasive GBC are asymptomatic OR cholelithiasis / cholecystitis like symptoms ^ Symptomatic patients ^ Duodenal Obstruction ^ Rare symptoms

12. Diagnosis ^ US

13. Diagnosis ^ CT

14. Treatment ^ Gallbladder polyp

15. Treatment cont. ^ Gallbladder Cancer Following Cholecystectomy

16. Treatment cont. ^ Patients suspected of having GBC preoperatively

17. Treatment cont. ^ Patients with advanced disease at presentation

18. Survival ^ Overall survival of gallbladder cancer is less than 15% ^ T1a > Excellent prognosis ^ T2 > 20-60% (5-year survival) ^ T3 > less than 20% ^ T4 > Months ^ Patients with metastatic disease at presentation > 13 months

19. THANK YOU !