Gall bladder cancer (GBC) presents notable obstacles when it comes to detection and diagnosis. This is especially true in this new molecular based era where precise and accurate diagnosis is crucial. GBC often is undetected until it progresses to advanced stages. While universally rare, GBC presents a considerable burden, particularly in India, where it contributes to about 10% of the global GBC cases. Additionally, the incidence of GBC within India varies regionally, with high prevalence in North, North-East, Central, and Eastern regions. Combating these challenges, recent advances in imaging technology are ushering in a transformative era in the diagnosis and management of GBC.
Risk factors and susceptibility
Gall bladder cancer arises from a complex interplay of various factors, although its exact etiology remains elusive. Individuals aged 70 and above, particularly women, are at higher risk of developing this malignancy. The presence of gallstones and chronic inflammation of the gall bladder have been suggested to significantly elevates the risk, with up to 90% of diagnosed cases exhibiting these conditions, notably more prevalent in females. Porcelain gall bladder, characterized by calcium deposits on the gall bladder wall, and gall bladder polyps, some of which may progress to cancer, also contribute to the risk profile. Additionally, repeated infections with salmonella, such as in cases of typhoid fever, have been associated with an increased likelihood of gall bladder cancer development. Highlighting the multifactorial nature of this disease, a recent research examines how the use of mustard oil in cooking and various dietary components impact the occurrence of gall bladder cancer in regions across India, regardless of their incidence rates. Furthermore, risk factors such as obesity, often associated with diets high in carbohydrates and low in fibre, and a family history of the disease, further compound the susceptibility to gall bladder cancer.
Despite these known risk factors, one of the primary challenges in diagnosing gall bladder cancer lies in its nonspecific symptoms, which often mimic those of other gastrointestinal conditions. Patients may present with abdominal pain, jaundice, nausea, vomiting, and weight loss, making it difficult to differentiate gallbladder cancer from benign gall bladder diseases or other malignancies.
Gall bladder cancer management
The utilisation of advanced imaging techniques has emerged as a pivotal aspect of patient care. These cutting-edge methods enable oncologists to precisely delineate the size, location, and characteristics of gall bladder tumours, aiding in crucial treatment decisions and prognostic assessments.
CT scans: Cross-sectional imaging provided by CT scans plays a fundamental role in assessing the extent of gall bladder cancer, determining its localized presence or potential spread to adjacent structures such as the liver, bile ducts, and lymph nodes. At the forefront of this technology, triphasic or 4-phase CT scans capture dynamic images during distinct phases of blood flow through the liver, offering comprehensive insights for treatment planning.
Ultrasound: Ultrasound is useful for detecting the location and number of tumours and whether the tumour involves the main blood vessels. It also assists in distinguishing between cancerous and benign gallstone disease, providing essential information for treatment decisions without radiation exposure.
Magnetic Resonance Cholangiopancreatography (MRCP): Leveraging the unparalleled soft tissue contrast of magnetic resonance imaging (MRI), MRCP offers detailed visualisation of gall bladder tumours, enabling precise assessment of tumour size and local invasion. This modality aids clinicians in determining the feasibility of surgical resection and evaluating potential spread to adjacent organs, thus guiding optimal treatment strategies.
Positron Emission Tomography: PET scans, often employed in conjunction with CT imaging (PET-CT), provide functional information regarding the metabolic activity of gall bladder tumours and their potential metastatic spread. By accurately delineating disease extent beyond anatomical boundaries, PET-CT scans play a crucial role in staging gall bladder cancer and guiding the selection of appropriate therapeutic interventions. However this technology is less likely to add any further diagnostic value and its use would be weighed against the extreme radiation exposure and cost.
While imaging techniques have revolutionized gall bladder cancer diagnosis, ongoing research continues to explore novel approaches to enhance sensitivity, specificity, and accuracy.
Artificial intelligence (AI) and machine learning algorithms are being developed to analyse imaging data and assist radiologists in interpreting complex images, potentially improving diagnostic accuracy and efficiency. Continued research and innovation in this field hold the promise of further advancements, ultimately leading to better patient care and outcomes.
(Ghassan K Abou-Alfa is a gatrointestinal oncologist at Memorial Sloan Kettering Cancer Center, New York)