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gallbladder cancer

Cancer is a group of diseases that start when cells in the body start to grow out of control. When this abnormal growth of cells occurs to the gallbladder it is called gallbladder cancer. This type of cancer is very rare in Tanzania while number of women being slightly higher compared to that of men. To understand better about gallbladder cancer it is important for one to know a little bit about gallbladder and its functions.

About Gallbladder
Gallbladder is a small sac shaped organ in which bile is stored. It is located directly underneath the liver. Both liver and gallbladder are behind the lower right ribs. Bile is a bitter greenish-brown alkaline fluid secreted by liver for facilitating digestion of fats in foods.

> Mucosa. It is the inner most layer of esophageal wall. It is further subdivided into epithelium, lamina propria and muscularis mucosa.
> Submucosa. It is the layer of the esophageal wall with connective tissues. It is made up of blood vessels and nerves. Submucosa is located under mucosa.
> Muscularis propria. This is a layer that is made up of muscles that help to push food down the esophagus to the stomach. It is located under submucosa.
> Adventitia. It is the outermost layer of esophageal wall. It is made of connective tissues.

The epithelial part of mucosa is made of squamous cell from which most of esophageal cancer cases start. Mucus secreting glands of the esophagus are locates in the submucosa from which some of the cancer cases develop.

Types of gallbladder cancer
There are various types of this cancer but the most common type is adenocarcinoma. Adenocarcinoma starts in the glandular cells of gallbladder. Other types of gallbladder cancer include,;

Papillary adenocarcinoma Small cell carcinoma Squamous cell carcinoma Sarcomas

Risk factors
When it comes to cancer, anything that increases your probability of developing cancer is called a risk factor. Risk factors only influence development of cancer but it does not directly cause cancer. Sometimes people with risk factors do not develop the disease while those with no risk factors do develop the disease. Knowing risk factors will help you live your life making some better healthy choices to reduce the risk. The risk factors of gallbladder cancer include the following.

> Age.Gallbladder cancer is most common to older people. Commonly from 50 years and above..
>Gender. Gallbladder cancers are more common to women when compared to men.
Gallstones. Statistics shows that most people with gallbladder cancer have a history of gallstones. Gallstones are rock like formations of cholesterol and bile salt that occur in gallbladder or bile duc.
>Polyps. These are non-cancerous tumors of gallbladder that increase your chance of developing gallbladder cancer. Sometimes these are formed when gallstones get embedded on the gallbladder wall..
Smoking. Tobacco use increases the risk of developing gallbladder cancer.
>Calcification of gallbladder. This is the accumulation of calcium on the wall of gallbladder. Researches shows it increases the chance of developing gallbladder cancer.
>Family history. People with family history of this type of cancer have a slightly higher risk of developing gallbladder cancer.

Early detection and screening
Most of gallbladder cases are detected when they are already at advanced stage. It is hard to detect gallbladder cancer at an early stage because it is difficult to even feel this organ by physical examination due to the fact that it is located deep inside the body. So the only way most cases are detected is when they start showing signs and symptoms of the disease. When signs and symptoms of gallbladder cancer start to show, it is high likely that the disease is already at advanced stage..

Some people detect gallbladder while it is still early when they go for treatment of gallstones disease by surgery. As for screening tests (tests done to someone with no symptoms of the disease including cancer), currently there are no any recommended screening tests for gallbladder cancers.

Signs and symptoms of gallbladder cancers
People with gallbladder cancer can experience some of the following signs and symptoms. Sometimes people with gallbladder cancer do not show any of those signs and symptoms and it is possible also for those signs and symptoms to be associated with other health conditions, so the only possible way to find the truth is through examinations in hospital. Those signs and symptoms include;

> Abdominal pain. People with gallbladder cancer may experience some pain on their upper right part of their abdomen (belly).
> Jaundice. When gallbladder cancer blocks bile duct it prevents bile from entering pancreatic duct where it will be directed into small intestine for digestion of fats in food. In return bilirubin (chemical in the bile giving it yellowish) will build up and enter into blood stream where it will be deposited in different parts of the body. This condition commonly causes skin and eyes to look yellow in colour.
> Nausea and vomiting. Some people with gallbladder cancer will suffer from nausea and vomiting.
> Loss of appetite. Also some tend to loose desire to eat.
> Abdominal lump. This can be caused because of the increased size of gallbladder or by small other tumors from other organs that gallbladder cancer has spread to.
> Bloating. Sometimes people with gallbladder cancer have the problem of having their stomach filled with gas.
> fever
> Weight loss.
> Itchy skin
> Pale stool
> Urine becoming dark yellow in color.

Diagnosis Following suspicion of the disease, doctors normally run combination of tests to determine whether there are cancerous cells in the body or not and if there are cancer cells, how far have they spread. Along with thorough medical history and physical examination, doctors normally use combination of the following tests to diagnose cancer.

> Laboratory tests. Laboratory tests are important in ruling out other conditions and confirming diagnosis. For cancer diagnosis laboratory tests normally include blood tests, urine tests, tumor markers and other body fluids tests. >>> Blood tests. Blood tests help to reveal level of different substances in the blood which will help doctors to know if there is anything wrong in the body. From blood tests doctors can see complete blood count which indicates number, size and maturity of blood cells. Also from the blood tests doctors can analyze if kidney and liver are working properly
>>> Urine tests. Urine tests (urinalysis) involve laboratory examination of urine to check presence of blood, proteins, and other substances such as drugs. For instance blood in the urine may be an indication of benign condition, infection or other health problem
>>> Tumor markers. These are biomarkers (proteins) that can be produced by both cancer cells and normal body cells in response to cancer. Tumor markers are released into the blood or urine. Although studies are still conducted to determine role of these markers in diagnosing cancer because sometimes people with benign condition will have elevated level of these proteins. Also not all tumors have their markers and some markers are not specific to one type of tumor.
>>> Other body fluids. Despite being rarely used, sometimes body fluids can be tested in the lab during diagnosis of cancer. For instance the use of cerebral spinal fluid (CSF) and pleural fluid. CSF is used in diagnosis of brain tumors while pleural fluid for lung cancer..

The following are some of the diagnostic tests for esophagus cancer although not everyone will need to go through all those tests during diagnosis.

> Diagnostic imaging. Diagnostic imagings involve tests that create pictures of inside the body that help the doctor to see if there is tumor or not. There are several imaging tests used in cancer diagnosis depending on the type and location of cancer suspected. These imaging tests include;

>>> Computed tomography (CT) scan. CT scan machine is a donut-shaped scanner that uses x-rays to create series of pictures of body organs from different angles. This machine is linked to a computer where those series of pictures taken will be combined to create a 3D- image of inside the body. During the scanning process patient will lie still on the table which will slide into the scanner. In order to get a clear image, sometimes the doctor will inject the patient with a contrast material before scanning. From the images the doctor will be able to differentiate between healthy and unhealthy tissues.
>>> Magnetic resonance imaging (MRI). MRI is an imaging technique that uses powerful magnet and radio waves to take series of pictures of body organs and create a 3D image in a computer linked to a machine. Just like in CT, during MRI procedure the patient will lie on a table that will slide into a long round chamber. Also during this procedure the doctor may inject the patient with a contrast material for clear image view.
>>> X-ray. This is an imaging technique that is uses low dose of radiation to create pictures of inside your body. Technician will position the patient and direct the x-ray beam to the intended part of the body.
>>> Ultrasound. Ultrasound is a diagnostic imaging procedure that uses high energy sound waves to produce images of organs inside the body. During the examination, a patient will lie on the table while the technician will slowly move a device called transducer on the skin over the part of the body that is being examined.
>>> PET scan. Positron emission tomography (PET) scan is an imaging test that uses radioactive glucose to create 3-D images of areas inside the body. Radioactive glucose is used for this test because cancer cells tend to absorb more glucose than normal body cells, so the scan will show which areas of the body has more glucose than others. Before the scan, doctor will inject the patient with tracer called radioactive glucose then during imaging the patient will be asked to lie on the table that will be moving back and forth through the scanner.
Bone scan. Bone scan is used to examine bones. When it comes to cancer, bone scan is used for diagnosis of bone cancer or cancer that has metastasized into the bones. Before the test, patient will be injected with small amount of radioactive material that tends to collect more on abnormal parts of the bones. Then pictures that will be taken by a scan will indicate the distribution of those radioactive materials in the bones throughout the body.
>>> MRI scan. Unlike CT scan, magnetic resonance imaging uses strong magnetic field and radio waves to produce images of inside parts of the body. The scanner takes several images of parts of the body. Computer combine these images to form three dimensional image of inside parts of the body. Before the scanning, you may be given a contrast medium so as to produce a clear image.

> Biopsy. Biopsy is a diagnostic procedure that involves removing a tissue sample from the body and examines it under microscope in the laboratory. Examination in the laboratory is normally done by a pathologist who will check if the cells in the tissue are cancerous or not. In most cancer cases, biopsy is considered to be the confirmatory test. Depending on the location and type of cancer, biopsy can be obtained in different ways. Some of them include;
>>> Using needle. By using a thin needle, doctors can draw same tissue or fluid for examination under microscope. This method can be used to draw some fluid (spinal tap), bone marrow (bone marrow aspiration), blood or small amount of tumor from the suspected organ such as liver and breast (fine needle aspiration).
>>> Surgery. Abnormal tissue samples are obtained while the doctor is performing the surgery. Tissues are then sent to the lab for examination during the surgery. If the surgeon removes just a portion of abnormal area it is called incisional biopsy while when the entire tumor (abnormal site) is removed it is called excisional biopsy.
>>> Using endoscope. Endoscope is a thin, lighted tube with a camera (focusing telescope) at the end. It is used for viewing inside the body through natural openings like mouth and anus. During an examination if the doctor sees any abnormal tissue, then endoscope can also be used to take sample for that tissue. There are different kinds of endoscopy exams depending on the site of the body being examined. Some of the exams include colonoscopy (for rectum and colon), bronchoscopy (for trachea, bronchi and lungs) and esophagogastroduodenoscopy EGD (for esophagus, stomach and duodenum)

In addition to physical examination, diagnosis of gallbladder cancer normally involves the use of blood tests (checking presence of carcinoembryonic antigen, CEA and CA 19-9), ultrasound, X-ray, CT- Scan, MRI Scan, Biopsy and percutaneous cholangiography which involve inserting a thin needle through the skin to the gallbladder. Then dye is injected to improve quality of the X-ray image that will be taken.


In staging of gallbladder cancer, TNM staging system is used. TNM is the combination of tumor; node and metastasis meaning it include assessment of tumor size, nodes involved and its metastasis as described below.
>>> Tumor. Tumor explains size (how large is the tumor?) and its location.
>>> Node. This explain lymph nodes involved.
>>> Metastasis. Metastasis explains how far has disease spread.

The results are combined to determine the stage of cancer for the particular case. Knowing the stage of cancer will provide a common way for doctors to work together in treatment planning and delivery for the particular case. There are five stages (stage 0 to IV) as described below.

Tumor (T). > TX: The primary tumor cannot be evaluated.
> T0: No evidence of primary tumor.
> Tis: Carcinoma in situ. This is very early cancer and is confined in the gallbladder.
> T1: The tumor is in the gallbladder and has only invaded the lamina propria or muscle layer
> T2: The tumor has invaded the perimuscular connective tissue.
> T3: The tumor extends beyond the gallbladder. It has invaded the liver and/or one other adjacent organ or structure, such as the stomach, duodenum (part of the small bowel), colon, and pancreas.
> T4: The tumor has invaded the main portal vein or hepatic artery or has invaded more than one organ or structure beyond the liver.

Node (N) > NX: Regional lymph nodes involvement cannot be evaluated.
> N0: No evidence of reginal nodes involvement.
> N1: Reginal lymph nodes are involved.
> N2: Distant lymph nodes are involved.

Metastasis (M) > MX. Distant metastasis cannot be evaluated.
> M0. No evidence of distant metastasis.
> M1. The disease has spread to other parts of the body.

Stage 0(Tis, N0, M0): Very early disease with no lymph node involvement or distant metastasis.
Stage I (T1, N0, M0): A tumor is only in the gallbladder with no lymph node involvement or distant metastasis.
Stage II (T2, N0, M0): Tumor has invaded the perimuscular connective tissue but there is no node involvement or distant metastasis
Stage IIIA (T3, N0, M0): Tumor has spread beyond the gallbladder but not to nearby arteries or veins. There is no lymph node involvement or distant metastasis.
Stage IIIB (T1, T2, T3; N1, M0): Tumor is of any size but has not spread to nearby arteries or veins. There is lymph node involvement but no distant metastasis.
Stage IVA (T4, N0 or N1, M0): Tumor has spread to nearby arteries or veins. Reginal nodes may or may not be involved but there is no distant metastasis.
Stage IVB (any T, any N, M1): Tumor of any size with any kind of node involvement but with distant metastasis.
(any T, N2, M0) : Tumor is of any T with distant node involvement but there are no distant organs involved.

Treatment Following cancer diagnosis, the doctor will break the news and it is normally not very easy to accept that it is cancer. The doctor will be there to help the patient process the news and to help the patient in taking the next steps.
After the patient receives and processes the news that he/she has cancer, one of the most important steps that will follow is decision making. The doctor will present to the patient (relatives/parents/guardians) with all the possible treatment options and explain what they mean. Then with the help of the doctor, the patient (relatives/parents/guardian) will have to choose which treatment option is good depending on benefits of such option.

Despite all the information given by the doctor, sometimes the patient may still be unsatisfied with what he/she has been told. In such situation, the patient is free and advised to seek a second opinion. Second opinion is the opinion that the patient may seek from another specialist (doctor) regarding his/her health problem and in this case it is cancer. Second opinion may include confirmation of the diagnosis, more clarification on your primary doctor recommendations or even reassurances that all the options have been explored.

In addition to standard care treatment options, sometimes there are those new treatments or drugs or combination of treatments that have not been approved yet to be used as standard care treatments for a particular cancer (disease) but have shown some promising results that they may help. These type of treatments are called clinical trials.

If there are some clinical trials for your case, the doctor may present to the patient or the patient may ask if there are any clinical trials for the particular cancer case. Over the years, have improved treatments and led to better outcomes to people diagnosed with various diseases including cancer. If you have decided to take part in clinical trial, you can also withdraw at any time
Treatment options Treatment of gallbladder cancer requires a team of doctors and other health care professionals. This team work together and it is called multidisciplinary team. Team may vary depending on the treatment option for a particular case. But normally multidisciplinary team for treatment of gallbladder cancer includes surgical oncologist, medical oncologist, radiation oncologist, radiation therapist, pathologist and other health care professionals like oncology nurses, physiotherapist and palliative care team. Treatment options include the following;

Surgery is the treatment option that involve removal of tumor and surrounding tissue through operation. This is treatment option is done by a doctor called surgical oncologist. There are various kinds of surgery for treatment of gallbladder cancer. This include:-

> Simple cholecystectomy which include removal of gallbladder and small part of liver tissues near gallbladder
> Radical cholecystectomy. This involve the removal of gallbladder, small part of liver near gallbladder, bile duct and ligaments between liver and intestine and nearby lymph nodes

If the disease is very advanced, then surgery may be done in order to relieve signs and symptoms of the disease and in this case surgery will involve removal of cancer as much as possible.

Side effects of surgery
Possible bleeding after surgery
Pain. This can be relieved by medications
Possible bile leakage. This can occur to those who had radical cholecystectomy.
Possible liver failure after radical cholecystectomy
Blood clots
Possible effects to the digestive system due to the removal of some organs involved in digestion

Chemotherapy is the use of drugs to destroy cancer cells or stop its growth. This treatment is given by a specialized doctor known as medical oncologist. Type of chemotherapy used for treatment of gallbladder cancer is known as systemic chemotherapy. In systemic chemotherapy drug gets into the bloodstream to reach cancer cells throughout the body.
Generally chemotherapy is can be given through injection into vein (intravenously) by using a needle or given as a pill or capsule that is swallowed (orally). Chemotherapy can sometimes be given in combination with radiation therapy.
Side effects
Side effects of chemotherapy depend on the dose given, type of drug used and periodic time by which it has been used. Some of the possible side effects include the following.

Hair loss
Nausea and vomiting
Mouth sores
Fatigue, this can be the result of low red blood cells due to drugs
Possible increased infection risk. This is mainly due to decreased white blood cell count in the body caused by certain drugs
Easy bruising and bleeding, due to low platelets count.

Radiation therapy This is the treatment option that involve the use of high energy X-rays or other radiation particles to destroy cancer cells. This type of treatment is given radiation oncologist, a doctor specialized in treating cancer by using radiations. For treatment of gallbladder, external beam radiation therapy is used. External-beam radiation therapy is a type of radiation therapy given from a machine outside the body.
Sometimes radiation therapy is given before surgery in order to shrink the tumor first or it can be given after surgery in order to destroy possible remaining cancer cells.

Side effects of radiotherapy
Side effects of radiation therapy depend on the dose of radiation therapy given. These side effects normally go away soon after completion of treatment but also there are some medications that may help to relieve if they become too severe. Some of the possible side effects include the following;
Loss of appetite
Skin reaction at the area where radiations enters the body

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