A case-control assessment of risk factors for gallbladder carcinoma

Evidence-based clinical practice guidelines for cholelithiasis 2021

The Japanese Society of Gastroenterology first published evidence-based clinical practice guidelines for cholelithiasis in 2010, followed by a revision in 2016. Currently, the revised third edition was published to reflect recent evidence on the diagnosis, treatment, and prognosis of cholelithiasis conforming to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. Following this revision, the present English version of the guidelines was updated and published herein. The clinical questions (CQ) in the previous version were reviewed and rearranged into three newly divided categories: background questions (BQ) dealing with basic background knowledge, CQ, and future research questions (FRQ), which refer to issues that require further accumulation of evidence. Finally, 52 questions (29 BQs, 19 CQs, and 4 FRQs) were adopted to cover the epidemiology, pathogenesis, diagnosis, treatment, complications, and prognosis. Based on a literature search using MEDLINE, Cochrane Library, and Igaku Chuo Zasshi databases for the period between 1983 and August 2019, along with a manual search of new information reported over the past 5 years, the level of evidence was evaluated for each CQ. The strengths of recommendations were determined using the Delphi method by the committee members considering the body of evidence, including benefits and harms, patient preference, and cost-benefit balance. A comprehensive flowchart was prepared for the diagnosis and treatment of gallbladder stones, common bile duct stones, and intrahepatic stones, respectively. The current revised guidelines are expected to be of great assistance to gastroenterologists and general physicians in making decisions on contemporary clinical management for cholelithiasis patients.

Histopathological changes in gall bladder mucosa in relation to the number, and size of gallstones, and analysis of the findings in the context of age distribution of the patients: A perspective

Backgrounds/Aims

To study histopathological changes in gall bladder mucosa in cholelithiasis patients, and analyse their relation to the number and size of gallstones. These findings were evaluated in the context of age distribution of the study population.

Methods

One hundred cases of cholecystectomy were part of the study, which was conducted in collaboration with the pathology department. The time period of the study was January 2020 to June 2021.

Results

Maximum cases had multiple stones (69.0%), while one third cases (31.0%) had solitary stones. While initial univariate analysis showed age (odds ratio [OR], 6.882; p = 0.043), gallstone number (OR, 9.1; p = 0.050), gallstone size (OR, 17.111; p = 0.013), and duration of symptom (OR, 34.125; p = 0.001) to be significant risk factors associated with gallbladder carcinoma, multivariate analysis found none of these variables to be significant. However, conditional multivariate analysis for the duration of symptom (p = 0.008; OR, 21.118) yielded significant p- value. With histopathological diagnoses, 5% of cases had gallbladder cancer.

Conclusions

This study shed light on the rising incidence of cholelithiasis in the young population and the high rate of gallbladder carcinoma in Punjab, India. Although gall stone characteristics (size, number) and patient age appeared to be significant risk factors when their individual relation with gallbladder carcinoma was studied, multivariate analysis, could not prove that. Conditional multivariate analysis showed the duration of symptom to be the only significant risk factor associated with gallbladder carcinoma. Further research with larger sample size is needed to study the rising incidence of gallbladder carcinoma, and the risk factors associated with it.

Threshold dose-response association between smoking pack-years and the risk of gallbladder cancer: A nationwide cohort study

BACKGROUND AND AIMS

The association between smoking and gallbladder cancer (GBC) risk is unclear. We investigated the association between smoking (including pack-years) and GBC risk. We also examined the combined effects of smoking and diabetes or prediabetes on GBC risk.

METHODS

This Korean nationwide cohort study included 9,520,629 adults without cancer who underwent national health screening in 2009 and were followed-up until 2018. Multivariable Cox proportional hazards models were used to determine risk estimates after adjusting for potential confounders.

RESULTS

During 78.4 million person-years (mean 8.2 ± 0.9 years) of follow-up, we identified 6066 patients with newly diagnosed GBC. Current and former smokers were associated with increased GBC risk (hazard ratio [HR], 95% confidence interval [CI]: 1.117, 1.029-1.212 and 1.105, 1.016-1.202, respectively). Smoking of 20 to <30 and ≥30 pack-years was independently associated with increased GBC risk compared with never smoking (HR, 95% CI; 1.241, 1.100-1.400 and 1.231, 1.107-1.370, respectively). However, smoking of <10 and 10 to <20 pack-years was not. This threshold dose-response association between smoking pack-years and GBC risk was observed regardless of the glycaemic status (all P < 0.01). Furthermore, smoking of ≥20 pack-years and hyperglycaemia had a synergistic effect on the GBC risk (all P < 0.01). Smokers with ≥20 pack-years with diabetes had the highest risk of GBC compared to never smokers with normoglycaemia (HR, 1.658; 95% CI, 1.437-1.914).

CONCLUSIONS

Smoking was associated with increased GBC risk with a threshold dose-response effect for smoking pack-years. The risk of GBC increases synergistically when smoking and hyperglycaemia coexist. More individualised cancer prevention education is required to reduce GBC risk.

Incidental adenocarcinoma of the gallbladder in a patient with Y insertion gallbladder duplication in the context of recurrent biliary colic: A video case report

RATIONALE

Gallbladder cancer is the most common malignancy of the biliary tree. Despite this, the only curative therapy remains surgical resection of the lesion achieving microscopically clear margins before malignant spread has occurred. Gallbladder duplication is an uncommon anatomical variance which occurs globally. It can present in a range of ways dependent on the embryological origin of the variance.

CASE

A 52-year-old female presented for planned laparoscopic cholecystectomy in the context of cholelithiasis resulting in recurrent biliary colic. The patient had no personal history of malignancy or significant medical comorbidities.

DIAGNOSIS

Intraoperatively, the patient was found to have Y-insertion variation of gallbladder duplication. Histopathology of the resected gallbladders showed an incidental invasive gallbladder adenocarcinoma affecting one of the gallbladders.

INTERVENTION

Both gallbladders were laparoscopically resected en-bloc.

OUTCOMES

The patient underwent oncology staging, which found no evidence of metastatic spread. Regular surveillance is attended with no recurrence of disease identified.

CONCLUSION

There are few reported cases detailing the occurrence of gallbladder adenocarcinoma in the presence of duplication of the gallbladder. This case demonstrates the clinical benefit of R0 surgical resection of gallbladder cancer, whilst highlighting the difficulties of diagnosing duplication of the gallbladder or gallbladder adenocarcinoma.

Incidence and Preoperative Predictor Factors of Gallbladder Cancer Before Laparoscopic Cholecystectomy: a Systematic Review

INTRODUCTION

Many cases of gallbladder cancer (GBC) were made incidentally after cholecystectomy for presumed benign disease. The aim of this review is to assess the preoperative predictor factors of gallbladder cancer.

METHODS

This systematic review was conducted according to PRISMA guidelines when it was applicable. We conducted bibliographic researches on October 2nd, 2019, in the following sources: The National Library of Medicine through PubMed, Cochrane database, and Google scholar. We have assessed the univariate and multivariate analysis outcomes.

RESULTS

We included ten studies. Incidence of incidental GBC was 0.36%. Seven studies reported age as a significant predictive factor of iGBC. Comorbidities were the second significant predictor. One study found that iGBC group was more likely to have elevated TB, DB, PAL, and ALT. Another study reported a significantly higher rate of TB, PAL, and AST. One study concluded that elevated CA19-9 combined with CEA or CA-125 was significantly more frequent in the group with iGBC. Polyps, porcelain GB, GB wall thickness, and CBD dilation were reported to be associated with iGBC. iGBC group were more likely to have solitary and larger GS and gallbladder wall thickening, essentially focal.

CONCLUSION

Incidence of iGBC was 0.365% varying between 0.19 and 1.6% of laparoscopic cholecystectomy and about 50% of GBC cases. This highlights the deficiency of preoperative diagnostic features. Despite the efforts made, the rate of this condition is still high, underlining the need of new radiological technologies.

Favorable gallbladder cancer mortality-to-incidence ratios of countries with good ranking of world's health system and high expenditures on health

Background

The mortality-to-incidence ratio (MIR) is a marker that reflects the clinical outcome of cancer treatment. MIR as a prognostic marker is more accessible when compared with long-term follow-up survival surveys. Theoretically, countries with good health care systems would have favorable outcomes for cancer; however, no report has yet demonstrated an association between gallbladder cancer MIR and the World’s Health System ranking.

Methods

We used linear regression to analyze the correlation of MIRs with the World Health Organization (WHO) rankings and total expenditures on health/gross domestic product (e/GDP) in 57 countries selected according to the data quality.

Results

The results showed high crude rates of incidence/mortality but low MIR in more developed regions. Among continents, Europe had the highest crude rates of incidence/mortality, whereas the highest age-standardized rates (ASR) of incidence/mortality were in Asia. The MIR was lowest in North America and highest in Africa (0.40 and 1.00, respectively). Furthermore, favorable MIRs were correlated with good WHO rankings and high e/GDP (p = 0.01 and p = 0.030, respectively).

Conclusions

The MIR variation for gallbladder cancer is therefore associated with the ranking of the health system and the expenditure on health.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-7160-z) contains supplementary material, which is available to authorized users.

Diet and biliary tract cancer risk in Shanghai, China

Trends in biliary tract cancer incidence rates have increased in Shanghai, China. These trends have coincided with economic and developmental growth, as well as a shift in dietary patterns to a more Westernized diet. To examine the effect of dietary changes on incident disease, we evaluated associations between diet and biliary tract cancers amongst men and women from a population-based case-control study in Shanghai, China. Biliary tract cancer cases were recruited from 42 collaborating hospitals in urban Shanghai, and population-based controls were randomly selected from the Shanghai Household Registry. Food frequency questionnaire data were available for 225 gallbladder, 190 extrahepatic bile duct, and 68 ampulla of Vater cancer cases. A total of 39 food groups were created and examined for associations with biliary tract cancer. Interestingly, only four food groups demonstrated a suggested association with gallbladder, extrahepatic bile duct, or ampulla of Vater cancers. The allium food group, consisting of onions, garlic, and shallots showed an inverse association with gallbladder cancer (OR: 0.81, 95% CI: 0.68-0.97). Similar trends were seen in the food group containing seaweed and kelp (OR: 0.79, 95% CI: 0.67-0.96). In contrast, both preserved vegetables and salted meats food groups showed positive associations with gallbladder cancer (OR:1.27, 95% CI: 1.06-1.52; OR: 1.18, 95% CI: 1.02-1.37, respectively). Each of these four food groups showed similar trends for extrahepatic bile duct and ampulla of Vater cancers. The results of our analysis suggest intake of foods with greater anti-inflammatory properties may play a role in decreasing the risk of biliary tract cancers. Future studies should be done to better understand effects of cultural changes on diet, and to further examine the impact diet and inflammation have on biliary tract cancer incidence.

Type 2 diabetes mellitus and risk of gallbladder cancer: a systematic review and meta-analysis of observational studies

AIMS

Increasing evidence suggests that a history of type 2 diabetes mellitus (type 2 DM) may be involved in the development of various sites of cancer. However, the association with risk of gallbladder cancer remains unclear.

METHODS

We identified studies by a literature search of MEDLINE and EMBASE through 31 August 2014 and by searching the reference lists of pertinent articles. All data were independently extracted by two investigators using a standardized data abstraction tool. Summary relative risks (SRRs) with 95% confidence intervals (CIs) were calculated with a random effects model.

RESULTS

A total of 20 studies (eight case-control studies and 12 cohort studies) were included in this meta-analysis. Analysis of these 20 studies found that compared with non-diabetic individuals, diabetic individuals had an increased risk of gallbladder cancer (SRR = 1.56, 95% CI: 1.36-1.79). There was evidence of moderate heterogeneity among these studies (p = 0.010 and I(2)  = 43.5%). This increased risk relationship is independent of smoking, body mass index and a history of gallstones. However, whether or not controlled for, alcohol use may be one of the potential confounders that significantly affect the association between type 2 DM and the risk of gallbladder cancer. Diabetic women and men had a similarly increased risk of gallbladder cancer associated with type 2 DM.

CONCLUSIONS

These findings of this systematic review indicate that compared with non-diabetic individuals, both men and women with type 2 DM had an increased risk of gallbladder cancer. Copyright © 2015 John Wiley & Sons, Ltd.

Colorectal Liver Metastasis, Primary Gallbladder Carcinoma and Myelofibrosis Present Simultaneously in a Liver Resection Specimen

Myelofibrosis and gallbladder carcinoma are both very rare diseases. This case report describes a patient with a history of myelofibrosis and colorectal carcinoma who was diagnosed with colorectal liver metastases. Surgery was performed to remove the metastases, and on site, the gallbladder was removed because of involvement in one of the liver lesions. After pathological examination, a primary gallbladder carcinoma and myelofibrosis were found in addition to the liver metastases. The combination of diseases was not likely to be interconnected but rather an unlucky course of events for the patient.

Medical conditions, family history of cancer, and the risk of biliary tract cancers

BACKGROUND

Scanty data exist on the role of personal medical conditions, except for gallstones, and family history of cancer on the risk of biliary tract cancers (BTC).

METHODS

We analyzed this issue using data from two Italian case-control studies, including 159 cases of BTC and 795 matched hospital controls. Odds ratios (ORs) of BTC and corresponding 95% confidence intervals (CIs) were estimated using multiple logistic regression models.

RESULTS

Gallstones were associated with a 2-fold excess risk of BTC (95% CI 1.24-3.45). No significant associations were observed with other conditions investigated, including diabetes (OR 1.15, 95% CI 0.63-2.11), hypertension (OR 0.65, 95% CI 0.39-1.11), hyperlipidemia (OR 0.61, 95% CI 0.31-1.21), allergy (OR 0.64, 95% CI 0.29-1.40), gastroduodenal ulcer (OR 0.52, 95% CI 0.24-1.12), hepatitis (OR 2.02, 95% CI 0.35-11.67), benign thyroid diseases (OR 1.16, 95% CI 0.56-2.40), hysterectomy (OR 1.19, 95% CI 0.53-2.68), unilateral oophorectomy (OR 1.75, 95% CI 0.44-6.93), and bilateral oophorectomy (OR 2.48, 95% CI 0.79-7.82). We found an excess risk of BTC in relation to family history of any cancer (OR 1.52, 95% CI 1.03-2.24) and family history of gallbladder cancer (OR 3.83, 95% CI 0.59-24.75).

CONCLUSIONS

The present study confirms a strong association between BTC and history of gallstones, and provides further evidence of a positive association with family history of cancer.

Incidental gallbladder cancers: Our clinical experience and review of the literature

OBJECTIVE

Gallbladder carcinomas are rare and aggressive neoplasms. They are usually advanced at the time of diagnosis. We aimed to evaluate incidental gallbladder cancers in our clinic, in terms of patients' demographics, diagnosis, treatment and follow-up, and compared our results with the literature.

MATERIAL AND METHODS

Patients who underwent laparoscopic cholecystectomy in the last 9 years were retrospectively reviewed, and features of the patients diagnosed with gallbladder cancer after histopathological evaluation were further evaluated.

RESULTS

Thirteen patients were female and two were male. The mean age was 67 years. Additional treatment was applied in seven patients. All patients were operated on laparoscopically, with conversion to open surgery in four patients. The rate of incidental gallbladder cancer was 0.17% in our patients. Survival rates were found to be 22.2% in patients who had been operated at least 5 years ago.

CONCLUSION

Surgery is the only curative treatment in gallbladder cancers; however, they are usually at advanced stages at the time of diagnosis. In incidental gallbladder cancers, survival can be prolonged with appropriate treatment models if they are identified at early stages. The relatively low rates that have been reported in our population may be due to geographical differences and problems in study design.

Is cancer risk still reduced if you give up smoking in later life?

SUMMARY This report summarizes the experimental and epidemiological evidence examining the ability of smoking cessation to influence cancer risk reduction in later life. Available evidence suggests that smoking cessation even in later years can significantly reduce mortality and yield risk reductions for many cancers including lung, oral, head and neck, and stomach cancer, among others. More research is necessary to accurately quantify the degree of cancer risk reduction for particular age groups and to calculate the minimum time of cessation necessary to produce a significant benefit for the patient. Smoking cessation is the only approach that has been shown to effectively reduce the risk of many cancers on a mass scale. Considering this, we recommend that healthcare providers communicate these benefits to patients at every opportunity and reinforce the notion that it is never too late to quit smoking.

The effect of smoking on the risk of gallbladder cancer: a meta-analysis of observational studies

BACKGROUND

Cigarette smoking has been shown to cause many nonpulmonary cancers, including those of liver, pancreas and bladder. However, results of epidemiologic studies examining the association between smoking and gallbladder cancer (GBC) have been mixed. To clarify the association of cigarette smoking and GBC, we performed a meta-analysis of observational studies.

METHODS

A literature search was performed using Medline (from 1 January 1966) and Embase (from 1 January 1974), through 31 January 2012, and by manually searching the reference lists of pertinent articles. Summary relative risks (SRRs) with corresponding 95% confidence intervals (CIs) were calculated with a random-effects model.

RESULTS

A total of 11 articles (10 case-control and one prospective cohort studies) were used in this meta-analysis, which is based on a total of 1178 GBC cases. Analysis of 11 studies found that smokers had an increased risk of GBC development, compared with nonsmokers (SRRs 1.45, 95% CIs, 1.11-1.89). There was moderate heterogeneity among studies (Q=18.15, P=0.052, I2 =44.9%). These increased risks were independent of alcohol use and a history of gallstones. No significant publication bias was found.

CONCLUSION

Although the current evidence supports a positive link between cigarette smoking and risk of gallbladder cancer, additional population-based studies, particularly cohort studies, are needed before definitive conclusions can be drawn.

Risk factors for gallbladder cancer: a case-control study

Risk factors for gallbladder cancer (GBC) except gallstones are not well known. The objective was to study the risk factors for GBC. In a case-control study, 200 patients with GBC, 200 healthy controls and 200 gallstones patients as diseased controls were included prospectively. The risk factors studied were related to socioeconomic profile, life style, reproduction, diet and bile acids. On comparing GBC patients (mean age 51.7 years; 130 females) with healthy controls, risk factors were chemical exposure [odd ratios (OR): 7.0 (2.7-18.2); p < 0.001)], family history of gallstones [OR: 5.3 (1.5-18.9); p < 0.01)], tobacco [OR: 4.1 (1.8-9.7); p < 0.001)], fried foods [OR: 3.1 (1.7-5.6); p < 0.001], joint family [OR: 3.2 (1.7-6.2); p < 0.001], long interval between meals [OR: 1.4 (1.2-1.6); p < 0.001] and residence in Gangetic belt [OR: 3.3 (1.8-6.2); p < 0.001]. On comparing GBC cases with gallstone controls, risk factors were female gender [OR: 2.4 (1.3-4.3); p = 0.004], residence in Gangetic belt [OR: 2.3 (1.2-4.4); p = 0.012], fried foods [OR: 2.5 (1.4-4.4); p < 0.001], diabetes [OR: 2.7 (1.2-6.4); p = 0.02)], tobacco [OR 3.8 (1.7-8.1); p < 0.001)] and joint family [OR: 2.1 (1.2-3.4); p = 0.004]. The ratio of secondary to primary bile acids was significantly higher in GBC cases than gallstone controls (20.8 vs. 0.44). Fried foods, tobacco, chemical exposure, family history of gallstones, residence in Gangetic belt and secondary bile acids were significant risk factors for GBC.

Risk factors for gallbladder cancer and cholangiocarcinoma: similarities, differences and updates

INTRODUCTION

Far-ranging variation in the incidence of gallbladder cancer (GBC) and cholangiocarcinoma (CCA) in different geographic regions on the globe may reflect the risk factor distribution for these tumors

METHODS

The authors give a comprehensive review on the known risk factors for GBC and CCA, and analyze both similarities and differences between the risk factors for the two main types of biliary cancer

DISCUSSION AND CONCLUSION

Leading risk factors for GBC include gallstones, female gender, and advancing age. Primary sclerosing cholangitis, nitrosamine exposure, choledochal cysts, Clonorchis sinensis and Opisthorchis viverrini represent important risk factors for CCA, although a specific risk factor cannot be identified for many patients. While both cancers affect mostly individuals in their sixth decade or older, CCA has a male predominance and GBC--a predilection for females. Although the current level of understanding of the molecular pathogenesis of GBC and CCA at the interface with specific risk factors is significantly lower than for other gastrointestinal malignancies, it continues to evolve and may soon open new avenues for the therapy of biliary cancers.

Incidental gallbladder cancer diagnosed following laparoscopic cholecystectomy

BACKGROUND

Laparoscopic cholecystectomy (LC) is the treatment of choice for benign gallbladder disease. Gallbladder cancers have been found following LC. The aim of the present study was to evaluate the survival outcome and prognosis of incidental gallbladder cancer diagnosed after LC.

METHODS

From January 2002 to December 2007, 3,145 patients underwent LC at the Department of Surgery, Korea University Medical Center. Of these, 33 patients (1.05%) were diagnosed with gallbladder cancer after LC. Clinicopathological characteristics were retrospectively reviewed in this study.

RESULTS

Of the 33 patients studied, 9 were men and 24 were women. Laparoscopic cholecystectomy alone was performed in 26 patients, and additional radical surgery was performed in 7 others. Regarding tumor staging, there were 2 Tis, 6 T1a, 4 T1b, 17 T2, and 4 T3 tumors. Male patients had a significantly higher incidence of moderately and poorly differentiated tumors (P < 0.001), T2 and T3 tumors (P = 0.02), additional second operations (P = 0.046), and recurrence (P = 0.016). The cumulative 1-, 3-, and 5-year survival rates were 87.2, 73.1, and 47.0%, respectively. Univariate analysis revealed that significant prognostic factors for poorer survival were male gender (P = 0.026), age older than 65 years (P = 0.013), the presence of inflammation (P = 0.009), moderately or poorly differentiated tumor (P < 0.001), nonpolypoid gross type (P = 0.003), and pT stage (P < 0.001). Tumor differentiation was a significantly independent predictor of poor prognosis.

CONCLUSIONS

Male patients exhibited aggressive tumor characteristics. Laparoscopic cholecystectomy is an adequate treatment for pT1 tumors. For pT2 and pT3 patients, additional radical surgery might be needed to achieve a tumor-free surgical margin, along with lymph node dissection.

Incidence, management, and outcome of incidental gallbladder carcinoma: analysis of the database of the Swiss association of laparoscopic and thoracoscopic surgery

BACKGROUND

Little is known about the long-term survival of patients with incidental gallbladder carcinoma (IGBC). The role of radical resection for this disease is discussed controversially in the literature. We present the long-term survival and the results of re-resection versus simple cholecystectomy of the database of the Swiss Association for Laparoscopic and Thoracoscopic Surgery (SALTS) from 1994 to 2004.

METHODS

Eighty-nine patients with histologically confirmed carcinoma of the gallbladder were identified out of 30,960 patients undergoing laparoscopic cholecystectomy. Sixty-nine patients were included in our study. Long-term survival by different T-stage and comparison of patients with extended resection versus simple cholecystectomy were calculated using the log-rank test. The time-to-event data are demonstrated by Kaplan-Meier curves.

RESULTS

The overall incidence of IGBC in patients who underwent laparoscopic cholecystectomy was 0.28% (89 of 30,960). Fifty patients underwent simple cholecystectomy [n = 2: carcinoma in situ (CIS); n = 2: pT1a; n = 10: pT1b; n = 23: pT2; n = 8: pT3; n = 5: pT4], whereas extended resection was performed in 19 cases (n = 2: pT1b; n = 11: pT2; n = 6: pT3). The comparison of simple cholecystectomy versus extended re-resection of the gallbladder bed and regional lymph node resections showed a significant benefit in overall survival for the pT2 and pT3 group (p < 0.05). The pT1b group showed no significant benefit in overall survival (p = 0.34).

CONCLUSION

IGBC has a low incidence (0.28%). We present a large study of patients with IGBC, comparing the overall survival by different histological findings. We observed a significant benefit for the group with pT2 and pT3. Therefore we recommend extended resection of the gallbladder bed and the regional lymph nodes for patient with incidental histologically confirmed pT2 and pT3 carcinoma of the gallbladder after performance of laparoscopic cholecystectomy. For patients with pT1b stage no recommendations can be given based on this study.

Diabetes and risk of incident cancer: a large population-based cohort study in Israel

Type 2 diabetes mellitus has been associated with an increased risk of a variety of cancers in observational studies, but few have reported the relationship between diabetes and cancer risk in men and women separately. The main goal of this retrospective cohort study was to evaluate the sex-specific risk of incident overall and site-specific cancer among people with DM compared with those without, who had no reported history of cancer at the start of the follow-up in January 2000. During an average of 8 years of follow-up (SD = 2.5), we documented 1,639 and 7,945 incident cases of cancer among 16,721 people with DM and 83,874 free of DM, respectively. In women, DM was associated with an adjusted hazard ratio of 1.96 (95% CI: 1.53-2.50) and 1.41 (95% CI: 1.20-1.66) for cancers of genital organs and digestive organs, respectively. A significantly reduced HR was observed for skin cancer (0.38; 95% CI: 0.22-0.66). In men with DM, there was no significant increase in overall risk of cancer. DM was related with a 47% reduction in the risk of prostate cancer. These findings suggest that the nature of the association between DM and cancer depends on sex and specific cancer site.

Stones from cancerous and benign gallbladders are different: A proton nuclear magnetic resonance spectroscopy study

AIM

Gallbladder cancer (GBC) is frequently associated with gallstones (GS). At the same time, however, a very small number of patients with GS develop GBC. Cholesterol and metal salts are the common constituents of all GS. To understand their role in the etiopathogenesis of GBC, cholesterol, calcium, and magnesium composition in GS is compared in cancerous and benign gallbladders.

METHODS

GS from patients with GBC (n = 11), chronic cholecystitis (CC; n = 23), and xanthogranulomatous cholecystitis (XGC; n = 11) undergoing cholecystectomy were analyzed using proton nuclear magnetic resonance spectroscopy. The diagnosis of the gallbladder disease was based on histopathological examinations. Cholesterol, calcium, and magnesium in the GS of GBC, XGC, and CC were analyzed, compared, and correlated using statistical methods.

RESULTS

The quantity of cholesterol was significantly less in the GS of GBC than in benign gallbladder diseases (CC or XGC, P < 0.0001 for both). Both calcium and magnesium were significantly higher in GBC than in benign disease (calcium: P < 0.0005 and magnesium: P < 0.0001 for GBC vs CC; calcium: P < 0.02 and magnesium: P < 0.04 for GBC vs XGC). In all the GS, calcium was higher than magnesium. Calcium and magnesium were positively correlated in GBC (R = 0.69) and XGC (R = 0.75), and cholesterol and calcium were negatively correlated in CC (R =-0.61).

CONCLUSION

Differences in the GS composition between malignant and benign gallbladder patients may provide useful clues to the etiopathogenesis of GBC. These clues could lead to the identification of patients with GS in vivo who are at high risk of developing GBC, and advocate prophylactic cholecystectomy to prevent GBC.

Cigarette smoking, alcohol drinking and the risk of gallbladder cancer death: a prospective cohort study in Japan

Gallbladder cancer is a rare cancer with a poor prognosis, and few risk factors have been identified to date. This prospective study was conducted to evaluate the association of cigarette smoking and alcohol consumption with the risk of gallbladder cancer death. A baseline survey in 45 areas throughout Japan was conducted from 1988 to 1990 using a self-administered questionnaire, and a total of 113,496 participants (65,740 women) aged 40-89 years at entry were followed for 15 years. During the follow-up period, 165 gallbladder cancer deaths (95 women) were observed. Among women, the hazard ratio (HR) [95 percent confidence interval: 95% CI] of current smoker was 2.00 [0.91-4.42], when adjusted for age and drinking. There was no clear association between alcohol consumption and the risk. Among men, HR of current smoker was 2.27 [1.05-4.90]. HRs of those who smoked 21 cigarettes or more per day and those with 801-1,000 cigarette-years were 3.18 [1.18-8.53] and 3.44 [1.40-8.45], respectively, and positive linear associations were observed between that risk and the number of cigarettes per day (p for trend = 0.007) or "cigarette-years" (p for trend = 0.012). The alcohol dose was linearly associated with risk (p for trend = 0.004), where the HR among those who consumed 72.0 g or more of alcohol per day was 3.60 [1.29-9.85]. Among both men and women, cigarette smoking may elevate the risk of death from gallbladder cancer. Drinking may pose an elevated risk among men, but that seems to be less true among women.

Family history of gallstones and the risk of biliary tract cancer and gallstones: a population-based study in Shanghai, China

Cancers of the biliary tract arise from the gallbladder, extrahepatic bile ducts and ampulla of Vater. Although relatively uncommon, the incidence of biliary tract cancer rose more than 100% in Shanghai, China between 1972 and 1994. Gallstones are the predominant risk factor for biliary tract cancers, with over 60% of the cancer cases having gallstones. A familial tendency to gallstones has been reported and may elevate the risk of gallbladder cancer further. As part of a large population-based case-control study of biliary tract cancers in Shanghai, China, we examined the association between a family history of gallstones and biliary tract cancers as well as biliary stones. A total of 627 biliary tract cancers (368 gallbladder, 191 bile duct, 68 ampulla of Vater), 1,037 biliary stone cases (774 gallbladder, 263 bile duct) and 959 healthy subjects randomly selected from the population were included in this study. Information on family history of gallstones among first-degree relatives (i.e., parents, siblings, offspring) was obtained through a self-reported history during in-person interviews. A family history of gallstones was associated with increased risks of biliary stones [odds ratio (OR) = 2.8, 95% confidence interval (CI) = 2.1-3.8], gallbladder cancer (OR = 2.1, 95% CI = 1.4-3.3) and bile duct cancer (OR = 1.5, 95% CI = 0.9-2.5), after adjustment for age, gender, marital status, education, smoking, alcohol drinking and body mass index. For gallbladder cancer, subjects with gallstones but without a family history of gallstones had a 21-fold risk (95% CI 14.8-30.1), while those with both gallstones and a positive family history had a 57-fold risk (95% CI 32.0-110.5). Significant risks for gallbladder cancer persisted after additional adjustment for gallstones, and when the analysis was restricted to subjects with first-degree relatives whose gallstones were treated with cholecystectomy. The significant associations with a family history of gallstones were seen for all first-degree relatives, including parents, siblings and offspring, but not spouses. This large population-based study not only supports the role of gallstones in biliary carcinogenesis but also suggests that the underlying genetic or lifestyle determinants of stones within families contribute to the risk of biliary tract cancer.

Management of cancer gallbladder found as a surprise on a resected gallbladder specimen

Carcinoma gallbladder is associated with an overall 5-year survival rate reported less than 5% due to late diagnosis. Advent of ultrasound scanning may help in detecting gallbladder polyps and an early gallbladder cancer. Excellent 5-year survival (up to 100%) has been reported for Stage Ia disease and the survival has significantly improved for Stage Ib, II, and III if appropriate re-operation is carried out soon after the incidental detection of gallbladder cancer. Laparoscopic cholecystectomy (LC) is contraindicated in the presence of gallbladder cancer. It is recommended to excise all laparoscopic port sites, at the time of re-operation. Re-operation for Stage II gallbladder cancer is associated with a 90-100% 3-year survival rate. Patients with Stage III and IV tumors also benefit from an extended cholecystectomy. Patients with bulky primary tumors without lymph node metastases (T4N0) seem to have a better prognosis than those with distant lymph node metastases, and should be treated aggressively. It is advantageous to perform the appropriate extent of surgery for gallbladder cancer at the initial operation. Heightened awareness of the presence of cancer and the knowledge of appropriate management are important. For patients whose cancer is an incidental finding on pathologic review, re-resection is indicated for all disease except Stage Ia. Radiotherapy and chemotherapy have not been found effective as an adjuvant or palliative therapy in gallbladder cancer.

An objective assessment of demography of gallbladder cancer

BACKGROUND AND OBJECTIVES

Gallbladder cancer (GBC) is a lethal disease with a wide geographical, ethnic, and cultural variation suggesting major environmental influences such as diet and life style factors in the development of disease. An objective assessment of demographic profile and full implication of these features to recognize the population at risk is needed. This study was therefore undertaken to study the demography of GBC in Varanasi.

METHODS

A retrospective study as a case-control model comprised 328 cases of GBC and 328 controls with gallstone disease (GSD). The relevant demographic data were collected and analyzed for identification of independent significant features and for the risk of GBC based on these features by calculating odds ratio.

RESULTS AND CONCLUSIONS

GBC predominantly a disease of females belonged to fourth and fifth decade of life. Among 328 cases of GBC only 75 were male and 253 female (M:F = 1:3.37). Majority of GBC patients were above 40 years and multiparous females. Family history of GBC was higher in GBC patients. Majority of GBC patients were of low socioeconomic status and hailed from rural background. This group tends to consume open mustard oil and water from hand pump. This study emphasizes the usefulness of demographic evaluation in diagnosis of GBC and a systematic approach to assessment of demographic features of GBC is recommended.

Factors associated with the development of post-infectious functional gastrointestinal diseases: does smoking play a role?

OBJECTIVES

Irritable bowel syndrome (IBS) is associated with psychological stress, alterations in gut motor function and/or visceral perception. Previous studies suggest 7-32% of people develop IBS after bacterial gastroenteritis but the exact mechanisms underlying post-infectious IBS are not clear. The present study's aim was to examine the role of possible causative factors in the development of post-infectious functional gastro-intestinal disorders (FGIDs), including IBS.

METHODS

A prospective cohort study where 122 people without a prior FGID under study and with stool-positive bacterial gastroenteritis consented to participate. The presence or not of IBS, functional dyspepsia or functional diarrhoea was diagnosed at the start and on 6-month follow-up using self-complete Rome II modular questionnaires. Demographic data, smoking, alcohol use, anxiety and depression (using the Hospital Anxiety and Depression Scale), and life events and impact (using the Life Events Survey) were collected at the start of the study.

RESULTS

One hundred and seven questionnaires were returned with 25 participants (23.4%) developing a FGID and 16 participants presenting symptoms consistent with IBS (15%). Smoking was significantly associated with the development of a post-infectious FGID (odds ratio = 4.8, 95% confidence interval = 1.5-15.2) on regression analysis.

CONCLUSIONS

Post-infectious FGIDs appear to be associated with smoking. Smoking is known to moderate gut immunity in other disorders such as ulcerative colitis and Crohn's disease. This study adds to increasing evidence for an organic basis to post-infectious FGIDs, perhaps moderated via inflammatory pathways.

Gallbladder cancer: current status

Gallbladder cancer (GBC) is the most common biliary tract malignancy. There is a tremendous regional variability in its incidence. Risk factors include genetic susceptibility, gender, presence of gallstones, chronic biliary infections, diet and some anatomical anomalies. Several genetic abnormalities have been described which may be aetiologically important as well as carry prognostic significance. These include mutations in the proteins K-RAS and P53, and altered expression of P-glycoprotein, COX-2 and epidermal growth factor receptor. Most patients present at an advanced stage, overall prognosis is very poor. TNM stage and the extent of surgical resection are the most important prognostic factors. Surgery is the only curative therapy reserved for patients with early-stage disease. The role of adjuvant therapy is not fully defined. Patients with advanced disease are managed with systemic chemotherapy that is primarily palliative. Although 5-fluorouracil alone, or in combination, has been most commonly utilised, there is much greater enthusiasm for the combination of cisplatin and gemcitabine. The availability of better drugs and combinations may affect the use of chemotherapy in neoadjuvant and adjuvant settings. Novel targeted therapies require exploration alone or in combination with chemotherapy.

Overview of smoking and all cancers

Tobacco consumption has been clearly implicated in the causation of many cancer types, with irrefutable evidence to support the association in multiple organ systems. Tobacco cessation leads to reduced cancer risk and improved survival of those under treatment for their already established cancers. As understanding of the mechanisms by which tobacco products cause cancer increases, clinicians may be able to identify those at highest risk for tobacco-related malignancies and allow for more focused interventions toward risk reduction among current tobacco users. This article reviews the carcinogens present in tobacco products, the mechanisms by which tobacco causes cancer, and the various tumor types causally related to tobacco use.

Bowel movement frequency, medical history and the risk of gallbladder cancer death: a cohort study in Japan

Few risk factors for gallbladder cancer have been identified with sufficient statistical power, because this cancer is rare. The present study was conducted to evaluate the association of bowel movement frequency and medical history with the risk of death from gallbladder cancer using the data set from a large-scale cohort study. A total of 113,394 participants (42.0% males), aged 40 to 89 years, were followed up for 11 years. Information on the medical history of selected diseases, history of blood transfusions, frequency of stools, and tendency toward diarrhea at baseline was collected through a self-administered questionnaire. The Cox proportional hazard model was used to estimate the hazard ratio (HR). During the follow-up period, a total of 116 deaths (46 males, 70 females) from gallbladder cancer were identified. After adjustments for age and gender, history of hepatic disease (HR: 2.28; 95% confidence intervals (95% CI): 1.24-4.21), frequency of stool, and tendency toward diarrhea (HR: 0.26; 95% CI: 0.08-0.83) were found to be significantly associated with the risk of death from gallbladder cancer. Compared with those who had a stool at least once a day, the HR was 2.06 (95% CI: 0.82-5.18) for those who had a stool less than once in 6 days (P for trend = 0.050). In this prospective study, constipation and a history of hepatic disease were found to elevate the risk of gallbladder cancer death, whereas a tendency toward diarrhea diminished it.

Association of chili pepper consumption, low socioeconomic status and longstanding gallstones with gallbladder cancer in a Chilean population

We explored the risk factors for gallbladder cancer and explanations for its sharp and constant incidence increase in Chile since the 1970s. We compared 114 consecutive patients with verified gallbladder cancer, diagnosed 1992-1995, to 114 matched hospital patients with gallstones, using conditional logistic regression analysis. Low education showed a nonsignificant positive relationship with gallbladder cancer [odds ratio (OR) = 2.3, 95% confidence interval (CI) 0.8-6.2], and low socioeconomic level showed a significant relationship (OR = 5.0, 95% CI 1.5-17.3). A very long history of gallstone disease was significantly more prevalent among cases (OR = 11.0, 95% CI 1.4-85.2). Significant red chili pepper consumption was observed in gallbladder cancer patients (OR = 2.9, 95% CI 1.6-5.2). Low intake of both fresh fruit and sugar as soft drinks was associated with gallbladder cancer, with ORs of 6.4 (95% CI 1.4-30.3) and 3.6 (95% CI 1.3-10.1), respectively. Multivariate analysis kept only a very low socioeconomic status and red chili pepper consumption as significant independent risk factors for gallbladder cancer, ORs of 6.3 (95% CI 1.7-23.0) and 3.2 (95% CI 1.7-5.9). Longstanding gallstone cases were removed from the multivariate model because all were in the low and very low socioeconomic groups, reinforcing the association. Patients with gallbladder cancer differed from matched controls by exhibiting lower socioeconomic levels, having a much longer history of gallstone disease and presenting a dietary pattern characterized by high red chili pepper consumption and low fresh fruit intake.

Tobacco use and cancer causation: association by tumour type

In the second part of our review we describe the association between tobacco use and risk of specific cancer types. There is evidence for an established association of tobacco use with cancer of the lung and larynx, head and neck, bladder, oesophagus, pancreas, stomach and kidney. In contrast, endometrial cancer is less common in women who smoke cigarettes. There are some data suggesting that tobacco use increases the risk for myeloid leukaemia, squamous cell sinonasal cancer, liver cancer, cervical cancer, colorectal cancer after an extended latency, childhood cancers and cancer of the gall bladder, adrenal gland and small intestine. Other forms of cancer, including breast, ovarian and prostate cancer, are unlikely to be linked to tobacco use.

Incidental carcinoma of the gallbladder

Incidental gallbladder carcinoma (GBC) is a difficult management issue as there are no established guidelines. Laparoscopic cholecystectomy is associated with increased dissemination of the tumour cells (both in the peritoneal cavity and port sites). Depth of tumour invasion (T stage) and positive surgical margins are the most important prognostic factors, although tumour differentiation, lymphatic, perineural and vascular invasion may also affect the outcome. Simple cholecystectomy is adequate for mucosal (T1a) lesions only. For T1b tumours port site/wound excision with second radical operation (probably extended cholecystectomy -- wedge liver excision with regional lymphadenectomy) should be advised. T2 tumours should be treated with second radical operation (extended cholecystectomy or excision of medial liver segments 4b and 5 or 4, 5 and 8 with regional lymphadenectomy with or without excision of the extra-hepatic bile duct). Few T3 tumours can be cured and in some survival time may be prolonged by a second radical operation. More extensive liver resection (segments 4b and 5 or segments 4, 5 and 8) with regional lymphadenectomy with excision of the extra-hepatic bile duct should be advised. A second radical operation may palliate some T4 tumours. In the absence of extensive nodal disease, this operation may prolong the survival time. Excision of the extra-hepatic bile duct should be undertaken whenever the tumour involves the cystic duct margin or the extra-hepatic biliary tree. Epidemiology, risk factors, aetiopathogenesis and the modes of spread of GBC are discussed in relation to appropriateness of the second radical operation. Indications, types and role of the second radical operation are discussed.

Pancreatic and biliary disorders in the elderly

Structural and functional changes in the biliary tract and pancreas associated with advanced age are well documented in the literature and must be taken into account in evaluating patients with possible biliary and pancreatic disorders. The relationship between normal, age-related physiologic changes and various pancreatico-biliary diseases is not well defined. Elderly patients may present with severe biliary and pancreatic disease that may pose difficult management problems because of coexisting medical illnesses. Despite these challenges, all but the most frail elderly patients can benefit from appropriate medical, endoscopic, and surgical therapy.

Gallbladder cancer

Gallbladder cancer has a reputation for being aggressive and incurable. Single institution series, however, have defined successful management strategies in which the extent of resection is based on the stage of the tumor at presentation. Careful ultrasound screening for abnormalities in the gallbladder wall, and CA19-9 serum determination prior to routine cholecystectomy may heighten awareness for cancer in this population. For tumors confined to the muscular layer of the gallbladder a simple cholecystectomy is associated with an almost 100% cure rate. Tumors invading through the muscle wall (Stage II) should be managed with extended cholecystectomy, including resection of hepatic segments IVb and V, and an extensive lymph node dissection of the porta hepatis, posterior pancreaticoduodenal, and interaortocaval lymph nodes. This operation for Stage II gallbladder cancer is associated with a 90% to 100% 3-year survival rate. Simple cholecystectomy fails in the majority of Stage II patients. Patients with Stage III and IV tumors may also benefit from an extended cholecystectomy. Patients with bulky primary tumors without lymph node metastases (T4N0) seem to have a better prognosis than those with distant lymph node metastases, and should be treated aggressively when possible. It is advantageous to perform the appropriate extent of surgery for gallbladder cancer at the initial operation. Heightened awareness of the presence of cancer and the knowledge of appropriate management are important. For patients whose cancer is an incidental finding on pathologic review, re-resection is indicated for all disease except Stage I. This review will discuss the epidemiology, pathology, and staging of gallbladder cancer and describe the appropriate surgical management based on the stage of the cancer.