Gallstones and gall bladder carcinoma

Cracking the silent gallstone code: Wait or operate?

The widespread availability of abdominal ultrasound has revealed the common occurrence of asymptomatic gallstones. While the treatment for symptomatic gallstones is clear, the benefits of minimally invasive laparoscopic cholecystectomy have sparked debate about the best approach to managing silent gallstones. The potential for asymptomatic gallstones to become symptomatic or lead to complications complicates the decision-making process regarding surgical intervention, as it's uncertain when or which patients might develop complications. Consequently, risk stratification appears to play a critical role in guiding decisions about silent gallstones. However, there is no definitive evidence to direct management, and a consensus-based on high-quality evidence is yet to be established.

Dietary Considerations in Cholecystectomy: Investigating the Impact of Various Dietary Factors on Symptoms and Outcomes

Cholecystectomy is commonly performed to address gallstone diseases, including the development of gallstones, which can lead to symptoms such as nausea, vomiting, and abdominal pain. Bile acids (BAs) produced by the liver are primarily stored and concentrated in the gallbladder (GB). After cholecystectomy, the body's ability to digest lipids is reduced due to the absence of the GB. Post-cholecystectomy syndrome (PCS) can occur when abdominal symptoms manifest after surgery. The purpose of this review is to look at the various effects of different dietary factors on patients undergoing cholecystectomy, how they affect their overall health after surgery, and how they contribute to symptoms of PCS. Some individuals may experience mild discomfort or alterations in bowel patterns, especially after consuming high-fat meals. The findings from the conducted studies suggest that, although dietary changes are a common recommendation, these measures are not sufficiently supported by evidence when it comes to alleviating symptoms and improving outcomes post-cholecystectomy. The studies found that subjects who consumed particular foods, such as processed meat and fried fatty foods, had exacerbated symptoms after cholecystectomy. Further studies are still required to understand the precise food factors that might affect post-surgical symptoms, as well as outcomes, and to develop tailored measures to enhance patient care and long-term prognosis after undergoing cholecystectomy.

Cholesterol Gallstone among Patients with Cholelithiasis Admitted to the Department of Surgery of a Tertiary Care Center

Introduction

Gallstone is one of the most common pathological conditions found mostly in females. The incidence of cholesterol gallstones is developing higher nowadays which is increasing the burden of cost in society. This study aimed to find out the prevalence of cholesterol gallstones among patients with cholelithiasis admitted to the Department of Surgery of a tertiary care centre.

Methods

A descriptive cross-sectional study was conducted among patients with cholelithiasis who presented in the Department of Surgery of tertiary care centre for cholecystectomy (laparoscopic or open) from 23 December 2022 to 22 September 2023 after obtaining ethical approval from the Institutional Review Committee. Patients who were diagnosed by use of abdominal ultrasound or CT scan were included. Those patients with gallbladder polyps, cholangitis, and gallbladder tumours were excluded from the study. A convenience sampling method was used. The point estimate was calculated at a 95% Confidence Interval.

Results

Among 190 patients, the prevalence of cholesterol gallstones was seen in 85 (44.74%) (37.67-51.81, 95% Confidence Interval). The female to male ratio was 6.72:1.

Conclusions

The prevalence of cholesterol gallstones was found to be higher as compared to other studies done in similar settings.

Keywords

cholesterol; gallbladder; gallstone; prevalence.

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.

Gallbladder Cancer: Current Multimodality Treatment Concepts and Future Directions

Gallbladder cancer (GBC) is the most common primary tumor site of biliary tract cancer (BTC), accounting for 0.6% of newly diagnosed cancers and 0.9% of cancer-related deaths. Risk factors, including female sex, age, ethnic background, and chronic inflammation of the gallbladder, have been identified. Surgery is the only curative option for early-stage GBC, but only 10% of patients are primary eligible for curative treatment. After neoadjuvant treatment, up to one-third of locally advanced GBC patients could benefit from secondary surgical treatment. After surgery, only a high-risk subset of patients benefits from adjuvant treatment. For advanced-stage GBC, palliative chemotherapy with gemcitabine and cisplatin is the current standard of care in line with other BTCs. After the failure of gemcitabine and cisplatin, data for second-line treatment in non-resectable GBC is poor, and the only recommended chemotherapy regimen is FOLFOX (5-FU/folinic acid and oxaliplatin). Recent advances with the PD-L1 inhibitor durvalumab open the therapy landscape for immune checkpoint inhibition in GBC. Meanwhile, targeted therapy approaches are a cornerstone of GBC therapy based on molecular profiling and new evidence of molecular differences between different BTC forms and might further improve the prognosis of GBC patients.

Best evidence topic: Does the presence of a large gallstone carry a higher risk of gallbladder cancer?

A best evidence topic has been constructed using a described protocol. The three-part question addressed was: In a patient with symptomatic gallstone disease does the presence of a large sized gallstone associated with a higher risk of gallbladder cancer?

Using the reported search, 3876 papers were found. 6 studies were deemed to be suitable to answer the question. The outcome assessed was the relationship between the presence of large sized gallstones and the risk of gallbladder cancer. It appears from the current available evidence that there is a strong association of a large sized gallstones and gallbladder cancer. Larger stones (>3 cm) have the greatest risk to develop gallbladder cancer, especially in symptomatic gallstone disease patients. Authors recommend special care for this patient's group and to warrant cholecystectomy when the clinical condition allows.

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A strong relationship between the gallstone size and gallbladder cancer.

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Stones larger than 3 cm have the highest risk.

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Cholecystectomy is warranted when the clinical condition allows.

Histopathological Changes in Gallbladder Mucosa Associated with Cholelithiasis: A Prospective Study

Background and Aims

Cholelithiasis is known to produce diverse histopathological changes in the gallbladder mucosa. In the present study, we aimed to find the correlation between various gallstone characteristics (i.e., number, size, and morphological type) with the type of mucosal response in gallbladder mucosa (i.e., inflammation, hyperplasia, metaplasia, and carcinoma).

Methods

The present study was conducted prospectively on 100 patients undergoing cholecystectomy for symptomatic cholecystitis. Gallstones were assessed for various parameters, i.e., number, size, and morphological type. Gallbladder mucosa was subjected to histopathological examination. Sections were taken from body, fundus, and neck of gallbladder.

Results

Of 100 cases, maximum type was of mixed stones (54%) and was multiple in number (46%). However, gallstone type and number are nonsignificant variables to produce precancerous lesions (i.e., hyperplasia and metaplasia). Statistically significant results were obtained while comparing the mucosal response with gallstone size (P = 0.012).

Conclusion

As the gallstone size increases, the response in gallbladder mucosa changes from cholecystitis, hyperplasia, and metaplasia to carcinoma. Gallstone type and number are nonsignificant variables to produce precancerous lesions.

Locus minoris resistentiae: An old but still valid way of thinking in medicine

Locus minoris resistentiae (lmr) refers to a body region more vulnerable than others. This ancient concept, which is also present in Achilles' and Siegfried's old epic myths, weaves through many fields of medicine. In any internal organ or external body region with a congenital or acquired altered defense capacity, a disease process may occur more easily than elsewhere. Illustrative instances are the appearance of hepatocarcinoma on a cirrhotic liver, the onset of lung carcinoma in a tuberculosis scar, cases of osteosarcoma arising in chronic osteomyelitis, and carcinoma complicating chronic cholelithiasis, just to name a few. In dermatology there are countless reports of privileged localization of cutaneous lesions on injured skin which, therefore, represents a typical condition of lmr. The Köbner phenomenon itself features the oldest, simplest, and most common example of lmr, because it denotes the appearance of new lesions pertaining to a previously present skin disorder at the sites of trauma or other insult. The modern transposition of this old but still valid way of thinking in medicine is the reading key of this issue, devoted to lmr in dermatology.

Routine versus selective histologic analysis of gallbladder specimens for the detection of incidental gallbladder cancers. A retrospective review over 9 years of activity with a special focus on patients' age

BACKGROUND

Incidental gallbladder cancer (IGC) is an infrequent possibility in patients undergoing cholecystectomies. Routine histologic examination of all gallbladder specimens is the current approach to detect this disease. Our study presents the influence of age to perform a selective histologic analysis.

METHODS

A retrospective review was conducted of all gallbladder specimens during the last 9 years in our hospital. The medical notes were retrieved for cases of IGC or dysplasia and perioperative data were collected.

RESULTS

A total of 3,330 cholecystectomies were conducted over the study period, 3,041 for gallstone disease. Twelve patients were found with dysplasia and 13 patients with IGC, all of them occurred in gallbladders removed for gallstone diseases. There were 18 men with a median age of 65 years (range 18 to 85). Median age for cancer patients was 70 years (range 51 to 85) and 54 years for dysplasia (range 18 to 75). No patient below the age of 51 years (n = 1,464) experienced IGCs.

CONCLUSION

Age should be considered as an additional factor for a selective approach to the histologic analysis of all gallbladder specimens following cholecystectomies.

Asymptomatic Gallstones (AsGS) - To Treat or Not to?

With ready availability of abdominal ultrasound, asymptomatic gallstones (AsGS) are being diagnosed with increasing frequency. Management decisions need to take into account the natural history of AsGS as well as the risks of cholecystectomy. Long-term follow up studies from the West have consistently shown that only a small minority of asymptomatic gallstones lead to development of symptoms or complications. Some sub-groups of patients (eg those with chronic hemolytic syndromes) have been shown to be at a higher risk of developing symptoms and complications and prophylactic cholecystectomy has been advised for them. Clear division of patients into low or high risk categories is still far from ideal and better identification of risk factors and risk stratification is needed. Overall, both open and laparoscopic cholecystectomy, are generally safe procedures. However, the incidence of bile duct injury (with all its serious consequences) continues to be higher with laparoscopic cholecystectomy and this should receive due consideration before offering prophylactic cholecystectomy to an asymptomatic patient who is not expected to receive any clinical benefit from it. Gallbladder cancer is rare in most of the developed world and prophylactic cholecystectomy has generally not been recommended to prevent development of GBC. Considering the wide geographical/ethnic variation in incidence of GBC across the world and the strong association of GBC with gallstones, it may not be prudent to extrapolate the results of studies of natural history of AsGS from one part of the world to another. Since northern India has one of the highest incidences of GBC in the world, it is imperative to have data on natural history of AsGS in patients from this area to allow formulation of precise guidelines for management of AsGs.

A 10-year follow-up of a longitudinal study of gallstone prevalence at necropsy in South East England

The purpose of this study was to examine a previous increase in male gallstone disease and to consider the burden of gallstones in a necropsy study with matched controls over a decade. Gallstone prevalence in 5,050 males fell from 20.2% to 19.1% (P=0.022) and in 4,125 females fell from 30.4% to 29.0% (P=0.03). Female gallstone subjects had a higher BMI than controls 24.5 vs. 23.3 (P<0.01), but males did not. Gallstones were twice as common in diabetics, but not with coronary heart disease (CHD). A third of elderly patients of both sexes had gallstones, but cholecystectomy was more common in females, 17:10%. Gallstone-related mortality was 0.7%. The prevalence of gallstones fell slightly. The association between gallstones and diabetes was confirmed, but not for CHD, and for BMI this was confined to females. Gallstones are very common in the elderly, but most are unoperated and seldom cause death.

Gallbladder cancer: a morphological and molecular update

Gallbladder cancer (GBC) shows a marked geographical variation in its incidence, with the highest figures being seen in India and Chile and relatively low levels in many Western countries. Risk factors for its development include the presence of gallstones, infection and the presence of an anomalous pancreatobiliary ductal junction. It can arise from either a pathway involving metaplasia or dysplasia or one in which there is a pre-existing adenoma. The former is the more common and, because it is often not associated with a macroscopically recognizable lesion, leads to the recommendation that all gallbladders need to be examined microscopically. Accurate staging of invasive cancers is essential to determine prognosis and treatment, and this requires extensive tumour sampling. A number of genetic alterations have been identified in the preinvasive and invasive stages of GBC and they support the morphological evidence of there being two pathways by which tumours develop. Some of these genetic changes are associated with particular risk factors. For example, cases with anomalous pancreatobiliary ductal junction show a higher frequency of K-ras mutations. Some changes are associated with differences in prognosis. For example, cancers without expression of p21 but with expression for p27 have a better prognosis, whereas those that express c-erb-B2 have a worse one. Work has also been done on identifying clinical, imaging and other factors that indicate that patients have a higher risk of having GBC. This is particularly important in high-incidence areas in which GBC is a significant public health problem.

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.

Reactive oxygen species and the hypomotility of the gall bladder as targets for the treatment of gallstones with melatonin: a review

Free radical-mediated damage of the gall bladder epithelium predisposes to the development of both gall bladder inflammation and gallstone formation, which often coexist. Melatonin, a pineal and gut secretory product, due to its antioxidant activity along with its effect on the aging gall bladder myocytes, inhibits gallstone formation. Melatonin reduces the biliary levels of cholesterol by inhibiting cholesterol absorption across the intestinal epithelium and by increasing the conversion of cholesterol to bile acids. The incidence of gallstones is increasing and is expected to rise dramatically with the increase in the longevity and the risk factors such as obesity. The change in the prevalence of cholelithiasis is associated with a proportionate rise in the incidence of cholangiocarcinoma. In an attempt to improve the quality of life of the rapidly increasing aging population, this article reviews up-to-date information on the pathophysiology of the gall bladder function and discusses the development of new therapies with potential good patient compliance and lower cost than the current treatments.

Mechanical factors activate beta-catenin-dependent oncogene expression in APC mouse colon

beta-catenin acts as a critical regulator of gastrointestinal homeostasis through its control of the Wnt signaling pathway, and genetic or epigenetic lesions which activate Wnt signaling are the primary feature of colon cancer. beta-catenin is also a key element of mechanotranscription pathways, leading to upregulation of master developmental gene expression during Drosophila gastrulation, or regulating mammalian bone development and maintenance. Here we investigate the impact of mechanical stimulation on the initiation of colon cancer. Myc and Twist1, two oncogenes regulated through beta-catenin, are expressed in response to transient compression in APC deficient (APC(1638N+)) colon tissue explants, but not in wild-type colon explants. Mechanical stimulation of APC(1638N+) tissue leads to the phosphorylation of beta-catenin at tyrosine 654, the site of interaction with E-cadherin, as well as to increased nuclear localization of beta-catenin. The mechanical activation of Myc and Twist1 expression in APC(1638N+) colon can be prevented by blocking beta-catenin phosphorylation using Src kinase inhibitors. Microenvironmental signals are known to cooperate with genetic lesions to promote the nuclear beta-catenin accumulation which drives colon cancer. Here we demonstrate that when APC is limiting, mechanical strain, such as that associated with intestinal transit or tumor growth, can be interpreted by cells of preneoplastic colon tissue as a signal to initiate a beta-catenin dependent transcriptional program characteristic of cancer.

Targeted therapies for cancer of the gallbladder

PURPOSE OF REVIEW

Adenocarcinomas of the gallbladder are uncommon, aggressive tumors with poor survival. This review summarizes advances in understanding the biology of gallbladder cancer.

RECENT FINDINGS

Published response rates of adenocarcinomas of the gallbladder to chemotherapy are less than 30% and no survival benefit has been demonstrated from palliative systemic therapy. New information on the molecular carcinogenic mechanisms of these malignancies, combined with findings from animal models, may lead to improved treatment for patients.

SUMMARY

Improved understanding of the molecular carcinogenesis of adenocarcinomas of the gallbladder, coupled with the availability of novel molecularly 'targeted' chemotherapeutic agents, may improve outcome for patients.

[Precancerous lesions of the gallbladder]

This Mini-review summarizes the epidemiology, predisposing and pre-cancerous conditions related to carcinoma of the gallbladder. In 75% of cases, gallbladder cancer is a cholangiocarcinoma, usually presenting in a late and advanced stage, and it carries one of the worst prognoses of all GI malignancies. Early stage disease is usually discovered incidentally by the pathologist in a gallbladder specimen removed for calculous cholecystitis. It occurs three times more frequently in women than in men and invasive forms usually occur after the age of 60. Incidence varies with geographic location. Besides genetic and geographic factors, the presence of one or more large gallstones is a major risk factor. Gallbladder polyps larger than 1.5 cm. (especially solitary sessile hypoechogenic polyps) are associated with a 50% risk of malignancy. Choledochal cysts and other variations of the biliopancreatic junction are also associated with high risk; cancer may occur at a much younger age in these patients and in the absence of gallstones. Porcelain gallbladder is a risk factor, particularly when there is calcification of the gallbladder mucosa. Chronic gallbladder infection has been implicated as a risk factor for malignant degeneration. Finally, cancer of both the gallbladder and the bile ducts is more frequent in patients suffering from primary biliary cirrhosis.

Gallstones and the risk of biliary tract cancer: a population-based study in China

We conducted a population-based study of 627 patients with biliary tract cancers (368 of gallbladder, 191 bile duct, and 68 ampulla of Vater), 1037 with biliary stones, and 959 healthy controls randomly selected from the Shanghai population, all personally interviewed. Gallstone status was based on information from self-reports, imaging procedures, surgical notes, and medical records. Among controls, a transabdominal ultrasound was performed to detect asymptomatic gallstones. Gallstones removed from cancer cases and gallstone patients were classified by size, weight, colour, pattern, and content of cholesterol, bilirubin, and bile acids. Of the cancer patients, 69% had gallstones compared with 23% of the population controls. Compared with subjects without gallstones, odds ratios associated with gallstones were 23.8 (95% confidence interval (CI), 17.0–33.4), 8.0 (95% CI 5.6–11.4), and 4.2 (95% CI 2.5–7.0) for cancers of the gallbladder, extrahepatic bile ducts, and ampulla of Vater, respectively, persisting when restricted to those with gallstones at least 10 years prior to cancer. Biliary cancer risks were higher among subjects with both gallstones and self-reported cholecystitis, particularly for gallbladder cancer (OR=34.3, 95% CI 19.9–59.2). Subjects with bile duct cancer were more likely to have pigment stones, and with gallbladder cancer to have cholesterol stones (P<0.001). Gallstone weight in gallbladder cancer was significantly higher than in gallstone patients (4.9 vs 2.8 grams; P=0.001). We estimate that in Shanghai 80% (95% CI 75–84%), 59% (56–61%), and 41% (29–59%) of gallbladder, bile duct, and ampulla of Vater cancers, respectively, could be attributed to gallstones.

Biological characteristics of cancers in the gallbladder and biliary tract and targeted therapy

Adenocarcinomas of the gallbladder (GBC) and bile ducts (cholangiocarcinoma) (combined as biliary tract cancers, BTC) are uncommon tumors in the United States, but are endemic in parts of South America and Asia. BTC are aggressive tumors with poor survival. Published response rates to chemotherapy are less than 30% and no survival benefit has been demonstrated from palliative systemic therapy. Improved understanding of the biological characteristics and molecular carcinogenic mechanisms of these malignancies may lead to improved therapeutic regimens for patients.

Changing patterns of gallbladder carcinoma in New Mexico

BACKGROUND

American Indians in the U.S. have a high incidence of gallbladder carcinoma (GBC). Furthermore, American Indians in New Mexico (NM) have the highest incidence rate of GBC in the U.S. The epidemiology of GBC in NM has not been studied in the past 3 decades.

METHODS

By using the NM Tumor Registry (NMTR) and the Surveillance, Epidemiology, and End Results (SEER) database, age-specific incidence rates, average annual age-adjusted incidence rates, and incidence rate time trends of GBC were compared among the three major ethnic groups in NM: American Indians, Hispanics, and non-Hispanic whites, for the period 1973-2001.

RESULTS

A sharp increase in GBC incidence occurred with advanced age and started earlier in American Indians (at age 55) than Hispanics (at age 60) than non-Hispanic whites (at age 65). GBC occurred more frequently in females than in males in all ethnic groups. In females, the incidence of GBC was the highest in American Indians (14.5 per 100,000) followed by Hispanics (6.8 per 100,000) and non-Hispanic whites (1.4 per 100,000). Similarly in males, American Indians had the highest incidence rate of GBC (7.8 per 100,000), followed by Hispanics (2.0 per 100,000), and non-Hispanic whites (1.0 per 100,000). The time trend analysis revealed that there has been a disproportionate decline in the incidence of GBC in the three ethnic groups, with the greatest drop in American Indians and Hispanics followed by non-Hispanic whites. Despite the decline, American Indians continued to have the highest incidence rate of GBC in NM.

CONCLUSION

The incidence of GBC has declined disproportionately in the three major ethnic groups, with the greatest decrease in American Indians and Hispanics followed by non-Hispanic whites.

Overview of epidemiology of bile duct and gallbladder cancer focusing on the JACC Study

BACKGROUND: This review discusses the epidemiologic features of bile duct and gallbladder cance in Japan, mainly focusing on results of Japan Collaborative Cohort Study (JACC Study) for Evaluation of Cancer Risk Sponsored by the Ministry of Education, Science, Sports and Culture of Japan (Monbusho) in comparison with results of other studies.

METHODS: The theses and papers derived from JACC Study on bile duct and gallbladder cancer were all collected for this review. Hirayama’s cohort study, which is a representative epidemiologic study, and a large scale case-control study on bile duct and gallbladder cancer in Japan by Kato et al. were also taken into consideration. Small scale cross-sectional studies or ecological studies and the studies conducted outside Japan were collected by the literature reference services on the web net such as Pub Med or Japan Centra Revuo Medicina (Igaku- Chuo- Zasshi) limited to the published after 1980 and use key words bile duct cancer, gallbladder cancer and epidemiology.

RESULTS: In the JACC Study, high intake of fried food was regarded as a factor that significantly elevated the risk of the diseases (hazard ratio [HR] = 2.58, 95% confidence interval [CI]: 1.08-6.16 in males; HR = 2.98, 95% CI: 1.28-6.86 in females). The JACC Study indicated that a high intake of boiled beans had a significant preventive relation to the diseases in females (relative risk [RR] = 0.50, 95% CI: 0.26-0.98). High consumption of fish also had a significant preventive relationship to bile duct cancer in males (RR = 0.53, 95% CI: 0.26-0.98) and gallbladder cancer in females (RR = 0.43, 95% CI: 0.24-0.79). A history of blood transfusion also had a significant relationship (HR = 2.27, 95% CI: 1.29-3.98) as which elevated the risk. The JACC Study determined bowel movement as a risk factor. The group with bowel movements less than once per six days had a significantly elevated hazard ratio (HR = 5.21, 95% CI: 1.25-21.68).

CONCLUSION: As to recent epidemiologic features of bile duct and gallbladder cancer revealed by the JACC Study, its outline became obvious in comparison with the results of other studies. Evidence for the contribution of the JACC Study is strong because it provides some important findings on the epidemiology of bile duct and gallbladder cancer.

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.

[Gallbladder and bile duct carcinoma. Biology and pathology]

Biliary tract cancers are a consequence of a stepwise malignant transformation of the biliary epithelium. Intrahepatic cholangiocarcinomas arises from any portions of the intrahepatic bile duct epithelium: the segmental or area ducts and their finer branches or intrahepatic small bile ducts. Cholangiocarcinoma arising from the hepatic ducts or near their junction are called hilar cholangiocarcinoma or Klatskin tumour, and are considered as extrahepatic lesion. Cancer of extrahepatic bile ducts may also arise in the Ductus cysticus or choledochus as well as in the gall bladder. For intrahepatic cholangiocarcinoma, the UICC-TNM classification system of malignant liver tumors is applied, differing from the UICC-TNM staging system of extrahepatic bile ducts and gall bladder carcinomas. The cause of carcinomas of the bile ducts remains speculative in most cases. However, chronic inflammation due to sclerosing cholangitis, hepatolithiasis or parasites is associated with carcinogenesis. Histopathologically, the vast majority are adenocarcinomas; mesenchymal tumors and primary melanomas are extremely rare. Different genetic alterations are discussed to be of importance.

Intraoperative radiation therapy in the multimodality approach to hepatobiliary tract cancer

IOERT is a reasonable option to consider in patients who have biliary tract cancers above AJCC or Bismuth stage I disease. Inherent resistance of biliary tract cancer cells to ionizing radiation would indicate that IOERT alone would not eradicate most of the tumor clonagen. EBRT (either preoperatively or postoperatively) should be used in combination with IOERT at experienced institutions that have access to both modalities. The single IOERT dose ranges are 10 to 20 Gy [55,67], whereas the EBRT dose ranges from 45 to 50 Gy in 25 to 28 fractions [67]. The most common energy level used is 8 MeV or less. In addition, IOERT port sizes of less than 6 cm in diameter, and often 4 cm or less, are recommended. Finally, intraoperative reconstruction of severely damaged blood vessels may decrease the clinical manifestation of radiation-induced injury to vessels [68].

Gallbladder cancer in northern Jordan

BACKGROUND AND AIM

To highlight the epidemiological, clinical, and pathological features of gallbladder cancer in Jordan as a model for the Middle East. Only scattered reports are available from this region.

METHODS

The histopathological reports and the hospital records for all cholecystectomies performed at Princess Basma Teaching Hospital between 1994-2000 were retrospectively reviewed to identify all patients with gallbladder carcinoma. All the histological slides for the cancer group were reviewed and reclassified by a single pathologist.

RESULTS

Of 4502 cholecystectomies performed, 33 cases (0.73%) of gallbladder carcinoma were found. The mean age was 61.4 years (range 39-80 years). The male : female ratio was 1 : 3.7. Biliary colic and/or acute cholecystitis were the main presentations. Gallstones were present in 88% (29/33) of the patients. The spectrum of histological subtypes was similar to other series. Only three cases were diagnosed preoperatively, making the incidence of incidental gallbladder cancer 0.66% (30/4502). Simple cholecystectomy was performed for 13 patients. The remaining 20 patients underwent cholecystectomy and portal lymphadenectomy with (five cases) or without (15 cases) extrahepatic resection of the bile ducts. The mean follow up was 22 months (SD +/- 18.95 months; range 1-96 months). The 2-year survival rates for stages I, II, III, and IV were 100%, 42.9%, 10.8%, and 0%, respectively (P = 0.0013).

CONCLUSIONS

The importance of a high index of suspicion when dealing with cholelithiasis in elderly patients, particularly with large sized stones, cannot be over-emphasized. Proper gross inspection in the theater should be a routine procedure performed by all surgeons. Routine ultrasound for suspected gallbladder stones should always be performed under the supervision of senior radiologists.

Current perspectives in gallbladder carcinoma

Carcinoma gallbladder (CaGB) is not a common malignancy in a large number of countries in the world, except Chile, Japan, some parts of India, and a few other regions. Lacunae exist even today in terms of understanding of its epidemiology, aetiopathogenesis, and in the early pick up of malignanacy, as well as in choosing the most appropriate treatment option for a given case. While Japanese surgeons have advocated radical resections for CaGB and have shown good outcome resulting in long- term survival, others have not felt convinced about the desirability of undertaking such morbid surgical procedures in all patients. Also, radical resections have not always resulted in a tumor-free state and a cure in a large percentage of cases. Under the circumstances, the clinician's mind is often confused as to the most beneficial option for that patient once curative resection is not possible. Palliation of the jaundice and/or gastric outlet obstruction relieves the symptoms but does not prolong survival. The role of adjuvant chemotherapy with or without cytoreductive surgery has not been fully explored in CaGB. The present review quotes experience that seems to support the above contention. However, a number of well-designed multicentric trials are required to confirm the above philosophy of treatment for the benefit of patients suffering from CaGB.