1. Tumors of the bile ducts

2. Gallbladder cancer Fifth most frequent GI cancer 2/3 women
75% >65 ani
70-90% associated to litiasis
ETIOLOGY
Gallbladder litiasis
Abnormal bilio-pancreatic junction
Porcelain gallbladder
Cyst of the main bile duct
Sclerozng cholangitis

3. Gallbladder cancer Pathology 90% adenocarcinoma
Scquamous cell with small cells, mostly undifferentiated
At diagnosis
25% limited to the wall
35% loco-regional metastasis
40% distant metastasis
1% incidentally found on apparently normal gallbladders after cholecystectomy
Spread
Lymph – cystic ln – ln near main bile duct – retropancreatic ln – intercavoaortic ln; retroportal ln; coeliac ln.
Direct into the liver
Angiolymphatic along portal tracts
Hematogeneous

4. TNM Staging for Gallbladder Cancer
T1 Tumor invades lamina propria (T1a) or muscular (T1b) layer
T2 Tumor invades perimuscular connective tissue, no extension beyond the serosa or into the liver
T3 Tumor perforates the serosa (visceral peritoneum) and/or directly invades into liver and/or one other adjacent organ or structure such as the stomach, duodenum, colon, pancreas, omentum, or extrahepatic bile ducts
T4 Tumor invades main portal vein or hepatic artery or invades multiple extrahepatic organs and/or structures
N0 No lymph node metastases
N1 Regional lymph node metastases
M0 No distant metastases
M1 Distant metastases
StageStage Grouping
IA T1 N0 M0
IB T2 N0 M0
IIA T3 N0 M0
IIB T1 N1 M0 
T2 N1 M0 
T3 N1 M0
III T4 Any N M0
IV Any T Any N M1

5. Gallbladder cancer CLINICAL Can resemble:
Chronic cholecystitis – 40-45%
Acute cholecystitis – 15-20%
Jaundice – 30-35%
Weight loss – 25-30%
Other GI symptoms (upper GI bleeding, bowel obstruction) <5%

6. Gallbladder cancer US
CT, MRI
Echoendoscopy
ERCP
Guided biopsy

7. Gallbladder cancer TREATMENT T1 - cholecystectomy
>T2 - cholecystectomy+lymphadenectomy+hepatectomy with 3-5 cm margin
Unresectable:
Palliative care
Endoscopic or percutaneous stent placing
Radio and chemotherapy – weak chances
PROGNOSIS
85% die within the first year
5 year survival
T1a – 100%
T1b – 75%
Std IIa 28-63%
Std IIb 19-25%
Std IV – 1-3 luni

8. CHOLANGIOCARCINOMA Rare W:M=1:1 95% adenocarcinoma
Intra- or extrahepatic
Klatskin tumors
ETIOLOGY
Primary sclerotizing cholangitis
Parasites – Clonorchis sinesis
Liver litiasis – 5-10%
Coledoco-duodenal anastomosis

9. CHOLANGIOCARCINOMA Symptoms Variable depending on site and stage
Jaundice
Abdominal pain
Fever, chills
Pruritus
General signs of neoplasia
Palpable gallbaldder
Courvoisier sign

10. CHOLANGIOCARCINOMA Diagnosis Lab Imaging Positive cholestasis tests
CEA, CA 19-9 positive – 40% of patients
Alfa-fetoprotein increased < CH
Imaging US
CT, MRI

11. ERCP

12. brushing

13. Echoendoscopy

14. Transhepatic percutaneous cholangiography

15. Treatment
Surgical
Periferal tumor
hepatectomy

16. Tumor in the hilum
Bile ducts resection + hepatectomy

17. Tumor of the extrahepatic bile ducts located halfway between the hilum and the papila
Bile duct resection

18. Tumor of the extrahepatic bile ducts located distally
Bile duct resection + duodenopancreatectomy

19. Endoscopicaly
Percutaneously
Palliative treatment
Stent placing

20. CHOLANGIOCARCINOMA TREATMENT Photodynamic therapy Radiotherapy
Unresectable tumors
Chemotherapy
Weak results
PROGNOSIS
5 year survival
hepatic tumors– 30-40%
perihilar tumors– 10-20%
distale tumors– 40-45%
Unresectable tumors– 5-8 months