Gallbladder cancer

Gallbladder cancer is the most common malignancy of the biliary tract, accounting for 80–95% of biliary tract cancers (Zhu et al, 2010; Hundal and Shaffer, 2014). However, it is still a relatively rare condition in the UK, with approximately 1130 new cases of gallbladder cancer being diagnosed each year, equivalent to less than 1% of all cancers (Cancer Research UK, 2021).

The gallbladder

The gallbladder is located under the liver and above the pancreas; it is a small, pear-shaped organ, approximately 9 cm long and 4.5 cm wide when full (Figure1). Both the gallbladder and the liver are located behind the right lower ribs. The gallbladder acts as a storage place for bile, which the liver continually produces, holding approximately 30–60 ml (Guyton and Hall, 2021). Bile is required for the breakdown of fats to smaller lipid particles for absorption and digestion. Fats are essential for the body, as they

The most significant risk factor for gallbladder cancer is the presence of gallstones (Hundall and Shaffer, 2014; Cancer Research UK, 2023). Other risk factors include:

• obesity
• advancing age
• gallbladder polyps – especially if greater than 1 cm in size
• chronic infection – eg cholecystitis, which can additionally lead to the development of a porcelain gallbladder, where the gallbladder wall becomes calcified (Grand et al, 2004).

The risk of gallbladder cancer is further increased in people with primary sclerosing cholangitis, an autoimmune disease (Razumilava et al, 2011). Ethnicity is also a risk factor, with higher rates of gallbladder cancer noted in Asia, Latin American countries and in native north Americans. Gallbladder cancer is also more prevalent among females than males (Cancer Research UK, 2023).

According to the latest government statistics, over 63% of adults in England and Scotland are overweight, with over 30% considered obese (Scottish Government, 2020; NHS Digital, 2021).

Stage one, carcinoma in situ (Table 1) gallbladder cancer is often discovered incidentally by the histopathologist, who routinely examines removed gallbladders post cholecystectomy for gallstones. Symptoms of gallbladder cancer often do not present until the cancer has advanced and spread to other parts of the body (eg blocking the cystic or common bile duct, where bile is unable to enter the intestinal system and jaundice develops). Other symptoms of gallbladder cancer may include abdominal pain, dark urine and pale stools. Gallbladder cancer is associated with the development of:

• jaundice
• pyrexia
• weight loss
• loss of appetite
• indigestion
• tiredness/lethargy
• nausea and vomiting
• pruritis

Most of these symptoms are related to advanced disease, although abdominal pain, indigestion, tiredness and lethargy can occur at an earlier stage. Treatment options are limited at the advanced stage (American Cancer Society, 2018; Cancer Research UK, 2020a; NHS, 2023).

If gallbladder cancer is confined to the gallbladder (T1), then removal of the gallbladder is sufficient, and the cancer is most likely curable (Chijiiwa and Tanaka, 1994). If the tumour has spread from the gallbladder (T1b) to the liver, then segments of the liver may have to be removed (eg segmental resection). If more advanced (T2), the whole lobe of the liver can be resected (hepatectomy with lymph node dissection).

After the initial diagnosis and staging of gallbladder cancer, if other treatments are an option, then patients should be referred to the oncologist to discuss adjuvant treatment with chemotherapy, radiotherapy or both.

If the gallbladder cancer is classed as stages T3 and T4 and curative resection is not an option, bypass surgery may be undertaken to relieve symptoms (ie jaundice and pruritis). In patients with jaundice (T3 or T4), preoperative percutaneous transhepatic biliary drainage for relief of biliary

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