gallbladder cancer
Introduction
Introduction to gallbladder cancer In gallbladder malignant tumors, carcinoma of the gallbladder is the first, and other sarcoma, carcinoid, primary malignant melanoma, giant cell adenocarcinoma. Because the latter are rare, this chapter mainly discusses primary gallbladder cancer, which was considered to be a rare malignant tumor in the past. No matter how it is treated by any method, the course of disease progresses rapidly and eventually leads to death. Women are 2 to 4 times more likely than men. More common in 50 to 70 years old, early diagnosis and appropriate treatment are of great significance for the prognosis of this disease. basic knowledge The proportion of illness: 0.004% Susceptible people: no specific people Mode of infection: non-infectious Complications: liver abscess subgingival abscess thrombosis
Cause
Causes of gallbladder cancer
Cholelithiasis (25%):
Patients with gallbladder cancer often have gallstones, the combined rate is 70%-80% in Europe and America, 58.8% in Japan, and 80% in China. Gallbladder cancer occurs in the gallbladder neck which is easily hit by stones, and is often caused by stones. More than 10 years, it is considered that gallstones are closely related to gallbladder cancer. If the diameter of stones is more than 3cm, the risk of gallbladder cancer is 10 times larger than that of patients with diameter less than 1cm. Some people think that gallstone contains carcinogenic factors, but there is no clear evidence. And the incidence of gallbladder cancer in patients with cholelithiasis is only 1% to 2%. Therefore, there is no clear causal relationship between gallstone and gallbladder cancer, which is still unclear.
Strauch counts the relationship between gallbladder cancer and gallstones in 54 articles from 54.3% to 96.9%, Jones reports that 3/4 gallbladder cancer is associated with gallstones, Balaroutsos reports 77% of gallbladder cancer cases with gallstones, and Priehler and Crichlow review literature 2000 cases Gallbladder cancer is associated with gallstones, accounting for 73.9%. Animal experiments have shown that methyl cholanthrene prepared from cholic acid, deoxycholic acid, and cholesterol is implanted into the gallbladder of a cat to form gallbladder cancer. Lowenfels believes that The occurrence of biliary tract tumors is related to obstruction and infection of these organs, resulting in the conversion of bile acids into more active substances. Hill et al found Clostridium in 2/3 gallstones, which can deoxidize bile acids. Converted to deoxycholic acid and lithocholic acid, which are related to carcinogenic factors of polycyclic aromatic hydrocarbons, gallstone can cause chronic inflammation, gallbladder calcification of porcelain gallbladder (procellaneous gallbladder) malignant rate, but gallstones Long-term chronic stimulation, whether it induces gallbladder cancer, has not been fully proved, can only say that gallstone can increase the incidence of gallbladder cancer, American Indian women cholelithiasis for 20 years, gallbladder cancer The incidence rate increased from 0.13% to 1.5%. Nervi et al. used Logistic regression model to calculate the incidence of gallbladder cancer in patients with gallstones 7 times higher than those without stones.
40% to 50% of patients with gallbladder cancer have chronic gallbladder inflammation. Some people have studied gallbladder resection specimens. The chronic inflammation of the gallbladder group has a higher ratio of atypical cell proliferation and malignant transformation than the non-cancerous group; Epithelial metaplasia; there is a tumor structure similar to intestinal epithelium in the cancer, which is considered to be an important lesion of carcinogenesis. Gallbladder cancer may be: normal gallbladder mucosa chronic cholecystitis (including stones) intestine The development and progression of epithelial metaplasiadifferentiated gallbladder carcinoma (intestinal cancer).
Gallbladder adenoma (10%):
Sawyer reported 29 cases of benign gallbladder tumors, including 4 cases of malignant transformation. He reviewed the literature for nearly 20 years. He believes that gallbladder adenoma is a precancerous lesion. Gallbladder adenoma is more common, pedicled, and the cancer rate is about 10%. Stones have an increased risk of cancer. Some studies have found that those with a diameter of less than 12 mm are mostly benign adenomas. Those with a diameter greater than 12 mm are mostly malignant lesions. All carcinomas in situ and 19% of invasive carcinomas have adenomas. Adenomas have the potential to become cancerous.
Yamagiwa and Tomiyama studied 1000 cases of gallbladder histological examination, including 4% intestinal metaplasia without cholelithiasis, including gallstone cases, intestinal metaplasia accounted for 30.6%, dysplasia 69.8%, gallbladder cancer accounted for 61.1%, 36 cases In the tissues of gallbladder carcinoma, dysplasia and adenoma are 22.2% and 8.3%, respectively. Therefore, it is considered that intestinal metaplasia to developmental abnormalities to gallbladder cancer may have the significance of the order of the disease.
Gallbladder adenomyosis: In the past, gallbladder adenosis was not considered to be malignant, but in recent years there have been reports of gallbladder cancer in patients with gallbladder adenosis, which has been confirmed as precancerous lesions of gallbladder cancer.
Abnormal cholangiopancreatic duct (5%):
Kinoshita and Nagata study, the common channel of cholangiopancreatic duct confluence exceeds 15mm, and there is pancreaticobiliary reflux, which is called biliary-pancreatic collateral abnormality. Many authors point out the abnormal convergence of biliary and pancreatic ducts, which increases the incidence of gallbladder cancer and the junction of pancreaticobiliary and biliary tract. In the case of malformation, long-term reflux of pancreatic juice causes the gallbladder mucosa to be destroyed continuously and repeatedly regenerated. In this process, cancer may occur. It has been reported that ERCP examination found that 16% of patients with gallbladder cancer have pancreatic-biliary confluence malformation, Kimura et al. 65 cases of gallbladder carcinoma were confirmed by angiography. 65 cases of abnormal bile and pancreatic ducts were observed. Sixty-six cases of abnormal bile and pancreas were observed, 16.7% had gallbladder carcinoma, and 641 cases of normal bile duct and pancreatic duct were combined. The incidence of gallbladder cancer was 8%. One group reported abnormal bile duct and pancreatic ducts, the incidence of gallbladder cancer was 25%, and the normal confluence group was 635. The incidence of gallbladder cancer was 1.9%.
Other factors (5%):
In addition, Ritchie et al reported that chronic ulcerative colitis is often associated with gallbladder cancer, and the incidence of gallbladder cancer in patients with Mirizzi syndrome may be one of the causes. It is reported that the incidence of gallbladder cancer is associated with abnormal cystic duct or congenital bile duct dilatation.
The etiology of gallbladder cancer is still unclear. Clinical observation of gallbladder cancer often coincides with benign gallbladder disease. The most common is coexistence with gallstones. Most people think that chronic stimulation of gallstones is an important cause of disease. Moosa points out "hidden stones". After 5 to 20 years, gallbladder cancer occurs in 3.3% to 50%, and domestic bulk data reports that 20% to 82.6% of gallbladder cancers have gallstones, and foreign reports are as high as 54.3% to 100%. Cancer occurrence and stones The size of the relationship is close, the stone diameter is less than 10mm, the probability of cancer is 1.0, the stone diameter is 20 ~ 22mm, the probability of the stone is 2.4, the stone diameter, the probability of 30mm or more can be as high as 10%, there are people who may have gallbladder cancer There is a malformation between the lower end of the common bile duct and the main pancreatic duct of the patient. Because of this malformation, the pancreatic juice enters the bile duct, which increases the concentration of pancreatic juice in the bile, causing chronic inflammation of the gallbladder, mucosal changes, and finally canceration. The cause of gallbladder cancer is unclear.
Pathogenesis
There are many different types of gallbladder cancer, but none of them have their fixed growth patterns and special clinical manifestations. The majority of gallbladder cancers are adenocarcinomas, accounting for about 80%, of which 60% are hard adenocarcinomas, 25%. For papillary adenocarcinoma, 15% are mucinous adenocarcinoma, the rest are undifferentiated carcinomas, 6%, squamous carcinomas, 3%, mixed tumors or acanthomas, 1%, and other rare tumors including carcinoid, sarcoma, melanin Tumors and lymphomas, etc.
Macroscopic observations are characterized by diffuse thickening of the gallbladder wall and invasion of adjacent organs. Occasionally, papillary projections grow into the gallbladder cavity. The diffusion of gallbladder cancer mainly involves local infiltration of the liver and surrounding organs such as the duodenum and colon. As well as the anterior abdominal wall is more common, such as the gallbladder neck or Hartmann bag tumor directly infiltrated the common hepatic duct, it is difficult to distinguish with cholangiocarcinoma in clinical manifestations and radiographic examination, early lesions can be directly infiltrated into the gallbladder fossa, but also through Blood-borne dissemination, invading the liver lobe along the gallbladder neck through the gallbladder vein, the gallbladder wall is rich in lymphatic vessels, which is beneficial to the early spread of the lymph nodes to the cystic duct, common bile duct and pancreaticoduodenal area until the tumor In the late stage of the tumor, distant metastasis and transabdominal dissemination can be seen. Only 10% of patients in the clinic have found that the tumor is confined to the gallbladder due to cholecystectomy, and another 15% have already invaded the gallbladder fossa or surrounding lymph nodes. If the radical radical operation is performed, there is still a possibility of cure. Piehler et al. (1978) collected 984 cases of gallbladder carcinoma reported in the literature, 69% of the invading liver and 45% of the regional lymph nodes.
75% of gallbladder cancer can directly invade surrounding organs, and the frequency of occurrence is liver, bile duct, pancreas, stomach, duodenum, omentum and colon, 60% have lymphatic metastasis, and distant metastasis accounts for about 15%, peritoneum Less than 20% of metastases, diffusion along the nerve sheath is one of the characteristics of hepatobiliary cancer, and nearly 90% of patients with advanced gallbladder cancer have neurological invasion, which is the main cause of pain caused by this disease.
Pathological staging of gallbladder carcinoma: In 1976, Nevin et al first proposed the clinical pathological staging and grading scheme of primary gallbladder carcinoma, which is based on the extent of infiltration and proliferation of gallbladder carcinoma tissue and the degree of differentiation of cells. It is quickly recognized and widely adopted by the majority of surgical scholars. It is divided into 5 stages and 3 levels. The plan is as follows: stage: stage I, cancer tissue is limited to gallbladder mucosa; stage II, cancer tissue invades gallbladder mucosa and muscle layer; stage III, cancer The tissue invades the whole layer of the gallbladder wall, that is, the mucosa, muscle layer and serosal layer; in stage IV, the cancer tissue invades the whole layer of the gallbladder wall and has lymph node metastasis; in stage V, the cancer tissue directly invades the liver or has liver metastasis, or has any organs. Metastasis, grade: grade I, well-differentiated carcinoma; grade II, moderately differentiated carcinoma; grade III, poorly differentiated carcinoma, stage and grade are associated with prognosis alone, and the additive value of stage and grade has a significant correlation with prognosis. The higher the prognosis, the worse.
The International Union Against Cancer (UICC) published the unified TNM staging criteria for gallbladder cancer in 1995, which became an important reference for comprehensively measuring the condition, determining treatment strategies and assessing prognosis. Studies have shown that after radical surgery for gallbladder cancer, stage I and II There was no significant difference in the survival curve of the tumor. The cumulative survival time was significantly longer than that of the III and IV patients. There were many factors affecting the prognosis of gallbladder cancer, such as tissue classification and pathological type, but the pathological stage was the most important. In addition, the correct diagnosis of gallbladder cancer was made. TNM staging is necessary in the development of surgical procedures and adjuvant treatment plans.
Prevention
Gallbladder cancer prevention
The early diagnosis of this disease is not easy, so the prognosis is poor. The 5-year survival rate after surgery is 0-7%. Occasionally, more than 10% report, 80% of patients die within 1 year after diagnosis.
In 1992, Heason collected data on 3038 cases of gallbladder cancer, and found that the age, sex, weight, ethnicity, geographical environment and diet of patients were related to the incidence of gallbladder cancer. The age of onset of gallbladder cancer was concentrated in 40-60 years old. Women are high; obesity is an important risk factor for cholelithiasis; excessive intake of greasy foods, monosaccharides and disaccharides increases the risk of gallbladder cancer, and these findings have implications for the prevention of gallbladder cancer.
For middle-aged and above, especially female patients with chronic atrophic cholecystitis, chronic calcific cholecystitis, long-term treatment of gallbladder stones, gallbladder adenomatous polyps, especially polyps >10mm, wide base, polyps with stones, inflammation, should Early cholecystectomy, in view of the relationship between benign gallbladder disease and gallbladder cancer, it is generally considered to take preventive measures against high-risk groups of gallbladder cancer:
Cholecystitis with obvious symptoms over 140 years old, gallstones, especially stones with a diameter greater than 3 cm, thickened and atrophied gallbladder wall, or "porcelain" should be removed from the gallbladder.
2 patients with acute cholecystitis, gallstones, necrosis and gallbladder ostomy, if there is no contraindications, should strive for early removal of the gallbladder.
3 benign gallbladder tumors such as adenomas, adenomyoma should be regularly checked or removed in time.
4 For cystic duct malformation, abnormal pancreaticobiliary confluence, congenital bile duct expansion, long-term ulcerative colitis and long-term exposure to chemical carcinogens, the changes of gallbladder should be observed regularly.
Complication
Gallbladder cancer complications Complications Liver abscess subphrenic abscess thrombosis
Complications include gallbladder infection, empyema, perforation, and liver abscess, underarm abscess, pancreatitis, portal vein thrombosis, intestinal obstruction, gastrointestinal and intra-abdominal hemorrhage, etc., and can also form fistulas with nearby gastrointestinal tract.
1. Most cases show signs of weight loss, weight loss, fatigue, and a vicious constitution.
2. In some cases, lymph nodes can be touched on the clavicle, and there may be metastatic masses in the breast and the like.
3. In advanced cases, gastrointestinal bleeding, ascites and liver failure may occur due to portal pressure.
4. Abscess obstruction of the common bile duct can cause multiple liver abscesses, and it is common to form an abscess in or around the gallbladder cavity where the tumor occurs.
Symptom
Gallbladder cancer symptoms Common symptoms Helium gallstones Gallbladder stones cachexia persistent pain Common bile duct stones Gallbladder empyema Gallbladder wall rough gallbladder wall thinning
Early clinical manifestations of gallbladder carcinoma, or only the symptoms of chronic cholecystitis, early diagnosis is very difficult, once there is persistent pain in the upper abdomen, mass, jaundice, etc., the lesion has reached the late stage, and its various examinations are also abnormal. Therefore, for patients with discomfort or pain in the gallbladder area, especially in middle-aged and elderly patients over 50 years of age, gallbladder stones, inflammation, polyps, should be regularly B-ultrasound, in order to clear diagnosis.
First, the symptoms
1. Right upper quadrant pain: Most of them are persistent pain in the right upper abdomen, and may have paroxysmal aggravation. It radiates to the right shoulder and lower back. This symptom accounts for 84%. Because gallbladder cancer is complicated with gallstones and inflammation, inflammation coexists. The nature of the pain is similar to that of calculous cholecystitis, beginning with discomfort in the right upper quadrant, followed by persistent dull or dull pain, sometimes with paroxysmal severe pain and radiation to the right shoulder.
2. Gastrointestinal symptoms:
The vast majority (90%) developed indigestion, irritability, suffocation, and decreased appetite. This is due to the replacement function of the gallbladder, which can not be digested by fatty substances. Nausea and vomiting are also common, and there is often loss of appetite.
3. Astragalus: Due to the spread of cancer, about one-third to one-half of patients have jaundice. A few patients have jaundice as the first symptom. Most of the jaundice appears after pain. The jaundice is persistent, progressive, and a few patients. For intermittent jaundice, jaundice often appears in the late stage of the disease, accounting for 36.5%, mostly due to cancer tissue invasion of the bile duct, causing malignant obstruction, accompanied by weight loss, fatigue, and even cachexia, skin and yellow pigmentation, with difficult to treat skin Itching.
4. chills, fever: more in the late stage of cancer, 25.9% of patients with fever, and can have high fever continued.
5. Right upper abdomen mass: the lesion progresses to the advanced stage, and the right upper abdomen or upper abdomen has a mass, accounting for 54.5%. One is that the tumor grows rapidly, the bile duct is blocked, and the gallbladder is enlarged; the second is the obstruction caused by the duodenum, and at the same time Obstructive symptoms appear; in addition to invasion of the liver, stomach, pancreas, etc., the corresponding part of the mass may also appear.
Second, physical signs
1. Astragalus: manifested in mucous membranes, yellowish skin, yellow staining is heavy, mostly obstructive, once the jaundice appears, the lesions have reached the late stage.
2. Right upper abdomen mass: The right upper abdomen can touch the smooth and enlarged gallbladder. When there is no adhesion to the surrounding tissue, the mobility is great. When there is adhesion to the surrounding tissue, several masses can be touched, sometimes touching the swollen liver. Tumors of duodenal obstruction, abdominal masses, nearly half of the cases in the right upper quadrant of the gallbladder area can be found in the initial diagnosis, some of the texture is hard, and can have nodular sensation, this block is For the gallbladder, accidentally due to obstruction of the cystic duct, the gallbladder may have water or abscess formation, tenderness in the gallbladder area, and rebound tenderness, the signs are very similar to acute cholecystitis or obstructive cholangitis.
3. Weight loss: Most cases show signs of weight loss, weight loss, fatigue, and a vicious constitution.
4. Signs caused by metastasis: In some cases, lymph nodes can be touched on the clavicle, and there may be metastatic masses in the breast. In advanced cases, gastrointestinal bleeding, ascites, and liver failure may occur due to portal pressure. .
The comprehensive manifestations of five major diseases: gallbladder cancer is insidious, no specific performance, but it is not irregular. The clinical manifestations from high to low are abdominal pain, nausea and vomiting, jaundice and weight loss. The syndrome group is classified into five categories of diseases: 1 acute cholecystitis: some cases have transient right upper abdominal pain, nausea, vomiting, fever and palpitations, suggesting acute cholecystitis, about 1% due to acute cholecystitis surgery Cases of gallbladder cancer exist, at this time the lesions are often early, high resection rate, long survival, 2 chronic cholecystitis: many patients with primary gallbladder cancer symptoms similar to chronic cholecystitis, difficult to distinguish, be highly vigilant benign lesions Combined with gallbladder cancer, or benign lesions develop into gallbladder cancer, 3 biliary malignant tumors: some patients may have jaundice, weight loss, poor general condition, right upper abdominal pain, etc., tumor lesions are often late, poor efficacy, 4 signs of extra-biliary malignant tumors: A small number of cases may have nausea, weight loss, general weakness, and symptoms of internal fistula formation or invasion of adjacent organs. This type of tumor often cannot be removed. outer benign biliary manifestations: rare, such as gastrointestinal bleeding, or other upper gastrointestinal obstruction.
(1) Chronic gallbladder inflammation: 30% to 50% of cases have long-term right upper abdominal pain and other symptoms of chronic cholecystitis or gallstones, which is difficult to differentiate, chronic cholecystitis or patients with stones, aged over 40 years old, Recently, right upper quadrant pain has become persistent or progressive and has obvious symptoms of digestive disorders; asymptomatic gallstones over 40 years old, especially in larger single stone patients, recent persistent upper right abdomen pain or dull pain Chronic cholecystitis has a short history, local pain and systemic changes have obvious changes; patients with gallbladder stones or chronic cholecystitis recently with obstructive jaundice or right upper quadrant sputum and mass, should be highly suspected of the possibility of gallbladder cancer, should Make further examinations to confirm the diagnosis.
(2) acute gallbladder symptoms: 10% to 16% of gallbladder cancer, such patients with multiple gallbladder neck tumors or stone incarceration caused by acute cholecystitis or gallbladder empyema, the resection rate and survival rate of such patients are Higher, the resection rate is 70%, but it is almost impossible to diagnose before surgery. Some patients are misdiagnosed according to acute cholecystitis medication or simple gallbladder ostomy, so acute cholecystitis occurs suddenly in the elderly, especially in the past without biliary tract. Patients with systemic diseases should pay special attention to the possibility of gallbladder cancer for early surgical treatment. Because of the need for gallbladder fistula, the gallbladder cavity should be carefully examined to exclude gallbladder cancer.
(3) Obstructive jaundice symptoms: Some patients are treated with jaundice as the main symptom. Among the patients with gallbladder cancer, jaundice accounts for about 40%. The appearance of jaundice suggests that the tumor has invaded the bile duct or accompanied by common bile duct stones. The situation can be encountered in cases of resection of gallbladder cancer.
(4) right upper abdomen mass: tumor or stone obstruction or gallbladder neck, can cause gallbladder effusion, empyema, make the gallbladder swell, this smooth and elastic mass can be removed, and the prognosis is good, but hard The nodular mass is a late stage cancer that cannot be cured.
(5) Others: Liver, wasting, ascites, and anemia may all be late signs of gallbladder cancer, indicating that there is liver metastasis or gastroduodenal invasion, which may not be surgically removed.
The clinical manifestations of gallbladder carcinoma are lack of specificity, and their early signs are often obscured by cholelithiasis and its complications. In addition to the diagnosis of the first episode of acute cholecystitis, it is difficult to make early clinical diagnosis based on clinical manifestations. The preoperative diagnosis rate is 29.6%, and most of them are advanced. Therefore, to be asymptomatic and early diagnosis, close follow-up should be performed for high-risk groups, such as patients with resting gallstones, gallbladder polyps, and gallbladder gland hyperplasia. Active treatment to prevent gallbladder cancer if necessary. In recent years, with the development of imaging diagnostic techniques, early diagnosis of gallbladder cancer has an increasing tendency. Anyone with the following performance should consider the possibility of gallbladder cancer:
1. Over 40 years old, female patient, has a history of chronic cholecystitis or gallstone disease, and the symptoms are repeated.
2. Astragalus, loss of appetite, general weakness, weight loss, the upper right abdomen touches the mass.
3. Pain in the right upper abdomen or heart socket, according to the general liver, gastric disease treatment is invalid.
4. Digestive disorders, such as nausea, vomiting, anorexia, anaesthesia, loose stools, etc., generally symptomatic treatment is invalid.
Examine
Examination of gallbladder cancer
Laboratory inspection:
1. Blood test: more anemia and white blood cell count and neutrophil increase, a few cases may have leukemia-like reactions.
2. Serum biochemical examination: serum total bilirubin increased, serum one minute increased bilirubin, alkaline phosphatase, cholesterol can also be elevated, -glutamyl transpeptidase increased and other obstructive jaundice performance, its rise High is proportional to the degree of biliary obstruction, and erythrocyte sedimentation rate is accelerated.
3. Serum radioimmunoassay: no specific tumor markers for gallbladder cancer have been found. The more commonly used serum carcinoembryonic antigen (CEA), the determination of various sugar chain antigens (CA19-9), sialic acid (SA) and The increase of DNA polymerase (DNA-Plca) is helpful for diagnosis. The positive rate of CA19-9 is higher, which is reported to be 81.3%. The early cancer can also be positive, and the depth of the invasive gallbladder wall increases. Increased, therefore, has a certain reference value for the early diagnosis and treatment options of gallbladder cancer. Recently, it has been found that the content of CEA and CA19-9 in bile is significantly higher than serum, it is speculated that the determination of this marker in bile will be more meaningful, but still Need to be further explored, it is an indicator of postoperative monitoring for patients with preoperative CEA.
Image inspection:
1. Ultrasound: Ultrasound is the first line of diagnosis for the diagnosis of gallbladder disease. Due to its non-invasive, reproducible and economical advantages, it has been widely used in clinical practice. High-sensitivity ultrasonic diagnostic equipment can be used. Discriminating the lesions of 0.2 cm in the gallbladder wall, it can be found in early gallbladder cancer. Many early gallbladder cancer ultrasonography is only a radiological description of "cacerous polypoid lesions" or bulging lesions, and the true diagnosis of gallbladder cancer is It is not easy, ultrasound examination has a large instrument and operator dependence factors, such as an experienced operator using high-resolution instruments, the correct diagnosis rate can reach 80% or higher, and under general outpatient conditions, ultrasound The correct diagnosis rate may be very low, B-ultrasound is simple and non-invasive, and can be used repeatedly. The diagnostic accuracy rate is 75%-82.1%, which should be the preferred method of examination, but B-ultrasound (US) is susceptible to abdominal wall hypertrophy, intestinal tube accumulation. The influence of gas, and it is not easy to determine the condition of stone filling and atrophic gallbladder wall. In recent years, people have adopted EUS (endoscopic ultrasound) method to better solve the above problems of US. EUS uses a high-frequency probe to scan the gallbladder only from the stomach or the duodenal wall, which greatly improves the detection rate of gallbladder cancer, and can further determine the extent of the tumor layer infiltrating the layers of the gallbladder wall. Therefore, people will use EUS. As a further accurate method after US examination, whether the US or EUS, the ultrasound images of early gallbladder cancer are mainly characterized by elevated lesions and localized wall hypertrophy, and there are also mixed types.
The sonogram of gallbladder cancer can be divided into 5 types.
(1) Small nodular type: the lesion is generally small, about 1cm ~ 2.5cm, showing a medium echo of the papillary shape. The mass protrudes from the wall of the capsule into the cavity. The base is wide, the surface is uneven, and the small nodule is generally expressed. For the bulging lesions, mostly belong to the early gallbladder cancer, in the case of bile filling in the gallbladder, ultrasound found that the gallbladder wall is more sensitive to the lesions; but when the gallbladder is atrophy, the stones are full, it is not easy to judge, at the same time, ultrasound The examination is susceptible to flatulence and abdominal wall fat.
(2) umbrella type: the umbrella-shaped mass with a wide base and irregular edges protrudes into the gallbladder cavity, showing weak or medium echo, often multiple.
(3) Thick-walled type: the wall of the gallbladder is unevenly thickened, limited or diffuse.
(4) Real block type: It is a solid mass with weak echo or echo unevenness, or filled with uneven spotted echo in the gallbladder cavity.
(5) Mixed type: presented as thickening of the gallbladder wall, accompanied by a papillary or sacral mass protruding into the gallbladder cavity.
The characteristics of these sonograms provide a strong basis for the detection of gallbladder cancer. The gallbladder wall is unevenly thickened. The echogenic mass with and without sound and shadow in the cavity is the basic feature of gallbladder cancer, and the liver is affected. Peripheral metastatic lymph nodes, as well as coexisting stones are all auxiliary diagnosis. In the case of suspicious cases, B-ultrasound guided fine needle gallbladder mass cytology, which is helpful for early diagnosis of gallbladder cancer.
With the rapid development of ultrasonic diagnostic technology, high-resolution real-time ultrasound imaging cameras are widely used in clinical practice. With a 5MHz high-frequency scanning probe, the three-layer structure echo of the gallbladder wall can be observed (ie, mucosa, muscle layer, serosa layer). ) and microscopic uplift lesions in the gallbladder, color Doppler examination can determine the relationship between the mass and the main blood vessels of the hilum and the blood supply of the mass, which is conducive to the evaluation of the feasibility of resection before surgery and improve the accuracy of ultrasound diagnosis, so Generally, it is also used as a routine examination before surgery. Color Doppler ultrasonography can detect arterial blood flow in gallbladder cancer and gallbladder wall, and it is faster and has obvious difference from benign tumor. It has certain differential diagnosis significance.
2. X-ray inspection:
(1) Abdominal X-ray film: Some patients can see calcified gallbladder shadow, or soft tissue mass shadow, or intestinal obstruction in the right upper abdomen.
(2) Oral cholecystography: The gallbladder is not developed in most cases of gallbladder cancer. In rare cases, the filling defect in the gallbladder is seen due to the small cancer. Therefore, this method has little value in the diagnosis of gallbladder cancer.
(3) venous cholangiography: in double-dose angiography, some patients may show gallbladder shadow, which can be seen as filling defect image.
(4) Direct cholangiography (PTC, ERCP): It is rare to have a complete gallbladder image, especially in PTC, but it can be seen that the extrahepatic biliary tract is squeezed and narrowed, occluded, etc., combined with PTC and ERCP. Can accurately determine the location of the tumor, gallbladder cancer with endoscopic retrograde cholangiopancreatography (ERCP) examination, more common gallbladder wall with shadow defects, irregular or papillary bulge, etc., reported ERCP for the ability to show gallbladder The diagnosis rate of gallbladder cancer can reach 70%-90%, but more than half of them can not show gallbladder. This method is mostly used for the diagnosis of abnormal bile duct and pancreatic duct, and can also be used to diagnose the involvement of common bile duct. Some scholars report that according to direct biliary tract. According to angiography, 79% of patients can be diagnosed before surgery. Some scholars have found that all types of cystic duct occlusion can be removed, but all of the biliary occlusion can not be removed. There is no possibility of palliative resection of hilar biliary obstruction.
(5) Upper digestive tract barium meal: Duodenum can be found in advanced cases, and there is an external pressure defect in the stomach or colon hepatic flexion. In a few cases, gallbladder duodenal fistula or gallbladder colon fistula can be found.
(6) Selective angiography: Selective angiography through the celiac artery or superior mesenteric artery is a very useful method for the diagnosis of gallbladder cancer, with a diagnosis rate of 72% or 100%.
The characteristic manifestations of gallbladder carcinoma in angiography are:
1 gallbladder artery dilatation.
2 The gallbladder artery is not smooth.
3 gallbladder artery fracture.
4 "tumor staining" of the gallbladder area.
5 The gallbladder in the venous phase is "not smooth and thick wall".
6 signs of compression of the branches of the internal hepatic artery.
7 signs of compression of the gastroduodenal artery and the proper hepatic artery.
8 stenosis and occlusion of the right branch of the hepatic artery.
9 stenosis of the gastroduodenal artery, common hepatic artery, splenic artery and pancreatic head artery.
10 concentrated image of the head of the pancreas.
11 Abnormal blood flow from the branch of the gastroduodenal artery.
12 abnormal blood flow from the branch of the middle cerebral artery. In angiography, the identification of gallbladder cancer and gallbladder inflammatory disease is difficult. Generally speaking, in gallbladder cancer, most of the above characteristics coexist with 3-4, or Invasive images and interruptions of cancer, and most of the above characteristics are less than 2 to 3 in cholecystitis. The combination is the most common in the gallbladder abscess, and the extension of the image and the extent of the gallbladder artery is the most common. In chronic cholecystitis, arterial distortion or sclerosis is most common.
In addition, angiography not only contributes to the diagnosis of gallbladder cancer, but also understands the anatomy of the tumor and the morphology of the surrounding arteries. It provides indispensable information for judging whether the tumor can be resected. Some people have proposed radical resection. The angiographic features of gallbladder carcinoma are: 1 gallbladder artery dilatation, the inner diameter of the gallbladder artery reaches 1/3 to 1/2 of the inner diameter of the right hepatic artery; 2 the primary branch diameter of the gallbladder artery is not smooth; 3 the gallbladder wall in the neovascular proliferation area It is thick and thick, with an eggshell shadow, or a small range of plaque-like stains of less than 1.5cm.
3. CT: Ultrasound is superior to CT in finding the sensitivity of small nodules and small bulging lesions of gallbladder, but CT is superior to ultrasound in the diagnosis of gallbladder cancer. CT can not only display gallbladder without overlapping, biliary tract Local anatomical relationship, and can clearly show the relationship between liver, hilar and hepatic hilum and adjacent organs. It can accurately determine the size, shape and position of the gallbladder, especially the gallbladder wall. The accuracy of the gallbladder and liver is flat. Unclear, enhanced scan can show the true thickness of the gallbladder wall, can identify chronic cholecystitis and thick-walled gallbladder cancer, CT can provide important clues in the display of nodular gallbladder cancer, local metastatic lymph nodes and adjacent organ infiltration, CT not only used In the diagnosis of gallbladder cancer, the choice of surgery is also helpful.
Diagnosis
Diagnosis and diagnosis of gallbladder cancer
Differential diagnosis
The differential diagnosis of gallbladder cancer presents different requirements depending on the course of the tumor.
1. Gallbladder polypoid lesions: Early gallbladder cancer is mainly differentiated from gallbladder polypoid lesions. The diameter of gallbladder carcinoma is greater than 1.2cm, pedicle width, gallbladder wall thickening, as for adenomatous polyposis of gallbladder and benign adenoma Identification is very difficult, because considering gallbladder adenoma is a precancerous lesion, once diagnosed, should be surgically removed, so it does not affect the surgical treatment decision.
2. Gallbladder stones: About 57% of patients with gallbladder cancer in China have gallstones. Patients often have long-term symptoms of biliary tract disease. These patients are most likely to be ignored, or the symptoms caused by gallbladder cancer are treated with gallstones. Explain that in the differential diagnosis is mainly for the elderly, women, long-term suffering from gallstones, gallbladder atrophy or full-filled stones, abdominal pain symptoms and increased, should consider the possibility of gallbladder cancer, should be in-depth examination.
3. Invasion of primary liver cancer to the gallbladder: advanced gallbladder cancer needs to be differentiated from primary liver cancer to the gallbladder, a mass in the gallbladder and a blockage of the gallbladder outlet. Hepatocellular carcinoma invading the gallbladder can be in the hilar and Large lymph node metastasis on the duodenal ligament, similar to lymph node metastasis in advanced gallbladder cancer, gallbladder neck cancer can directly invade or through lymphatic metastasis, high biliary obstruction, clinical manifestations similar to hilar cholangiocarcinoma, sometimes The gallbladder with cancer has been surgically removed, but the pathological diagnosis has not been obtained for various reasons. The postoperative local recurrence of the tumor and the obstruction of the hilar bile duct may make the differential diagnosis difficult.
Identification of gallbladder cancer invading the liver and liver cancer invading the gallbladder:
(1) The incidence of gallbladder cancer with bile duct expansion is higher than that of liver cancer.
(2) Gallbladder carcinoma is evident after CT-enhanced scan and lasts for a long time.
(3) If there is a stone shadow in the soft tissue mass, support the diagnosis of gallbladder cancer.
(4) The incidence of gallbladder cancer invading the portal vein to form a tumor thrombus is significantly lower than that of liver cancer.
(5) Clinical data such as hepatitis, history of cirrhosis, AFP detection, etc. also contribute to the identification of both.
4. Atrophic cholecystitis: When ultrasound finds that the gallbladder is small, the cystic cavity is narrow, the mucosa is rough, and the emergency is not diagnosed as atrophic cholecystitis, it is necessary to consider the possibility of invasive gallbladder cancer, such as the thickening of the wall. Irregular, mucosal line destruction, interruption, hypoechoic area of tumor infiltration outside the gallbladder wall, can be diagnosed as gallbladder cancer, and conversely, the diagnosis of atrophic cholecystitis should be considered.
The identification of gallbladder carcinoma and cholecystitis can be expressed as diffuse thickening of the gallbladder wall, which makes the differential diagnosis difficult. Smathens et al believe that the following CT signs can be used as a reference for the diagnosis of gallbladder cancer:
(1) Non-uniformity of the gallbladder wall, especially nodular thickening.
(2) The gallbladder wall is enhanced significantly.
(3) Bile duct obstruction.
(4) Direct invasion of the liver, manifested as a low-density area with unclear borders of liver tissue.
(5) Nodular metastases in the liver: The following signs support the diagnosis of cholecystitis:
1 Clear low-density curve of the gallbladder circumference, caused by edema of the gallbladder wall or fluid exudation around the gallbladder caused by cholecystitis.
2 The wall of the gallbladder is thickened and the inner surface of the cavity is smooth.
5. Single crystal cholesterol, inflammatory granulation tissue, polyps and adenoma: early exogenous gallbladder cancer, when the lesion is limited, it is often necessary to identify it. Cholesterol crystals adhere to the surface of the mucosa, and the echo is more uniform, mostly granular. Accumulation, inflammatory granulation tissue often has chronic cholecystitis sonogram, the lesion from the mucosa to the gallbladder cavity, the contour is smoother, the mucosa and gallbladder wall are not damaged, the polyp is papillary, uniform medium echo, pedicle and mucosa The lines are connected, gallbladder cancer is low-infrared, the distribution is not uniform, the shape is irregular, the mucosa and wall layer are destroyed, and interrupted.
6. Segmental or localized adenomyosis invasive gallbladder cancer is often identified in the early and middle stages. The segmental type of sonogram shows a thickening of the gallbladder wall and a ring-shaped stenosis in the middle of the gallbladder; The echo of the lesion is often detected at the bottom of the gallbladder. A shallow concave is often seen in the middle of the surface. The gallbladder wall is invaded and irregularly thickened in the late stage of gallbladder cancer. It is often differentiated from diffuse adenomyosis, and the wall of the latter is obviously thickened. The echo is uneven, and there is no echo area in the needle size.
7. Hepatic portal area metastatic lymphadenopathy and hepatic parenchyma hepatic parenchymal lesions: gallbladder neck cancer often needs to be differentiated, metastatic lymph node hypoechoic lesions outside the liver contour, round, oval, gallbladder There are no abnormalities in the echo, and the mucosa and the wall of the tube are not damaged. However, the hepatic bile duct can be widened and expanded above the lesion. The echo of the hepatic space-occupying lesion in the hepatic hilum is within the contour of the liver. The gallbladder neck and the adjacent bile duct are both It is obviously stressed and the hepatic bile duct is expanded above the pressure.
