Raising Awareness in Gallbladder Cancer: Symptoms and Insights

Dr. Shaun P. McKenzie sat down for a two-part interview with CURE to discuss gallbladder cancer awareness during Gallbladder and Bile Duct Cancer Awareness Month. He highlighted disease risk factors, clinical warning signs, imaging findings that warrant further evaluation and the role of surgical planning.

He also highlighted the challenges of screening for a rare malignancy and emphasized the importance of prompt evaluation of both symptoms and incidental imaging abnormalities.

McKenzie is board certified in general surgery and in surgical oncology, hepatobiliary surgery, and pancreatic surgery. He is a surgical oncologist with Texas Oncology Surgical Specialists–South Austin and serves as medical director for surgical oncology at Texas Oncology.

Be sure to check back for part 2 of this conversation on bile duct cancer!

CURE: Gallbladder cancer is frequently discovered incidentally or at advanced stages, unfortunately. What clinical or imaging findings should raise suspicion earlier in the disease course that patients should know about?

McKenzie: The first thing you must remember is you cannot ignore abdominal pain that is chronic. It is one thing to have an upset stomach every once in a while, but when you consistently have discomfort in the upper right side of your belly, or even right underneath your chest, you need to have that looked at because it could be any number of things, but gallbladder cancer, even though rare, would be one of them.

The other thing that we encounter is that there are some imaging findings that can be very suspicious. The imaging has gotten so good nowadays that you can get a lot more information than you used to, but patients who have a very thickened gallbladder wall, typically that number we think about is approximately six and a half to seven millimeters, which may sound like nothing, but the gallbladder wall is approximately two millimeters normally in diameter. Masses within the gallbladder itself or on the wall, and then if it appears that the process that is going on around the gallbladder is extending into the organs next to it, because the gallbladder is attached to the liver and the stomach and intestine are very close, a regular gallbladder attack is not going to grow into those structures.

Additionally, if you are having gallbladder symptoms and you have a lot of enlarged lymph nodes on your CT scan or your MRI, we tend to be concerned about those findings as well.

Which patient populations are at highest risk for this kind of cancer, and are there any evidence-based screenings or surveillance strategies that you would want to highlight?

Yeah, so there are some patient populations. The first one, unfortunately, is women. This cancer is much more common in women than men. Patients who have gallstones are at risk for gallbladder cancer, even though gallstones are common and gallbladder cancer is rare, but it is a risk factor. There are certain nationalities, including some South American populations, because of the indigenous populations there that have a very high risk of gallbladder cancer for genetic reasons, and those populations are followed a little bit more closely.

In terms of modifiable risk factors, central obesity is a risk factor for gallbladder cancer. There is some suggestion about tobacco use, although that is not as strong as others, but those are the most common things that we see listed. Unfortunately, this is always the challenge with screening for cancers. The screening programs that work best are in cancers that are common, and if a cancer is very rare, it is very difficult to have a good screening program.

What I would tell you is there are not any great screening programs other than to inform patients not to ignore chronic abdominal symptoms. You have to have them seen as soon as possible.

How do surgical approaches and lymph node evaluations influence staging accuracy and long-term outcomes in this disease?

Well, one of the things that we have learned about gallbladder cancer, because it is often found accidentally and sadly in many cases mistaken for acute cholecystitis, which is the medical term for an infectious or inflammatory attack of the gallbladder, is that if you remove the gallbladder and leave cancer in the patient, so you have cut through the cancer, those patients are at a significantly increased risk of their gallbladder cancer coming back.

In terms of planning for surgery, if there is a concern for gallbladder cancer, it is difficult to biopsy the gallbladder because it is a bag full of fluid. You can imagine if you put a needle into a bag full of fluid, it is going to leak, so it is a challenge. If there is a concern, you need to strive to take a rim of the liver around the gallbladder to make sure that you get all of the abnormality out.

The lymph node question is a good one. It is important because gallbladder cancer very frequently will spread in the lymph nodes that are immediately adjacent to it, and these sit along the blood vessels that feed the liver, because the gallbladder is part of the bile duct which exits the liver. It is important during surgery to sample those lymph nodes, and the recommendation has been approximately three to six lymph nodes need to be excised. That is the standard of care. It can be difficult to do that sometimes because that area of the body does not have many lymph nodes in some patients. It is important not only because it tells us about the prognosis or the likelihood of the cancer coming back, but it also directs the treatment after gallbladder cancer.

If gallbladder cancer has spread to the lymph nodes, the patient is going to receive a totally different treatment after surgery than if it has not. That is why that is an important part of the surgery as well.

Is there anything else on the topic of gallbladder cancer awareness that you would like to add before we shift over to bile duct cancer?

I think with all of these things, you cannot ignore abnormalities. Another patient population that I always think about with gallbladder cancer is patients who get CT scans or MRIs for any number of reasons, and they have a very abnormal-looking gallbladder but absolutely no symptoms, no pain, no nausea. Even that is a concerning finding because you would expect that if their gallbladder is sick, they should feel sick.

The important thing is that abnormalities, whether they are symptoms or imaging findings, have to be evaluated right away and not put off until a later date.

Transcript has been edited for clarity and conciseness.

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