Br. J. Surg. Vol. 62 (1975) 33-36
Primary carcinoma of the gallbladder A. T. M . P R A K A S H , L A L I T K . S H A R M A A N D P . N . P A N D I T * SUMMARY
The clinical and pathological features of 100 conseciitive cases of primary carcinoma of the gallbladder, treated by n single surgical unit, are described. Females outnumbered males by 2 to 1. The maximum incidence was seen in the fifth decade. Pain and the presence of a mass were the two most common clinieal features. Gal!stones coexisted in 45 per cent of cases. Ancillary investigations were of little value in preoperative diagnosis. A t laparotomy biopsj) alone was possible in a large number of cases owing to the advanced disease process. Two patients were alive 5 years after surgery. Prophylactic cholecystectomy for all diseased gallbladders, whether symptomatic or not, is advocated,
EVERsince the first review of 100 cases of carcinoma of the gallbladder by Musser (1889), there has been little change in the outlook and survival rate of patients with this disease. The signs and symptoms of a resectable carcinoma of the gallbladder are similar to those of chronic cholecystitis and cholelithiasis. Persistent right upper quadrant pain, a hard gallbladder lump, jaundice and weight loss often suggest the diagnosis, but by then the disease is invariably inoperable. A 5-year survival is rare, unless an early lesion is found coincidentally in a gallbladder removed for chronic cholecystitis and cholelithiasis. There are very few reports in the literature of a series of 100 or more cases of carcinoma of the gallbladder treated by a single team and particularly from India. The present article gives the experience of 100 cases of histologically proved carcinoma of the gallbladder, treated in the Professorial Unit of the All India Institute of Medical Sciences Hospital, New Delhi, over a period of 15 years from 1959. Age and sex incidence There were 68 females and 32 males, giving a female to male ratio of 2 : 1 . The ages of the patients ranged from 30 to 75 years, the average being 49 years; the majority of patients, however, were between 40 and 50 years (Fig. 1).
Clinical features A history suggestive of chronic cholecystitis of long duration was available in only 12 cases. Surprisingly, the average duration of symptoms in most patients was only 8 weeks. Ninety-five patients complained of pain, often severe, usually in the epigastrium or right hypochondrium (Fig. 2). In the majority, it was a continuous ache. Less than 10 per cent of cases had colicky pain, with or without radiation. Seventy-five patients had marked anorexia and 70 of them had a 3
significant weight loss. Nearly a quarter of the patients (24) complained of low grade fever. Seven patients presented with obstruction : 4 at the pylorus and 3 in the small bowel. None of these cases presented as acute cholecystitis.
Female Male
Inn, 51-60
41-50
30-40
71-80
61-70
Age (Y r)
Fig. 1. Age and sex incidence.
Anorexia Weight loss Hepatomegaly Fever Jaundice Tenderness
R t . hypochondrium Ascites Vomiting
+ ,
0
I
20
,
I
40
,
m
-
60
v
I
80
I
i
100
No. of patients Fig. 2. Clinical features.
* Department of Surgery, All India Institute of Medical Sciences, New Delhi 110016, India. 33
A. T. M. Prakash et al. In 92 cases there was a lump in the right hypochondrium which was often hard and irregular; 15 patients complained of pain over the lump. Hepatomegaly was present in 65 per cent and jaundice on admission was seen in 20 per cent of the patients. Ascites and tenderness under the right costal margin were less common.
Investigations Radiology was of little help in diagnosis. Plain X-ray of the abdomen revealed radio-opaque calculi in only 8 cases. Oral cholecystography was carried out in 60 of the non-jaundiced patients, including 4 of those showing calculi on plain X-ray; in 2 patients only, was the gallbladder visualized faintly, and not at all in the remainder. A neoplastic filling defect in the gallbladder was never seen. In about half of the cases where an oral cholecystogam did not outline the gallbladder intravenous cholangiography was undertaken, but did not provide any additional information. Percutaneous transhepatic cholangiography was attempted in 10 of the 20 jaundiced patients; it failed in 2, the obstruction at the porta hepatis was seen in 6 and obstruction of the common hepatic duct in 2. These findings were confirmed at operation. Routine chest X-ray revealed secondaries in the lungs in 2 cases. Barium meal, barium enema and intravenous pyelography were done when indicated. Barium meal examinations showed extrinsic pressure on the duodenum in 6 cases. Barium enema studies showed evidence of extrinsic pressure on the hepatic flexure on 3 occasions. Intravenous pyelography, done in 3 patients, did not contribute further information. Biochemical investigations were of little assistance. The liver function tests were diagnostic of obstructive jaundice. However, in the absence of icterus, the serum alkaline pliosphatase was elevated in about 25 per cent of the cases. Association with gallstones Gallstones were present in 45 patients. However, this may not represent the true number as in a majority of the inoperable cases a biopsy alone was done and the gallbladder was not opened. Gross pathology (Table I ) The growth involved the gallbladder diffusely in 78 cases, it was in the fundus in 12 cases and the neck of the gallbladder was involved in 8 cases; Hartmann’s pouch and the cystic duct were involved in 2 cases. In almost 75 per cent of the cases the tumour had infiltrated into the adjacent liver tissue. Histology Histologically, 90 per cent of the tumours were adenocarcinoma. Two were colloid carcinoma, 4 squamous cell carcinoma and 4 undifferentiated tumour. Treatment (Table ZI) Cholecystectomy alone or with hepatic wedge resection was performed in 32 cases. Segmental
Table 1: GROSS PATHOLOGY Site: Diffuse growth Fundus Neck Hartmann’s pouch Cystic duct
No. of cases: 78 12 8 1
1
Table 11: OPERATIONS PERFORMED Operation: Cholecystectomy Cholecystectomy with wedge resection of liver Cholecystectomy with resection of hepatic flexure Biliaryiintestinal short circuiting Diagnostic laparotomy and biopsy
No. of cases: 20 12 6 10
52
resection of the hepatic flexure of the colon was an added procedure in 6 cases. Bypass procedures were done in 10 patients; 6 of these were for gastrointestinal obstruction and 4 for biliary obstruction. In the remainder the disease was too far advanced for any major surgical procedure; in these patients biopsy alone could be done from the gallbladder, liver, lymph nodes or omentum.
Survival Twelve patients died within 1 month of the operation. Biliary peritonitis, hepatic coma and wound dehiscence were the main causes of death. Gastric dilatation was the cause of death in 1 patient. The cause of death was not known in 2 patients. Only 15 patients were alive 1 year after operation and 3 were alivc after 3 years. The average survival time for the patients after operation was 6 months. Thus, the overall prognosis is gloomy. Two patients are alive 5 years after a ‘curative’ excision. Discussion The incidence of primary carcinoma of the gallbladder varies widely in different reports. In Britain less than 1 per cent of carcinomas arise in the gallbladder (Solan and Jackson, 1971). The condition appears to be more common in the United States (Holmes and Mark, 1971; Pemberton et al., 1971). In contrast, owing to the lack of a cancer registry, the actual incidence of carcinoma of gallbladder in India is subject to a variety of opinions. However, this series of 100 histologically proved cases over a period of 15 years from a single surgical unit indicates that the disease is not uncommon in India. Almost all reports suggest that gallbladder carcinoma is predominantly a disease of middle-aged or elderly women. The female to male ratio of 2 : 1 in this series is typical. There are only one or two reports in the literature stating that the disease is more common in men (D’Aunoy et al., 1938), and these reports relate to small series. The average age of 49 years in this series is lower than that mentioned in Western literature (Holmes and Mark, 1971; Solan and Jackson, 1971). Most of our patients were in the 40-50 age group. There was no sex difference in age incidence. The youngest
Primary carcinoma of the gallbladder patient in this series was a female aged 30 years. However, Rudolph and Cohen (1972) reported carcinoma of the gallbladder in an 11-year-old Navajo girl, this being the youngest patient reported so far. The aetiology of carcinoma of gallbladder is not clear. Chronic infection, gallstones and benign neoplasms have been mentioned. The incidence of gallstones in association with carcinoma of the gallbladder varies from 54 to 100 per cent (Strauch and Providence 1960; McLaughlin, 1964). Hart et al. (1971) stated that cholelithiasis plays a major part in the aetiology of gallbladder cancer. Comfort et al. (1948) could not find carcinoma of the gallbladder in 112 cases of asymptomatic biliary calculi followed over a period of 10-25 years. Warren and Blach (1940) reported that 2.5 per cent of patients of cholelithiasis would eventually develop carcinoma. In our series gallstones were present in 45 per cent of the cases. However, this may not represent the true figure, as in a large number of cases biopsy alone was obtained. A combination of factors such as chronic mechanical irritation, infection, local metabolic dysfunction, bile stasis and individual host susceptibility may play a role in the development of carcinoma of the gallbladder (Strauch and Providence, 1960; Solan and Jackson, 1971). The clinical picture of carcinoma of the gallbladder is non-specific. A low clinical diagnosis rate is common in almost all reported series. This is accounted for by the indefinite symptoms and signs and the lack of help from ancillary investigations. Gallbladder carcinoma is asymptomatic in its early and potentially curable stage. The clinical features in our patients were typical of late presentation. Pain in the epigastrium or right hypochondrium, anorexia, weight loss and low grade fever were the common symptoms. A right upper quadrant mass, hepatomegaly and jaundice were the most common physical signs. These clinical features have also been seen in the majority of cases reported in the literature. Solan and Jackson (1971) commented on the frequent history of long-standing biliary disease in association with gallbladder cancer, but this occurred in only 12 per cent of our cases. Ancillary investigations are of little help in diagnosis. Anaemia, jaundice and disturbed liver functions are non-specific findings. Plain X-ray of the abdomen showed radio-opaque calculi in only 8 cases. Cholecystography, both oral and intravenous, usually showed a non-functioning gallbladder. A filling defect due to a neoplasm, as described by Samuel (1966), was never seen. Percutaneous transhepatic cholangiography can be a useful aid in jaundiced patients to decide the level and nature of the obstruction and to assess operability (Machado, 1971). Selective angiography has also been used by some workers, but its efficacy has yet to be established (Sato et al., 1969). Adenocarcinoma is the commonest type of gallbladder carcinoma. This was confirmed in our series, followed by squamous cell, colloid and undifferentiated tumours. An almost similar incidence has been
reported by other authors (Strauch and Providence, 1960). However, Litwin (1967) reported a higher number of undifferentiated carcinomas. The rare tumours like carcinoid, melanoma (Gradisar and Kelly, 1970) and angiosarcoma (Tanga and Ewing, 1970) were not seen in our series. In the majority of our cases, only a diagnostic laparotomy and biopsy were possible. Several authors reported a similar experience (Litwin, 1967; Robertson and Carlisle, 1967; Solan and Jackson, 1971). Despite a fairly large number of curative excisions, only 2 patients lived for 5 years. One of them was operated upon for benign gallbladder disease and carcinoma was an incidental finding. Uniformly bad prognosis has also been the experience of other workers. In the collective review published by Strauch and Providence (1960) the 5-year survival rate was 1 per cent out of a total of 1061 cases. No large series has reported a higher than 6 per cent 5-year survival rate. The dismal outlook in gallbladder carcinoma is attributed mainly to three factors: elderly patients, early spread to the liver and lack of specific clinical features (Chandler and Fletcher, 1963). Fahim et al. (1962) described in detail the modes of spread of carcinoma of the gallbladder. Based on this and on our own experience, we tend to agree with Appleman et al. (1963) that radical surgery has a very limited role to play in improving the overall prognosis of gallbladder carcinoma. Since early diagnosis is almost impossible and improvement of surgical technique has not altered the prognosis, the only way one can perhaps improve this dismal outlook is to emphasize prophylaxis. Prophylactic cholecystectomy in cases of asymptomatic gallstones has been suggested on the grounds that it may prevent future cancer (Nield, 1964; Hart et al., 1971; Holmes and Mark, 1971). There are others who disagree with this contention (Solan and Jackson, 1971). Although there is no convincing proof that gallstones are carcinogenic, we feel that early cholecystectomy should be done for all cases of cholelithiasis, whether symptomatic or asymptomatic, provided that there is no surgical contraindication.
References APPLEMAN R. M., MORLOCK C. G., DAHLIN D. C. and ADSON M. A. (1963) Longterm survival in carcinoma
of the gallbladder. Surg. Gynecul. Obstet, 117, 459-464. CHANDLER J. J. and FLETCHER w. s. (1963) A clinical study of primary carcinoma of the gallbladder. Surg. Gynecul. Obstet. 117, 297-300. COMFORT M. W., GRAY H. K. and WILSON J. M. (1948) Silent gallstone-a 10 to 25 years followup study of 112 cases. Ann. Surg. 123, 931-937. D'AUNOY R., OGDEN M. A. and HALPERT B. (1938) Primary carcinoma of biliary system, clinicopathological analysis of 40 cases. Surgery 3, 67Cb678. 35
A. T. M. Prakash et al.
w. A. and CARLISLE B. B. (1967) Primary carcinoma of the gallbladder: review of 52 cases. study of its mode of spread. Ann. Surg. 156, Am. J. Surg. 113,738-742. 114-124. RUDOLPH R. and COHEN J. I. (1972) Cancer of the gallGRADISAR I. A. and KELLY T. R. (1970) Primary bladder in an 11 year old Navajo girl. J. Pediatr. carcinoma of the gallbladder. Arch. Surg. 100, Surg. 7,66-67. 232-235. SAMUEL E. (1966) Radiology of the gallbladder. In: HART J., MODAN B. and SHANI M. (1971) Cholelithiasis ROB c., SMITH R. and MORGAN c. N. (ed.) Clinical in the aetiology of gallbladder neoplasms. Lancet Surgery: Vol. 10, Abdomen and Rectum and Anus. 1, 1151-1 153. London, Butterworths, pp. 326-333. HOLMES s. L. and MARK J. B. D. (1971) Carcinoma of the SATO T., WATANABE K., SAITOH Y., KOYAMA K. and gallbladder. Surg. Gynecol. Obstet. 133,561-564. SUDA Y. (1969) Selective arteriography for gallLITWIN M. s. (1967) Primary carcinoma of the gallbladder diseases. Evaluation with reference to bladder: a review of 78 patients. Arch. Surg. 95, carcinoma of the gallbladder. Arch. Surg. 99, 236-240. 598-605. MACHADO A. L. (1971) Percutaneous transhepatic SOLAN M. J. and JACKSON B. T. (1971) Carcinoma of the cholangiography. Br. J. Surg. 58, 616-624. gallbladder-a clinical appraisal and review of MCLAUGHLIN c. w. jun. (1964) Carcinoma of the gall57 cases. Br. J. Surg. 58, 593-597. bladder: an added hazard in untreated calculous STRAUCH G. 0. and PROVIDENCE R. I. (1960) Primary cholecystitis in older patients. Surgery 56, 757carcinoma of the gallbladder. Surgery 47, 759. 368-383. MUSSER J. H. (1889) cited by SOLAN M. J. and JACKSON TANGA M. R. and EWING J. B. (1970) Primary malignant B. T. (1971). tumours of the gallbladder-report of 43 cases. MELD J. M. (1964) Primary carcinoma of the gallSurgery 67,418426. bladder. Aust. NZ. J . Surg. 34,4346. WARREN R. and BLACH F. c. (1940) Carcinoma of the PEMBERTON L. B., DIFFENBAUGH w. F. and STROHL E. L. gallbladder-the etiological role of gallstones. (1971) The surgical significance of carcinoma of Surgery 7,657-666. the gallbladder. Am. J . Surg. 122, 381-383. FAHIM R. B., MCDONALD J. R., RICHARD J. c. and FERRIS D. o. (1962) Carcinoma of the gallbladder-a
36
ROBERTSON
Primary carcinoma of the gallbladder A. T. M . P R A K A S H , L A L I T K . S H A R M A A N D P . N . P A N D I T * SUMMARY
The clinical and pathological features of 100 conseciitive cases of primary carcinoma of the gallbladder, treated by n single surgical unit, are described. Females outnumbered males by 2 to 1. The maximum incidence was seen in the fifth decade. Pain and the presence of a mass were the two most common clinieal features. Gal!stones coexisted in 45 per cent of cases. Ancillary investigations were of little value in preoperative diagnosis. A t laparotomy biopsj) alone was possible in a large number of cases owing to the advanced disease process. Two patients were alive 5 years after surgery. Prophylactic cholecystectomy for all diseased gallbladders, whether symptomatic or not, is advocated,
EVERsince the first review of 100 cases of carcinoma of the gallbladder by Musser (1889), there has been little change in the outlook and survival rate of patients with this disease. The signs and symptoms of a resectable carcinoma of the gallbladder are similar to those of chronic cholecystitis and cholelithiasis. Persistent right upper quadrant pain, a hard gallbladder lump, jaundice and weight loss often suggest the diagnosis, but by then the disease is invariably inoperable. A 5-year survival is rare, unless an early lesion is found coincidentally in a gallbladder removed for chronic cholecystitis and cholelithiasis. There are very few reports in the literature of a series of 100 or more cases of carcinoma of the gallbladder treated by a single team and particularly from India. The present article gives the experience of 100 cases of histologically proved carcinoma of the gallbladder, treated in the Professorial Unit of the All India Institute of Medical Sciences Hospital, New Delhi, over a period of 15 years from 1959. Age and sex incidence There were 68 females and 32 males, giving a female to male ratio of 2 : 1 . The ages of the patients ranged from 30 to 75 years, the average being 49 years; the majority of patients, however, were between 40 and 50 years (Fig. 1).
Clinical features A history suggestive of chronic cholecystitis of long duration was available in only 12 cases. Surprisingly, the average duration of symptoms in most patients was only 8 weeks. Ninety-five patients complained of pain, often severe, usually in the epigastrium or right hypochondrium (Fig. 2). In the majority, it was a continuous ache. Less than 10 per cent of cases had colicky pain, with or without radiation. Seventy-five patients had marked anorexia and 70 of them had a 3
significant weight loss. Nearly a quarter of the patients (24) complained of low grade fever. Seven patients presented with obstruction : 4 at the pylorus and 3 in the small bowel. None of these cases presented as acute cholecystitis.
Female Male
Inn, 51-60
41-50
30-40
71-80
61-70
Age (Y r)
Fig. 1. Age and sex incidence.
Anorexia Weight loss Hepatomegaly Fever Jaundice Tenderness
R t . hypochondrium Ascites Vomiting
+ ,
0
I
20
,
I
40
,
m
-
60
v
I
80
I
i
100
No. of patients Fig. 2. Clinical features.
* Department of Surgery, All India Institute of Medical Sciences, New Delhi 110016, India. 33
A. T. M. Prakash et al. In 92 cases there was a lump in the right hypochondrium which was often hard and irregular; 15 patients complained of pain over the lump. Hepatomegaly was present in 65 per cent and jaundice on admission was seen in 20 per cent of the patients. Ascites and tenderness under the right costal margin were less common.
Investigations Radiology was of little help in diagnosis. Plain X-ray of the abdomen revealed radio-opaque calculi in only 8 cases. Oral cholecystography was carried out in 60 of the non-jaundiced patients, including 4 of those showing calculi on plain X-ray; in 2 patients only, was the gallbladder visualized faintly, and not at all in the remainder. A neoplastic filling defect in the gallbladder was never seen. In about half of the cases where an oral cholecystogam did not outline the gallbladder intravenous cholangiography was undertaken, but did not provide any additional information. Percutaneous transhepatic cholangiography was attempted in 10 of the 20 jaundiced patients; it failed in 2, the obstruction at the porta hepatis was seen in 6 and obstruction of the common hepatic duct in 2. These findings were confirmed at operation. Routine chest X-ray revealed secondaries in the lungs in 2 cases. Barium meal, barium enema and intravenous pyelography were done when indicated. Barium meal examinations showed extrinsic pressure on the duodenum in 6 cases. Barium enema studies showed evidence of extrinsic pressure on the hepatic flexure on 3 occasions. Intravenous pyelography, done in 3 patients, did not contribute further information. Biochemical investigations were of little assistance. The liver function tests were diagnostic of obstructive jaundice. However, in the absence of icterus, the serum alkaline pliosphatase was elevated in about 25 per cent of the cases. Association with gallstones Gallstones were present in 45 patients. However, this may not represent the true number as in a majority of the inoperable cases a biopsy alone was done and the gallbladder was not opened. Gross pathology (Table I ) The growth involved the gallbladder diffusely in 78 cases, it was in the fundus in 12 cases and the neck of the gallbladder was involved in 8 cases; Hartmann’s pouch and the cystic duct were involved in 2 cases. In almost 75 per cent of the cases the tumour had infiltrated into the adjacent liver tissue. Histology Histologically, 90 per cent of the tumours were adenocarcinoma. Two were colloid carcinoma, 4 squamous cell carcinoma and 4 undifferentiated tumour. Treatment (Table ZI) Cholecystectomy alone or with hepatic wedge resection was performed in 32 cases. Segmental
Table 1: GROSS PATHOLOGY Site: Diffuse growth Fundus Neck Hartmann’s pouch Cystic duct
No. of cases: 78 12 8 1
1
Table 11: OPERATIONS PERFORMED Operation: Cholecystectomy Cholecystectomy with wedge resection of liver Cholecystectomy with resection of hepatic flexure Biliaryiintestinal short circuiting Diagnostic laparotomy and biopsy
No. of cases: 20 12 6 10
52
resection of the hepatic flexure of the colon was an added procedure in 6 cases. Bypass procedures were done in 10 patients; 6 of these were for gastrointestinal obstruction and 4 for biliary obstruction. In the remainder the disease was too far advanced for any major surgical procedure; in these patients biopsy alone could be done from the gallbladder, liver, lymph nodes or omentum.
Survival Twelve patients died within 1 month of the operation. Biliary peritonitis, hepatic coma and wound dehiscence were the main causes of death. Gastric dilatation was the cause of death in 1 patient. The cause of death was not known in 2 patients. Only 15 patients were alive 1 year after operation and 3 were alivc after 3 years. The average survival time for the patients after operation was 6 months. Thus, the overall prognosis is gloomy. Two patients are alive 5 years after a ‘curative’ excision. Discussion The incidence of primary carcinoma of the gallbladder varies widely in different reports. In Britain less than 1 per cent of carcinomas arise in the gallbladder (Solan and Jackson, 1971). The condition appears to be more common in the United States (Holmes and Mark, 1971; Pemberton et al., 1971). In contrast, owing to the lack of a cancer registry, the actual incidence of carcinoma of gallbladder in India is subject to a variety of opinions. However, this series of 100 histologically proved cases over a period of 15 years from a single surgical unit indicates that the disease is not uncommon in India. Almost all reports suggest that gallbladder carcinoma is predominantly a disease of middle-aged or elderly women. The female to male ratio of 2 : 1 in this series is typical. There are only one or two reports in the literature stating that the disease is more common in men (D’Aunoy et al., 1938), and these reports relate to small series. The average age of 49 years in this series is lower than that mentioned in Western literature (Holmes and Mark, 1971; Solan and Jackson, 1971). Most of our patients were in the 40-50 age group. There was no sex difference in age incidence. The youngest
Primary carcinoma of the gallbladder patient in this series was a female aged 30 years. However, Rudolph and Cohen (1972) reported carcinoma of the gallbladder in an 11-year-old Navajo girl, this being the youngest patient reported so far. The aetiology of carcinoma of gallbladder is not clear. Chronic infection, gallstones and benign neoplasms have been mentioned. The incidence of gallstones in association with carcinoma of the gallbladder varies from 54 to 100 per cent (Strauch and Providence 1960; McLaughlin, 1964). Hart et al. (1971) stated that cholelithiasis plays a major part in the aetiology of gallbladder cancer. Comfort et al. (1948) could not find carcinoma of the gallbladder in 112 cases of asymptomatic biliary calculi followed over a period of 10-25 years. Warren and Blach (1940) reported that 2.5 per cent of patients of cholelithiasis would eventually develop carcinoma. In our series gallstones were present in 45 per cent of the cases. However, this may not represent the true figure, as in a large number of cases biopsy alone was obtained. A combination of factors such as chronic mechanical irritation, infection, local metabolic dysfunction, bile stasis and individual host susceptibility may play a role in the development of carcinoma of the gallbladder (Strauch and Providence, 1960; Solan and Jackson, 1971). The clinical picture of carcinoma of the gallbladder is non-specific. A low clinical diagnosis rate is common in almost all reported series. This is accounted for by the indefinite symptoms and signs and the lack of help from ancillary investigations. Gallbladder carcinoma is asymptomatic in its early and potentially curable stage. The clinical features in our patients were typical of late presentation. Pain in the epigastrium or right hypochondrium, anorexia, weight loss and low grade fever were the common symptoms. A right upper quadrant mass, hepatomegaly and jaundice were the most common physical signs. These clinical features have also been seen in the majority of cases reported in the literature. Solan and Jackson (1971) commented on the frequent history of long-standing biliary disease in association with gallbladder cancer, but this occurred in only 12 per cent of our cases. Ancillary investigations are of little help in diagnosis. Anaemia, jaundice and disturbed liver functions are non-specific findings. Plain X-ray of the abdomen showed radio-opaque calculi in only 8 cases. Cholecystography, both oral and intravenous, usually showed a non-functioning gallbladder. A filling defect due to a neoplasm, as described by Samuel (1966), was never seen. Percutaneous transhepatic cholangiography can be a useful aid in jaundiced patients to decide the level and nature of the obstruction and to assess operability (Machado, 1971). Selective angiography has also been used by some workers, but its efficacy has yet to be established (Sato et al., 1969). Adenocarcinoma is the commonest type of gallbladder carcinoma. This was confirmed in our series, followed by squamous cell, colloid and undifferentiated tumours. An almost similar incidence has been
reported by other authors (Strauch and Providence, 1960). However, Litwin (1967) reported a higher number of undifferentiated carcinomas. The rare tumours like carcinoid, melanoma (Gradisar and Kelly, 1970) and angiosarcoma (Tanga and Ewing, 1970) were not seen in our series. In the majority of our cases, only a diagnostic laparotomy and biopsy were possible. Several authors reported a similar experience (Litwin, 1967; Robertson and Carlisle, 1967; Solan and Jackson, 1971). Despite a fairly large number of curative excisions, only 2 patients lived for 5 years. One of them was operated upon for benign gallbladder disease and carcinoma was an incidental finding. Uniformly bad prognosis has also been the experience of other workers. In the collective review published by Strauch and Providence (1960) the 5-year survival rate was 1 per cent out of a total of 1061 cases. No large series has reported a higher than 6 per cent 5-year survival rate. The dismal outlook in gallbladder carcinoma is attributed mainly to three factors: elderly patients, early spread to the liver and lack of specific clinical features (Chandler and Fletcher, 1963). Fahim et al. (1962) described in detail the modes of spread of carcinoma of the gallbladder. Based on this and on our own experience, we tend to agree with Appleman et al. (1963) that radical surgery has a very limited role to play in improving the overall prognosis of gallbladder carcinoma. Since early diagnosis is almost impossible and improvement of surgical technique has not altered the prognosis, the only way one can perhaps improve this dismal outlook is to emphasize prophylaxis. Prophylactic cholecystectomy in cases of asymptomatic gallstones has been suggested on the grounds that it may prevent future cancer (Nield, 1964; Hart et al., 1971; Holmes and Mark, 1971). There are others who disagree with this contention (Solan and Jackson, 1971). Although there is no convincing proof that gallstones are carcinogenic, we feel that early cholecystectomy should be done for all cases of cholelithiasis, whether symptomatic or asymptomatic, provided that there is no surgical contraindication.
References APPLEMAN R. M., MORLOCK C. G., DAHLIN D. C. and ADSON M. A. (1963) Longterm survival in carcinoma
of the gallbladder. Surg. Gynecul. Obstet, 117, 459-464. CHANDLER J. J. and FLETCHER w. s. (1963) A clinical study of primary carcinoma of the gallbladder. Surg. Gynecul. Obstet. 117, 297-300. COMFORT M. W., GRAY H. K. and WILSON J. M. (1948) Silent gallstone-a 10 to 25 years followup study of 112 cases. Ann. Surg. 123, 931-937. D'AUNOY R., OGDEN M. A. and HALPERT B. (1938) Primary carcinoma of biliary system, clinicopathological analysis of 40 cases. Surgery 3, 67Cb678. 35
A. T. M. Prakash et al.
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