How is gallbladder cancer diagnosed?
Some gallbladder cancers are found after a gallbladder has been removed to treat gallstones or chronic (long-term) gallbladder inflammation. Gallbladders removed for those reasons are always looked at under a microscope by a pathologist (a doctor specializing in lab tests) to see if they contain cancer cells.
Most gallbladder cancers, though, are not found until patients go to a doctor because they have symptoms.
Signs and symptoms of gallbladder cancer
Signs and symptoms are usually not present until the later stages of gallbladder cancer, but in some cases they may lead to an early diagnosis. If you go to your doctor when you first notice symptoms, your cancer might be diagnosed at an earlier stage, when treatment may be more effective. Some of the most common symptoms of gallbladder cancer are:
Most people with gallbladder cancer have abdominal (stomach area) pain when they are first diagnosed. Most often this is in the upper right part of the abdomen.
Nausea and/or vomiting
At the time of their diagnosis, many people with gallbladder cancer report vomiting as a symptom.
Jaundice is a condition that gives a yellowish color to the skin and the white part of the eyes. This can happen when bile from the liver is unable to drain into the intestines because the cancer blocks the bile duct. Bilirubin, a chemical in bile that gives it a yellow color, may build up in the blood and settle in different parts of the body. This can cause the color changes seen in the skin and eyes. Some patients with gallbladder cancer have jaundice when they are diagnosed.
If the cancer blocks the bile duct, bile can also build up in the gallbladder, making it larger than usual. The enlarged gallbladder can sometimes be felt by the doctor during a physical exam. It can also be detected by imaging tests such as ultrasound.
Less common symptoms include loss of appetite, weight loss, abdominal swelling, severe itching, and black, tarry stools.
These are the symptoms and signs of gallbladder cancer, but they are more likely to be caused by non-cancerous diseases. For example, people with gallstones also have many of these symptoms. There are many causes of abdominal pain that are far more common than gallbladder cancer. And viral hepatitis (infection of the liver) is a much more common cause of jaundice. Still, if you have any of these problems, it's important to see your doctor right away so the cause can be found and treated, if needed.
Medical history and physical exam
If you have any signs or symptoms that suggest you might have gallbladder cancer, your doctor will want to take a complete medical history to check for risk factors and to learn more about your symptoms.
Your doctor will do a physical exam to look for signs of gallbladder cancer and other health problems. If gallbladder cancer is suspected, the exam will focus mostly on the abdomen to check for any masses, tenderness, or buildup of fluid. The skin and the white part of the eyes will be checked for jaundice (a yellowish color). Sometimes, cancer of the gallbladder spreads to lymph nodes, causing a lump that can be felt beneath the skin. Lymph nodes above the collarbone and in several other locations may be examined carefully.
If symptoms and/or the results of the physical exam suggest you might have gallbladder cancer, more involved tests will be done. These might include lab tests, imaging tests, and other procedures.
Tests of liver and gallbladder function
Your doctor may order lab tests to determine how much bilirubin is in the blood. Bilirubin is the chemical that gives the bile its yellow color. Problems in the gallbladder or liver may cause the level of bilirubin in the blood to get too high. When this happens the bilirubin can settle into other tissues, which can yellow the color of the skin and whites of the eyes (jaundice). A high bilirubin level tells the doctor that there may be either gallbladder or liver problems.
The doctor may also order tests for other substances in your blood, such as albumin, alkaline phosphatase, AST, ALT, and GGT, which can also be abnormal if you have liver or gallbladder disease.
CEA and CA 19-9 are tumor markers (proteins found in the blood when certain cancers are present). High levels of these substances are often (but not always) found in people with gallbladder cancer. Usually the blood levels of these markers are high only when the cancer is in an advanced stage. These markers are not specific for gallbladder cancer -- that is, other cancers or even some other health conditions can cause high levels.
Imaging tests use x-rays, magnetic fields, or sound waves to create pictures of the inside of your body. Imaging tests may be done for a number of reasons, including:
- To help find a suspicious area that might be cancerous
- To help a doctor guide a biopsy needle into a suspicious area to take a sample
- To learn how far cancer may have spread
- To help guide certain types of treatments
- To help determine if treatment has been effective
- To look for a possible recurrence of the cancer
People who have (or may have) gallbladder cancer may have one or more of the following tests.
Ultrasound (ultrasonography) is often the first imaging test done in people who have symptoms (such as jaundice or pain in the right upper part of their abdomen) that might be caused by gallbladder problems.
For this test, a small instrument called a transducer emits sound waves and picks up their echoes as they bounce off internal organs. The echoes are converted by a computer into a black-and-white image that is displayed on a video screen. The echoes produced by most tumors differ from those of normal tissue. The patterns of echoes can help find tumors and determine how far they may have grown into nearby areas.
This is an easy test to have done, and it uses no radiation. For a gallbladder ultrasound exam, you simply lie on a table while the doctor or ultrasound technician moves the transducer (which is shaped like a wand) along the skin over the right upper abdomen. Usually, the skin is first lubricated with gel.
Endoscopic or laparoscopic ultrasound: These techniques let the doctor to place the ultrasound transducer inside the body and closer to the gallbladder to produce more detailed images than a standard ultrasound. The transducer is on the end of a thin, lighted tube that has an attached viewing device (an endoscope or laparoscope). The tube is either passed through the mouth and down through the stomach and near the gallbladder area (endoscopic ultrasound) or through a surgical incision (cut) in the abdomen (belly) (laparoscopic ultrasound).
If there is a tumor, ultrasound may help the doctor tell if and how far it has invaded the gallbladder wall, which helps in planning for surgery. Ultrasound may be able to show if nearby lymph nodes are enlarged, which may be a sign that cancer has reached them. It may also be used to guide a needle into a suspicious node so that cells can be removed (biopsied) and viewed under a microscope.
Computed tomography (CT) scan
The CT scan is an x-ray test that produces detailed cross-sectional images of your body. Instead of taking one picture, like a regular x-ray, a CT scanner takes many pictures as it rotates around you while you lie on a table. A computer then combines these into images of slices of the part of your body that is being studied.
Before any pictures are taken, you may be asked to drink 1 to 2 pints of a liquid called oral contrast. This helps outline the intestine so that certain areas are not mistaken for tumors. You may also receive an IV (intravenous) line through which a different kind of contrast dye (IV contrast) is injected. This helps better outline structures throughout your body.
The injection can cause some flushing (redness and warm feeling). Some people are allergic and get hives or, rarely, more serious reactions like trouble breathing and low blood pressure. Be sure to tell the doctor if you have any allergies or have ever had a reaction to any contrast material used for x-rays.
CT scans take longer than standard x-ray tests. You need to lie still on a table while the scan is being done. During the test, the table slides in and out of the scanner, a ring-shaped machine that completely surrounds the table. You might feel a bit confined by the ring you have to lie in while the pictures are being taken.
CT scans can have several uses:
- They are often used to help make the initial diagnosis of gallbladder cancer by showing tumors in the area.
- They can be helpful in staging the cancer (finding out how far it has spread). CT scans can show the organs near the gallbladder (especially the liver), as well as lymph nodes and distant organs the cancer might have spread to. A type of CT known as CT angiography can also be used to look at the blood vessels near the gallbladder. These tests can help determine if surgery is a good treatment option.
- CT scans can also be used to guide a biopsy needle precisely into a suspected tumor or metastasis. For this procedure, called a CT-guided needle biopsy, you remain on the CT scanning table, while a radiologist advances a biopsy needle through the skin and toward the location of the mass. CT scans are repeated until the needle is within the mass. A biopsy sample is then removed and looked at under a microscope.
Magnetic resonance imaging (MRI) scan
Like CT scans, MRI scans provide detailed images of soft tissues in the body. But MRI scans use radio waves and strong magnets instead of x-rays. The energy from the radio waves is absorbed and then released in a pattern formed by the type of body tissue and by certain diseases. A computer translates the pattern into very detailed images of parts of the body. A contrast material called gadolinium may be injected into a vein before the scan to better see details.
MRI scans provide a great deal of detail and can be very helpful in looking at the gallbladder and nearby bile ducts and other organs. Sometimes they can help tell a benign tumor from a malignant one.
Special types of MRI scans can also be used in people who may have gallbladder cancer. MR cholangiopancreatography (MRCP), which can be used to look at the bile ducts, is described below in the section on cholangiography. MR angiography (MRA), which looks at blood vessels, is mentioned below in the next section on cholangiography.
MRI scans may be a little more uncomfortable than CT scans. They take longer, often up to an hour. You may be placed inside a narrow tube, which is confining and can upset people with a fear of enclosed spaces. Newer, more open MRI machines can sometimes be used instead. The MRI machine also makes buzzing and clicking noises that might be disturbing. Some places will provide earplugs to help block this noise out.
A cholangiogram is an imaging test that looks specifically at the bile ducts to see if they are blocked, narrowed, or dilated. It can be used in people who may have gallbladder cancer to help plan surgery. There are several types of cholangiograms, which have different pros and cons.
Magnetic resonance cholangiopancreatography (MRCP): This is a non-invasive way to take images of the bile ducts using the same type of machine used for standard MRI scans. It does not require an IV infusion of a contrast agent and is not invasive, unlike other types of cholangiograms. Because it is non-invasive, doctors often use MRCP instead of these other tests if the purpose of the test is just to image the bile ducts.
Endoscopic retrograde cholangiopancreatography (ERCP): In this procedure, a doctor passes a long, flexible tube (endoscope) down the patient's throat, through the esophagus and stomach and into the first part of the small intestine. A small catheter (tube) is passed from the end of the endoscope and into the common bile duct. A small amount of contrast dye is injected through the tube to help outline the bile duct and pancreatic duct as x-rays are taken. The images can show narrowing or blockage of these ducts. This test is more invasive than MRCP, but the advantage is that the doctor can also take samples of cells or fluid to be look at under a microscope. ERCP can also be used to place a stent (a small tube) into a duct to help keep it open.
Percutaneous transhepatic cholangiography (PTC): In this procedure, the doctor places a thin, hollow needle through the skin of the abdomen and into a bile duct within the liver. You will get medicine through an IV line to make you sleepy before the test. A local anesthetic is also used to numb the area before inserting the needle. A contrast dye is then injected through the needle, and x-rays are taken as it passes through the bile ducts. As with ERCP, this approach can also be used to take samples of fluid or tissues or to place a stent into a duct to help keep it open. Because it is more invasive (and may cause more pain), PTC is not usually used unless ERCP has already been tried or can't be done for some reason.
Angiography is an x-ray test for looking at blood vessels. For this test, a small amount of contrast dye is injected into an artery to outline blood vessels while x-ray images are taken. The images allow the doctors to see if blood flow in an area is blocked or affected by a tumor, and they can show any abnormal blood vessels in the area. Angiography can also show whether a gallbladder cancer has grown through the walls of certain blood vessels. This information is used to help surgeons decide whether a cancer can be removed and to help plan the operation.
Angiography can be uncomfortable because the radiologist who does the procedure has to put a small catheter (a flexible hollow tube) into the artery leading to the gallbladder to inject the dye. Usually the catheter is put into an artery in your inner thigh and threaded up into the artery supplying the gallbladder. A local anesthetic is often used to numb the area before inserting the catheter. Then the dye is injected quickly to outline all the vessels while the x-rays are being taken.
Angiography may also be done with a CT scanner (CT angiography) or an MRI scanner (MR angiography). These techniques are now used more often because they can give information about the blood vessels near the gallbladder without the need for a catheter in the artery. You may still need an IV line so that contrast dye can be injected into the bloodstream during the imaging.
For laparoscopy, a doctor inserts a thin tube with a light and a small video camera on the end (a laparoscope) through a small incision (cut) in the front of the abdomen to look at the gallbladder, liver, and other organs. (Sometimes more than one cut is made.) This procedure is done in the operating room while you are under general anesthesia (in a deep sleep).
Laparoscopy can help in planning surgery or other treatments, and can help doctors confirm the stage (extent) of the cancer. If needed, doctors can also insert instruments through the incisions to remove biopsy samples, which are then looked at under a microscope to make or confirm the diagnosis of cancer.
Laparoscopy is often used to remove the gallbladder to treat gallstones or chronic inflammation of the gallbladder. This operation is called a laparoscopic cholecystectomy. If gallbladder cancer is found or suspected during that operation, surgeons usually convert the operation to an open cholecystectomy (removal of the gallbladder through a larger cut in the abdomen). The open method lets the surgeon see more and may lower the chance of releasing cancer cells into the abdominal cavity when the gallbladder is removed. The use of the open procedure depends on the size of the cancer and whether surgery can remove all the cancer.
A biopsy procedure is the removal of a sample of tissue to be looked at under a microscope to see if cancer (or some other disease) is present. For most types of cancer, a biopsy is needed to diagnose cancer. Biopsies may also be used to help find out how far the cancer has spread. This is important when determining the best treatment options.
But when gallbladder cancer is likely, a biopsy may not always be done before surgery to remove the tumor. Doctors are often concerned that sticking a needle into the tumor or otherwise disturbing it without completely removing it might allow cancer cells to spread to other areas.
If imaging tests (ultrasound, CT or MRI scans, cholangiography, etc.) suggest there is a tumor in the gallbladder and there are no obvious signs of distant spread, the doctor may decide to proceed directly to surgery and to treat it as a gallbladder cancer. (See the section, "Surgery for gallbladder cancer.") In these cases, the gallbladder tissue is looked at under a microscope after the gallbladder is removed.
In other cases, a doctor may feel that a biopsy of a suspicious area in the gallbladder is the best approach to know for certain that it is gallbladder cancer. For example, imaging tests may show that a tumor has spread or grown too large to be completely removed by surgery. Unfortunately, many gallbladder cancers are not removable by the time they are first found.
Types of biopsies
There are several ways to take biopsy samples of the gallbladder.
If cholangiography (ERCP or PTC) is being done, a sample of bile may be collected during the procedure to look for cancer cells within the fluid.
As noted earlier, biopsy specimens can be taken during laparoscopy. This lets the doctor to view the surface of the gallbladder and nearby areas and take samples of suspicious areas.
If the cancer appears to be too advanced for surgery, a needle biopsy may be done to confirm the diagnosis, which may help guide treatment. For this test, a thin, hollow needle is inserted through the skin and into the tumor without making a surgical incision. (The skin is numbed first with a local anesthetic.) The needle is usually guided into place using ultrasound or CT scans. Then the needle is slowly moved forward while doctors check its position by viewing images from one of these imaging tests. When the images show that the needle is in the tumor, a sample is drawn into the needle and sent to the lab to be viewed under a microscope.
In most cases, this is done as a fine needle aspiration (FNA) biopsy, which uses a very thin needle attached to a syringe to suck out (aspirate) a sample of cells. If this isn't successful, a core needle biopsy, which uses a slightly larger needle to get a bigger sample, may be done. Doctors don't usually do a core needle biopsy first because it has a higher chance of spreading cancer cells.
Last Medical Review: 04/30/2012
Last Revised: 01/18/2013