Gallbladder Cancer

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Early Detection, Diagnosis, and Staging TOPICS

How is gallbladder cancer diagnosed?

Some gallbladder cancers are found after the gallbladder has been removed to treat gallstones or chronic (long-term) inflammation. Gallbladders removed for those reasons are always looked at under a microscope to see if they contain cancer cells.

Most gallbladder cancers, though, are not found until a person goes to a doctor because they have symptoms.

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 examine you to look for signs of gallbladder cancer and other health problems. The exam will focus mostly on the abdomen to check for any lumps, 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 physical exam suggest you might have gallbladder cancer, other tests will be done. These might include lab tests, imaging tests, and other procedures.

Blood tests

Tests of liver and gallbladder function

Your doctor may order lab tests to find out how much bilirubin is in the blood. Bilirubin is the chemical that gives the bile its yellow color. Problems in the gallbladder, bile ducts, or liver can raise the blood level of bilirubin. A high bilirubin level tells the doctor that there may be gallbladder, bile duct, 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, bile duct, or gallbladder disease. These are sometimes referred to as liver function tests.

Tumor markers

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.

These tests can sometimes be useful after a person is diagnosed with gallbladder cancer. If the levels of these markers are found to be high, they can be followed over time to help tell how well treatment is working.

Imaging tests

Imaging tests use x-rays, magnetic fields, or sound waves to create pictures of the inside of your body. Imaging tests can be done for a number of reasons, including:

  • To look for suspicious areas that might be cancer
  • To help a doctor guide a biopsy needle into a suspicious area to take a sample
  • To learn how far cancer has spread
  • To help guide certain types of treatments
  • To help determine if treatment is working
  • To look for signs of the cancer coming back after treatment

People who have (or might have) gallbladder cancer may have one or more of the following tests.

Ultrasound

For this test, a small instrument called a transducer gives off sound waves and picks up their echoes as they bounce off organs inside the body. The echoes are converted by a computer into an image on a screen. The patterns of echoes can help find tumors and show how far they have grown into nearby areas.

Abdominal ultrasound: This 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.

This is an easy test to have done, and it uses no radiation. 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: In these techniques, the doctor puts the ultrasound transducer inside the body and closer to the gallbladder, which gives more detailed images than a standard ultrasound. The transducer is on the end of a thin, lighted tube that has an attached viewing device. The tube is either passed through the mouth, down through the stomach, and near the gallbladder area (endoscopic ultrasound) or through a small surgical cut in the belly (laparoscopic ultrasound).

If there is a tumor, ultrasound might 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 can be a sign that cancer has reached them.

Ultrasound can also be used to guide a needle into a suspicious lymph node so that cells can be removed (biopsied) and viewed under a microscope. This is known as an ultrasound-guided needle biopsy.

Computed tomography (CT) scan

The CT scan uses x-rays to make 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.

A CT scanner has been described as a large donut, with a narrow table that slides in and out of the middle opening. You will need to lie still on the table while the scan is being done. CT scans take longer than regular x-rays, and you might feel a bit confined by the ring while the pictures are being taken.

Before any pictures are taken, you might 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 might also need 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 can have several uses for gallbladder cancer:

  • They are often used to help diagnose gallbladder cancer by showing tumors in the area.
  • They can help stage the cancer (find 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 be used to look at the blood vessels near the gallbladder. This can help determine if surgery is a treatment option.
  • CT scans can also be used to guide a biopsy needle into a suspected tumor or metastasis. For this procedure, called a CT-guided needle biopsy, you remain on the CT scanning table, while the doctor advances a biopsy needle through the skin and toward 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. 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 cancerous 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 angiography.

MRI scans can be a little more uncomfortable than CT scans. They take longer, often up to an hour. You may have to lie inside a narrow tube, which is confining and can upset people who have a fear of enclosed spaces. Special, 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.

Cholangiography

A cholangiogram is an imaging test that looks at the bile ducts to see if they are blocked, narrowed, or dilated. This can help show if someone might have a tumor that is blocking a duct. It can also be used to help plan surgery. There are several types of cholangiograms, each of which has 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 use of a contrast agent and is not invasive, unlike other types of cholangiograms. Because it is non-invasive, doctors often use MRCP if the purpose of the test is just to image the bile ducts. But this test can’t be used to get biopsy samples of tumors or to place stents (small tubes) in the ducts to keep them open.

Endoscopic retrograde cholangiopancreatography (ERCP): In this procedure, a doctor passes a long, flexible tube (endoscope) down the throat, through the esophagus and stomach and into the first part of the small intestine. This is usually done while you are sedated (given medicine to make you sleepy). 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 ducts 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 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 belly 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 might cause more pain), PTC is not usually used unless ERCP has already been tried or can’t be done for some reason.

Angiography

Angiography or an angiogram is an x-ray test used to look 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 show if blood flow in an area is blocked or affected by a tumor, and any abnormal blood vessels in the area. The test can also show if 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.

X-ray angiography can be uncomfortable because the doctor 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 can 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.

Laparoscopy

Laparoscopy is a type of minor surgery. The 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 doctors plan surgery or other treatments, and can help determine 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 abdomen 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.

Biopsy

During a biopsy, the doctor removes a tissue sample 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 for a diagnosis. Biopsies are also used to help find out how far the cancer has spread. This is important when determining the best treatment options.

But a biopsy may not always be done before surgery to remove a gallbladder 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 way to know for certain if it is cancer. For example, imaging tests may show that a tumor has spread or grown too large to be removed completely 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 see 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 and 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. 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.

For more information about biopsies and how they are tested, see our document Testing Biopsy and Cytology Specimens for Cancer.


Last Medical Review: 10/29/2014
Last Revised: 10/29/2014