Gallbladder cancer in the elderly

Introduction to gallbladder cancer in the elderly Carcinoma of the gallbladder is the first in gallbladder malignant tumors. Others include sarcoma, carcinoid, primary malignant melanoma, and giant cell adenocarcinoma. Gallbladder cancer insidious onset, most of the early asymptomatic, clinical manifestations are non-specific, can be similar to acute, chronic cholecystitis or cholelithiasis, should pay attention to identification, right upper abdomen and blockage accounted for about half, late liver can appear, Fever, ascites and anemia. basic knowledge The proportion of sickness: 0.01% Susceptible people: the elderly Mode of infection: non-infectious Complications: liver abscess subgingival abscess

The cause of gallbladder cancer in the elderly

Secondary infection (80%):

Patients with gallbladder cancer with cholelithiasis account for 60% to 90%, and those with cholelithiasis account for 3% to 14% of patients with gallstone disease. Therefore, it is generally considered that chronic cholecystitis and cholelithiasis are closely related to the occurrence of gallbladder cancer.

Other diseases (20%):

Cholestasis, abnormal cholesterol metabolism, inflammatory bowel disease, genetic factors, sex hormones, X-ray irradiation, carcinogenic factors in bile, benign tumor malignant transformation, etc. are also assumed to be the pathogenesis of gallbladder cancer, but there is no reliable evidence. It is generally believed that the occurrence of this disease may be related to a variety of factors.

Pathogenesis

Gallbladder cancer can be divided into mass type and invasive type. The pathological tissue type is mainly adenocarcinoma, accounting for 80%-90%, undifferentiated cancer about 10%, squamous cell carcinoma and squamous cell carcinoma 5%~10%.

Gallbladder cancer mainly passes lymphatic metastasis. It is found that there are 25% to 75% of lymphatic metastasis in operation. More than half of the cancers can be directly spread to neighboring organs. The frequency of occurrence is liver, bile duct, pancreas, stomach, and twelve. Refers to the intestine, omentum, colon and abdominal wall; blood line spreaders less than 1/5.

Elderly gallbladder cancer prevention

Early detection of early diagnosis and surgical treatment.

Elderly gallbladder cancer complications Complications, liver abscess, underarm abscess

Gallbladder cancer mainly through lymphatic metastasis, and found that there are lymphatic metastasis in the surgery 25% to 75%; more than half of the cancer can be directly spread to adjacent organs, the frequency of which occurs in the liver, bile duct, pancreas, stomach and duodenum , omentum, colon and abdominal wall; blood line spread less than 1/5. Complications include gallbladder infection, empyema, perforation, and liver abscess, underarm abscess, pancreatitis, gastrointestinal bleeding, etc., and can also form fistulas with the nearby gastrointestinal tract.

Gallbladder cancer in the elderly Common symptoms Ascites nodules

Gallbladder cancer insidious onset, most of the early asymptomatic, clinical manifestations are non-specific, can be similar to acute, chronic cholecystitis or cholelithiasis, should pay attention to identification, right upper abdomen and blockage accounted for about half, late liver can appear, Fever, ascites and anemia.

Real-time ultrasound is a non-invasive method. It can be seen that the irregular thickening of the gallbladder wall and the echogenic mass of the gallbladder without acoustic shadow are diagnosed at 50%-90%. It should be the first choice. Ultrasound endoscopy for early gallbladder cancer The diagnosis and its infiltration depth and liver and biliary infiltration have certain value. Percutaneous transhepatic cholangiography (PTC), retrograde cholangiopancreatography (ERCP), CT and MRI have certain diagnostic value, and ER-CP and In the case of PTC, bile can be collected for cytological examination, and percutaneous transhepatic percutaneous transhepatic angiography is performed under X-ray or ultrasound guidance. The success rate is 85% and 95% respectively. In addition, the gallbladder wall can be used to take the living tissue. Cytological examination, the diagnostic accuracy is about 85%, laparoscopic findings can be found in tumor nodules, and biopsy can be made cytological or histological diagnosis, the diagnostic accuracy of celiac angiography is 70% to 80%, and may be found Early cancer, which is characterized by widening of the gallbladder artery, uneven thickness or interruption.

Examination of gallbladder cancer in the elderly

Liver function test

Serum bilirubin is elevated, with direct bilirubin in the early stage, elevated indirect bilirubin in the late stage, elevated serum transaminases (mainly ALT), and disproportionate to jaundice. In the case of jaundice, ALT is only slightly elevated. High, alkaline phosphatase (ALP) lactate dehydrogenase (LDH), gamma-glutamyltransferase (GGT) and 5'-nucleotidase (5'-NT) were significantly elevated.

2. Tumor markers

The detection of carcinoembryonic antigen (CEA) and serum CA19-9 and CA50 in serum or bile can be elevated in gallbladder carcinoma, which is also helpful for diagnosis. It has been reported that gallbladder cancer group CA19-9 is 153U/ml, gallstone group is 67U. /ml (P<0.0001), can be used as a reference for differential diagnosis.

3. Detection of oncogene and oncogene products: The positive expression rates of oncogene ras and c-erbB-2 in gallbladder carcinoma were 60% and 50%, respectively, and some biliary adenomas showed weak positive expression of ras, while C-erbB-2 The positive reaction was limited to cancer cells, but no positive expression was observed in adjacent mucosa and gallbladder adenoma. The positive expression rate of P53 in gallbladder carcinoma was 50%-65.5%. The expression of P53 protein was often associated with high proliferation of gallbladder carcinoma, bcl-2. The expression rate of gene products in gallbladder carcinoma is 54%. Therefore, the simultaneous detection of multi-gene expression is important for the early diagnosis and prognosis of gallbladder carcinoma. In addition, the expression of NDPK/nm23 in gallbladder carcinoma is significantly higher than that in benign tissue (P<0.05). ), and is closely related to local invasion and lymphatic metastasis of cancer tissues (P<0.05), and also has certain value for differential diagnosis and prognosis estimation.

4. Apoptosis

The apoptosis rate of gallbladder carcinoma is 40%, and the apoptosis rate of gallbladder carcinoma with poor differentiation is higher than that of highly differentiated gallbladder carcinoma, indicating that apoptosis plays an important role in the pathogenesis of gallbladder carcinoma and can be used as a prognostic indicator for gallbladder cancer.

5.B type ultrasound

It is the first choice for the diagnosis of gallbladder cancer. The positive rate of diagnosis of gallbladder cancer by B-ultrasound is 60%-80%. Generally, the ultrasound image of gallbladder cancer has wall thickening type, bulging type, mixed type and real block type. Loss of normal morphology; thickening of the gallbladder wall, uneven surface; localized echogenic mass of the gallbladder wall; high-vibration blood spectrum inside, should be highly alert to gallbladder cancer, at the same time, B-ultrasound can also find intrahepatic metastases, Important signs such as hilar biliary obstruction, intrahepatic bile duct dilatation, hilar lymphadenopathy, etc. In addition, direct cholangiography of the gallbladder under ultrasound guidance can help to clarify the cause of gallbladder non-development, for thickened walls or masses. First, the cytology examination is performed, and then the bile in the gallbladder is used for cytological examination and biochemical examination to help diagnose.

6.CT

The diagnosis rate of gallbladder cancer is 65%-90%, which can be qualitatively characterized, showing irregular nodular thickening or uniform thickening of the gallbladder wall; soft tissue block in the cyst cavity; single or multiple small nodules in the cavity; Often accompanied by gallstones or cystic wall calcification, according to the above-mentioned performance CT classification of gallbladder cancer into cystic wall hypertrophy (also known as inflammation type, accounting for 25%) mass type (50%), nodular type (25%) 3 species Types, all of the above types can occur with bile duct obstruction and liver metastasis.

7.MRI

The diagnostic rate is similar to B-ultrasound, CT, gallbladder cancer MRI examination mostly uses spin echo, gallbladder cancer is divided into mass type and infiltration type, mass type T1 weighted image is low signal, T2 weighted image is high or slightly high signal The infiltrating T1-weighted image is a slightly lower or affirmative low signal, and the T2-weighted image appears as a signal with a slightly higher or a certain higher inhomogeneity. MRI is better for tumor invasion of blood vessels and various diffusion methods than CT, and magnetic resonance cholangiography The normal gallbladder shadow on the MRC' image does not show a local mass.

8. Retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic cholangiography (PTC) have a diagnostic rate of 50% to 70% for gallbladder cancer, which can show gallbladder bile duct lesions, gallbladder filling defects or no development, hilar Or the common bile duct shift or stenosis.

9. Laparoscopic or Ultrasound Laparoscopy (IVS) Laparoscopic swelling can be observed under laparoscopy. The cystic wall is thick and turbid or the appearance is gray-white mass or the surface of the gallbladder is nodular and uneven, with abnormal blood vessels walking, such as in laparoscopy. Direct cholecystography under direct vision, biopsy or biliary cytology can confirm the diagnosis.

Ultrasound laparoscopy (IUS) has high resolution and can be examined in all directions of the gallbladder. The structure of the gallbladder can be more clearly observed, and the small bulging lesions that cannot be detected by the surface ultrasound can also be diagnosed.

10. Celiac angiography

The diagnosis rate is 70% to 80%. It can be seen that the gallbladder artery is widened, the thickness is uneven, interrupted, distorted or there are new tumor blood vessels.

11. X-ray inspection

Oral cholecystography and venous cholangiography can show the gallbladder, bile duct morphology and size, to predict whether there is obstructive gallbladder or bile duct dilatation, while understanding the gallbladder, bile duct filling defect and compression, but more than 85% do not develop, the diagnostic value is more small.

Diagnosis and diagnosis of gallbladder cancer in the elderly

Diagnostic criteria

Ultrasound can be seen in the irregular thickening of the gallbladder wall and the position of the gallbladder without echogenic echogenic mass diagnostic rate of 50% to 90%, should be the first choice. Endoscopic ultrasonography has a certain value in the diagnosis of early gallbladder carcinoma and its depth of invasion and infiltration of the liver biliary tract. Percutaneous transhepatic cholangiography (PTC) retrograde cholangiopancreatography (ERCP), CT and MRI have certain diagnostic value. When performing ER-CP and PTC, bile can be collected for cytological examination. Under the guidance of X-ray or ultrasound guided percutaneous liver for direct gallbladder angiography, the success rate was 85% and 95% respectively; in addition, the biopsy of the gallbladder wall was taken for cytological examination, and the diagnostic accuracy was about 85%. Laparoscopy can detect tumor nodules and biopsy for cytological or histological diagnosis. The diagnostic accuracy of celiac angiography is 70% to 80% and early cancer may be detected. It manifests as a widening of the gallbladder artery, uneven thickness or interruption.

Differential diagnosis

Primary liver cancer

There is a history of cirrhosis, often malignant on the basis of cirrhosis, so there is clinical manifestations of cirrhosis, liver right lobe shrink, left lobe compensatory, gallbladder can not touch, splenomegaly, AFP positive, B-ultrasound, CT, MRI The inspection can be identified.

2. Periampullary cancer

It is characterized by middle and upper abdominal pain, obstructive jaundice, weight loss and gallbladder enlargement, similar to gallbladder cancer, but this disease is often not associated with chronic cholecystitis, cholelithiasis, more common gastrointestinal bleeding, duodenal microscopy and biopsy can confirm the diagnosis .

3. Common bile duct stones: patients with sudden chills, high fever, paroxysmal upper abdominal pain, jaundice for deep and shallow volatility, complete obstructive jaundice rarely more than 1 week and other characteristics can be differentiated from gallbladder cancer, ERCP, PTC, The diagnostic rate of venous cholangiography is high.

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