Gallbladder cancer is a rare but highly aggressive malignancy that begins in the cells lining the gallbladder — a small, pear-shaped organ located beneath the liver. In Singapore, gallbladder cancer accounts for less than 1% of all cancers. However, the concern with gallbladder cancer is that it is often found at a later stage, making it harder to treat effectively and leading to a less favourable outcome.
Gallbladder cancer is classified into stages, from Stage 0 (early, localised disease) to Stage IV (widespread metastasis), according to the tumour's spread within and beyond the gallbladder. This staging system is crucial for guiding treatment decisions and estimating prognosis.
Gallbladder Cancer Stages
Early diagnosis of gallbladder cancer is challenging due to its often vague or absent symptoms. In Singapore, many cases are found incidentally during gallbladder removal for gallstones. The similarity of its symptoms to common gallbladder conditions like biliary colic or cholecystitis often leads to delayed diagnosis until the cancer has advanced.
The TNM Staging System
Doctors use the TNM system, established by the American Joint Committee on Cancer (AJCC), to assess the cancer's reach:
- T (Tumour): Indicates how deeply the cancer has penetrated the gallbladder wall and whether it has reached nearby structures such as the liver or bile ducts.
- N (Nodes): Describes whether cancer has spread to regional lymph nodes, and how many are affected.
- M (Metastasis): Refers to the presence of cancer in distant organs, like the lungs or abdominal lining.
Each component is assigned a number (e.g., T1, N2) to reflect its severity. If information is incomplete, doctors may label it as TX, NX, or MX. These TNM values are then combined to assign an overall stage:
Stage 0
Stage 0 (Tis, N0, M0) gallbladder cancer is the earliest detectable form, with cancer cells still contained within the inner lining and no spread. It is usually asymptomatic, discovered by chance, and highly curable when surgically removed early.
Stage 1
Stage I gallbladder cancer (T1, N0, M0) signifies early invasion into the gallbladder wall, either the lamina propria (T1a) or the muscular layer (T1b). However, cancer has not yet spread to lymph nodes or other organs. Early detection and appropriate surgical intervention offer promising survival outcomes.
Stage 2
Stage II gallbladder cancer (T2, N0, M0) means the tumour has moved beyond the muscle layer into deeper tissue, either facing the abdomen (T2a) or liver (T2b). Still, it has not escaped the gallbladder or reached the lymph nodes or other organs. This stage calls for precise surgical management, and patients are usually referred to hepatobiliary specialists for further treatment if T2 is found.
Stage 3
In stage III gallbladder cancer, the tumour has extended through the gallbladder wall into the liver or nearby organs (Stage IIIA – T3, N0, M0), or has spread to 1–3 regional lymph nodes (Stage IIIB – any T, N1, M0). Surgical intervention becomes more complex, and treatment may involve a combination of surgery and other therapies.
Stage 4
Stage IV gallbladder cancer is the most advanced stage. The tumour has either grown into major liver blood vessels or spread to multiple nearby organs (Stage IVA – T4, N0/N1, M0), or it has spread to four or more lymph nodes or distant organs (Stage IVB – any T, N2, M0 or any T, any N, M1). Surgery is often not feasible, and palliative care becomes a key focus.
Treatment Options by Stages
Gallbladder cancer treatment is guided by tumour size, location, and whether it has spread to nearby lymph nodes or distant organs. Depending on these factors, doctors may use a single treatment or a combination approach to manage the disease.
- Gallbladder Surgery: Surgery is the primary treatment for early-stage gallbladder cancer (commonly for stages 0 to 2). The goal is to remove the tumour completely. Common procedures for gallbladder cancer include:
- Simple Cholecystectomy: This refers to the removal of only the gallbladder. It is usually done when cancer is detected incidentally during surgery for gallstones.
- Extended Cholecystectomy: This is a more comprehensive procedure that removes the gallbladder, part of the liver, nearby lymph nodes, and possibly parts of the bile duct or intestine.
- Radical Resection: This procedure includes all components of extended cholecystectomy, and may also involve nearby organs like the duodenum or pancreas, depending on cancer spread.
- Chemotherapy: This treatment uses drugs to kill or stop cancer cells from growing. It may be used:
- After surgery to reduce the risk of recurrence (Stages 1 and 2).
- When surgery is not possible, to slow the spread or relieve symptoms (typically in Stage 4).
- Often combined with radiation therapy for better results (Stages 0 to 4).
- Radiation Therapy: Radiation uses high-energy beams to destroy cancer cells, typically external beam radiation therapy (EBRT). It is most commonly used for Stages 2 to 4 or when surgery is not feasible.
Prognosis and Survival Rates by Stage
The prognosis for gallbladder cancer is heavily reliant on the stage at which it is diagnosed. However, patient-specific factors also contribute significantly to the outcome.
- Age: Younger patients often tolerate treatment better and may have more favourable outcomes.
- Overall Health: People with fewer medical conditions recover faster and handle surgery or chemotherapy more effectively.
- Response to Treatment: Some tumours shrink well with chemotherapy or radiotherapy. This responsiveness can extend survival.
- Pathologic Features: Certain markers on biopsy or imaging, like tumour grade or vascular invasion, also affect prognosis.
While specific survival rates in Singapore are limited, global data offers general insights into treatment outcomes:
- Localised (Stages 0–I): When detected early and confined to the gallbladder, the 5-year survival rate is approximately 69%.
- Regional (Stages II–III): As the cancer spreads to nearby organs or lymph nodes, survival rates decrease significantly. While specific percentages for Singapore are not available, global data suggest a 5-year survival rate of around 28% for regional spread.
- Distant (Stage IV): Once the cancer has metastasised to distant organs, the 5-year survival rate drops to approximately 3%.
Consult a Gallbladder Cancer Doctor
Gallbladder cancer’s quiet progression and lack of early symptoms often lead to a late-stage diagnosis, when treatment becomes more challenging and outcomes are less optimistic.
Despite its asymptomatic nature, it remains important to undergo regular check-ups with a gallbladder doctor. Early detection can help prevent complications that may raise the risk of developing cancer and significantly improve treatment outcomes.
For those facing gallbladder conditions, including gallbladder cancer, consulting an experienced specialist is essential for effective and personalised treatment. Dr Wong Jen San, the head of the Hepatobiliary & Pancreatic Surgery Centre, offers specialised expertise in the diagnosis and management of gallbladder diseases, including complex cancer cases.
You may contact us at (65) 6235 4088 or email enquiry@liverpancreassurgery.sg to schedule an appointment.