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如何治療膽囊癌？

一般依據膽囊癌發現的時機與症狀，醫療人員通常會有不同的建議與對策。譬如患者因膽結石切除膽囊，病理化驗突然發現標本上有癌症病灶，此時患者早已完成手術，已目前腹腔鏡的技術，搞不好已經出院了。所以若在常規膽囊手術，像膽結石開刀，外科醫師發現膽囊有異常，或許會立即進行冷凍切片病理檢查，以決定下一個步驟。因此面對不同狀況時，會有不一樣的決定。不過概括說來，對於膽囊癌的治療，首要還是外科手術切除，所以臨床上依據是否可採外科治療，大致可分成三部份來談。

局部可切除期

相對於膽囊癌症分期上的 Tis，T1a 或 b，某些 T2的病患，與即少數 T3; N0; M0。這些患者，病灶侷限在膽囊與其附近，以外科手術即可清除乾淨，尤其是意外在標本上發現癌病變，大多數僅在黏膜上，或者未穿過肌肉層都，幾乎可完全治癒，不需要再次剖腹清除。不過在某些已確定為 I 或 II 期膽囊癌患者，重新剖腹清除膽囊附近的淋巴結與肝臟，可減少局部復發的機會。倘若手術間懷疑膽囊癌已非早期，則清廓切除鄰近血管淋巴等組織，即使對第 III 或 IV 期的患者，有時還是可進行病灶切除。但是要注意的是，近年來腹腔鏡手術的進展與流行，對一些較小的病灶不易檢測，必要時還是改採傳統手術，以期望作完整切除癌細胞病灶。 

　

2. External-beam irradiation: The use of external-beam irradiation with or without chemotherapy as a primary treatment has been reported in small groups of patients to produce short-term control. Similar benefits have been reported for radiation therapy with or without chemotherapy administered following resection.[6,7]

　

此外也有利用某些藥物對放射線的敏感度，先與注射後，在進行放射治療，但這些仍在臨床研究中。

　

局部無法切除期

末期。

　

　

References:

UNRESECTABLE GALLBLADDER CANCER

(any T, N1, M0; any T, N0 or N1, M1; most T3, N0, M0; T4, N0, M0)

These patients are not curable. Significant symptomatic benefit can often be achieved with relief of biliary obstruction. A few patients have very slow-growing tumors and may live several years.

Treatment options:

Standard:

Palliative treatment options may include the following:

　

1. Palliative surgery will often relieve bile duct obstruction and is warranted when symptoms produced by biliary blockade (pruritus, hepatic dysfunction, cholangitis) outweigh other symptoms from the cancer.

2. An alternative approach to biliary obstruction is percutaneous transhepatic radiologic catheter bypass or endoscopically placed stents.

3. Standard external-beam radiation therapy can, on occasion, alleviate biliary obstruction in some patients and may supplement bypass procedures.

4. Standard chemotherapy is usually not effective although occasional patients may be palliated. Clinical trials should be considered as a first option for most patients.[1,2]

　

Under clinical evaluation:
Clinical trials are in progress to improve local control rates by radiation therapy using brachytherapy and/or radiosensitizer drugs or to discover more effective forms of chemotherapy. When possible, patients should be considered for these clinical trials.

　

References:

  1. Pitt HA, Grochow LB, Abrams RA: Hepatobiliary cancers: cancers of the biliary tree. In: DeVita VT Jr, Hellman S, Rosenberg SA, eds.: Cancer: Principles and Practice of Oncology. Philadelphia, Pa: Lippincott-Raven Publishers, 5th ed., 1997, pp 1114-1128.
  2. Hejna M, Pruckmayer M, Raderer M: The role of chemotherapy and radiation in the management of biliary cancer: a review of the literature. European Journal of Cancer 34(7): 977-986, 1998.

RECURRENT GALLBLADDER CANCER

The prognosis for any treated cancer patient with progressing or recurrent gallbladder cancer is poor. The question and selection of further treatment depends on many factors: tumor burden, prior treatment, site of recurrence, and individual patient considerations. Patients may have portal hypertension caused by portal vein compression by the tumor. Transperitoneal and intrahepatic metastases are not uncommon. Clinical trials are appropriate and should be considered when possible.

Localized

Cancer is found only in the tissues that make up the wall of the gallbladder, and it can be removed completely in an operation.

　

Unresectable

All of the cancer cannot be removed in an operation. Cancer has spread to the tissues around the gallbladder, such as the liver, stomach, pancreas, or intestine and/or to lymph nodes in the area. (Lymph nodes are small, bean-shaped structures that are found throughout the body. They produce and store infection-fighting cells.)

　

Recurrent

Recurrent disease means that the cancer has come back (recurred) after it has been treated. It may come back in the gallbladder or in another part of the body.

LOCALIZED GALLBLADDER CANCER

Treatment may be one of the following:
1. Surgery to remove the gallbladder and some of the tissues around it (cholecystectomy).
2. External-beam radiation therapy with or without chemotherapy, possibly followed by surgery.
3. A clinical trial evaluating radiation therapy plus chemotherapy or drugs to make the cancer cells more sensitive to radiation (radiosensitizers).

　

UNRESECTABLE GALLBLADDER CANCER

Treatment may be one of the following:
1. Surgery or other procedures to relieve symptoms.
2. Surgery to bypass the obstructed ducts of the gallbladder.
3. External-beam radiation therapy with or without chemotherapy possibly followed by surgery.
4. Chemotherapy to relieve symptoms. Clinical trials are testing new chemotherapy drugs.
5. A clinical trial evaluating radiation therapy plus chemotherapy or drugs to make the cancer cells more sensitive to radiation (radiosensitizers).

　

RECURRENT GALLBLADDER CANCER

Treatment for recurrent cancer of the gallbladder depends on the type of treatment the patient received before, the place where the cancer has recurred and other facts about the cancer, and the patient's general health. The patient may wish to consider taking part in a clinical trial.

　

　

How Cancer Of The Gallbladder Is Treated

There are treatments for all patients with cancer of the gallbladder. Three treatments are used: surgery (taking out the cancer or relieving symptoms of the cancer in an operation) radiation therapy (using high-dose x-rays to kill cancer cells) chemotherapy (using drugs to kill cancer).

Surgery is a common treatment for cancer of the gallbladder if it has not spread to surrounding tissues. Your doctor may take out the gallbladder in an operation called a cholecystectomy. Part of the liver around the gallbladder and lymph nodes in the abdomen may also be removed.

If your cancer has spread and cannot be removed, your doctor may do surgery to relieve symptoms. If the cancer is blocking the bile ducts and bile builds up in the gallbladder, your doctor may do surgery to go around (bypass) the cancer. During this operation, your doctor will cut the gallbladder or bile duct and sew it to the small intestine. This is called biliary bypass. Surgery or other procedures may also be done to put in a tube (catheter) to drain bile that has built up in the area. During these procedures, your doctor may place the catheter so that it drains through a tube to the outside of your body or so that it goes around the blocked area and drains the bile into the small intestine.

Radiation therapy is the use of high-energy x-rays to kill cancer cells and shrink tumors. Radiation for gallbladder cancer usually comes from a machine outside the body (external-beam radiation therapy). Radiation may be used alone or in addition to surgery.

Chemotherapy is the use of drugs to kill cancer cells. Chemotherapy for cancer of the gallbladder is usually put into the body by a needle inserted into a vein. Chemotherapy is called a systemic treatment because the drug enters the bloodstream, travels through the body, and can kill cancer cells outside the gallbladder. Chemotherapy or other drugs may be given with radiation therapy to make cancer cells more sensitive to radiation (radiosensitizers).

Treatment By Stage

Treatments for cancer of the gallbladder depend on the stage of the disease and your general health.

You may receive treatment that is considered standard based on its effectiveness in a number of patients in past studies, or you may choose to go into a clinical trial. Most patients with gallbladder cancer are not cured with standard therapy and some standard treatments may have more side effects than are desired. For these reasons, clinical trials are designed to find better ways to treat cancer patients and are based on the most up-to-date information. Clinical trials are going on in many parts of the country for patients with cancer of the gallbladder. If you want more information, call the Cancer Information Service at 1-800-4-CANCER (1-800-422-6237); TTY at 1-800-332-8615.

LOCALIZED GALLBLADDER CANCER

Your treatment may be one of the following: 1. Surgery to remove the gallbladder and some of the tissues around it (cholecystectomy). 2. External-beam radiation therapy. 3. Surgery followed by external-beam radiation therapy. 4. Clinical trials of radiation therapy plus chemotherapy or drugs to make the cancer cells more sensitive to radiation (radiosensitizers).

UNRESECTABLE GALLBLADDER CANCER

Your treatment may be one of the following: 1. Surgery or other procedures to relieve symptoms. 2. External-beam radiation therapy with or without surgery or other procedures to relieve symptoms. 3. Chemotherapy to relieve symptoms. Clinical trials are testing new chemotherapy drugs. 4. Clinical trials of radiation therapy plus chemotherapy or drugs to make the cancer cells more sensitive to radiation (radiosensitizers).

RECURRENT GALLBLADDER CANCER

Treatment for recurrent cancer of the gallbladder depends on the type of treatment you received before, the place where the cancer has recurred, and other facts about your cancer and your general health. You may wish to consider taking part in a clinical trial.

HOW IS GALLBLADDER CANCER TREATED?

　

After the cancer is found and staged, your cancer care team will discuss treatment options (choices) with you. It is important to take time and think about all of the choices. In choosing a treatment plan, factors to consider include your overall physical health, the type and stage of the cancer, likely side effects of the treatment, and the probability of curing the disease, extending life, or relieving symptoms.

It is often a good idea to seek a second opinion, particularly for an uncommon cancer like gallbladder cancer. A second opinion can provide more information and help you feel more confident about your chosen treatment plan.

Nearly all doctors agree that surgery offers the only hope for curing people with gallbladder cancer. But at this time, there are differences of opinion about how advanced a gallbladder cancer may be and still be curable. Doctors also occasionally disagree about which operations remove enough tissue to give the patient the best chance of cure. Although early studies of radical operations (removing more than just the gallbladder and some lymph nodes) showed no proof that they helped most patients to live longer, some studies showed the opposite.

In general, spread of the cancer beyond the gallbladder does not always make it incurable by surgery unless the cancer has spread too much. If, for instance, the cancer has invaded the liver but only in one area and not too deeply, it may be possible to surgically remove all of the cancer. If the cancer has spread to both sides of the liver, to the lining of the abdominal cavity, to organs farther away from the gallbladder than the liver, or if it surrounds the vein bringing blood to the liver from the stomach and intestines, surgery may not be able to remove it all.

Surgery

There are two general types of surgical treatment for cancer of the gallbladder -- potentially curative surgery and palliative surgery.

Potentially curative surgery is used when imaging studies indicate a high likelihood that the surgeon will be able to remove all of the cancer known to be present. Doctors may use the term resectable to describe cancers they believe can be removed by potentially curative surgery and unresectable to describe those they think have spread too far or are in too difficult a place to be entirely removed by surgery. Palliative surgery may be performed to relieve pain or prevent complications such as blockage of the bile ducts, if imaging studies indicate that the tumor is too widespread to be completely removed. Palliative surgery is not expected to cure the cancer.

Surgery to remove gallbladder cancer has significant side effects and may require several weeks for recovery. The average (median) survival of patients with stage III unresectable gallbladder cancer is only 6 months after diagnosis, and stage IV patients with unresectable gallbladder cancer may survive only 1 to 3 months. Patients whose cancer is not curable may want to carefully weigh the value of surgery or treatments that require a significant time for recovery. Unless there is clear evidence that such treatments will improve the patient's chance for significantly longer survival or improve quality of life, some patients with very advanced stages of gallbladder cancer may choose to avoid them.

Cholecystectomy (simple cholecystectomy): If the entire gallbladder (but only the gallbladder) is removed, the operation is called a cholecystectomy (pronounced "co-le-sis-tek-toe-me") or simple cholecystectomy. The operation gets its name from cholecyst, the Greek word for gallbladder (chole means bile and cyst means small sack). The last part of the word, the suffix --ectomy, is Greek for removal of a body part by surgery.

Extended cholecystectomy: This operation involves:

Radical gallbladder resection: This procedure includes at least:

　

Open cholecystectomy: If the surgeon removes the gallbladder through a large cut in the abdominal wall, it is called an open cholecystectomy. If it seems likely from imaging and/or other diagnostic tests that gallbladder cancer may be present, the open cholecystectomy is almost always chosen instead of the laparascopic cholecystectomy.

Laparascopic cholecystectomy: If imaging and/or other diagnostic tests do not lead doctors to think that gallbladder cancer is present, but indicate that the gallbladder should be removed because of gallstones or other problems, the operation may be done with the aid of an instrument called a laparascope. The operation is called a laparascopic cholecystectomy.

The laparascope is a thin, flexible tube with a tiny video camera on the end that is inserted through a small surgical opening in the patient's side. Other surgical instruments are used to withdraw the gallbladder. Because laparascopic cholecystectomy has sometimes been responsible for the accidental release in the body of cancer cells from the tissue being removed, it is usually not done if gallbladder cancer is suspected. It is very important that the laparascopic cholecystectomy be done by a surgeon very experienced with the procedure and that proper precautions be taken to prevent any cancer cells possibly present being released as the gallbladder is squeezed during removal.

If gallbladder cancer is discovered during a laparascopic cholecystectomy, most surgeons would switch to an open cholecystectomy (a larger incision, without the laparascope). That change is made to avoid the risk of leaving behind cancer that may have spread outside the gallbladder. It may also avoid "seeding" of the abdominal cavity with cancer cells squeezed out of the gallbladder as it is removed. If cancer is found in the gallbladder only after it is removed, it may be necessary to operate again to remove cancer that was more widespread than originally suspected.

Gastrojejunostomy: The stomach is attached directly to the small intestine once the gallbladder and ducts have been removed. The word is pronounced "gastro-jeh-june-oz-toe-me."

Segmental hepatic resection: An operation to remove a segment of liver tissue is referred to as a segmental hepatic resection. It may be done if cancer has invaded the liver.

Hepatic lobectomy: Removal of a whole lobe of the liver is called a hepatic lobectomy. The phrase is pronounced "hep-at-ik lobe-ek-toe-me."

Hepatopancreatoduodenectomy: The removal of liver tissue may be combined in some cases with the removal of the pancreas and a portion of the small intestine. That operation is called a hepatopancreatoduodenectomy (pronounced "hep pat-o pan cree at-o due oh den ek toe me.")

Pancreatoduodenectomy: This procedure, (pronounced "pan cree at oh due oh den eck toe me") removes the pancreas and the upper part of the small intestine known as the duodenum.

Colon resection: If the cancer has spread to the colon (large intestine), doctors may remove the affected part of the colon, and re-join the unaffected parts.

All of the operations listed above, and virtually any other operation involving removal of the gallbladder, involve general anesthesia (the patient is "asleep" during the operation).

Unfortunately, removal of all of the visible cancer is possible in only about 25 percent of gallbladder cancer cases. That is because early gallbladder cancer usually does not cause symptoms and so it usually is not discovered until late in the course of the disease when the cancer has spread to other areas.

Radiation Therapy

There are several different kinds of radiation therapy. External beam radiation uses x-rays from a machine outside the patient's body to kill cancer cells. In brachytherapy, radioactive material inside very small casings called "seeds" is placed inside the patient's body. Either type of radiation therapy can be given after an operation or during the operation. If either type is done during an operation, it is called intra-operative radiation therapy (abbreviated as IORT). In one study, IORT was believed to have increased the percentage of stage IV gallbladder cancer patients surviving five years or more from zero percent to 10 percent, after the patients underwent an extended cholecystectomy. These results have not been confirmed by other studies, however. IORT is almost always external-beam radiation, but intra-operative (during an operation) use has been made of brachytherapy in gallbladder cancer also.

Radiation therapy may be used in several ways to treat gallbladder cancer. It may be used as an adjuvant therapy (a therapy that adds to the effect of the main therapy, which is usually surgery) to kill any cancer cells that remain after surgery. Because gallbladder cancer is somewhat rare, the studies that have been done to determine the value of radiation as an adjuvant therapy for gallbladder cancer have been done with small numbers of patients. However, most of the reported studies seem to suggest that using radiation in that way helps patients to live longer after potentially curative surgery.

Radiation therapy can also be used as a main therapy for patients whose cancer has spread too far to be completely removed by surgery. The radiation cannot be expected to cure such patients. Some evidence suggests it may help such patients live longer but researchers are not certain, and there is no agreement on whether such therapy is really useful to the patient in such circumstances.

Radiation is often used as palliative therapy when a patient's cancer is too far advanced to be cured. It may be used to relieve pain or other symptoms by shrinking tumors that are blocking passageways for blood or bile or are pressing on nerves. There is general agreement among doctors that palliative radiation for gallbladder cancer is useful.

Chemotherapy

Chemotherapy is treated with anticancer drugs that are given into a vein or by mouth. These drugs enter the bloodstream and reach all areas of the body, making this treatment useful in some cancers that have spread or metastasized to organs beyond the gallbladder. Unfortunately, gallbladder cancer seems to be very resistant to chemotherapy, and for that reason it is not widely or consistently used against the disease.

Chemotherapy alone cannot cure gallbladder cancer, and there is no chemotherapy regimen known to consistently prolong survival in gallbladder cancer patients if used without surgery or radiation. For those reasons, chemotherapy is used as an adjuvant therapy (to boost the effectiveness of the main therapy, which usually is surgery) against gallbladder cancer.

Some studies have found that chemotherapy drugs such as mitomycin or a combination of 5-fluorouracil (5-FU), doxorubicin, and mitomycin can shrink gallbladder cancers. Unfortunately, the percentage of patients whose tumors are reduced by 50 percent or more in response to the drugs has been small. As a result, most doctors will not recommend chemotherapy as an adjuvant to surgery.

Some doctors feel that chemotherapy has more effect on gallbladder cancer when used in combination with radiation. That combination has shown some ability to control gallbladder cancer for short periods of time, when used either with or without surgery. More studies are planned with those and similar combination therapies.

Direct hepatic arterial infusion (injection of the drugs directly into the artery bringing blood to the liver) with a combination of drugs has been shown to allow some patients whose cancer was not removable by surgery to live longer.

Palliative Therapy

The word palliative comes from the Latin word for a protective cloak, and palliative therapy is treatment meant to protect the patient from unnecessary pain and other symptoms, but is not expected to cure the disease.

If the cancer has spread too far to be completely removed by surgery, doctors may concentrate on palliative operations, palliative radiation, and other palliative therapies.

Biliary bypass: If cancer is blocking the ducts that carry bile from the gallbladder to the small intestine, the doctor may use surgery to restore flow of bile. There are several different biliary bypass operations. Which one is used is based on the exact location of the blockage. A choledochojejunostomy joins the common bile duct to the jejunum of the small intestine. A gastrojejunostomy joins the stomach directly to the jejunum of the small intestine. A hepaticojejunostomy joins the duct that carries bile from the liver to the jejunum of the small intestine.

Biliary stent or biliary catheter: Another option to release bile from the gallbladder is for the doctor to insert a tube (called a stent or catheter) into the bile duct or the gallbladder. This may be done surgically or, in some cases, the tube may be inserted through the skin (percutaneous stent). The tube may drain the bile into the small intestine, or to a bag outside the body that can be emptied when necessary. The stent or catheter may need to be replaced every two to three months to reduce the risk of jaundice or gallbladder inflammation.

Alcohol injection: To relieve pain, doctors may deaden the nerves that convey sensations of pain from the gallbladder and intestinal area to the brain, by injecting these nerves with alcohol. This operation is called an alcohol splanchnicectomy, (pronounced "splanch-nuh-sect-o-mee").

Palliative radiation: Radiation therapy may be used to help relieve pain and other symptoms by killing some cancer cells that are causing blockage of the bile ducts or are pressing on nerves.

Pain medications: Doctors can prescribe strong pain-killing drugs if needed. Some people with cancer may hesitate to use narcotic drugs for fear of becoming addicted to them. Yet some of the most effective pain-killing drugs are narcotics, and studies show that most patients are not at risk of becoming addicted to drugs prescribed for them to stop pain for medical conditions.

Complementary and Alternative Methods

If you are considering any unproven alternative or complementary treatments, it is best to discuss this openly with your cancer care team and request information from the American Cancer Society or the National Cancer Institute. Some unproven treatments can interfere with standard medical treatments or may cause serious side effects.

Clinical Trials

Studies of promising new or experimental treatments in patients are known as clinical trials. During a course of treatment for gallbladder cancer, the doctor may suggest that a patient take part in a clinical trial of a new treatment. A clinical trial is only done when there is some reason to believe that the treatment being studied may be of value to the patient. Treatments used in clinical trials are often found to have real benefits.

There are three phases of clinical trials in which a treatment is studied before it is eligible for approval by the FDA (Food and Drug Administration).

The purpose of a Phase I study is to find the best way to give a new treatment and how much of it can be given safely. Physicians watch patients carefully for any harmful side effects. The research treatment has been well tested in laboratory and animal studies, but the side effects in patients are not completely predictable.

Phase II trials determine the effectiveness of a research treatment after safety has been evaluated in a Phase I trial. Patients are closely observed for an anti-cancer effect by careful measurement of cancer sites present at the beginning of the trial. In addition to monitoring patients for response, any side effects are carefully recorded and assessed.

Phase III trials require entry of large numbers of patients; some trials enroll thousands of patients. One of the groups may receive standard (the most accepted) treatment, so the new treatments can be directly compared. The group that receives the standard treatment is called the "control group." For example, one group of patients (the control group) may receive the standard chemotherapy for a certain type of cancer, while another patient group may receive another type of chemotherapy that may or may not contain an investigational drug to see if this improves survival. All patients in Phase III trials are monitored closely for side effects, and treatment is discontinued if the side effects are too severe.

Researchers conduct studies of new treatments to answer the following questions:

However, there are some risks. No one involved in the study knows in advance whether the treatment will work or exactly what side effects will occur. That is what the study is designed to discover. While most side effects will disappear in time, some can be permanent or even life threatening. Keep in mind, though, that standard treatments have side effects, too. Depending on many factors, you may decide that a clinical trial may be beneficial to you.

Enrollment in any clinical trial is completely up to you. Your doctors and nurses will explain the study to you in detail and will give you a form to read and sign indicating your desire to take part. This process is known as giving your informed consent. Even after signing the form and after the clinical trial begins, you are free to leave the study at any time, for any reason. Taking part in the study does not prevent you from getting other medical care you may need.

To find out more about clinical trials, ask your cancer care team. Among the questions you should ask are:

You can get a list of current clinical trials by calling the National Cancer Institute's Cancer Information Service toll free at 1-800-4-CANCER or visiting the NCI clinical trials web site for patients (http://cancertrials.nci.nih.gov/) or health care professionals (cancernet.nci.nih.gov/prot/protsrch.shtml).

TREATMENT OPTIONS BY STAGE

Stage I

Surgery: Most gallbladder cancers in this early stage are found when the gallbladder is removed as a treatment for gallstones or chronic inflammation of the gallbladder. Between 10 and 20 percent of gallbladder cancers are found during such a procedure. If a stage I cancer is found in a gallbladder removed by a simple cholecystectomy no further treatment may be needed. However, even stage I tumors may tend to recur (come back) if they are in the liver bed (that part of the gallbladder wall that rests against the liver) and are removed only with a simple cholecystectomy. If a stage I tumor in this location is discovered during a cholecystectomy or is seen on imaging tests before the operation, a portion of the liver closest to the tumor is usually removed. The surgeon may choose to perform an extended cholecystectomy at that time, taking out nearby lymph nodes, along with a part of the liver, to reduce the chances of the cancer coming back.

If the gallbladder is removed as a treatment for gallstones or chronic gallbladder inflammation and it is discovered after the operation that there was cancer, a second operation may be recommended to remove any cancer that may have spread outside the gallbladder before it was removed. If the second operation is successful in removing all of the cancer, it may allow the patient to live five years or longer.

Radiation therapy: A few studies have shown that some patients with stage I gallbladder cancer may benefit more from a combination of radiation therapy and surgery than from surgery alone. In these patients, the radiation appeared to have killed microscopic deposits of cancer cells that were not removed by surgery because they were too small for the surgeon to see. Because of the small number of patients involved in these studies, it is difficult to judge the significance of the results. Some doctors recommend radiation therapy for stage I cancers while others do not.

Stage II

Surgery: When a cancer is detected by imaging studies done before surgery, studies suggest that the extended cholecystectomy or more radical operations may help more patients live longer. Only about 15 percent of all patients with stage II gallbladder cancer survive five years or longer after diagnosis, but some studies suggest that survival rates are higher when an extended cholecystectomy is done.

Radiation therapy: Some studies suggest that external beam radiation therapy used as an adjuvant to surgery can help some patients with stage II gallbladder cancer survive longer. The radiation is meant to kill any cancer cells that may not have been removed during surgery. A "boost" dose of radiation may be given after the main dose, by brachytherapy (radioactive "seeds" implanted into the patient's body) or by more external beam radiotherapy.

Chemotherapy: Although most gallbladder cancers are relatively resistant to chemotherapy, some doctors believe adjuvant chemotherapy may help some people with stage II gallbladder cancers.

Palliative therapy: For patients whose cancer is too far advanced to be completely removed by surgery or who are too frail to withstand surgery, palliative treatment may be recommended. Examples include palliative operations, radiation therapy, or the placement of stents to restore flow of bile. Alcohol injections into nerves that relay sensations of pain from the gallbladder and affected areas to the brain are another example of palliative therapies.

Stage III

Surgery: In the recent past, stage III gallbladder cancers have been considered unresectable (not entirely removable by surgery) and incurable. New surgical techniques such as the extended cholecystectomy or radical gallbladder resection may offer hope of a cure or provide extended survival to some people with stage III cancers. Overall, only about 5 percent of all stage III gallbladder cancer patients survive five years or longer. However, removing liver tissue near the tumor and regional lymph nodes by these extensive operations appears to improve survival rates somewhat.

Patients told their gallbladder cancer is unresectable may want to ask their doctors about these operations and/or seek a second opinion before concluding their cancer is incurable.

Radiation therapy: There is some evidence to support use of radiation therapy given after surgery meant to completely remove a stage III gallbladder cancer. The external-beam radiation is given over a five-week period and may be followed by a "boost" of additional radiation. The boost may come from additional external beam radiation or from brachytherapy (radioactive "seeds" implanted into the area to be treated). Because there have been no large trials comparing many patients given radiation after gallbladder surgery to others treated with surgery alone, it is difficult to be certain of the benefit and some doctors do not recommend radiation for patients in this group.

For those stage III patients whose cancer cannot be removed by surgery, survival times tend to be very short, whether radiation is used or not. Palliative radiation therapy may help such patients by relieving pain and other symptoms, however.

Chemotherapy: Although most gallbladder cancers are relatively resistant to chemotherapy, some doctors believe adjuvant chemotherapy may help some people with stage III gallbladder cancers. Studies have shown that chemotherapy has more effect on gallbladder cancer when used in combination with radiation, and that combination has shown some ability to control gallbladder cancer for short periods of time, when used either with or without surgery.

Stage IV

Surgery: Most stage IV gallbladder cancers are not curable and survival time is generally short. Overall, only one percent of all people with stage IV gallbladder cancers will survive five years or longer. Curative surgery is not usually an option, although some doctors feel that aggressive surgery may prolong survival.

Radiation therapy: Combining surgery and radiation is thought by some doctors to extend survival and reduce recurrences in some patients with advanced gallbladder cancer.

Chemotherapy: Gallbladder cancer is usually quite resistant to chemotherapy. It may be offered as palliation in some cases alone or with surgery and/or radiation therapy.

Recurrent Gallbladder Cancer

Recurrent gallbladder cancer is treated in much the same way as advanced (Stage III or IV) gallbladder cancer. However, treatment may also depend on where the cancer recurs, what kind of treatment was previously used, and on the patient's general health at the time of recurrence.

WHAT SHOULD YOU ASK YOUR DOCTOR ABOUT GALLBLADDER CANCER?

　

As noted earlier, it is important to have honest, open discussions with your cancer care team. They want to answer all of your questions, no matter how trivial they might seem to you. For instance, consider these questions:

  • What kind of gallbladder cancer do I have?
  • Has my cancer spread beyond the primary site?
  • What is the stage of my cancer and what does that mean in my case?
  • What treatment choices do I have?
  • What do you recommend and why?
  • What risks or side effects are there to the treatments you suggest?
  • What are the chances my cancer will recur with these treatment plans?
  • What should I do to be ready for treatment?
  • Based on what you've learned about my cancer, how long do you think I'll survive?

In addition to these sample questions, be sure to write down some of your own. For instance, you might want more information about recovery times so you can plan your work schedule. Or, you may want to ask about second opinions or about clinical trials for which you may qualify.

WHAT'S NEW IN GALLBLADDER CANCER RESEARCH AND TREATMENT?

　

Research into the causes, diagnosis, and treatment of gallbladder cancer is currently underway in many medical centers throughout the world.

Chemotherapy and radiation therapy: Researchers are also looking at new ways of increasing the effectiveness of radiation therapy, and at chemotherapy drugs that have not been tried against gallbladder cancer in the past or are being tried in new ways. These drugs include, among others, irinotecan (CPT-11), doxorubicin, oxaliplatin, aminocamptothecin, and a combination of hydroxyurea and 5-FU.

Immunotherapy: Experimental treatments that boost the patient's immune response to fight gallbladder cancer more effectively are being tested in clinical trials. One such treatment currently under study is the use of interleukin-12 (IL-12), a substance that aids in communication among the patient's immune system cells.

Gene therapy: Another therapy being tested in clinical trials uses an altered cold virus known as ONYX-15. Most cold viruses produce a protein known as E1B that neutralizes the cells’ p53 protein. The cells of many gallbladder cancers have abnormal p53 genes that produce p53 protein that doesn't work properly. Scientists have removed the E1B protein in the ONYX-15 cold virus, so that normal cells with intact p53 genes can kill the virus, but cancer cells with damaged or missing p53 genes, cannot kill the virus and are killed by it. This therapy has shown promise when used in some other cancers and is now being tested in gallbladder cancer.

WHAT HAPPENS AFTER TREATMENT FOR GALLBLADDER CANCER?

　

After the initial course of treatment is completed, it is very important to keep all scheduled follow-up appointments. During these appointments, your doctors will ask questions about any symptoms, do physical examinations, and order blood tests or imaging studies such as CT scans and ultrasonography to check for cancer recurrence, further spread of cancer, or side effects of certain treatments.

The earlier that recurrences and certain side effects of treatment are detected, the more effectively they can usually be treated. Patients should never hesitate to tell their doctors or other health care providers about any symptoms or side effects that concern them. There are effective treatments for pain associated with cancer and for many of the side effects of cancer treatment.

Each type of treatment has adverse effects that may last for a few months; some complications, however, can be permanent. You may be able to hasten your recovery by being aware of the side effects before you start treatment. You might be able to take steps to reduce them and shorten the length of time they last.

Remember that your body is unique, and so are your emotional needs and your personal circumstances. In some ways, your cancer is like no one else's. No one can predict precisely how you will respond to cancer or its treatment. Statistics can paint an overall picture, but you may have special strengths such as a healthy immune system, a history of good nutrition, a strong family support system, or a deep spiritual faith. All of these have an impact on how you cope with cancer.

Cancer treatment can make you feel tired so give yourself time to recover. Don't feel you have to rush back to work or resume all of your normal activities right away. Give your body the rest it needs and you will feel better in the long run.

Do as much as you can to help yourself stay healthy and active. If you smoke, try to quit. Ask your health care team for suggestions about how to quit smoking. Eat a balanced diet of healthy foods, including plenty of fruits, vegetables, and whole grains. Once you get your strength back, try to exercise a few hours each week. Your care providers can suggest the types of exercise that are right for you.

Your health care team can suggest other organizations that might help you during your recovery from treatment. There are many support groups available that provide emotional support, friendship, and understanding.

Revised: 06/29/2000
　

參考資料：

  1. Chijiiwa K, Tanaka M: Carcinoma of the gallbladder: an appraisal of surgical resection. Surgery 115(6): 751-756, 1994.
  2. Yamaguchi K, Chijiiwa K, Saiki S, et al.: Retrospective analysis of 70 operations for gallbladder carcinoma. British Journal of Surgery 84(2): 200-204, 1997.
  3. Wibbenmeyer LA, Wade TP, Chen RC, et al.: Laparoscopic cholecystectomy can disseminate in situ carcinoma of the gallbladder. Journal of the American College of Surgeons 181(6): 504-510, 1995.
  4. Hejna M, Pruckmayer M, Raderer M: The role of chemotherapy and radiation in the management of biliary cancer: a review of the literature. European Journal of Cancer 34(7): 977-986, 1998.
  5. American Cancer Society

　

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