Risk factors for gallbladder cancer. An international collaborative case-control study

Global epidemiological trends and variations in the burden of gallbladder cancer

BACKGROUND

Gallbladder cancer (GBC) is a rare but lethal malignancy with a dismal prognosis. The aim of this study is to analyze the burdens and trends of GBC across the world based on geography, socioeconomic development (based on human development index [HDI]), and gender.

METHODS

GLOBOCAN 2020 database was used to extract data (2020-2040) relating to the incidence and mortality of GBC across the world.

RESULTS

Asia had the highest burden of GBC with India and China contributing to majority of the absolute burden. The burden of GBC by age standardized rate was highest in Latin America (Bolivia and Chile) and Southeast Asia (Bangladesh and Nepal). Medium HDI countries had a higher mortality rate compared to very high HDI countries. Females had a higher predilection for GBC across different regions and socioeconomic groups. GBC burden is expected to significantly increase across the world by 2040 with variable trends across different regions, age groups, and genders.

CONCLUSION

The global burden of GBC will significantly increase over the next two decades with marked regional and demographic variations. The results of this study will empower national and global health leaders to develop policies to address the increasing burden of this lethal malignancy.

Metabolic dysfunction-associated gallstone disease: expecting more from critical care manifestations

About 20% of adults worldwide have gallstones which are solid conglomerates in the biliary tree made of cholesterol monohydrate crystals, mucin, calcium bilirubinate, and protein aggregates. About 20% of gallstone patients will definitively develop gallstone disease, a condition which consists of gallstone-related symptoms and/or complications requiring medical therapy, endoscopic procedures, and/or cholecystectomy. Gallstones represent one of the most prevalent digestive disorders in Western countries and patients with gallstone disease are one of the largest categories admitted to European hospitals. About 80% of gallstones in Western countries are made of cholesterol due to disturbed cholesterol homeostasis which involves the liver, the gallbladder and the intestine on a genetic background. The incidence of cholesterol gallstones is dramatically increasing in parallel with the global epidemic of insulin resistance, type 2 diabetes, expansion of visceral adiposity, obesity, and metabolic syndrome. In this context, gallstones can be largely considered a metabolic dysfunction-associated gallstone disease, a condition prone to specific and systemic preventive measures. In this review we discuss the key pathogenic and clinical aspects of gallstones, as the main clinical consequences of metabolic dysfunction-associated disease.

Spatial Patterns of Gallbladder and Biliary Tract Carcinoma in China From 1990 to 2019: An Analysis at the Provincial Level

Background Despite a high rate of fatal malignancy, little is known regarding the spatial and temporal patterns of the disease burden of gallbladder and biliary tract carcinoma in China, especially at the provincial level. Methodology Using data from the 2019 Global Burden of Diseases, Injuries, and Risk Factors Study, we estimated the temporal trend of the disease burden of gallbladder and biliary tract carcinoma from 1990 to 2019 as well as its incidence, mortality, prevalence, and disability-adjusted life-years (DALYs). We estimated the spatial pattern of the disease burden of gallbladder and biliary tract carcinoma at the provincial level. Results The disease burden of gallbladder and biliary tract carcinoma significantly increased from 1990 to 2019 in China. The age-standardized incidence, prevalence, mortality, and DALYs increased by 28.3%, 50.5%, 13.0%, and 7.0%, respectively. The disease burden of gallbladder carcinoma revealed substantial heterogeneity at the provincial level with a higher disease burden in developed provinces or cities than in developing provinces. The disease burden of gallbladder and biliary tract carcinoma was also heavier among males than among females (e.g., age-standardized DALYs: 42.60 per 100,000 people among males vs. 33.57 per 100,000 people among females in 2019). Conclusions The disease burden of gallbladder and biliary tract carcinoma has shown rapid changes during the past three decades, with a higher burden in economically advantaged regions than in disadvantaged regions in China. New public health policies and initiatives are needed to address this rising disease burden.

Understanding the Clinical Significance of MUC5AC in Biliary Tract Cancers

Biliary tract cancers (BTC) arise from biliary epithelium and include cholangiocarcinomas or CCA (including intrahepatic (ICC) and extrahepatic (ECC)) and gallbladder cancers (GBC). They often have poor outcomes owing to limited treatment options, advanced presentations, frequent recurrence, and poor response to available systemic therapy. Mucin 5AC (MUC5AC) is rarely expressed in normal biliary epithelium, but can be upregulated in tissues of benign biliary disease, premalignant conditions (e.g., biliary intraepithelial neoplasia), and BTCs. This mucin's numerous glycoforms can be divided into less-glycosylated immature and heavily-glycosylated mature forms. Reported MUC5AC tissue expression in BTC varies widely, with some associations based on cancer location (e.g., perihilar vs. peripheral ICC). Study methods were variable regarding cancer subtypes, expression positivity thresholds, and MUC5AC glycoforms. MUC5AC can be detected in serum of BTC patients at high concentrations. The hesitancy in developing MUC5AC into a clinically useful biomarker in BTC management is due to variable evidence on the diagnostic and prognostic value. Concrete conclusions on tissue MUC5AC are difficult, but serum detection might be relevant for diagnosis and is associated with poor prognosis. Future studies are needed to further the understanding of the potential clinical value of MUC5AC in BTC, especially regarding predictive and therapeutic value.

Update on immunotherapy in the management of gallbladder cancer

Gallbladder cancer (GBC) is a relatively infrequent but highly lethal cancer with a poor prognosis. Management remains challenging and controversial, and most patients are diagnosed at an advanced stage. However, with the progressive advances in the use of immunotherapies, new treatment modalities are being implemented. In September 2022, the US FDA approved durvalumab (a PD-L1 inhibitor) in combination with chemotherapy for adult patients with locally advanced or metastatic GBC. This groundbreaking news is the first FDA approval for the use of immunotherapy in biliary tract cancers. This article reviews the newest advances and trials regarding immunotherapy for GBC.

A Review of the Etiology and Epidemiology of Gallbladder Cancer: What You Need to Know

Gallbladder cancer (GBC) is the sixth most prevalent cancer of the gastrointestinal system but the most prevalent cancer of the biliary tract. This tumor is a highly fatal condition. The importance of early diagnosis cannot be overstated because GBC develops quietly with late detection. Several genetic and environmental variables have been associated with the onset of GBC. Cholelithiasis and chronic inflammation from the biliary tract and parasite infections are prime examples of environmental factors that significantly influence the development of GBC. Abnormal pancreaticobiliary duct junction and biliary cysts are examples of congenital causes. In the past decade, new imaging technologies and a more radical and aggressive surgical approach have improved patient outcomes and aided prolonged survival for GBC patients. This review article focuses on the epidemiology of GBC, its risk factors, and clinical characteristics.

Trends in Primary Gallbladder Cancer Incidence and Incidence-based Mortality in the United States, 1973 to 2015

OBJECTIVES

Primary gallbladder cancer (GBC) is the most common biliary tract cancer with poor survival despite aggressive treatment. This study aimed to investigate the trends of GBC incidence and incidence-based mortality (IBM) over the last 4 decades.

MATERIALS AND METHODS

GBC cases diagnosed between 1973 and 2015 were retrieved from the Surveillance, Epidemiology, and End Results (SEER) database. Incidence rates, IBM rates, and annual percent changes (APCs) were calculated and stratified according to population and tumor characteristics.

RESULTS

The cohort consisted of 10,792 predominantly white (81%) and female (71%) GBC patients. The overall GBC incidence decreased by 1.65% (95% confidence interval [CI]: 1.45% to 1.84%) per year since 1973, but has plateaued since 2002. IBM decreased by 1.69% (95% CI: 1.22% to 2.16%) per year from 1980 to 2015; the rate of decrease in IBM rates was lower during 1997 to 2015 (APC: -1.19%, 95% CI: -1.68% to -0.71%) compared with 1980 to 1997 (APC: -3.13%, 95% CI: -3.68% to -2.58%).

CONCLUSIONS

The incidence and IBM rates of GBC have been decreasing over the last 40 years, but the decrease plateaued over the last 2 decades. The effects of treatment modalities, including laparoscopic cholecystectomy, adjuvant chemotherapy, and radiation on the incidence and IBM of GBC need to be further investigated.

Reproductive factors and gall-bladder cancer, and the effect of common genetic variants on these associations: a case-control study in India

BACKGROUND

In India, as elsewhere, the incidence of gall-bladder cancer (GBC) is substantially higher in women than in men. Yet, the relevance of reproductive factors to GBC remains poorly understood.

METHODS

We used logistic regression adjusted for age, education and area to examine associations between reproductive factors and GBC risk, using 790 cases of histologically confirmed GBC and group-matched 1726 visitor controls. We tested the interaction of these associations by genetic variants known to increase the risk of GBC.

RESULTS

Parity was strongly positively associated with GBC risk: each additional pregnancy was associated with an ∼25% higher risk {odds ratio [OR] 1.26 [95% confidence interval (95% CI) 1.17-1.37]}. After controlling for parity, GBC risk was weakly positively associated with later age of menarche [postmenopausal women, OR 1.11 (95% CI 1.00-1.22) per year], earlier menopause [OR 1.03 (95% CI 1.00-1.06) per year] and shorter reproductive lifespan [OR 1.04 (95% CI 1.01-1.07) per year], but there was little evidence of an association with breastfeeding duration or years since last pregnancy. Risk alleles of single-nucleotide polymorphisms in the ABCB4 and ABCB1 genetic regions had a multiplicative effect on the association with parity, but did not interact with other reproductive factors.

CONCLUSIONS

We observed higher GBC risk with higher parity and shorter reproductive lifespan, suggesting an important role for reproductive and hormonal factors.

Changing Landscape of Systemic Therapy in Biliary Tract Cancer

Biliary tract cancers (BTC) are often diagnosed at advanced stages and have a grave outcome due to limited systemic options. Gemcitabine and cisplatin combination (GC) has been the first-line standard for more than a decade. Second-line chemotherapy (CT) options are limited. Targeted therapy or TT (fibroblast growth factor 2 inhibitors or FGFR2, isocitrate dehydrogenase 1 or IDH-1, and neurotrophic tyrosine receptor kinase or NTRK gene fusions inhibitors) have had reasonable success, but <5% of total BTC patients are eligible for them. The use of immune checkpoint inhibitors (ICI) such as pembrolizumab is restricted to microsatellite instability high (MSI-H) patients in the first line. The success of the TOPAZ-1 trial (GC plus durvalumab) is promising, with numerous trials underway that might soon bring targeted therapy (pemigatinib and infrigatinib) and ICI combinations (with CT or TT in microsatellite stable cancers) in the first line. Newer targets and newer agents for established targets are being investigated, and this may change the BTC management landscape in the coming years from traditional CT to individualized therapy (TT) or ICI-centered combinations. The latter group may occupy major space in BTC management due to the paucity of targetable mutations and a greater toxicity profile.

Environmental and Lifestyle Risk Factors in the Carcinogenesis of Gallbladder Cancer

Gallbladder cancer (GBC) is an aggressive neoplasm that in an early stage is generally asymptomatic and, in most cases, is diagnosed in advanced stages with a very low life expectancy because there is no curative treatment. Therefore, understanding the early carcinogenic mechanisms of this pathology is crucial to proposing preventive strategies for this cancer. The main risk factor is the presence of gallstones, which are associated with some environmental factors such as a sedentary lifestyle and a high-fat diet. Other risk factors such as autoimmune disorders and bacterial, parasitic and fungal infections have also been described. All these factors can generate a long-term inflammatory state characterized by the persistent activation of the immune system, the frequent release of pro-inflammatory cytokines, and the constant production of reactive oxygen species that result in a chronic damage/repair cycle, subsequently inducing the loss of the normal architecture of the gallbladder mucosa that leads to the development of GBC. This review addresses how the different risk factors could promote a chronic inflammatory state essential to the development of gallbladder carcinogenesis, which will make it possible to define some strategies such as anti-inflammatory drugs or public health proposals in the prevention of GBC.

Bacterial and Parasitic Pathogens as Risk Factors for Cancers in the Gastrointestinal Tract: A Review of Current Epidemiological Knowledge

The oncogenic potential of viral infections is well established and documented for many years already. However, the contribution of (commensal) bacteria and parasites to the development and progression of cancers has only recently gained momentum, resulting in a rapid growth of publications on the topic. Indeed, various bacteria and parasites have been suggested to play a role in the development of gastrointestinal cancer in particular. Therefore, an overview of the current epidemiological knowledge on the association between infections with bacteria and parasites and cancers of the gastrointestinal tract is needed. In this review, we summarized the methodological characteristics and main results of epidemiological studies investigating the association of 10 different bacteria (Bacteroides fragilis, Campylobacter spp., Clostridium spp., Enterococcus faecalis, Escherichia coli, Fusobacterium nucleatum, Porphyromonas gingivalis, non-typhoidal Salmonella, Salmonella Typhi, and Streptococcus spp.) and three parasites (Cryptosporidium spp., Schistosoma spp., and Strongyloides stercoralis) with gastrointestinal cancer. While the large body of studies based on microbiome sequencing provides valuable insights into the relative abundance of different bacterial taxa in cancer patients as compared to individuals with pre-malignant conditions or healthy controls, more research is needed to fulfill Koch's postulates, possibly making use of follow-up data, to assess the complex role of bacterial and parasitic infections in cancer epidemiology. Studies incorporating follow-up time between detection of the bacterium or parasite and cancer diagnosis remain valuable as these allow for estimation of cause-effect relationships.

Attempt of Real-Time Near-Infrared Fluorescence Imaging Using Indocyanine Green (ICG) in Radical Resection of Gallbladder Cancer: A Case Report

Surgery is the mainstay of treatment for resectable gallbladder cancer. Near-infrared fluorescence (NIRF) imaging using ICG is an innovation in laparoscopic surgery, which can provide real-time navigation during the whole operation. In this article, we present a 56-year older woman with gallbladder cancer, in which we evaluated the applicability of NIRF imaging using ICG for tumor and biliary tree visualization during the operative procedure of gallbladder cancer. The tumor and biliary tree were clearly visualized by utilizing a green fluorescence dye. The patient was successfully operated radical resection of gallbladder cancer under fluorescence laparoscope, without any complications. According to this case, the utilization of ICG based NIRF imaging is feasible and beneficial in identifying tumors and the biliary tree during radical resection. It can assist in the achievement of a negative margin and lymphatic clearance around the biliary tree. However, further studies are needed to corroborate the results of this case.

Genes involved in phosphatidylcholine biosynthesis correlate with nuclear factor-κB in biliary tract cancer patients: Evidence from 1H NMR and computational analyses

Gallbladder cancer (GBC) is an aggressive malignancy of gastrointestinal tract. Due to uncontrolled growth, GBC cells rapidly synthesize biomolecules including lipids. The lipids are integral component of cell membrane with a wide range of cellular functions. In this study, we measured the clinicopathological features in 40 cases of histologically confirmed GBC and 16 cases of chronic cholecystitis (CC). The female to male ratio in the GBC and CC groups were 3.44:1 and 2.2:1, respectively. The GBC patients exhibited well to poorly differentiated tumor. In the CC group, all patients showed cholecystitis with no evidence of dysplasia or malignancy. The majority of GBC and CC patients reported pain. Using ¹H NMR spectroscopy, we observed 4-folds increase in the level of choline containing phospholipids (CCPLs) in the gallbladder of GBC patients as compared to CC patients. Other lipid metabolites such as cholesterol ester, C18-cholesterol and saturated fatty acids were insignificantly changed between GBC and CC patients. Moreover, the level of CCPLs in the GBC patients with BMI <25 kg/m² was significantly higher as compared to CC patients. Further, a significant increase in the CCPLs level was observed in GBC female patients in comparison to CC patients. From the computational analyses, we observed that the genes involved in the biosynthesis of phosphatidylcholine (PtdCho) indirectly interact with the RELA, which encodes the NF-κB p65 subunit. The genes involved in the PtdCho biosynthesis were also correlated with the overall and disease-free survival of cholangiocarcinoma patients. The study opens new window for exploring the diagnostic and therapeutic potential of CCPLs in GBC patients.

Effects of infections on the pathogenesis of cancer

Several studies have shown an inverse relationship between acute infections and cancer development. On the other hand, there is a growing evidence that chronic infections may contribute significantly to the carcinogenesis. Factors responsible for increased susceptibility to infections may include modifications of normal defence mechanisms or impairment of host immunity due to altered immune function, genetic polymorphisms, ageing and malnourishment. Studies have demonstrated that children exposed to febrile infectious diseases show a subsequent reduced risk for ovarian cancer, melanoma and many other cancers, while common acute infections in adults are associated with reduced risks for melanoma, glioma, meningioma and multiple cancers. Chronic inflammation associated with certain infectious diseases has been suggested as a cause for the development of tumours. Mechanisms of carcinogenesis due to infections include cell proliferation and DNA replication by mitogen-activated protein kinase pathway, production of toxins that affect the cell cycle and lead to abnormal cell growth and inhibition of apoptosis. This review was aimed to summarize the available evidence on acute infections as a means of cancer prevention and on the role of chronic infections in the development and progression of cancer.

Roles of Salmonella typhi and Salmonella paratyphi in Gallbladder Cancer Development

BACKGROUND

Typhoid (Salmonella typhi and paratyphi) carriers and gall bladder cancer (GBC) are endemic in northern India. Results of previous studies about association of typhoid carriers with GBC are inconsistent. We studied antibodies against Salmonella typhi and paratyphi in serum samples of patients with GBC.

METHODS

We performed modified Widal test for antibodies against Salmonella typhi (Vi and O) and Salmonella paratyphi (AO and BO) antigens in patients with GBC (n=100), xanthogranulomatous cholecystitis (XGC, n=24), chronic cholecystitis (CC, n=200) and healthy controls (HC, n=200).

RESULTS

Serum antibodies against Salmonella were more frequently positive in GBC (22%) and XGC (29%), particularly in males in age ≥50 years (GBC: 47% and XGC: 50%) vs. HC (0) (p <0.01). Vi antibody was more common in GBC (13%, OR:9.8) and XGC (8%, OR:5.9) than HC (2%). O antibody was more common in GBC (8%, OR: 8.6) and XGC (8%, OR: 9.0) than HC (1%). O antibody was also more common in males with GBC (12%) than CC (1%) and HC (1%) (P=0.02 and p <0.001, respectively). AO (6%) and BO (4%) antibodies were detected in GBC, particularly in males, than HC (0), (p <0.01). Salmonella antibodies were more frequent in GBC with GS than those without GS (50% vs. 20%, OR=3.94, P=0.01).

CONCLUSIONS

Salmonella carrier state was more common in GBC and XGC, particularly in elderly males than HC. The Vi antibody was more common in GBC and XGC than HC. Salmonella infection was more common in GBC with GS than those without GS.

Survival analysis of patients with primary gallbladder cancer from 2010 to 2015: A retrospective study based on SEER data

This study aims to assess the survival status of patients with Primary gallbladder cancer (PGC) and analyze the prognosis factors to facilitate the exploration of the prevention and therapeutic strategies of PGC.Data from 2433 PGC patients collected from 2010 to 2015 were extracted from the Surveillance, Epidemiology, and End Results (SEER) database. The SEER*Stat, SPSS 23.0 and GraphPad Prism 8 were used for statistical analyses. Kaplan Meier analysis was performed for the survival curve, log-rank test analyses were used to compare the survival rate difference and Cox regression analyses were performed to determine the prognosis factors.A total of 2433 PGC cases were reported from 2010 to 2015. The median age was 64.2 ± 10.4 years old and the percentages of the white patients were 73.7% (1794/2433). The percentage of patients who received surgery treatment was 82.1% (1998/2433). The overall median survival time of all patients was 19 months and the 5-year survival rate was 28.8%. The 5-year survival rate of PGC patients in pN2 stage dropped to 0% and the 5-year survival rate for PGC patients with distant metastasis was only 2.7%. Age, tumor size, grade, pT stage, pM stage were risk factors for prognosis, surgery or not and radiation or not were protective factors for prognosis.Survival analysis of PGC patients based on the SEER database have provided an opportunity for understanding PGC prognosis and the basis for the exploration of viable PGC prevention and therapeutic strategies.

Targeted Therapies in Trial for Non-Resectable Gallbladder Cancer

PURPOSE

Gallbladder cancer (GBC) is the most common malignancy of the biliary tract. The median survival of the disease is around 6 months. In this study, we explore clinical trials related to non-resectable GBC, determine the shortcomings leading to the lack of development of new treatment, and shed light on possible areas of improvement.

METHODS

On April 20, 2019 the authors completed a search on ClinicalTrials.gov for all therapeutic and interventional clinical trials involving non-resectable GBC, without any limits on date or location. Trial characteristics such as duration, phase, sample size, and whether a publication was produced were collected and analyzed.

RESULTS

Sixty-two trials met our selection criteria. The average duration of trials was 5 years. Trials were conducted in 8 different countries: most of them in North America (USA and Canada). About 88% of trials were in early phases (I, I/II, and II) and 85% of trials were completed. Only 4 relevant publications were produced from all the trials in our study. Gemcitabine was the most common drug used. Use of gemcitabine alone or in combination with either capecitabine or cisplatin showed significant increase mean progression-free survival.

CONCLUSION

This study revealed a low number of trials, lack of geographic diversity, and scarcity of publications concerning non-resectable GBC. Adequate management of is of great importance to reach effective therapies for this disease.

Incidental gallbladder cancer after laparoscopic cholecystectomy: incidence, management, and prognosis

Aims

Although incidental gallbladder cancer (IGBC) diagnosed after laparoscopic cholecystectomy (LC) is not rare, its incidence, management, and prognosis are still unclear and controversial. The present study aimed to increase the understanding of IGBC after LC in the medical community.

Methods

Patients with IGBC treated at our institution between January 2001 and December 2018 were enrolled. Data collected included demographic characteristics, treatment pattern, pathological information, and prognoses. We compared the characteristics of patients with different prognoses and calculated the cumulative overall survival rate and mean survival period for IGBC.

Results

The cohort comprised 26 patients with a mean age of 66.4 ± 12.5 years. All patients were diagnosed with IGBC via postoperative pathology. Three patients underwent radical reoperation. As of June 2019, 26 patients were followed for a mean of 31.6 ± 29.6 months. Fourteen patients died during the follow‐up period, and 12 survived without recurrence. The mean survival duration was 50.5 months. The 1‐, 3‐, and 5‐year cumulative overall survival rates of the entire cohort were 79.8, 49.0, and 40.8%, respectively. IGBC patients with T1a stage had significantly longer survival than those with T1b or more advanced stages (96.1 vs 32.6 months, P = .006).

Conclusions

IGBC after LC is diagnosed in 0.2% of patients, accounting for 5.4% of all gallbladder cancer cases. IGBC patients with T1a stage had significantly longer survival than those with T1b or more advanced stages. Simple cholecystectomy is probably acceptable only in T1a lesions.

Incidental Carcinoma Gallbladder: Incidence, Risk Factors, and Factors Affecting Survival-5-Year Experience from a Tertiary Care Institute

INTRODUCTION

Carcinoma gallbladder is a very lethal disease. It can get detected incidentally after laparoscopic cholecystectomy. The overall outcome of incidentally detected carcinoma gallbladder is a matter of debate in literature.

AIM

To estimate the overall incidence of the incidental gallbladder carcinoma, the various risk factors associated with it and factors affecting overall survival in patients who underwent laparoscopic cholecystectomy with eventual histology turning out to be carcinoma gallbladder.

METHODS

Data of all the patients undergoing laparoscopic cholecystectomies in one surgical unit under the Department of Surgery at All India Institute of Medical Sciences, New Delhi, India, between January 2014 and December 2018 was retrospectively analyzed. All patients with incidental carcinoma gallbladder were followed up and completion radical cholecystectomy was performed. The demographic profile, preoperative imaging, intra-operative finding, histopathology of primary surgery, and median interval between two surgeries were analyzed to look for various risk factors associated with incidental carcinoma gallbladder and factors affecting overall survival.

RESULTS

Incidence of the incidental carcinoma gallbladder was 0.51% with a female/male ratio of 4:1 and mean age of 47.2 years. Preoperative imaging of most of them was suggestive of chronic cholecystitis; however, one patient had multiple gallbladder polyps. Six patients had uneventful laparoscopic cholecystectomy, while four had bile spillages intraoperatively. All the patients had adenocarcinoma on histopathology. Pathological staging of four patients was pT1b and six patients had pT2 tumor. The median interval between cholecystectomy and completion radical cholecystectomy in this series was 8 weeks. At the end of 19-month median follow-up, overall survival was 55.5%.

CONCLUSION

Incidence of incidental carcinoma gallbladder is 0.51%, most commonly affecting middle-aged females. Risk factors associated with incidental carcinoma gallbladder were found to be multiple gallbladder calculi, single large stone, and gallbladder polyps. Survival is better in males, young patients with uneventful primary surgery and better-differentiated pathology.

Favorable gallbladder cancer mortality-to-incidence ratios of countries with good ranking of world's health system and high expenditures on health

Background

The mortality-to-incidence ratio (MIR) is a marker that reflects the clinical outcome of cancer treatment. MIR as a prognostic marker is more accessible when compared with long-term follow-up survival surveys. Theoretically, countries with good health care systems would have favorable outcomes for cancer; however, no report has yet demonstrated an association between gallbladder cancer MIR and the World’s Health System ranking.

Methods

We used linear regression to analyze the correlation of MIRs with the World Health Organization (WHO) rankings and total expenditures on health/gross domestic product (e/GDP) in 57 countries selected according to the data quality.

Results

The results showed high crude rates of incidence/mortality but low MIR in more developed regions. Among continents, Europe had the highest crude rates of incidence/mortality, whereas the highest age-standardized rates (ASR) of incidence/mortality were in Asia. The MIR was lowest in North America and highest in Africa (0.40 and 1.00, respectively). Furthermore, favorable MIRs were correlated with good WHO rankings and high e/GDP (p = 0.01 and p = 0.030, respectively).

Conclusions

The MIR variation for gallbladder cancer is therefore associated with the ranking of the health system and the expenditure on health.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-7160-z) contains supplementary material, which is available to authorized users.

Significance of Metabolic Tumor Volume and Total Lesion Glycolysis Measured Using ¹⁸F-FDG PET/CT in Locally Advanced and Metastatic Gallbladder Carcinoma

PURPOSE

This study aimed to determine the prognostic value of new quantitative parameters of ¹⁸F-fluorodeoxyglucose positron emission tomography/computed tomography (¹⁸F-FDG PET/CT), including metabolic tumor volume (MTV), in patients with locally advanced and metastatic gallbladder cancer (GBC).

MATERIALS AND METHODS

In total, 83 patients initially diagnosed with locally advanced and metastatic GBC and who underwent ¹⁸F-FDG PET/CT at the time of initial diagnosis were retrospectively reviewed. The metabolic volume-based PET parameters of primary tumors and metastatic lesions were measured, including maximum and average standardized uptake values (SUV), MTV, and total lesion glycolysis. An overall survival (OS) analysis was performed using the Kaplan-Meier method with PET and clinical parameters. A Cox proportional hazards regression analysis was performed to determine independent prognostic factors.

RESULTS

In univariate analysis, pathologic differentiation (p<0.001), performance status (PS; p=0.003), C-reactive protein (CRP) level (p=0.009), and PET-related SUV_{mt max} (the highest SUV among the metastatic lesions) (p=0.040) and MTV_total (the sum of the MTVs of both the primary and metastatic lesions) (p=0.031), were significant for OS. In multivariate analysis, MTV_total (hazard ratio: 2.07; 95% confidence interval: 1.23-3.48; p=0.006) remained significant for the prediction of OS, as did differentiation (p=0.001), PS (p=0.001), and CRP (p=0.039).

CONCLUSION

In locally advanced and metastatic GBC, volume-based PET/CT parameters of the total tumor burden of malignancy, such as MTV_total, were found to be useful for the identification of patients with poor prognosis.

Epidemiology of gallbladder cancer

According to GLOBOCAN 2018 data, gallbladder cancer (GBC) accounts for 1.2% of all global cancer diagnoses, but 1.7% of all cancer deaths. Only 1 in 5 GBC cases in the United States is diagnosed at an early stage, and median survival for advanced stage cancer is no more than about a year. The incidence of the disease is increasing in the developed world. Gallstones, biliary cysts, carcinogen exposure, typhoid, and Helicobacter pylori infection, and abnormal pancreaticobiliary duct junctions are all risk factors, many of which account for its geographical, ethnic and sex distribution. Genetics also plays a strong role, as about a quarter of GBC cases are considered familial, and certain ethnicities, such as Native Americans, are at far higher risk for the neoplasm. Prevention includes weight loss, vaccination against and treatment of bacterial infections, early detection and elimination of polyps and cysts, and avoidance of oral estrogen replacement therapy.

Risk of cancer in patients with constipation

Background: It remains unclear whether constipation is associated with cancer. We evaluated the risk of malignancies in patients with constipation requiring hospitalization. Methods: Using Danish medical registries, we calculated cumulative incidences and standardized incidence ratios (SIRs) for cancer. SIRs were computed as the observed number of gastrointestinal (GI) cancers and selected non-GI cancers in patients with constipation compared with the expected number based on national incidence rates by sex, age, and calendar year (1978-2013). Results: We identified 1,75,901 patients with constipation (59% females, median age 54 years). The cumulative incidences of GI cancers and non-GI cancers after 15 years of follow-up were 2.5% and 2.6%, respectively. During the first year of follow-up, the SIR for any GI cancer was 5.0 (95% confidence interval (CI): 4.8-5.3), driven by colon and pancreas cancers and higher for younger age groups. Beyond 1 year of follow-up, the risk declined to near unity for colorectal cancer. The risk of other GI cancers (including cancers of the esophagus, stomach, small intestine, liver, and pancreas) remained moderately increased (overall SIR =1.3, 95% CI: 1.2-1.4). Except for ovarian cancer (SIR =7.3, 95% CI: 6.3-8.4), the risk of non-GI cancers was only slightly increased during the first year of follow-up and declined to unity thereafter. Conclusions: Patients with constipation had increased short-term risk of a diagnosis of GI cancer. Beyond 1 year of follow-up, a moderately elevated risk persisted only for GI cancers other than colorectal cancer. The risk of non-GI cancers was elevated only during the first year of follow-up, particularly for ovarian cancer.

Prevalence of gallbladder cancer In patients submitted to cholecystectomy: experience of the University Hospital, Faculty of Medical Sciences, State University of Campinas - UNICAMP

Objective:

to evaluate the prevalence of gallbladder carcinoma in patients submitted to cholecystectomy for chronic cholecystitis at the University Hospital of the State University of Campinas.

Methods:

we conducted a retrospective prevalence study through the analysis of histological specimens from January 2010 to May 2015.

Results:

we analyzed 893 patient reports. Emergency cholecystectomies amounted to 144, and elective ones, 749 (16.2% and 83.8%, respectively). Regarding gender, 72.8% were female and 27.2% male. Gallbladder adenocarcinoma occurred in 12 patients (1.3%) and non-Hodgkin's lymphoma in one (0.1%). In patients with cancer, seven (53.8%) were associated with cholelithiasis and two (15.3%) with gallbladder polyps.

Conclusion:

prevalence results of gallbladder adenocarcinoma in this study were similar to those of Western studies and the main risk factor was cholelithiasis, followed by the presence of gallbladder polyps.

Gemcitabine-based chemotherapy for advanced biliary tract carcinomas

BACKGROUND

Biliary tract cancers are a group of rare heterogeneous malignant tumours. They include intrahepatic and extrahepatic cholangiocarcinomas, gallbladder carcinomas, and ampullary carcinomas. Surgery remains the optimal modality of therapy leading to long-term survival for people diagnosed with resectable biliary tract carcinomas. Unfortunately, most people with biliary tract carcinomas are diagnosed with either unresectable locally-advanced or metastatic disease, and they are only suitable for palliative chemotherapy or supportive care.

OBJECTIVES

To assess the benefits and harms of intravenous administration of gemcitabine monotherapy or gemcitabine-based chemotherapy versus placebo, or no intervention, or other treatments (excluding gemcitabine) in adults with advanced biliary tract carcinomas.

SEARCH METHODS

We performed electronic searches in the Cochrane Hepato-Biliary Group Controlled Trials Register, CENTRAL, MEDLINE, Embase, LILACS, Science Citation Index Expanded, and Conference Proceedings Citation Index - Science up to June 2017. We also checked reference lists of primary original studies and review articles manually, for further related articles (cross-references).

SELECTION CRITERIA

Eligible studies include randomised clinical trials, irrespective of language or publication status, comparing intravenous administration of gemcitabine monotherapy or gemcitabine-based combination to placebo, to no intervention, or to treatments other than gemcitabine.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. We assessed risks of bias of the included trials using definitions of predefined bias risk domains, and presented the review results incorporating the methodological quality of the trials using GRADE.

MAIN RESULTS

We included seven published randomised clinical trials with 600 participants. All included trials were at high risk of bias, and we rated the evidence as very low quality. Cointerventions were equally applied in three trials (gemcitabine plus S-1 (a combination of tegafur, gimeracil, and oteracil) versus S-1 monotherapy; gemcitabine plus S-1 versus gemcitabine monotherapy versus S-1 monotherapy; and gemcitabine plus vandetanib versus gemcitabine plus placebo versus vandetanib monotherapy), while four trials compared gemcitabine plus cisplatin versus S-1 plus cisplatin; gemcitabine plus mitomycin C versus capecitabine plus mitomycin C; gemcitabine plus oxaliplatin versus chemoradiotherapy; and gemcitabine plus oxaliplatin versus 5-fluorouracil plus folinic acid versus best supportive care. The seven trials were conducted in India, Japan, France, China, Austria, South Korea, and Italy. The median age of the participants in the seven trials was between 50 and 60 years, and the male/female ratios were comparable in most of the trials. Based on these seven trials, we established eight comparisons. We could not perform all planned analyses in all comparisons because of insufficient data.Gemcitabine versus vandetanibOne three-arm trial compared gemcitabine versus vandetanib versus both drugs in combination. It reported no data for mortality, health-related quality of life, or tumour progression outcomes. We rated the increased risk of serious adverse events, anaemia, and overall response rate as very low-certainty evidence.Gemcitabine plus cisplatin versus S-1 plus cisplatinFrom one trial of 96 participants, we found very low-certainty evidence that gemcitabine can lower the risk of mortality at one year when used with cisplatin versus S-1 plus cisplatin (risk ratio (RR) 0.76, 95% confidence interval (CI) 0.58 to 0.98; P = 0.04; participants = 96). The trial did not report data for serious adverse events, quality of life, or tumour response outcomes. There is very low-certainty evidence that gemcitabine plus cisplatin combination leads to a higher risk of high-grade thrombocytopenia compared with S-1 plus cisplatin combination (RR 5.28, 95% CI 1.23 to 22.55; P = 0.02; participants = 96).Gemcitabine plus S-1 versus S-1From two trials enrolling 151 participants, we found no difference between the two groups in terms of risk of mortality at one year or risk of serious adverse events. Gemcitabine plus S-1 combination was associated with a higher overall response rate compared with S-1 alone (RR 2.46, 95% CI 1.27 to 4.75; P = 0.007; participants = 140; trials = 2; I² = 0%; very low certainty of evidence). Neither of the trials reported data for health-related quality of life or time to progression of the tumour.Gemcitabine plus oxaliplatin versus 5-fluorouracil plus folinic acid versus best supportive careOne three-arm trial compared gemcitabine plus oxaliplatin versus 5-fluorouracil plus folinic acid versus best supportive care. It reported no data for serious adverse events, health-related quality of life, or tumour progression. We rated the evidence for mortality and for overall response rate as of very low certainty.Gemcitabine plus oxaliplatin versus 5-fluorouracil plus cisplatin plus radiotherapyOne trial of 34 participants compared gemcitabine plus oxaliplatin versus 5-fluorouracil plus cisplatin plus radiotherapy. It reported no data for quality of life, overall response rate, or tumour progression outcomes. We rated the evidence for mortality and serious adverse events as of very low certainty.Gemcitabine plus mitomycin C versus capecitabine plus mitomycin COne trial of 51 participants compared gemcitabine plus mitomycin C versus capecitabine plus mitomycin C. It reported no data for serious adverse events, quality of life, or tumour progression. We rated the evidence for mortality, overall response rate and thrombocytopenia as of very low certainty.We also identified three ongoing trials evaluating outcomes of interest for our review, which we can incorporate in future updates.For-profit bias: there was a high risk of for-profit bias in two trials (because of industry sponsorship) while there was a low risk of for-profit bias in another three trials, and unclear risk in two trials.

AUTHORS' CONCLUSIONS

In adults with advanced biliary tract carcinomas, the effects of gemcitabine or gemcitabine-based chemotherapy are uncertain on mortality and overall response compared with a range of inactive or active controls. The very low certainty of evidence is due to risk of bias, lack of information in the analyses and hence large imprecision, and possible publication bias. The confidence intervals do not rule out meaningful benefits or lack of effect of gemcitabine in all comparisons but one on mortality where gemcitabine plus cisplatin is compared with S-1 plus cisplatin. Gemcitabine-based regimens showed an increase in non-serious adverse events (particularly haematological toxicities). Further randomised clinical trials are mandatory, to further explore the best therapeutic options for adults with advanced biliary tract carcinomas.

The association between BMI and gallbladder cancer risk: a meta-analysis

Obesity is a known cause of gallstone formation and gallstones increases the risk of gallbladder cancer (GBC), but the relation of body mass index (BMI) to GBC remains incompletely understood. To help elucidate the role of obesity in GBC, we performed a meta-analysis of the relationship between BMI and GBC risk. PUBMED and EMBASE databases were searched up to April 17, 2016. Fifteen articles with 5902 cases were identified. Random-effects models and dose-response meta-analyses were used to pool study results. Compared to normal weight, the pooled relative risks (RRs) and the corresponding 95% confidence intervals (CI) of GBC for overweight and obesity is 1.10 (0.98-1.23) and 1.58 (1.43-1.75) respectively. The RRs and 95% CI of overweight and obesity in man are 0.98 (0.90-1.08) and 1.43 (1.19-1.71), while the corresponding RRs in woman are 1.29 (1.08-1.55) and 1.68 (1.41-2.00) when compared to normal weight. A nonlinear dose-response relationship between BMI and risk of GBC was found (P=0.001), and the risk increased by 4% for each 1 kg/m2 increment in BMI. When adjusted for sex, at the point of BMI=25 kg/m2, the RRs (95% CIs) for women and men were 1.13 (1.01-1.25) and 0.98 (0.90-1.07) respectively. The corresponding RRs (95%CIs) at the point of BMI=30 kg/m2 were 1.56(1.39-1.75) vs. 1.24(1.06-1.44). These results suggest that association of obesity and risk of GBC is stronger in woman. Furthermore, overweight is only associated with GBC in woman. A even stricter weight control might be necessary for woman to prevent GBC.

Biofilm Producing Salmonella Typhi: Chronic Colonization and Development of Gallbladder Cancer

Salmonella enterica subspecies enterica serovar Typhi is the aetiological agent of typhoid or enteric fever. In a subset of individuals, S. Typhi colonizes the gallbladder causing an asymptomatic chronic infection. Nonetheless, these asymptomatic carriers provide a reservoir for further spreading of the disease. Epidemiological studies performed in regions where S. Typhi is endemic, revealed that the majority of chronically infected carriers also harbour gallstones, which in turn, have been indicated as a primary predisposing factor for the onset of gallbladder cancer (GC). It is now well recognised, that S. Typhi produces a typhoid toxin with a carcinogenic potential, that induces DNA damage and cell cycle alterations in intoxicated cells. In addition, biofilm production by S. Typhi may represent a key factor for the promotion of a persistent infection in the gallbladder, thus sustaining a chronic local inflammatory response and exposing the epithelium to repeated damage caused by carcinogenic toxins. This review aims to highlight the putative connection between the chronic colonization by highly pathogenic strains of S. Typhi capable of combining biofilm and toxin production and the onset of GC. Considering the high risk of GC associated with the asymptomatic carrier status, the rapid identification and profiling of biofilm production by S. Typhi strains would be key for effective therapeutic management and cancer prevention.

Risk Factors for Cholelithiasis

Gallstone disease is one of the most common public health problems in the United States. Approximately 10%-20% of the national adult populations currently carry gallstones, and gallstone prevalence is rising. In addition, nearly 750,000 cholecystectomies are performed annually in the United States; direct and indirect costs of gallbladder surgery are estimated to be $6.5 billion. Cholelithiasis is also strongly associated with gallbladder, pancreatic, and colorectal cancer occurrence. Moreover, the National Institutes of Health estimates that almost 3,000 deaths (0.12% of all deaths) per year are attributed to complications of cholelithiasis and gallbladder disease. Although extensive research has tried to identify risk factors for cholelithiasis, several studies indicate that definitive findings still remain elusive. In this review, predisposing factors for cholelithiasis are identified, the pathophysiology of gallstone disease is described, and nonsurgical preventive options are discussed. Understanding the risk factors for cholelithiasis may not only be useful in assisting nurses to provide resources and education for patients who are diagnosed with gallstones, but also in developing novel preventive measures for the disease.

Gallbladder Carcinoma in the United States: A Population Based Clinical Outcomes Study Involving 22,343 Patients from the Surveillance, Epidemiology, and End Result Database (1973-2013)

Introduction

Gallbladder carcinoma (GBC) is the most common malignancy of the biliary tract and the third most common gastrointestinal tract malignancy. This study examines a large cohort of GBC patients in the United States in an effort to define demographics, clinical, and pathologic features impacting clinical outcomes.

Methods

Demographic and clinical data on 22,343 GBC patients was abstracted from the SEER database (1973–2013).

Results

GBC was presented most often among Caucasian (63.9%) females (70.7%) as poorly or moderately differentiated (42.5% and 38.2%) tumors, with lymph node involvement (88.2%). Surgery alone was the most common treatment modality for GBC patients (55.0%). Combination surgery and radiation (10.6%) achieved significantly longer survival rates compared to surgery alone (4.0 ± 0.2 versus 3.7 ± 0.1 years, p = 0.004). Overall mortality was 87.0% and cancer-specific mortality was 75.4%.

Conclusions

GBC is an uncommon malignancy that presents most often among females in their 8th decade of life, with over a third of cases presenting with distant metastasis. The incidence of GBC has doubled in the last decade concurrent with increases in cholecystectomy rates attributable in part to improved histopathological detection, as well as laparoscopic advances and enhanced endoscopic techniques. Surgical resection confers significant survival benefit in GBC patients.

Salmonella enterica serovar Typhi and gallbladder cancer: a case-control study and meta-analysis

In Chile, where gallbladder cancer (GBC) rates are high and typhoid fever was endemic until the 1990s, we evaluated the association between Salmonella enterica serovar Typhi (S. Typhi) antibodies and GBC. We tested 39 GBC cases, 40 gallstone controls, and 39 population-based controls for S. Typhi Vi antibodies and performed culture and quantitative polymerase chain reaction for the subset with bile, gallstone, tissue, and stool samples available. We calculated gender and education-adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for the association with GBC. We also conducted a meta-analysis of >1000 GBC cases by combining our results with previous studies. GBC cases were more likely to have high Vi antibody titer levels than combined controls (OR: 4.0, 95% CI: 0.9-18.3), although S. Typhi was not recovered from bile, gallstone, tissue, or stool samples. In our meta-analysis, the summary relative risk was 4.6 (95% CI: 3.1-6.8, Pheterogeneity =0.6) for anti-Vi and 5.0 (95% CI: 2.7-9.3, Pheterogeneity  = 0.2) for bile or stool culture. Our results are consistent with the meta-analysis. Despite differences in study methods (e.g., S. Typhi detection assay), most studies found a positive association between S. Typhi and GBC. However, the mechanism underlying this association requires further investigation.

Epidemiological Characteristics of Gallbladder Cancer in Jeju Island: A Single-Center, Clinically Based, Age-Sex-Matched, Case-Control Study

BACKGROUND

Gallbladder cancer (GBC) is a rare but highly invasive malignancy characterized by poor survival. In a national cancer survey, the age-standardized incidence rate of GBC was highest in Jeju Island among the 15 provinces in South Korea. The aim of this descriptive epidemiological study was to suggest the modifiable risk factors for this rare malignant disease in Jeju Island by performing an age-sex-matched case- control study.

MATERIALS AND METHODS

The case group included patients diagnosed with GBC at the Department of Internal Medicine of Cheju Halla General Hospital, Jeju, South Korea, within the 5-year study period. The control group consisted of age-sex-matched subjects selected from among the participants of the health promotion center at the same institute and in the same period. We compared 78 case-control pairs in terms of clinical variables such as histories of hypertension, diabetes, vascular occlusive disorders, alcohol and smoking consumption, obesity, and combined polypoid lesions of the gallbladder (PLG) or gallstone diseases (GSDs).

RESULTS

Among the relevant risk factors, alcohol consumption, parity ≥ 2, PLG, and GSDs were significant risk factors in the univariate analysis. PLG (p < 0.01; OR, 51.1; 95% confidence interval [CI], 2.98-875.3) and GSD (p < 0.01; OR, 54.9; 95% CI, 3.00-1001.8) were associated risk factors of GBC in the multivariate analysis with the conditional logistic regression model. However, we failed to find any correlation between obesity and GBC. We also found a negative correlation between alcohol consumption history and GBC in the multivariate analysis (p < 0.01; OR, 0.06; 95% CI, 0.01-0.31).

CONCLUSIONS

These results suggest that combined PLG and GSDs are strongly associated with the GBC in Jeju Island and mild to moderate alcohol consumption may negatively correlate with GBC risk.

Overweight, obesity and the risk of gallbladder and extrahepatic bile duct cancers: A meta-analysis of observational studies

OBJECTIVE

Epidemiological studies have repeatedly investigated the association between excess body weight and the risk of biliary tract cancer with inconsistent results. The objective of this study was to quantitatively assess the associations between overweight and obesity and the risk of biliary tract cancer.

METHODS

A comprehensive search of PubMed, Embase, Web of Science, and China National Knowledge Infrastructure databases up to August 2015 was conducted, and the reference lists of retrieved articles for additional relevant studies were manually searched.

RESULTS

Fourteen prospective cohort studies and 15 case-control studies were included in this meta-analysis. These studies included 11,448,397 participants (6,733 patients with gallbladder cancer [GBC] and 5,798 patients with extrahepatic bile duct cancer [EBDC]) with follow-up durations ranging from 5 to 23 years. Among overweight adults, the pooled RR was 1.17 (95% CI, 1.07-1.28) for GBC and 1.26 (95% CI, 1.14-1.39) for EBDC, and among people with obesity, the pooled RR was 1.62 (95% CI, 1.49-1.75) for GBC and 1.48 (95% CI, 1.21-1.81) for EBDC. Visual inspection of the funnel plots and the Begg's and the Egger's tests did not show enough evidence of publication bias.

CONCLUSIONS

Integrated evidence from this meta-analysis suggests that excess body weight is associated with a significantly increased risk of GBC and EBDC.

Ochratoxin A Contamination of Red Chili Peppers from Chile, Bolivia and Peru, Countries with a High Incidence of Gallbladder Cancer

Our previous study detected aflatoxins in red chili peppers from Chile, Bolivia, and Peru, each of which have a high incidence of gallbladder cancer (GBC). Since the aflatoxin B1 concentration was not so high in these peppers, it is important to clarify the presence of other mycotoxins. Here we attempted to determine any associations between the concentrations of aflatoxins and ochratoxin A (OTA) in red chili peppers, and the corresponding GBC incidences. We collected red chili peppers from three areas in Peru: Trujillo (a high GBC incidence area), Cusco (an intermediate GBC incidence area), and Lima (a low GBC incidence rate), and from Chile and Bolivia. Aflatoxins and OTA were extracted with organic solvents. The concentrations of aflatoxins B1, B2, G1, and G2, and OTA were measured by high-performance liquid chromatography. The values obtained were compared with the incidence of GBC in each area or country. All of the red chili peppers from the three areas showed contamination with aflatoxins below the Commission of the European Communities (EC) recommended limits (5 μg/kg), but the OTA contamination of two samples was above the EC recommended limit (15 μg/kg). The mean concentrations of OTA in the peppers from Chile (mean 355 μg/kg, range <5-1,059 μg/kg) and Bolivia (mean 207 μg/kg, range 0.8-628 μg/kg), which has a high incidence of GBC, were higher than that in Peru (14 μg/kg, range <5-47 μg/kg), which has an intermediate GBC incidence. The OTA contamination in the red chili peppers from Chile, Bolivia, and Peru was stronger than that of aflatoxins. Our data suggest that OTA in red chili peppers may be associated with the development of GBC.

The inflammatory inception of gallbladder cancer

Gallbladder cancer is a lethal disease with notable geographical variations worldwide and a predilection towards women. Its main risk factor is prolonged exposure to gallstones, although bacterial infections and other inflammatory conditions are also associated. The recurrent cycles of gallbladder epithelium damage and repair enable a chronic inflammatory environment that promotes progressive morphological impairment through a metaplasia-dysplasia-carcinoma, along with cumulative genome instability. Inactivation of TP53, which is mutated in over 50% of GBC cases, seems to be the earliest and one of the most important carcinogenic pathways involved. Increased cell turnover and oxidative stress promote early alteration of TP53, cell cycle deregulation, apoptosis and replicative senescence. In this review, we will discuss evidence for the role of inflammation in gallbladder carcinogenesis obtained through epidemiological studies, genome-wide association studies, experimental carcinogenesis, morphogenetic studies and comparative studies with other inflammation-driven malignancies. The evidence strongly supports chronic, unresolved inflammation as the main carcinogenic mechanism of gallbladder cancer, regardless of the initial etiologic trigger. Given this central role of inflammation, evaluation of the potential for GBC prevention removing causes of inflammation or using anti-inflammatory drugs in high-risk populations may be warranted.

A Month for Gallbladder Cancer: A Case Report of Four Gallbladder Cancers Over a 30-Day Period at a Community Hospital

Gallbladder carcinoma is an exceedingly rare and fatal cancer. With stage 1 disease having a 5-year survival of only 50%, a diagnosis of gallbladder cancer carries a grim prognosis. Fortunately, especially in the developed world, it is exceedingly rare. Annual rates are reported as low as 1 - 2.5 per 100,000 people in the United States. Over the past 14 years, Newark Beth Israel in New Jersey has diagnosed 21 patients with gallbladder cancer. The purpose of this case report was to describe four new cases which occurred over a 30-day period in 2015 and review the risk factors, diagnosis and treatment strategies for this terrible disease.

Body Mass Index and Risk of Gallbladder Cancer: Systematic Review and Meta-Analysis of Observational Studies

OBJECTIVES

To provide a quantitative assessment of the association between excess body weight, interpreted as increased body mass index (BMI), and the risk of gallbladder cancer (GBC).

METHODS

We identified eligible studies in Medline and EMBASE up to 1 February 2015, and reference lists of retrieved articles. Summary relative risks with their 95% confidence intervals were calculated in a random-effects model. Subgroup analyses were performed according to study design, gender, geographic location, ascertainment of exposure and adjustment for confounders.

RESUITS

A total of 12 cohort studies and 8 case-control studies were included in the meta-analysis. Overall, compared with "normal" weight, the summary relative risks of GBC were 1.14 (95% CI, 1.04-1.25) for overweight individuals (BMI 25-30 kg/m²) and 1.56 (95% CI, 1.41-1.73) for obese individuals (BMI > 30 kg/m²). Obese women had a higher risk of GBC than men did (women: SRRs 1.67, 95% CI 1.38-2.02; men: SRRs 1.42, 95% CI 1.21-1.66), and there was significant association between overweight and GBC risk in women (SRRs 1.26, 95% CI 1.13-1.40), but not in men (SRRs 1.06, 95% CI 0.94-1.20).

CONCLUSIONS

Findings from this meta-analysis indicate that obesity is associated with an increased risk of GBC, especially in women. Overweight is associated with GBC risk only in women.

Exfoliative erythroderma as a paraneoplastic presentation of adenocarcinoma of the gallbladder

We report a case of a 71-year-old Caucasian male presenting with an exfoliative skin rash all over his body. The patient was also found to have a huge gall bladder mass extending into the liver that turned out to be adenocarcinoma of the gall bladder on biopsy. Gall bladder cancer usually presents with abdominal pain, swelling or jaundice. We report only the second case in literature of a gall bladder adenocarcinoma presenting with exfoliative erythroderma as its paraneoplastic presentation.

Body mass index and biliary tract disease: a systematic review and meta-analysis of prospective studies

OBJECTIVE

To evaluate the association between body mass index (BMI, kg/m(2)) and incidence of biliary tract disease.

METHODS

We performed a systematic review and a meta-analysis of prospective studies by searching the database of PubMed and EMBASE published up to December 31, 2013. Outcome of interest was disease of biliary tract system (gallbladder, extrahepatic bile duct and Ampullar of Vater). We used a random-effects model to combine the study-specific relative risks (RRs) and 95% confidence intervals (95% CIs) from 22 prospective studies. We examined whether BMI was associated with a higher risk of biliary tract disease in a combined analysis.

RESULTS

The positive association was stronger for non-cancer biliary tract disease than biliary tract cancer; combined RRs (95% CIs) comparing the top with bottom categories were 1.40 (1.15-1.65) for biliary tract cancer and 2.75 (2.35-3.15) for non-cancer biliary tract disease (P for difference<0.001). For non-cancer biliary tract disease, combined RRs (95% CIs) comparing the top with bottom categories were 3.21 (2.48-3.93) for women and 2.01 (1.66-2.37) for men (P for difference=0.04).

CONCLUSION

Obesity is associated with higher risks of biliary tract cancer and, to a greater extent, non-cancer biliary tract disease.

Imaging of malignancies of the biliary tract- an update

Malignancies of the biliary tract include cholangiocarcinoma, gallbladder cancers and carcinoma of the ampulla of Vater. Biliary tract adenocarcinomas are the second most common primary hepatobiliary cancer. Due to their slow growing nature, non-specific and late symptomatology, these malignancies are often diagnosed in advanced stages with poor prognosis. Apart from incidental discovery of gall bladder carcinoma upon cholecystectomy, early stage biliary tract cancers are now detected with computed tomography (CT) and magnetic resonance imaging (MRI) with magnetic resonance cholangiopancreatography (MRCP). Accurate characterization and staging of these indolent cancers will determine outcome as majority of the patients’ are inoperable at the time of presentation. Ultrasound is useful for initial evaluation of the biliary tract and gallbladder masses and in determining the next suitable modality for further evaluation. Multimodality imaging plays an integral role in the management of the biliary tract malignancies. The imaging techniques most useful are MRI with MRCP, endoscopic retrograde cholangiopancreatography (ERCP), endoscopic ultrasound (EUS) and positron emission tomography (PET). In this review we will discuss epidemiology and the role of imaging in detection, characterization and management of the biliary tract malignancies under the three broad categories of cholangiocarcinomas (intra- and extrahepatic), gallbladder cancers and ampullary carcinomas.

Systematic review with meta-analysis: the relationship between chronic Salmonella typhi carrier status and gall-bladder cancer

BACKGROUND

Carcinoma of the gall-bladder is the fifth commonest gastrointestinal tract cancer and is endemic in several countries. An association of chronic typhoid carriage and carcinoma of the gall-bladder has been reported.

AIM

To clarify whether chronic Salmonella typhi carrier state is associated with carcinoma of the gall-bladder.

METHODS

A systematic search was conducted using MEDLINE, PubMed, EMBASE, Current Contents, Cochrane library, Google Scholar, Science Direct and Web of Science. Original data were abstracted from each study and used to calculate a pooled odds ratio (OR) and 95% confidence interval (95% CI).

RESULTS

Of the articles selected, only 17 studies met full criteria for analysis. The overall OR for chronic S. typhi carrier state was 4.28(95% CI: 1.84-9.96). Most of the studies were from South Asia especially India and China. When a subgroup analysis was performed according to region, a significant association was observed in South-East Asia (OR: 4.13, 95% CI: 2.87-5.94, P value <0.01). Chronic S. typhi carrier state was associated with carcinoma of the gall-bladder based on detection methods of S. typhi antibody levels (OR: 3.52, 95% CI: 2.48-5.00, P value <0.01) and even more so on culture (OR: 4.14, 95% CI: 2.41-7.12, P value <0.01). The association was prominent in controls without gallstones (OR: 5.86, 95% CI: 3.84-8.95, P value <0.01) when compared with controls with gallstones (OR: 2.71, 95% CI: 1.92-3.83, P value <0.01).

CONCLUSIONS

Chronic S. typhi carrier state is an important risk factor among patients with carcinoma of the gall-bladder. Given the high risk associated with this carrier state, management options should include either elective cholecystectomy or careful monitoring using ultrasound.

Gallbladder cancer

Gallbladder cancer remains a relatively rare malignancy with a highly variable presentation. Gallbladder cancer is the most common biliary tract malignancy with the worst overall prognosis. With the advent of the laparoscope, in comparison with historical controls, this disease is now more commonly diagnosed incidentally and at an earlier stage. However, when symptoms of jaundice and pain are present, the prognosis remains dismal. From a surgical perspective, gallbladder cancer can be suspected preoperatively, identified intraoperatively, or discovered incidentally on final surgical pathology.

Epigenetic changes in carcinogenesis of gallbladder

Gallbladder cancer (GBC) is a lethal and a common malignancy affecting mostly females. There are restricted high incidence pockets across the world and in northern India highest incidence of GBC is reported from the Gangetic belt. The etiology of this disease remains largely unknown though several risk factors have been stated. The genetic aberrations in GBC involving mutations in tumor suppressor genes and oncogenes have been reported in literature. However, there is scarcity of data regarding epigenetic changes that may also be involved in gallbladder carcinogenesis. This review attempts to summarize our current understanding of the epigenetic changes in GBC.