Association of tea and coffee consumption and biliary tract cancer risk: The Biliary Tract Cancers Pooling Project

BACKGROUND AND AIMS

Tea and coffee are widely consumed beverages worldwide. We evaluated their association with biliary tract cancer (BTC) incidence.

APPROACH AND RESULTS

We pooled data from 15 studies in the Biliary Tract Cancers Pooling Project to evaluate associations between tea and coffee consumption and biliary tract cancer development. We categorized participants as nondrinkers (0 cup/day), moderate drinkers (>0 and <3 cups/day), and heavy drinkers (≥3 cups/day). We estimated multivariable HRs and 95% CIs using Cox models. During 29,911,744 person-years of follow-up, 851 gallbladder, 588 intrahepatic bile duct, 753 extrahepatic bile duct, and 458 ampulla of Vater cancer cases were diagnosed. Individuals who drank tea showed a statistically significantly lower incidence rate of gallbladder cancer (GBC) relative to tea nondrinkers (HR=0.77; 95% CI, 0.64-0.91), and intrahepatic bile duct cancer (IHBDC) had an inverse association (HR=0.81; 95% CI, 0.66-1.00). However, no associations were observed for extrahepatic bile duct cancer (EHBDC) or ampulla of Vater cancer (AVC). In contrast, coffee consumption was positively associated with GBC, with a higher incidence rate for individuals consuming more coffee (HR<3 cups/day =1.29; 95% CI, 1.01-1.66; HR≥3 cups/day =1.49; 95% CI, 1.11-1.99, Ptrend=0.01) relative to coffee nondrinkers. However, there was no association between coffee consumption and GBC when restricted to coffee drinkers. There was little evidence of associations between coffee consumption and other biliary tract cancers.

CONCLUSIONS

Tea consumption was associated with a lower incidence of GBC and possibly IHBDC. Further research is warranted to replicate the observed positive association between coffee and GBC.

Mustard oil consumption, cooking method, diet and gallbladder cancer risk in high- and low-risk regions of India

The current study aimed to investigate the role of cooking with mustard oil and other dietary factors in relation to gallbladder cancer (GBC) in high- and low-incidence regions of India. A case-control study was conducted including 1,170 histologically confirmed cases and 2,525 group-matched visitor controls from the largest cancer hospital in India. Dietary data were collected through a food frequency questionnaire. For oil consumption, we enquired about monthly consumption of 11 different types of cooking oil per family and the number of individuals usually sharing the meal to estimate per-individual consumption of oil. Information about method of cooking was also requested. Odds ratios (ORs) and 95% confidence intervals (CIs) quantifying the association of GBC risk consumption of different types of oil, method of cooking, and dietary food items, were estimated using logistic regression models, after adjusting for potential confounders. High consumption of mustard oil was associated with GBC risk in both high- and low-risk regions (OR = 1.33, 95% CI = 0.99-1.78; OR = 3.01, 95% CI = 1.66-5.45), respectively. An increased risk of GBC was observed with deep frying of fresh fish in mustard oil (OR = 1.57, 95% CI = 0.99-2.47, p-value = 0.052). A protective association was observed with consumption of leafy vegetables, fruits, onion and garlic. No association was observed between consumption of meat, spicy food, turmeric, pulses or with any other oil as a cooking medium. The effect of high consumption of mustard oil on GBC risk, if confirmed, has implications for the primary prevention of GBC, via a reduced consumption.

Current practices and future prospects for the management of gallbladder polyps: A topical review

A gallbladder polyp is an elevation of the gallbladder mucosa that protrudes into the gallbladder lumen. Gallbladder polyps have an estimated prevalence in adults of between 0.3%-12.3%. However, only 5% of polyps are considered to be "true" gallbladder polyps, meaning that they are malignant or have malignant potential. The main radiological modality used for diagnosing and surveilling gallbladder polyps is transabdominal ultrasonography. However, evidence shows that other modalities such as endoscopic ultrasound may improve diagnostic accuracy. These are discussed in turn during the course of this review. Current guidelines recommend cholecystectomy for gallbladder polyps sized 10 mm and greater, although this threshold is lowered when other risk factors are identified. The evidence behind this practice is relatively low quality. This review identifies current gaps in the available evidence and highlights the necessity for further research to enable better decision making regarding which patients should undergo cholecystectomy, and/or radiological follow-up.

Gallic acid loaded PEO-core/zein-shell nanofibers for chemopreventive action on gallbladder cancer cells

Coaxial electrospinning was used to develop gallic acid (GA) loaded poly(ethylene oxide)/zein nanofibers in order to improve its chemopreventive action on human gallbladder cancer cells. Using a Plackett-Burman design, the effects of poly(ethylene oxide) and zein concentration and applied voltage on the diameter and morphology index of nanofibers were investigated. Coaxial nanofibers were characterized by scanning electron microscopy (SEM), transmission electron microscopy (TEM), Fourier transform infrared spectroscopy (FTIR), thermogravimetric analysis (TGA) and differential scanning calorimetry (DSC). GA loading efficiency as high as 77% was obtained under optimal process conditions. The coaxial nanofibers controlled GA release in acid and neutral pH medium. Cytotoxicity and reactive oxygen species (ROS) production on gallbladder cancer cell lines GB-d1 and NOZ in the presence of GA-nanofibers were assessed. GA-nanofibers triggered an increase in the cellular cytotoxicity compared with free GA on GB-d1 and NOZ cells. Statistically significant differences were found in ROS levels of GA-nanofibers compared with free GA on NOZ cells. Differently, ROS production on GB-d1 cell line was similar. Based on these results, the coaxial nanofibers obtained in this study under optimized operational conditions offer an alternative for the development of a GA release system with improved chemopreventive action on gallbladder cancer cells.

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.

Pancreaticobiliary fistula evident after ESWL treatment of pancreatolithiasis

Here we report a patient with a pancreaticobiliary fistula that was possibly associated with pancreatolithiasis. He was admitted due to mild pancreatitis. Pancreatolithiasis was revealed in the parenchyma of the head region and in the main pancreatic duct of the pancreas body with distal dilatation. Extracorporeal shock wave lithotripsy (ESWL) effectively eliminated the pancreatic stones; however, an apparent internal fistula from the middle portion of the common bile duct (CBD) to the main pancreatic duct was revealed where the parenchymal stones had been located. The patient was considered to be in the same condition as pancreato-biliary malunion without CBD dilatation, and was treated with laparoscopic cholecystectomy.

Cholecystectomy in patients with asymptomatic gallstones to prevent gall bladder cancer--the case against

Gallstones (GS) are common in northern India. GS are the most important risk factor for gall bladder cancer (GBC). Data from the West, however, indicate that the risk of GBC in persons with asymptomatic GS is very small and does not warrant prophylactic cholecystectomy. Can these recommendations be applied to northern India where incidence rates of GBC are one of the highest in the world? Not all persons with asymptomatic GS require cholecystectomy. There may, however, be a case for offering cholecystectomy to a young woman in northern India with a large GS or a gall bladder packed with GS, though there is no evidence to support this recommendation. Type of stone, tumor markers and genetic markers need to be investigated to identify those with asymptomatic GS who are at the highest risk of developing GBC so that they can selectively be offered pre-emptive cholecystectomy to prevent GBC.

Cholecystectomy for asymptomatic gallstones can reduce gall bladder cancer mortality in northern Indian women

Gall bladder cancer (GBC) is a leading cause of cancer-related mortality in the northern parts of the Indian subcontinent. A majority of patients with GBC are middle-aged women, who normally would have substantial family responsibilities. Most patients are diagnosed with advanced cancer and are suitable for palliative care only. There is a strong association between long-standing gallstone disease and the development of GBC. Although randomized trials are lacking, prospective population-based data from low-risk and high-risk regions reveal that cholecystectomy reduces the mortality from GBC. Prophylactic cholecystectomy is recommended in populations with high incidence of GBC. The morbidity and mortality of laparoscopic cholecystectomy in uncomplicated gallstone disease is very low in India. Because of these reasons we argue that prophylactic cholecystectomy should be offered to young healthy women from high-risk regions of India whenever they are diagnosed to have asymptomatic gallstones. Simultaneously, population-based observational studies could be undertaken to generate more evidence.

Gallstones and gallbladder cancer-volume and weight of gallstones are associated with gallbladder cancer: a case-control study

BACKGROUND

Gallstones are considered the most important risk factor for gallbladder cancer.

AIM

To identify differences in the number, weight, volume, and density of gallstones associated with chronic cholecystitis (CC), gallbladder dysplasia (GD), and gallbladder cancer (GBC).

METHODS

A total of 125 cases were selected, of which 93 had gallstones associated with GBC and 31 had gallstones associated with GD. The controls were those with CC, matched by sex and age. The number, weight, volume, and density of these gallstones were examined in order to determine differences and relative cancer risk.

RESULTS

Number: Multiple gallstones were present in over 76% of cases (GBC and GD) and controls (P = ns). The average number of multiple stones was 21 in GBC versus 14 in controls (P < 0.01). Weight: The average weight of the gallstones was 9.6 g in GBC versus 6.0 g in controls (P = 0.0004). The average weight in multiple stones over 10 g had strong association with GBC (P = 0.0006). Volume: The average volume was 11.7 and 6.48 ml in GBC and controls (P = 0.0002). Average volumes of 6, 8, and 10 ml had a relative cancer risk of 5, 7, and 11 times, respectively. Size: No differences were shown between GBC, GD, and controls.

CONCLUSIONS

The volume of gallstones associated with other risk factors of GBC may be helpful in prioritizing cholecystectomies in symptomatic patients.

Contribution of silent gallstones in gallbladder cancer

Silent (asymptomatic) gallstones are detected frequently with the widespread use of abdominal ultrasonography. The presence of gallstones is found strongly associated with gallbladder carcinoma. Studies on the natural history and most decision analysis studies do not favor prophylactic cholecystectomy for patients with silent gallstones. Gallbladder carcinoma is known to be highly aggressive and lethal disease with a poor outcome. It is rarely diagnosed early and only 10-30% patients are offered radical surgery on presentation. This has lead to a dilemma leading most surgeons to opt for an expectant management of silent gallstones. It thus raises the important question of the implications of leaving asymptomatic gallstones untouched. In this paper the author has reviewed the current understanding on silent gallstones and gallbladder carcinoma.

Correlates between vegetable consumption and gallbladder cancer

The results of several studies indicate that a diet rich in fresh vegetables protects against several common epithelial neoplasms. This probable effect has been related to specific micronutrients contained in vegetables. In the present case-control study a systematic assessment of the relationship between vegetable intake and the risk of gallbladder cancer has been undertaken. The study is of particular interest in order to better understand the quantifying effect of vegetable consumption with regard to gallbladder cancer. One hundred and fifty-three patients with gallbladder cancer and 153 controls with gallstone disease were included. Each patient's consumption of vegetables was assessed by using a food frequency questionnaire. The frequency of vegetable consumption was divided into three levels: > or =3 days/week, 1-2 days/week and no or rare consumption. Participants were divided into three groups according to the level of vegetable intake. Odds ratios and 95% confidence intervals were computed for subsequent levels of vegetable consumption compared with the high level of consumption. A low consumption of vegetables showed an increase in odds ratio for gallbladder cancer for almost all the vegetables studied. A significant inverse trend was observed for green leafy vegetables and gallbladder cancer. An inverse association was observed for amaranth with an OR of 3.45 for the low vs. high level of consumption. Corresponding values were 2.14 for spinach, 1.86 for bathua, 1.02 for bengalgram leaves, 2.26 for cabbage, 3.06 for fenugreek leaves, 1.95 for mustard leaves and 1.44 for radish leaves. An inverse relationship between the risk of gallbladder cancer and the level of vegetable consumption was observed.

Gallbladder cancer: A global perspective

Gallbladder cancer, the commonest malignancy of the biliary tract worldwide, is common in northern India. It can be clinically obvious, an unexpected finding at laparotomy, detected incidentally on histological examination or may be missed only to present with recurrence during follow up. US, CECT, uppeer gastro-intestinal endoscopy, and laparoscopy are useful for diagnosis and staging. We have adopted a 'middle path'--between pessimistic nihilism of the West and aggressive radicalism of Japan--of management, i.e., extended cholecystectomy for early disease confined to the gallbladder and hepato-dudodenal ligament, and non-surgical palliation for advanced disease. The aetiological role of gallstones in the causation of gallbladder cancer needs to be investigated to decide the place of prophylactic cholecystectomy, if any.

Inhibitory effect of meloxicam, a cyclooxygenase-2 inhibitor, on N-nitrosobis (2-oxopropyl) amine induced biliary carcinogenesis in Syrian hamsters

Pancreaticobiliary maljunction (PBM) is a high risk factor in biliary tract carcinoma. The chemopreventive action of a cyclooxygenase (COX)-2 inhibitor (meloxicam) on N-nitrosobis (2-oxopropyl) amine (BOP)-induced gallbladder cancer in hamster PBM models was investigated. In 7-week-old female Syrian golden hamsters, the extrahepatic bile duct at the distal end of the common duct was ligated and cholecystoduodenostomy was performed (group I). In group II, the same surgery was performed and from week 4 after surgery, 10 mg/kg of BOP was injected subcutaneously once a week with a 1-week interval. In group III, in addition to the measures employed in group II, 5 mg/kg/day of meloxicam was administered once a day, every weekday. Pathological findings in the gallbladder in week 20 after surgery were as follows. In group I, proper epithelium (PE) was predominant and there was no cancer. In group II, PE was predominant, but there was also hyperplasia and atypical epithelium (AE) recognized in 8 of 11 cases (72.7%); the area of AE was more extensive than that in group I. Carcinoma in situ (CIS) was recognized in 4 of 11 cases (36.4%) in group II. Group III showed the same pathological findings as group I. However, compared with group II, the incidence of AE decreased to 27.3% and no cancerous lesion was observed. In week 20 after surgery, the proliferative cell nuclear antigen labeling index in group III was statistically significantly lower than in group II (P = 0.045). No statistically significant differences were noted among the groups in terms of apoptosis labeling index in week 20 after surgery. In conclusion, it was confirmed that meloxicam suppresses carcinogenesis in hamster PBM models and its mechanism may be based on the suppression of cell growth.

A review of association of dietary factors in gallbladder cancer

Gallbladder cancer (GBC) is the prominent malignancy of hepato-biliary tract, being the fifth most common carcinoma for gastrointestinal tract in United States. Epidemiological studies world wide have implicated dietary factors in the development of gallbladder cancer. The ecological evidences indicate considerable geographic variation in the incidence of gallbladder cancer. However the variations in GBC incidence of different populations might be partly determined by their dietary variations. Higher intake of energy and carbohydrate possibly increase the risk of gallbladder cancer. Obesity plays an important role in the causation of GBC. Adequate intake of fruits and vegetables probably reduce the risk of GBC. This nutritional preventive effect against GBC could be attributed to high content of vitamins, carotenes and fibers. They can not be too emphatically stated as the sole determinants of GBC. It is apparently clear that a variety of essential nutrients can significantly modify the carcinogenic process. Furthermore, an attempt has been made to establish an association between dietary factors and the occurrence of gallbladder cancer.

Bowel movement frequency, medical history and the risk of gallbladder cancer death: A cohort study in Japan

Few risk factors for gallbladder cancer have been identified with sufficient statistical power, because this cancer is rare. The present study was conducted to evaluate the association of bowel movement frequency and medical history with the risk of death from gallbladder cancer using the data set from a large-scale cohort study. A total of 113,394 participants (42.0% males), aged 40 to 89 years, were followed up for 11 years. Information on the medical history of selected diseases, history of blood transfusions, frequency of stools, and tendency toward diarrhea at baseline was collected through a self-administered questionnaire. The Cox proportional hazard model was used to estimate the hazard ratio (HR). During the follow-up period, a total of 116 deaths (46 males, 70 females) from gallbladder cancer were identified. After adjustments for age and gender, history of hepatic disease (HR: 2.28; 95% confidence intervals (95% CI): 1.24-4.21), frequency of stool, and tendency toward diarrhea (HR: 0.26; 95% CI: 0.08-0.83) were found to be significantly associated with the risk of death from gallbladder cancer. Compared with those who had a stool at least once a day, the HR was 2.06 (95% CI: 0.82-5.18) for those who had a stool less than once in 6 days (P for trend = 0.050). In this prospective study, constipation and a history of hepatic disease were found to elevate the risk of gallbladder cancer death, whereas a tendency toward diarrhea diminished it.

Evidenzbasierte Prävention der Cholezystolithiasis

Evidence based prevention of cholecystolithiasis. Cholesterol cholelithiasis is one of the most common and expensive gastroenterological diseases. Beside common exogenous risk factors, recent molecular genetic studies have identified genetic risk factors for both cholesterol and pigment stone formation. Examples are low phospholipid-associated cholelithiasis due to mutations of the gene encoding the hepatocanalicular phosphatidylcholine transporter, and pigment stones in association with mutations of the ileal bile salt transporter gene. Evidence-based options for primary prevention of cholecystolithiasis include physical activity, slow weight reduction, regular vitamin C supplementation, and moderate coffee consumption. The ongoing genome projects provide the basis for future epidemiological studies of human gallstone (LITH) genes, which might offer new prospects for individual risk assessment and prevention of gallstones.

Diet and gallbladder cancer: a case-control study

Cancer of the gallbladder is rare but fatal, and has an unusual geographic and demographic distribution. Gallstones and obesity have been suggested as possible risk factors. As diet is known to influence both these factors, we carried out the present study to evaluate the possible role of diet in gallbladder carcinogenesis. A case-control study involving 64 newly diagnosed cases of gallbladder cancer and 101 cases of gallstones was carried out. The dietary evaluation was carried out by the dietary recall method based on a preset questionnaire developed specifically for the present study, keeping in mind the common dietary habits prevailing in this part of the world. Odds ratios (OR) and 95% confidence interval (CI) were calculated for various dietary items. A significant reduction in odds ratio was seen with the consumption of radish (OR 0.4; 95% CI 0.17-0.94), green chilli (OR 0.45; 95% CI 0.21-0.94) and sweet potato (OR 0.33; 95% CI 0.13-0.83) among vegetables, and mango (OR 0.4; 95% CI 0.16-0.99), orange (OR; 0.45; 95% CI 0.22-0.93), melon (OR 0.3; 95% CI 0.14-0.64) and papaya (OR 0.44; 95% 0.2-0.64) among fruits. A reduction in odds was also seen with the consumption of cruciferous vegetables, beans, onion and turnip, however the difference was not statistically significant. On the other hand, an increase in the odds was observed with consumption of capsicum (OR 2.2), beef (OR 2.58), tea (OR 1.98), red chilli (OR 1.29) and mutton (OR 1.2), however the difference was statistically not significant. In conclusion, the results of the present study show a protective effect of vegetables and fruits on gallbladder carcinogenesis, but red meat (beef and mutton) was found to be associated with increased risk of gallbladder cancer.

Epidemiology and molecular pathology of gallbladder cancer

Gallbladder cancer is usually associated with gallstone disease, late diagnosis, unsatisfactory treatment, and poor prognosis. We report here the worldwide geographical distribution of gallbladder cancer, review the main etiologic hypotheses, and provide some comments on perspectives for prevention. The highest incidence rate of gallbladder cancer is found among populations of the Andean area, North American Indians, and Mexican Americans. Gallbladder cancer is up to three times higher among women than men in all populations. The highest incidence rates in Europe are found in Poland, the Czech Republic, and Slovakia. Incidence rates in other regions of the world are relatively low. The highest mortality rates are also reported from South America, 3.5-15.5 per 100,000 among Chilean Mapuche Indians, Bolivians, and Chilean Hispanics. Intermediate rates, 3.7 to 9.1 per 100,000, are reported from Peru, Ecuador, Colombia, and Brazil. Mortality rates are low in North America, with the exception of high rates among American Indians in New Mexico (11.3 per 100,000) and among Mexican Americans. The main associated risk factors identified so far include cholelithiasis (especially untreated chronic symptomatic gallstones), obesity, reproductive factors, chronic infections of the gallbladder, and environmental exposure to specific chemicals. These suspected factors likely represent promoters of carcinogenesis. The main limitations of epidemiologic studies on gallbladder cancer are the small sample sizes and specific problems in quantifying exposure to putative risk factors. The natural history of gallbladder disease should be characterized to support the allocation of more resources for early treatment of symptomatic gallbladder disease in high-risk populations. Secondary prevention of gallbladder cancer could be effective if supported by cost-effective studies of prophylactic cholecystectomy among asymptomatic gallstone patients in high-risk areas.

[Has gallbladder cancer mortality decrease in Chile?]

This paper analyses the information of the Ministry of Health on gallbladder cancer mortality in Chile since 1997. It becomes evident that the decrease in mortality in the last two years is only apparent and due to a statistical artifact, caused by the non validated application of the Tenth International Classification of Diseases. There is a consensus that one of the causes for an increase in gallbladder cancer in a specific country is a decrease in cholecystectomy rates. This association has been clearly demonstrated in Chile, but no control program for gallbladder cancer has been devised, considering that an early cholecystectomy is a good secondary prevention measure.

Prophylactic excision of the gallbladder and bile duct for patients with pancreaticobiliary maljunction

HYPOTHESIS

Pancreaticobiliary maljunction (PBM) is a high-risk factor for biliary tract carcinogenesis because of a continuous reflux of pancreatic juice into the biliary tract. It remains to be disclosed whether we should perform prophylactic excision of gallbladders and bile ducts.

DESIGN

A person-year method.

SETTING

A university hospital.

PATIENTS

We studied 68 patients with PBM treated between August 1, 1974, and December 31, 1999.

MAIN OUTCOME MEASURES

Relative risks (observed number-expected number ratios) of gallbladder and bile duct carcinomas according to type of bile duct dilation (ie, cystic dilation, diffuse dilation, and nondilation).

RESULTS

Observed number-expected number ratios of gallbladder carcinomas were high: 291.3 in 43 patients with cystic dilation, 167.2 in 16 patients with diffuse dilation, and 419.6 in 7 patients with nondilation. Observed number-expected number ratios of bile duct carcinomas were 194.2 in 43 patients with cystic dilation before surgery and 142.8 in 39 patients with cystic dilation after long postsurgical follow-up. All these values were statistically significant (P<.01).

CONCLUSIONS

The gallbladder carries a high risk for carcinogenesis in all types of dilation in patients with PBM. The bile duct carcinomas of PBM were exclusively identified by the type of cystic dilation. Prophylactic cholecystectomy should be recommended for all dilation types, and prophylactic excision of bile ducts including cholecystectomy should be performed in patients with PBM and cystic dilation. Complete excision of extrahepatic dilated bile ducts and careful follow-up for carcinogenesis in residual dilated bile ducts should be recommended for patients with PBM and cystic dilation.

Overweight as an avoidable cause of cancer in Europe

There is growing evidence that excess body weight increases the risk of cancer at several sites, including kidney, endometrium, colon, prostate, gallbladder and breast in post-menopausal women. The proportion of all cancers attributable to overweight has, however, never been systematically estimated. We reviewed the epidemiological literature and quantitatively summarised, by meta-analysis, the relationship between excess weight and the risk of developing cancer at the 6 sites listed above. Estimates were then combined with sex-specific estimates of the prevalence of overweight [body mass index (BMI) 25-29 kg/m(2)] and obesity (BMI > or = 30 kg/m(2)) in each country in the European Union to obtain the proportion of cancers attributable to excess weight. Overall, excess body mass accounts for 5% of all cancers in the European Union, 3% in men and 6% in women, corresponding to 27,000 male and 45,000 female cancer cases yearly. The attributable proportion varied, in men, between 2.1% for Greece and 4.9% for Germany and, in women, between 3.9% for Denmark and 8.8% for Spain. The highest attributable proportions were obtained for cancers of the endometrium (39%), kidney (25% in both sexes) and gallbladder (25% in men and 24% in women). The largest number of attributable cases was for colon cancer (21,500 annual cases), followed by endometrium (14,000 cases) and breast (12,800 cases). Some 36,000 cases could be avoided by halving the prevalence of overweight and obese people in Europe.

[Risk groups for pancreatic and bile duct carcinomas]

Biliopancreatic carcinoma has a poor prognosis since the diagnosis of the tumor occurs late when advanced disease is present. The identification of potential causes and earlier diagnosis are needed to prevent the disease or identify it early enough to improve survival. The main risk factors for pancreatic cancer include advanced age, cigarette smoking, high-fat diet, diabetes mellitus, chronic pancreatitis (especially hereditary pancreatitis) and a positive family history of pancreatic cancer. The most important etiologic factor for the development of gallbladder cancer is gallstone disease. Patients with anatomic abnormalities and chronic inflammatory conditions (primary sclerosing cholangitis, infections with parasites) have an increased incidence of bile duct cancers. Several new and promising imaging techniques have recently become available and our understanding of the mechanisms of carcinogenesis are growing rapidly. However, there is currently no effective screening strategy applicable and it is unknown when to begin screening. For pancreatic cancer, reduction of risk is likely to occur with avoidance of smoking and promotion of healthful diets. Cholecystectomy rates have increased since the introduction of new laparoscopic techniques and will eventually reduce the incidence of gallbladder cancer. Improved imaging techniques, the identification of new genes and a better definition of genetic alterations that characterize preinvasive lesions will hopefully allow to develop sensitive and specific technologies to screen and to detect early biliopancreatic cancer for even premalignant lesions to improve the mostly fatal prognosis if this tumor.

Primary gallbladder cancer: recognition of risk factors and the role of prophylactic cholecystectomy

The objective of this article is to review the available literature on the epidemiology, predisposing factors, and conditions associated with primary gallbladder cancer, and to discuss the role of prophylactic cholecystectomy in high-risk patient populations. Gallbladder cancer is a highly malignant tumor with a poor 5-yr-survival rate. It is a tumor of the elderly and has striking genetic, racial, and geographic characteristics, with an extremely high prevalence in Native Americans and Chileans. Cholelithiasis is a well-established risk factor for gallbladder cancer and the risk seems to correlate with stone size. Polyps that are >1 cm, single, sessile, and echopenic are associated with a higher risk of malignancy. Anomalous junction of pancreaticobiliary ducts (AJPBD), especially without choledochal cyst, and porcelain gallbladder are additional factors that predispose to gallbladder cancer. Lesser associations include chronic bacterial infections of the gallbladder, typhoid carrier state, certain occupational and environmental carcinogens, hormonal changes in women, and certain social, dietary, and familial factors. It is important to identify high-risk groups for gallbladder cancer because of the dismal nature of this tumor. In patients with porcelain gallbladder and anomalous junction of the pancreatic and biliary ducts, cholecystectomy is recommended provided that the patient is a good operative candidate. Patients with large solitary polyps or gallstones require close ultrasonic follow-up. With the advent of endoscopic ultrasound it is expected that early changes of malignancy in polyps will be reliably detected, and more patients will potentially be cured with a simple cholecystectomy. Through a MEDLINE/PAPERCHASE search we identified and reviewed articles regarding gallbladder cancer published in English-language journals between 1966 and 1999, using the key words biliary tract and gallbladder diseases, cancer, neoplasms, surgery, cholelithiasis, gallstones, cholecystitis, gallbladder polyps, risk factors, chemical industry, occupational diseases, typhoid, porcelain gallbladder, bacteremia, and precancerous conditions. We also used the bibliography of relevant articles to increase our search. A total of 122 publications were selected using the mentioned data source.

Primary gallbladder cancer: recognition of risk factors and the role of prophylactic cholecystectomy

The objective of this article is to review the available literature on the epidemiology, predisposing factors, and conditions associated with primary gallbladder cancer, and to discuss the role of prophylactic cholecystectomy in high-risk patient populations. Gallbladder cancer is a highly malignant tumor with a poor 5-yr-survival rate. It is a tumor of the elderly and has striking genetic, racial, and geographic characteristics, with an extremely high prevalence in Native Americans and Chileans. Cholelithiasis is a well-established risk factor for gallbladder cancer and the risk seems to correlate with stone size. Polyps that are >1 cm, single, sessile, and echopenic are associated with a higher risk of malignancy. Anomalous junction of pancreaticobiliary ducts (AJPBD), especially without choledochal cyst, and porcelain gallbladder are additional factors that predispose to gallbladder cancer. Lesser associations include chronic bacterial infections of the gallbladder, typhoid carrier state, certain occupational and environmental carcinogens, hormonal changes in women, and certain social, dietary, and familial factors. It is important to identify high-risk groups for gallbladder cancer because of the dismal nature of this tumor. In patients with porcelain gallbladder and anomalous junction of the pancreatic and biliary ducts, cholecystectomy is recommended provided that the patient is a good operative candidate. Patients with large solitary polyps or gallstones require close ultrasonic follow-up. With the advent of endoscopic ultrasound it is expected that early changes of malignancy in polyps will be reliably detected, and more patients will potentially be cured with a simple cholecystectomy. Through a MEDLINE/PAPERCHASE search we identified and reviewed articles regarding gallbladder cancer published in English-language journals between 1966 and 1999, using the key words biliary tract and gallbladder diseases, cancer, neoplasms, surgery, cholelithiasis, gallstones, cholecystitis, gallbladder polyps, risk factors, chemical industry, occupational diseases, typhoid, porcelain gallbladder, bacteremia, and precancerous conditions. We also used the bibliography of relevant articles to increase our search. A total of 122 publications were selected using the mentioned data source.

Effects of selenium on gallbladder carcinogenesis induced by an intracholecystic 3-methylcholanthrene beeswax pellet in female Syrian golden hamsters

This study represents the first report of the effects of selenium (Se) on chemically induced gallbladder carcinogenesis in hamsters. A total of 100 female Syrian golden hamsters was randomly assigned to four groups, which groups of 25 hamsters were given ad libitum drinking water containing either 0.0, 0.5, 2.0 or 4.0 ppm Se (as sodium selenite) for 24 weeks. Initiation was performed at week 4 by the insertion of a Beeswax pellet containing 3-methylcholanthrene (3-MC) into the gallbladder. The incidence of total malignant tumors at the end of the study (24 weeks) was 88, 75, 81 and 82% in the 0.0, 0.5, 2.0 and 4.0 ppm Se groups, respectively. All the cases of carcinoma but two were considered to develop through the sequence from dysplasia to carcinoma in situ (CIS) and from CIS to adenocarcinoma of invasive type. The incidence of CIS was significantly lower in hamsters treated without Se than in those treated with Se (P < 0.05). On the other hand, the incidence of invasive adenocarcinoma was significantly higher in the former than in the latter (P < 0.05). These results were summarized that Se might retard the progression of hamster gallbladder carcinogenesis induced by a 3-MC beeswax pellet.

Elective cholecystectomy and carcinoma of the gallbladder

The incidence of carcinoma of the gallbladder has been reputed to be approximately 1.5 per cent among those who undergo surgery for chronic cholecystitis. The incidence at Cabrini Medical Center coincides rather well with that from other studies but has shown a marked decline, 21.5 per cent, within recent years. A report from the American Cancer Society projects an even greater decline to 0.65 per cent in the incidence of this almost incurable disease within the next 1-2 years. The decrease in the incidence of cancer of the gallbladder is attributed to the great increase in the performance of elective cholecystectomy for chronic cholecystitis among people 50 years of age or younger, before they have reached the age when carcinoma of the gallbladder is most prevalent. Early surgery is advocated not only as an effective and safe form of therapy but also as a valuable preventive measure.

Serum CEA and CA 19-9: potential future diagnostic or screening tests for gallbladder cancer?

The poor prognosis of gallbladder cancer and the presence of high-risk populations make the identification of a screening test for this disease very desirable. As part of an ongoing case-control study of gallbladder cancer being conducted in Mexico City, Mexico, and in La Paz, Bolivia, blood specimens were sought from all patients with cancer of the gallbladder and on controls of similar age and sex undergoing upper abdominal surgery. Each sample was analyzed for carcino-embryonic antigen (CEA) and CA 19-9. Using the specimens from Bolivia, a serum CEA cutoff of 4.0 ng/ml yielded a sensitivity of 50.0% and a specificity of 92.7%, while a serum CA 19-9 cutoff of 20.0 units/ml yielded a sensitivity of 79.4% and a specificity of 79.2%. Using ROC curve analysis, the latter was a much better test than the former (p less than 0.05). Using the tests in series or in parallel did not substantively improve the results. The specimens from Mexico were used for validation purposes, and yielded very similar results. In conclusion, serum CA 19-9 and CEA are fairly good tests for discriminating patients with gallbladder cancer from patients with gallstones and no cancer, the former being a better test than the latter. These tests may be useful in identifying disease recurrences. In addition, if a sufficiently high-risk population could be identified, this could potentially become a useful screening test for this serious disease, allowing early intervention. However, additional data are needed prior to recommending this clinically.

[The importance of early cholecystectomy in cholelithiasis for the prevention of carcinoma of the gallbladder]

The authors report on a series of 324 patients operated on for cholelithiasis. They summarize the histological findings obtained by detailed examination of the surgical specimens carried out by one pathologist. The relatively high rate (43%) of severe pathological changes in the gallbladder wall in emphasized as these may be sites of predilection for the development of carcinoma. Three cases of only histologically established carcinoma are briefly described. In two of them carcinoma developed on the basis of chronic fibroproductive cholecystitis. In the third case the gall bladder was not removed and thus histologically not examined. In the light of their findings, the authors strongly advocate early cholecystectomy, particularly in patients of advanced age groups.

Modification of pancreatic carcinogenesis in the hamster model. 3. Inhibitory effect of alloxan

Alloxan, when given intravenously at a dose of 60 mg/kg body weight 2 hours prior to subcutaneous injection of the potent pancreatic carcinogen N-nitrosobis (2-oxopropyl) amine (BOP), inhibited the induction of hyperplastic and neoplastic pancreatic lesions in a statistically significant fashion (P less than 0.01). The number of lesions per animal affected was markedly less in these animals, compared with BOP-treated control animals. BOP administration 2 weeks after alloxan treatment, at which time pancreatic islet cell regeneration is considered completed, did not alter either the incidence or number of lesions. The results support our view that the pancreatic islet cells are the primary source of BOP metabolism. The concomitant inhibition of gallbladder tumors, but not of common duct neoplasms, in hamsters receiving BOP 2 hours after alloxan could indicate that alloxan's inhibitory effects on BOP carcinogenesis are not restricted to the pancreas.

Modifying factors in pancreatic carcinogenesis in the hamster model. I. Effect of protein-free diet fed during the early stages of carcinogenesis

The role of protein in pancreatic carcinogenesis was examined in outbred Syrian golden hamsters treated with the pancreatic carcinogen N-nitrosobis(2-oxopropyl)amine (BOP) and fed a purified protein-free diet (PPFD). The PPFD was fed for 28 days from 8 weeks of age; before and after animals were fed PPFD, they were given a commercial diet (CD). BOP was given before PPFD feeding (group 1) or at 18 days (group 2) and 28 days (group 3) from the beginning of the PPFD feeding. BOP-treated control hamsters (group 4) were pair-fed a purified control diet (PCD) instead of PPFD. All animals fed PPFD and PCD were returned to a CD for the rest of the experiment, which was terminated in each group 52 weeks after BOP treatment. The results showed a highly significant reduction of tumor incidence (P less than 0.0001) in hamsters that received PPFD, when compared to those fed PCD, regardless of the time of carcinogen administration during the dietary regimen. Hamsters treated with BOP at 18 days of PPFD (group 2) developed neither benign nor malignant pancreatic tumors. The inhibition of pancreatic neoplasms was not related to reduced calorie consumption, since this occurred in the BOP-treated hamsters that were pair-fed the PCD diet. The results indicated that both the initiation and promotion of pancreatic carcinogenesis with BOP in hamsters can be inhibited by lack of protein in the diet given for 4 weeks during the early stages of the neoplastic process.