Newly Diagnosed With Gallbladder Cancer: First Steps

Gallbladder cancer is rare, and it is hard to catch early. The National Cancer Institute puts it plainly: this cancer "is difficult to detect (find) and diagnose early." Three things get in the way. Early on it rarely causes symptoms, and when symptoms do show up they look like many other illnesses. The gallbladder also sits tucked behind the liver, where it is hard to see on a scan.

That is why many people meet this diagnosis in an odd way. They had the gallbladder taken out for gallstones, the surgery went fine, and then a lab report came back days later with cancer cells in it. If that is your story, nothing was missed and nothing was done wrong. This is simply how a lot of gallbladder cancer gets found.

Other people arrive by a different road, turning yellow or having pain above the stomach until a scan finds a mass. The NCI lists the usual signs as jaundice (yellow skin and yellow whites of the eyes), pain above the stomach, fever, nausea and vomiting, bloating, and lumps in the belly.

Most of what follows can wait a week, but these cannot. Call 911 or go to an emergency room, and do not wait for a call back, if you have:

• Yellow skin or yellow eyes along with a fever or shaking chills.
• Yellow skin or eyes with pain in the upper right belly.
• Dark urine, pale stools, and a fever at the same time.
• Confusion or feeling faint on top of any of the above.
• A temperature of 100.4°F (38°C) or higher once chemotherapy has started. CDC treats fever during chemotherapy as a medical emergency.

Yellow skin means bile is backing up. Bile is the fluid your gallbladder stores to help you digest fat, and when a tumor blocks the tube that carries it, bile builds up behind the blockage. Add a fever and that trapped bile may be infected, which is treated as an emergency and fixed with a drainage procedure rather than a wait-and-see plan.

Yellow skin on its own, with no fever, still needs a call the same day. It does not need an ambulance.

Staging uses the AJCC TNM system. T describes how deep the tumor has grown into the gallbladder wall, N is whether nearby lymph nodes are involved, and M is whether it has spread further. Those three letters combine into stages 0 through 4.

In the first days, though, your team is really chasing one word: resectable. That means the cancer can be fully removed by surgery.

The NCI defines the two camps clearly. Resectable means the cancer "is found in the wall of the gallbladder and can be completely removed by surgery," while unresectable means it "cannot be removed completely by surgery." The NCI also says plainly that most people with this cancer have the unresectable kind.

That is hard to read, and it is also the honest place to start. The whole plan forks at that word, so nearly everything in the first two weeks is aimed at answering it.

You may have several of the tests below. They are not repeats, because each one shows something the others cannot.

• Liver function tests and blood chemistry, which show how the liver is working and whether bile is backing up.
• Ultrasound and CT scan, the first look at the gallbladder, the liver beside it, and nearby lymph nodes.
• MRI with gadolinium, a scan that uses a dye to make the liver and bile ducts stand out.
• Endoscopic ultrasound, a probe passed down the throat that gets close to the gallbladder from inside.
• ERCP, a camera passed down to where the bile ducts drain. It can study a blockage and place a stent to relieve one.
• PTC, or percutaneous transhepatic cholangiography, which drains bile through the skin into the liver when ERCP will not work.
• Laparoscopy, a small camera operation to look at the liver surface and the lining of the belly for spread that scans miss.

That last one surprises people, because a camera operation before the real operation can feel like a delay. It is not. The American Cancer Society notes it "often is used before other surgery" to look for spread and to help plan the operation, which means it is what stops a big surgery that would not have helped you.

This is a common spot to be in, and a confusing one, so it deserves its own answer. A simple cholecystectomy removes the gallbladder alone, and that is the operation done for gallstones. An extended, or radical, cholecystectomy removes more, which the American Cancer Society describes as the gallbladder plus "about an inch or more of liver tissue" and lymph nodes.

The Society describes the fork this way. If the cancer is very early, called T1a, and is thought to have been removed completely, no further surgery may be needed. If there is a chance it reached beyond the gallbladder, more extensive surgery may be advised.

So your first real decision is often whether to go back to the operating room, and that is a genuine choice rather than a formality. It deserves a specialist opinion, and a second one if you want it.

Because this cancer is rare, not every general surgeon treats it often, and that matters more here than it does for common cancers.

• A hepatobiliary surgeon, meaning a surgeon who works on the liver, gallbladder and bile ducts. This is the most useful referral to push for early.
• A medical oncologist, the doctor who plans drug treatment such as chemotherapy.
• A radiation oncologist, if radiation is on the table.
• An interventional radiologist or a gastroenterologist, who place the stents and drains used when bile is blocked.
• A specialist nurse or navigator, often the fastest way to get a question answered between visits.

Two questions are worth asking out loud. Will my case be discussed at a team meeting where all these doctors review my scans together? And how many gallbladder cancers does this center treat in a year?

If your bile duct is blocked, drainage happens fast, and your team will treat that part as urgent. The rest usually moves at the speed of the work-up.

A few weeks spent getting the right scans, the right surgical opinion, and a careful second look at the pathology is not lost time. It is the difference between the right operation and the wrong one, and it is worth the wait.

On outlook, the range here is genuinely wide, and it turns on the stage and on whether surgery can take everything out. Numbers published for large groups will not tell you your own answer. Ask your own team what they expect in your case, and ask what would change it.

• National Cancer Institute — Gallbladder Cancer Treatment (PDQ) Patient Version
• National Cancer Institute — Gallbladder Cancer
• American Cancer Society — Surgery for Gallbladder Cancer
• CDC — Fever and Cancer Treatment