Risk factors for biliary tract and ampullary carcinomas and prophylactic surgery for these factors

Abstract

Curative resection is the only treatment for biliary tract cancer that achieves long-term survival. However, patients with advanced biliary tract cancer have only a limited prognosis even after radical surgical resection. Thus, to improve the longterm results, the early detection of biliary tract cancer and subsequent cure seem to be essential. The purpose of this study was to review the literature concerning the risk factors for cancerous and precancerous lesions of the biliary tract, and prophylactic surgery for these factors. It has been reported that pancreaticobiliary maljunction (PBM) with bile duct dilatation is a risk factor for gallbladder cancer and bile duct cancer, while PBM without bile duct dilatation is a risk factor for gallbladder cancer. Thus, in the former group, a prophylactic excision of the common bile duct and gallbladder should be recommended, while in the later group, a prophylactic cholecystectomy without bile duct resection may be the appropriate surgical procedure. It has also been reported that primary sclerosing cholangitis (PSC) is a risk factor for cholangiocarcinoma. Patients with PSC often develop advanced cholangiocarcinoma with a poor prognosis. In patients with PSC, therefore, strict follow-up should be recommended. Adenoma and dysplasia have been regarded as precancerous lesions of gallbladder cancer. A polypoid lesion of the gallbladder that is sessile, has a diameter greater than 10 mm, and /or grows rapidly, is highly likely to be cancerous and should be resected. Although gallstones seem to be closely associated with gallbladder cancer, there is no evidence of a direct causal relationship between gallstones and gallbladder cancer. Thus, a cholecystectomy is not advised for asymptomatic cholecystolithiasis. Controversy remains as to whether adenomyomatosis of the gallbladder and porcelain gallbladder are associated with gallbladder cancer. With respect to ampullary carcinoma, adenoma of the ampulla is considered to be a precancerous lesion. This article discusses the risk factors for cancerous and precancerous lesions of the biliary tract and prophylactic treatment for these factors.

Fig. 1

Macroscopic photograph of adenoma of the gallbladder

Fig. 2a–c

Histological examination of adenoma of the gallbladder. a Low magnification; b intermediate magnification; c high magnification (H&E)

Fig. 3a–c

Findings in adenomyomatosis. a Fundal type: circumscribed hypertrophy of the fundus of the gallbladder with Rokitansky-Aschoff sinus. Case complicated by cholecystolithiasis. Upper, resected specimen; lower left, abdominal computed tomography (CT; cross section); lower right, abdominal CT (sagittal section). b Segmental type: hypertrophy circumscribing the gallbladder with Rokitansky-Aschoff sinus. Upper, resected specimen; lower left, abdominal computed tomo graphy (CT; cross section); lower right, abdominal CT (sagittal section). c Diffuse (segmental-diffuse) type: hypertrophy and Rokitansky-Aschoff sinus from the gallbladder body to the fundus. Gallstones in the fundus. Left, resected specimen; right, abdominal CT

Fig. 4

This Loupe image shows growing and dilating Rokitansky-Aschoff sinuses from the muscularis propria to the subserosa, and the growing smooth muscle fiber and collagen fiber surrounding them (H&E)

Fig. 5

Endoscopic retrograde cholangiopancreatography image of PSC. Multifocal stricturing of intrahepatic and extrahepatic bile ducts, and shaggy appearance of extrahepatic bile ducts

Fig. 6a,b

Endoscopic retrograde cholangiopancreatography (ERCP) image of pancreaticobiliary maljunction (PBM): a patient with congenital bile duct dilatation (Kotani IV a type). a The pancreatic duct joins the biliary duct. b Pancreaticobiliary maljunction without bile duct dilatation (Fig 6a, with permission from Koyanagi K, Aoki T, editors. Pancreaticobiliary maljunction. Tokyo: Igaku Tosho Shuppan: 2002. p 25, Fig. 429)

Fig. 7

Ultrasound image of a cholesterol polyp: sessile polyp that has a higher echoic signal than the liver

Fig. 8

Ultrasound image of adenoma of the gallbladder: this image indicates a semipedunculate polyp with isoechoic signal

Fig. 9

Ultrasound image of early-stage gallbladder carcinoma: a pedunculated protrusion with a relatively high echoic signal. Depth of tumor invasion is limited to the mucosal layer

Fig. 10

Ultrasound image of gallbladder carcinoma: sessile protruding lesion. Depth of tumor invasion is to the subserosa