Gallbladder Cancer Diagnosis and Staging

November 22, 2024

This page was reviewed under our medical and editorial policy by Laleh Melstrom, M.D., M.S., associate professor of surgery and immuno-oncology, Division of Surgical Oncology, Department of Surgery, City of Hope® Cancer Center Duarte

TAKEAWAYS:

  • The care team may perform a variety of tests during the gallbladder cancer diagnosis process.
  • These may include a physical exam, imaging and lab tests, biopsy and more.
  • Following a diagnosis of gallbladder cancer, the care team may assign a stage to the disease.

An accurate gallbladder cancer diagnosis is the first step in developing a gallbladder cancer treatment plan. Cancer care experts will use a variety of tests and exams, including imaging and laboratory tests, during the diagnosis process and also to monitor the patient's response to treatment and modify the plan when needed.

Tests to Detect Gallbladder Cancer

Common tools used for diagnosing and staging gallbladder cancer include those listed below.

Physical Exam

If the patient is experiencing suspicious symptoms, or there’s some other reason to think he or she could have gallbladder cancer, a physical exam is often the first method the care team will use to evaluate the patient. The care team may perform the following evaluations during the exam:

  • The doctor may feel around the patient's belly to determine whether there are any suspicious lumps or swelling.
  • The patient may be asked whether he or she feels any pain or tenderness as the doctor presses down on different areas of the abdomen.
  • Various lymph nodes, such as those near the shoulders, may also be checked for lumps, as gallbladder cancer may spread to these areas.
  • The care team will look for signs of jaundice, which is a yellowing of the skin and whites of the eyes.

Before a physical exam, the patient's doctor may ask him or her a series of questions about symptoms and any past health problems.

Some of the most common symptoms of gallbladder cancer include:

  • Pain or lumps in the abdominal area
  • Nausea
  • Vomiting
  • Jaundice

The care team may want to know whether the patient has experienced any of these or other symptoms, how long they’ve lasted, and their severity.

While it’s an important part of the diagnostic process, gallbladder cancer may not be detectable through a physical exam in the early stages. Since the gallbladder is buried deep within the abdomen, it may be difficult to notice lumps or signs of cancer from outside the body. Even if a physical exam does lead the doctor to suspect there may be cancer in the gallbladder, other tests are needed to make the diagnosis.

Lab Tests

The care team may order a blood test to determine the level of bilirubin, a chemical that makes bile yellow. High levels of bilirubin may indicate a problem with either the gallbladder or the liver. Other markers of abnormal liver and/or gallbladder function that may be detected by a blood test are albumin, alkaline phosphatase, AST, ALT and GGT.

Levels of certain proteins known as tumor markers may also be checked. These proteins are often elevated in patients with certain types of cancers, although they are not specific to a certain kind of cancer, and levels may be higher than normal because of certain non-cancerous conditions. CEA and CA 19-9 are two tumor markers that may be associated with gallbladder cancer.

CT Scan

A computed tomography (CT scan) for gallbladder cancer uses X-ray images intended to give a detailed view of the abdomen and the gallbladder.

Ultrasound

This procedure is often performed with an ultrasound transducer, or wand, on the skin over the abdomen. In some cases, the care team may perform an endoscopic or laparoscopic ultrasound. For these techniques, the ultrasound device is attached to a tube, and inserted through the mouth, or through a small surgical incision.

MRI

A magnetic resonance imaging (MRI) scan is designed to examine the soft tissues within the body and is often used to diagnose gallbladder cancer.

MRI scans reveal what the gallbladder and surrounding area look like in great detail. These details may even help distinguish between a noncancerous (benign) growth and a cancerous (malignant) tumor.

An MRI scan may also help determine the size of the tumor and any spread beyond the gallbladder. To increase the clarity of the MRI images, the patient may receive an injection of a dye, which spreads through his or her bloodstream and provides contrast in the final images.

Two types of specialized MRI scans may be used to help diagnose gallbladder cancer:

  • Magnetic resonance cholangiopancreatography (MRCP) uses a regular MRI machine, but it focuses specifically on the bile ducts, creating detailed images of these structures (further described below).
  • Magnetic resonance angiography (MRA) uses a regular MRI machine to look at the blood vessels surrounding the gallbladder and determine whether a tumor has caused a blockage in blood flow or any other abnormalities are present. Before this scan, the patient may receive a contrast dye injection to increase the clarity of the images.

X-ray

A standard X-ray of the chest may be performed to see if the cancer cells have spread to the lungs.

Cholangiography

This test allows the care team to look at the bile ducts. It may also help in planning surgery. This test may be performed either by using an MRI machine or endoscope, or by inserting a needle through the skin of the abdomen.

There are three main types of cholangiography, as listed below.

Endoscopic retrograde cholangiopancreatography (ERCP) is a procedure that involves inserting a flexible and hollow instrument called an endoscope into the patient's throat until it reaches the upper part of the small intestine. Before an ERCP, the patient is given a sedative drug, so he or she isn't awake or able to feel the procedure. Once the endoscope has reached the small intestine, a catheter is passed through the hollow part of the instrument. The catheter releases a contrast dye into the area, and then an X-ray machine takes pictures. The contrast dye increases the clarity of the images produced by the X-ray and reveals whether the bile ducts and pancreatic duct are narrow or blocked. Because the endoscope allows access to the gallbladder area, important procedures such as a biopsy (removing cells for testing) or stent placement (placing a tube to unblock a duct) may be performed at the same time as an ERCP.

Percutaneous transhepatic cholangiography (PTC) involves inserting a needle into the skin covering the abdominal area, until it reaches the bile duct. The patient is given a sedative drug prior to a PTC, to induce sleepiness, and an anesthetic to numb the abdominal area. Once the needle has reached the bile duct, it releases a contrast dye and an X-ray machine takes pictures. A biopsy or stent placement can also be performed at the same time as a PTC. ERCP is more commonly used than a PTC, since it's less invasive and provides the same advantages.

Magnetic resonance cholangiopancreatography (MRCP), also described in the MRI section, uses an MRI machine to create detailed images of the bile ducts. MRCP is a noninvasive scan that examines the bile ducts without needing to enter the patient's body with an endoscope or needle (as in an ERCP and PTC). A biopsy or stent placement cannot be performed during an MRCP.

Biopsy

In some cases when gallbladder cancer is detected on other tests, a surgeon may remove the gallbladder first and send a sample to the pathologist afterwards. A biopsy may be performed during laparoscopy or cholangiography. When diagnosing gallbladder cancer, the care team may also use a procedure called fine needle aspiration, in which a thin needle is inserted into the gallbladder to remove cells, usually under the guidance of an ultrasound or CT scan.

Understanding Gallbladder Test Results

Gallbladder cancer may be difficult to detect in its early stages, as it may not cause noticeable symptoms or lumps. Oftentimes, the cancer is discovered when the gallbladder is removed for other reasons, such as an infection or gallstones. 

Following diagnostic tests for gallbladder cancer, the care team will contact the patient when the results are in and explain them in detail.

The information included in the results varies depending on which tests were performed, but it may include bilirubin levels from a blood test and descriptions of images taken with various scans, such as an MRI or CT scan. If a biopsy was performed, the care team may share whether the cells that were removed are cancerous.

Once gallbladder cancer is diagnosed, the next step is staging, which is a process that uses many of the same diagnostic tests above to assess whether the cancer has spread (metastasized) beyond the gallbladder and where it may have spread. By determining if and where the cancer has spread, the care team can recommend a treatment plan.

How Gallbladder Cancer is Staged

Following a gallbladder cancer diagnosis, the care team will review the patient's pathology to confirm the diagnosis and determine the stage of disease. Staging cancer is one of the most important factors in developing a personalized gallbladder cancer treatment plan that’s tailored to the patient's specific needs.

To understand the staging of this cancer, it’s important to know about the layers of tissue that make up the gallbladder. The innermost layer of the gallbladder is a thin sheet of tissue called the epithelium. The next layers are connective tissue called the lamina propria and muscularis, which are surrounded by another layer of connective tissue (perimuscular fibrous tissue). The outermost layer is the serosa.

Gallbladder cancer is rare and doesn’t usually cause symptoms in its earliest stage. Identifying the stage of gallbladder cancer is a way to learn how far it’s spread. Staging the cancer may include ordering imaging studies and blood tests, as well as looking at a sample of the cancer cells under a microscope.

If the gallbladder is removed during surgery as part of staging, it’s called pathological or surgical staging. Staging done without removing the gallbladder (through a biopsy) is known as clinical staging.

T, N, M Scores

Guidelines developed by the American Joint Committee on Cancer are often used to stage the disease and allow doctors to communicate important information about the cancer in a standardized way. Gallbladder cancer stages are based on three categories, listed below:

T (tumor): This describes the size of the original tumor.

N (node): This indicates whether the cancer is present in the lymph nodes.

M (metastasis): This refers to whether cancer has spread (metastasized) to other parts of the body.

Once the individual T, N and M scores have been established, an overall stage is assigned.

Stages of Gallbladder Cancer

Gallbladder cancers are staged as 0, 1, 2A, 2B, 3A, 3B, 4A and 4B. The earliest stage is 0, and 4B is the most advanced. Below find the details for each, as well as the TNM characteristics, according to the American Cancer Society.

Stage 0 Gallbladder Cancer

Also called carcinoma in situ, stage 0 gallbladder cancer is diagnosed when abnormal cells are present in the epithelium. The cancer hasn’t spread to the lymph nodes or other places in the body.

  • TNM characteristics: Tis, N0, M0

Stage 1 Gallbladder Cancer

In this stage, the cancer is still localized within the gallbladder, but the tumor has begun to penetrate into the lamina propria and the muscle layer.

  • TNM characteristics: T1, N0, M0

Stage 2 Gallbladder Cancer

This stage has two subcategories.

Stage 2A: Cancer cells have spread through the muscle to the next layer of connective tissue, but not on the side that sits under the liver.

  • TNM characteristics: T2A, N0, M0

Stage 2B: The cancer cells are in the connective tissue on the outside of the gallbladder on the same side as the liver, but they haven’t affected the liver.

  • TNM characteristics: T2B, N0, M0

Stage 3 Gallbladder Cancer

This stage has two subcategories.

Stage 3A: The cancer has spread through the outer layer of connective tissue to the serosa and/or to the liver or to a nearby organ or structure in the abdomen.

  • TNM characteristics: T3, N0, M0

Stage 3B: This stage shares stage 3A characteristics, but cancer may also be found in one to three lymph nodes.

  • TNM characteristics: T1-3, N1, M0

Stage 4 Gallbladder Cancer

This stage has two subcategories.

Stage 4A: The cancer has spread to the main artery or vein of the liver or to two or more abdominal organs or structures beyond the liver. Cancer cells may have reached nearby lymph nodes, but they haven’t reached distant organs.

  • TNM characteristics: T4, N0 or N1, M0

Stage 4B: Cancers at this stage are the most advanced. Cancer cells have either spread to lymph nodes farther away from the gallbladder, or they have spread to distant organs.

  • TNM characteristics: Any T, N2, M0 or any T, any N, M1

How Stage Affects Gallbladder Cancer Treatment

When it comes to treatment for gallbladder cancer, the stages may be arranged in two groups — resectable and unresectable cancers. Resectable or localized cancers haven’t spread outside the gallbladder, so they may be completely removed surgically.

Many people with gallbladder cancer are in the unresectable group. They may still undergo surgery, but the cancer isn’t completely removed. This means other treatments may be needed to control the cancer. These may include radiation therapy, chemotherapy, targeted therapy and immunotherapy.

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