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A 10-year experience with 14 patients with primary carcinoma of the gallbladder encountered in a typical community hospital has been reviewed. Abdominal discomfort in its many manifestations occurred in all patients, with chronic pain of long duration frequently being noted. Six patients were jaundiced. Twelve had documented cholelithiasis. Histologic examination revealed adenocarcinoma in all instances. One patient is alive and well at 3 years; survival of the remaining patients was from 9 days to 25 months. Primary carcinoma of the gallbladder occurs in more than 1% of surgically removed gallbladders. The disease is largely one of elderly persons with chronic calculous cholecystitis. Not only will it be seen with increasing frequency as life expectancy increases, but also it is preventable. Improvement in treatment can thus be initiated by prophylactic removal of diseased gallbladders in otherwise healthy persons. Malignancy may be obscured in those patients presenting with acute cholecystitis eluding surgeon and pathologist alike. These cases, as well as all early malignancies, are diagnosed only by careful histologic examination. Therefore, all gallbladders should be opened and examined by the surgeon in the operating room. Suspicious areas should be evaluated histologically by frozen section so that extension of the operation to include removal of adjacent hepatic parenchyma and performance of an extensive regional lymphadenectomy can be undertaken if cancer is found. By routinely considering every older patient who comes to cholecystectomy as suspect of harboring gallbladder cancer, survival may well be improved.

1. 1. A case report is given of cancer of the gallbladder of high-grade histologic malignancy with regional lymph node metastases. The patient has survived cholecystectomy and dissection of the cystic nodes for nearly eight years. 2. 2. Despite marked anaplasia and regional node metastases, cancer of the gall-bladder is a curable disease and an attempt to control this cancer is always in order.

Appropriate data from the California Tumor Registry and related sources were analyzed for carcinoma of the gallbladder and extrahepatic bile ducts including the ampulla of Vater (ICD No. 155.1,8). The median age for gallbladder cancer cases was 70.3 yr; the sex ratio was 1.88: 1. Regional spread of gallbladder cancer occurred in 33 per cent of the cases. There has been an improvement in the 5-yr survival of gallbladder cancer (relative 5-yr survival rate is 7 per cent) due to the increasing percentage of cases with localized disease who were treated with surgery. For localized cases the relative 5-yr survival rate is 23 per cent. Prophylactic operations for patients with cholelithiasis should take into consideration the epidemiologic data herein reported on the high incidence of gallbladder cancer in people over age 60, Japanese women, and Japanese migrants to the United States.

A study of all newly diagnosed patients with gallbladder and biliary tract cancer in Israel during a five-year period indicates that cholelithiasis plays a major part in the aetiology of gallbladder cancer. This conclusion is based on the following findings: ( a ) high frequency of gallstones in gallbladder cancer cases compared with biliary tract cancer and the general population; ( b ) similar frequency of gallstones in gallbladder cancer in both sexes and in all ethnic groups; ( c ) similar sex and ethnic population trends in the incidence of cholelithiasis and of gallbladder cancer.

1. Calculi alone despite their high incidence have not been proven the cause of carcinoma of the gall bladder.

Many factors and diseases have been claimed to be associated with increased frequency of cholesterol gallstone formation. Not all these claims stand up to critical examination. Age, sex, and race are associated with gallstone frequency and stones are unusually common in patients with gallbladder cancer or pancreatitis. For parity, body-weight, cirrhosis, ileal disease (or resection), and diabetes mellitus an association is probable but not definite. For the many other associations which have been proposed the evidence is contradictory, inadequate, or both.

(1) Biliary duct stone must receive surgical treatment at once. (2) Gallbladder stone must receive surgical treatment according to the symptoms, the clinical investigations (liver function, pancreas function, red cell sedimentation, leucocyte countta) and the roentgenological findings. (3) The gallbladder carcinoma with good cholecystogramm can be diagnosed roentgenologicaly.

Survival analysis based on a nationwide study of patients in Israel with gallbladder cancer revealed a relatively better survival in two subgroups: (1) patients with a localized tumor at operation and (2) patients with papillary adenocarcinoma. Further breakdown demonstrated that these two factors are interrelated, ie, patients with papillary adenocarcinoma have a relatively higher frequency of localized tumors. Consequently, the group of localized papillary adenocarcinoma of the gallbladder had a median survival extending beyond five years after diagnosis as compared with one month for the total group.

Primary gallbladder cancer is rare. The patient Nurenberg Anna, 40, a German, was admitted to Davlekanov Hospital on 26/XI 33. She considers herself to be sick from July 1933, when the first time there were not very severe pains in the area of the right subcostal.