Tratamento do Câncer de Vesícula Biliar por Estágio da Doença

A extensão do câncer de vesícula biliar é um fator importante na determinação das opções de tratamento. Os médicos utilizam o sistema TNM para estadiar formalmente o câncer. Mas para fins de tratamento, geralmente dividem os cânceres de vesícula biliar em dois grupos:

  • Cânceres Ressecáveis. São aqueles que os médicos acreditam que podem ser removidos completamente por cirurgia, com base nos resultados dos exames de imagem.
  • Cânceres Irressecáveis. Aqueles que se disseminaram para outros órgãos ou estão em locais difíceis de serem completamente removidos cirurgicamente.

Em geral, alguns cânceres que não se disseminaram muito além da vesícula biliar ainda podem ser tratáveis por cirurgia, a menos que a doença tenha se disseminado para os vasos sanguíneos principais. Por exemplo, se o câncer só atingiu uma área não muito profunda do fígado, pode ser possível remover todo o tumor por cirurgia. Por outro lado, se o tumor se disseminou para ambos os lados do fígado, para o revestimento da cavidade abdominal, para órgãos distantes da vesícula biliar ou se envolve um vaso sanguíneo principal, é pouco provável que a cirurgia possa removê-lo.

Em termos de estadiamento, os tumores estágios I e II e alguns tipos de tumores estágio III podem ser ressecáveis. Ainda assim, outros fatores, como o estado geral de saúde do paciente para a cirurgia, podem afetar se é ou não uma boa opção.

As condições do diagnóstico inicial também pode influenciar as opções de tratamento. Por exemplo, alguns cânceres são diagnosticados nos exames de imagem antes da cirurgia, enquanto outros são diagnosticados apenas após a cirurgia realizada para tratar outra condição clínica, como cálculos biliares.

Não importa o estágio do câncer, o importante é entender o objetivo do tratamento antes de iniciar, isto é, se é curativo ou para aliviar os sintomas, bem como a os benefícios e riscos do procedimento. Isso pode ajudar o paciente a tomar uma decisão informada ao entender suas opções de tratamento.

Câncer de Vesícula Biliar Potencialmente Ressecável

Estes são os cânceres em estágio inicial que os médicos acreditam que podem ser completamente removidos cirurgicamente. O tratamento destes cânceres depende em parte da forma como são diagnosticados.

Câncer Diagnosticado Após a Cirurgia por outro problema da Vesícula Biliar

Alguns cânceres de vesícula biliar são diagnosticados quando a vesícula biliar é retirada para tratar cálculos biliares ou inflamação crônica. A vesícula biliar é então estudada sob um microscópio no laboratório de patologia, momento em que o câncer é diagnosticado. Estes são tipicamente cânceres em estágio inicial. Se o câncer é confirmado apenas nas camadas internas da vesícula biliar (T1a), sem sinais de disseminação além do órgão, nenhum tratamento adicional será necessário, pois existe uma chance de que todo o tumor foi removido.

Se o tumor estiver mais disseminado dentro da vesícula biliar (T1b ou superior), outros exames deverão ser realizados para diagnosticar qualquer câncer remanescente no corpo e para determinar se é ressecável. Estes exames podem incluir tomografia computadorizada ou ressonância magnética e uma laparoscopia para o estadiamento.

Se o tumor for considerado ressecável após estes exames, uma cirurgia mais extensa será realizada para remover parte do fígado, linfonodos próximos e, possivelmente, parte do ducto biliar. Isso pode ser seguido por quimioterapia, com ou sem radioterapia, para tentar evitar a recidiva.

Se os exames de imagem ou a laparoscopia para estadiamento mostrarem que o tumor não pode ser ressecado, o tratamento será o mesmo descrito para tumores irressecáveis.

Câncer Diagnosticado durante a Cirurgia por outro problema da Vesícula Biliar

Em alguns casos, o câncer de vesícula biliar é diagnosticado durante uma colecistectomia simples. O cirurgião encontra áreas que parecem suspeitas de câncer durante a cirurgia e envia amostras para análise no laboratório de patologia.

Se o cirurgião acredita que o tumor é ressecável, ele pode mudar o procedimento para uma cirurgia mais extensa denominada colecistectomia extensiva.

Se o cirurgião não tem experiência no tratamento do câncer de vesícula biliar ou não tem certeza se o tumor é ressecável, a cirurgia pode ser interrompida neste momento. Outros exames, como tomografia computadorizada ou ressonância magnética, serão realizados para determinar sinais remanescentes da doença no corpo e se o tumor é ou não ressecável.

Se o câncer for considerado ressecável após estes os exames, uma cirurgia mais extensa será realizada para retirara parte do fígado, os linfonodos próximos e, possivelmente, partes do ducto biliar. Isso pode ser seguido de quimioterapia, com ou sem radioterapia, para tentar evitar uma recidiva da doença, mas não está claro sua eficácia.

Se os exames mostrarem que o tumor não pode ser ressecado, o tratamento será o mesmo descrito para cânceres não ressecáveis.

Câncer Diagnosticados em Exames de Imagem ou devido a Sintomas

Às vezes, se suspeita de câncer de vesícula biliar porque a pessoa está tendo sinais e sintomas como icterícia. Os exames de imagem podem determinar áreas suspeitas de câncer ou perto da vesícula biliar. Outros exames de imagem e a laparoscopia para estadiamento podem ser realizados para procurar outras áreas suspeitas no corpo. Esses exames ajudam a determinar se essas áreas são câncer e se pode (ou não) ser ressecável.

Se o câncer é ressecável e o paciente tem um bom estado geral de saúde para a cirurgia, o tratamento indicado é a colecistectomia extensiva. Se o paciente tiver icterícia antes da cirurgia, um stent ou cateter pode ser implantado no ducto biliar para permitir que a bile flua mais facilmente. Isso pode aliviar os sintomas por alguns dias e permite que o paciente possa realizar a cirurgia. Após o procedimento, o médico pode indicar quimioterapia, com ou sem radioterapia, para tentar diminuir a chance da recidiva, mas não está clara sua eficácia.

Se os exames de imagem ou a laparoscopia mostrarem que o câncer não é ressecável, é realizada uma biópsia para confirmar o diagnóstico. O tratamento será o mesmo descrito para cânceres não ressecáveis.

Cânceres de Vesícula Biliar Irressecáveis

Se o médico não considerar a cirurgia uma boa opção terapêutica, por exemplo, devido ao tamanho ou localização do tumor ou por causa do estado geral de saúde do paciente, o foco do tratamento é geralmente tentar controlar o câncer. Isso inclui alívio dos sintomas e aumento da sobrevida dos pacientes. O tratamento com radioterapia e/ou quimioterapia pode ser útil em alguns pacientes.

Para os pacientes com icterícia devido ao bloqueio do ducto biliar, um stent ou cateter pode ser implantado no duto para permitir o fluxo da bile. Desbloquear o ducto biliar é muitas vezes o primeiro tratamento paliativo realizado, antes de iniciar outros tratamentos, como a quimioterapia.

Para pacientes com dor, radioterapia, injeções de álcool nas terminações nervosas ao redor da vesícula biliar, e medicamentos para a dor podem ser úteis.

Como esses cânceres podem ser muito difíceis de serem tratados com as opções terapêuticas atuais, o paciente deve considerar a participação em um estudo clínico com novos tratamentos.

Recidiva do Câncer de Vesícula Biliar

A recidiva pode ser local ou à distância. Se o tumor recidivar após o tratamento inicial, o tratamento posterior depende da localização, dos tratamentos realizados inicialmente e do estado de saúde geral do paciente. Raramente, o câncer volta em uma área pequena perto de onde começou, caso em que a cirurgia para tentar removê-lo possa ser uma opção. Mas na maioria dos casos a recidiva é iressecável e é tratada como descrito acima.

A recidiva do câncer de vesícula biliar é geralmente muito difícil de ser tratada, por isso o paciente deve considerar a participação em um estudo clínico com novos tratamentos.

Fonte: American Cancer Society

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