Epithelial cyst of the gallbladder associated with adenocarcinoma

Epithelial cyst of the gallbladder associated with papillary adenoma and adenocarcinoma is presented herein. A 70‐year‐old male patient with general malaise was admitted to our hospital during the follow‐up of an elevated mucosal lesion in the fundus of the gallbladder. Endoscopic ultrasonography revealed a cystic lesion adjacent to the elevated lesion, and interruption of the hyperechoic third layer of the gallbladder wall next to the gallbladder bed of the liver. He was diagnosed as having an epithelial cyst of the gallbladder associated with gallbladder carcinoma that directly invaded the gallbladder bed. He underwent resection of the gallbladder with partial resection of the liver and regional lymph node dissection. The resected specimen, which showed multiple cysts with septum formation, measured 1.9–cm in size and was located in the subserosal layer of the gallbladder wall. The wall of the cyst was lined with columnar epithelium and papillary adenoma, and adenocarcinoma was scattered in some portions of the cyst wall. Furthermore, papillary adenoma associated with adenocarcinoma was independently identified in the luminal surface of the gallbladder epithelium covering the cysts. These histological findings were compatible with epithelial cyst of the gallbladder associated with papillary adenoma and adenocarcinoma. The tumor was diagnosed as T1bN0M0, stage I, in the TNM clinical classification. To our knowledge, this is the first report of an epithelial cyst of the gallbladder associated with papillary adenoma and adenocarcinoma, and provides some insight into the relationship between epithelial cyst and adenoma or cystadenocarcinoma of the gallbladder.     

Left-sided gallbladder associated with congenital liver cyst

Background. A left-sided gallbladder is a rare congenital anomaly defined as a gallbladder attached to the lower surface of the left lateral segment of the liver, i.e. to the left of the interlobar fissure and round ligament. Case outlines. In two women aged 42 and 70 years a left-sided gallbladder was associated with a congenital cyst of the liver. In the first patient, the ectopic gallbladder was an incidental finding at operation for a symptomatic liver cyst; as the gallbladder was normal it was not removed. The second patient underwent operation for chronic calculous cholecystitis, when the left-sided gallbladder and congenital liver cyst were found. An operative cholangiogram was normal, the cystic duct joining the common bile duct from the right side. The gallbladder was removed, and the cyst was de-roofed. Both patients had an uneventful recovery and remain symptom-free at 12 and 9 years respectively. Discussion. To the best of our knowledge, the association of these two congenital anomalies has not been described previously.     

椎管内胆脂瘤的诊断与治疗

对２７例经手术和病理证实的椎管内胆脂瘤患者的临床资料进行分析，发现虱的临床表现无特异性；ＣＴ示肿瘤呈均一低密度影，边界清楚，强化扫描多无增强；ＭＲ检查示肿瘤信号强度变化不定，边界清楚。２７例患者均手术治疗，肿瘤切６例，次全切除１７例，大部切除４例；术后对２３例随访０．５－７年，２年复发，均再次行手术治疗后好转。表明ＣＴ和ＭＲ检查有助于椎管内胆脂瘤的术前诊断。显微镜下全切是治疗本病的最好选择。     

Kidney metastasis from gallbladder cancer

A case of kidney metastasis from primary gallbladder cancer is presented. Five years after operation for gallbladder cancer, a 73-year-old woman exhibited hematuria. Imaging disclosed a 5×4cm solid mass in the right kidney and enlarged lymph nodes behind the inferior vena cava adjacent to the right renal vein. The right kidney and adjacent tissues, including retroperitoneum and regional lymph nodes, were resected en bloc. The renal tumor was diagnosed as a metastasis from the primary adenocarcinoma of the gallbladder, based on histological similarities, absence of other primary adenocarcinoma, and fluctuations in CA19-9 levels during the progress and after the resection of the metastatic tumor. The initial operation had been an extended cholecystectomy with wedge resection of the liver bed, plus regional lymphadenectomy. The excised gallbladder had a 2.3 ×1.2cm nodular tumor in the fundus. Histological examination indicated the gallbladder tumor to be a moderately differentiated tubular adenocarcinoma invading the subserosal layer. Mild lymphatic invasion was recognized in the gallbladder wall, although lymph node metastasis was negative. We believe this patient represents the first case of kidney metastasis from gallbladder cancer. The mode of spread of the gallbladder cancer to the kidney appeared to be lymphogenous.     

Total laparoscopic resection of the gallbladder together with the gallbladder bed

Patients with carcinoma of the gallbladder that is preoperatively diagnosed by radiology do not undergo laparoscopic resection, because such surgery is thought to worsen the prognosis of gallbladder carcinoma. However, the prognosis for patients with incidental T2 gallbladder carcinoma who are treated laparoscopically is reportedly no worse than that for patients undergoing conventional surgery. We successfully performed total laparoscopic resection of the gallbladder together with the gallbladder bed without any complications. We believe that this procedure represents a valid therapeutic option for carefully selected patients with T2 carcinoma of the gallbladder.     

Primary undifferentiated spindle-cell carcinoma of the gallbladder presenting as a liver tumor

Undifferentiated spindle-cell carcinoma (SpCC) of the gallbladder is extremely rare. There is very little information available regarding the characteristics and treatment of this disease. We herein report the unique case of a 76-year-old female patient with a primary SpCC of the gallbladder that presented as a liver tumor. Preoperative radiologic examinations showed a 5-cm liver tumor around the gallbladder bed, and irregular thickening of the gallbladder wall. The patient underwent en-bloc resection of the gallbladder and segments 4b and 5 of the liver (including the liver tumor). Microscopic findings revealed that both lesions consisted mainly of a sarcomatous spindle-shaped component. Small foci of well-differentiated adenocarcinoma cells were identified in the gallbladder mucosa. There was a gradual transition between the two different components, thereby implying that these two cell types had a common origin. Immunohistochemical studies showed that the spindle-shaped cells were epithelial in nature. The patient's postoperative course was uneventful. However, she died of recurrent liver disease 6 months after the surgery. In conclusion, we surmised that the sarcomatous spindle cells originated from a carcinomatous component in the gallbladder mucosa through dedifferentiation. Further studies are needed to better understand the characteristics of this deadly tumor, and to establish an effective therapy for it.     

胆囊囊肿合并潴留性肝囊肿1例报告并文献复习

临床中胆囊囊肿很罕见,大部分为后天性囊肿,极少数为先天性。患者可表现为消化不良、腹痛、黄疸,也可无明显症状。而胆囊囊肿合并潴留性肝囊肿国内外期刊尚无报道。现将北京医院收治的1例胆囊囊肿合并潴留性肝囊肿患者报告如下,并进行回顾性文献复习。     

Adenosquamous carcinoma of the gallbladder with tumor thrombus in left portal trunk

We report a surgically resected case of adenosquamous carcinoma of the gallbladder accompanied by portal tumor thrombosis, which is regarded as a rare complication. A 73-year-old man was admitted to our hospital because of epigastralgia. Preoperative examinations led to a diagnosis of advanced gallbladder carcinoma with liver metastasis, and operation was performed. Since intraoperative ultrasonography showed a tumor thrombus in the left main portal trunk originating from the metastatic lesion in the left medial segment of the liver, extended left lobectomy with extrahepatic bile duct resection and lymph node dissection was performed, instead of right trisegmentectomy, as proposed preoperatively. Histological examination revealed adenosquamous carcinoma of the gallbladder with medullary growth that was similar to the hepatocellular carcinoma, most notably in the metastatic lesion of the liver and in the portal tumor thrombus. We discuss the relation between portal tumor thrombosis and medullary tumors, and note the atypical operative method employed.     

Isolated metastasis to the gallbladder from hepatocellular carcinoma

Aim: Metastasis to gallbladder (GB) from hepatocellular carcinoma (HCC) is rare, and it is difficult to determine indications for surgery. We report eight cases of synchronous isolated GB metastasis, and analyze their features retrospectively. Methods: Among 439 HCC patients who underwent hepatectomy from 1998 to 2008 at our institution, 393 (89.5%) underwent concurrent cholecystectomy. Results: Among them, eight (1.8%) had GB metastasis without other distant metastases. None of these cases showed evidence of direct invasion. All cases had advanced portal vein thrombus (PVTT) and their main tumor located near the GB bed. Five cases had apparent tumor mass in the GB wall, and the other three cases had only tumor thrombus in the GB veins. Six cases were treated postoperatively with local infusion therapy with interferon, and three of them showed long‐term survival. Conclusion: Our eight cases of GB metastasis from HCC were closely related to PVTT. Surgical resection and multimodal treatment would be necessary for long‐term survival in cases with isolated GB metastasis.     

Multimodalities Imaging in Diagnosis of Pericardial Cyst

Pericardial cysts, an uncommon benign congenital anomaly belonging to the category of mediastinal masses. Cysts are usually detected incidentally on chest radiography or echocardiography, being most patients asymptomatic. In some cases, however, symptoms and complications occur, like dyspnea, chest pain, or persistent cough. Computed tomography and magnetic resonance imaging are the imaging techniques of choice to diagnose pericardial cysts. The removal of pericardial cysts is restricted to the cases with an uncertain diagnosis or in the presence of symptoms.     

A large inflammatory polyp of the gallbladder masquerading as gallbladder carcinoma

An inflammatory polyp of the gallbladder is a rare variant of benign gallbladder polyp. Differentiation between an inflammatory polyp and polypoid gallbladder carcinoma is difficult when the polyp is more than 1 cm in diameter. We report a rare case of a large inflammatory polyp of the gallbladder masquerading as gallbladder carcinoma in a 37-year-old Japanese woman who was incidentally diagnosed with a large gallbladder polyp, measuring 1 cm in diameter, by ultrasonography. She was asymptomatic and physical examination was unremarkable. Abdominal ultrasonography and endoscopic ultrasonography revealed three polypoid lesions in the gallbladder. One lesion was an isoechoic polyp, measuring 15 × 8 mm, showing a nodular surface and located in the fundus of the gallbladder. The other two lesions were hyperechoic polyps, measuring 5 × 5 mm, in the body of the gallbladder. Computed tomography and magnetic resonance imaging revealed marked enhancement of the largest polypoid lesion by dynamic study, and no lymph node enlargement was noted. Endoscopic retrograde cholangiography revealed a 12 × 8 mm polyp with an irregular surface in the fundus of the gallbladder. Superselective angiography of the cystic artery revealed neovascularity and a tumor stain in the fundus of the gallbladder. Cholecystectomy with lymph node dissection was performed. Intraoperative frozen section diagnosis of the largest polyp was an inflammatory polyp of the gallbladder. The other two polyps were cholesterol polyps. Inflammatory polyp should be considered as a differential diagnosis of hypervascular gallbladder polyps that measure more than 1 cm in diameter. Received Dec. 26, 1997; accepted Apr. 24, 1998     

Fibroadenoma of the gallbladder with borderline malignancy: a poorly recognized gallbladder tumor

Fibroadenoma of the gallbladder is extremely rare tumor, with only two cases reported in the world. It is characterized by abundant loose edematous connective tissue, glandular structure, polypoid structure covered by epithelia, and a filamentous pedicle. We report a case of 78-year-old woman histopathologically diagnosed after surgery. Macroscopically, the tumor was a dark-greenish solid mass with a short stalk, filling the gallbladder cavity, and it measured 11.5 × 4.0 × 3.5 cm in diameter. Microscopically, the tumor was composed of abundant loose stroma and a glandular component. Some of the glandular cells had hyperchromatic nuclei with disturbed polarity and were positively stained by p53 (30%) and Ki-67 (30–40%). Part of the stromal component revealed hypercellularity with an irregular nucleus, mitosis (2–3 cells/10 high-power fields), and positivity for Ki-67 (20%) and p53 (50%). We diagnosed this peculiar tumor as “fibroadenoma of the gallbladder with borderline malignancy”. We present the details of this extremely rare case and discuss the pathological findings, comparing them to those in the two previously reported cases and to carcinosarcoma of gallbladder.     

Long-term follow up of gallbladder polyps

Background and Aim:  The management of gallbladder polyps (GBP) is directly linked to the early diagnosis of gallbladder cancer (GBC). This study aimed to evaluate the malignant risk of GBP.
Methods:  In total, 1558 patients diagnosed with GBP were followed. Neoplastic polyps were defined as GBC and its premalignant lesions. The risk for malignancy was estimated with the cumulative detection rate of neoplastic polyps.
Results:  Thirty-three cases (2.1%) were diagnosed with neoplastic polyps. The cumulative detection rates of neoplastic polyps were 1.7% at 1 year, 2.8% at 5 years, and 4% at 8 years after diagnosis. The size of GBP and the presence of gallstones were risk factors for neoplastic polyps. Polyps ≥ 10 mm had a 24.2 times greater risk of malignancy than polyps < 10 mm. However, 15 of 33 neoplastic polyps (45.5%) were < 10 mm at the time of diagnosis of GBP. During follow up in 36 (3.5%) of 1027 cases, an increase in size was detected; of these, nine (25%) had neoplastic polyps.
Conclusion:  Even small polyps have a risk of malignancy, and careful long-term follow up of GBP will help detect and treat early GBC.     

Aberrant gallbladder situated beneath the left lobe of liver

BackgroundAberrant gallbladder beneath the left liver is a rare congenital anomaly that is found in 0.1–0.7 per cent of the population and causes confusion on imaging and at operation.Two such cases are presented.Case outlinesA man of 83 yr was explored for obstructive jaundice due to a hilar tumour, but the gallbladder was ‘missing’. Exploration of a cystic mass to the left of the falciform ligament revealed a gallbladder attached to segment III of the liver. Laparotomy for gallstones in a woman of 70 yr failed to reveal the gallbladder until further dissection was carried out to the left of the falciform ligament. In each of these cases the cystic duct described a hairpin bend before joining the common hepatic duct on its right-hand side.ConclusionA left-sided gallbladder can be truly ectopic or may just appear so because the falciform ligament is aberrantly placed to the right. In either case preoperative imaging can be misleading, and a careful search is needed at operation. The incidence of disease seems no commoner than in orthotopic gallbladders.     

肿瘤相关糖蛋白-72抗原在原发性胆囊癌中的表达及其临床意义

目的探讨抗肿瘤相关糖蛋白-72(TAG-72)抗原的表达及其与原发性胆囊癌(PGC)病理特征的关系。方法用原核表达获得抗TAG-72单链抗体,并用聚丙烯酰胺凝胶电泳(SDS-PAGE)和Western blot得以验证;用免疫组化方法检测TAG-72抗原在PGC的表达。结果通过原核表达获取大小为31 kDa的抗TAG-72单链抗体并得以证实。TAG-72抗原在胆囊良、恶性组织阳性率分别为59.6%、6.7%(P<0.05)。高分化PGC的TAG-72抗原表达显著低于中低分化PGC(P<0.05);肿瘤直径≤2 cm者TAG-72表达显著低于>2 cm者(P<0.05);在PGC Nevin临床分期~期与~期间则无显著性差异(P>0.05)。结论获得了抗TAG-72单链抗体的原核表达方法。TAG-72抗原可以作为一个肿瘤标志物在临床中应用,为抗TAG-72单链抗体在PGC诊治中的应用奠定实验基础。     

Agenesis of the gallbladder: difficulties in management

Gallbladder agenesis is a rare congenital biliary anomaly that may be associated with other biliary and extrabiliary congenital anomalies. Awareness of this entity by clinicians and radiologists is essential because many of these patients present with biliary symptoms and have unnecessary operations. In the present article, the relative epidemiological, etiological (embryology and development), pathophysiological, diagnostic tools and pitfalls and management aspects of this rare anatomic anomaly are briefly discussed through review of the literature. Particular reference to the difficulty in preoperative diagnosis is highlighted. The importance of the possibility of preoperative diagnosis to avoid unnecessary surgery is stressed.     

Hepatoid adenocarcinoma of the gallbladder

We describe here a rare case of hepatoid adenocarcinoma (HAC) of the gallbladder without the production of alpha‐fetoprotein (AFP). A 77‐year‐old man was referred to our division with complaints of general fatigue, loss of appetite, and loss of body weight. A preoperative diagnosis of advanced gallbladder cancer was made, and cholecystectomy with combined resection of two liver subsegments (S4a + S5) and lymph node dissection were performed. Microscopically, the tumor was mainly composed of characteristic cells featuring eosinophilic cytoplasm, enlarged nuclei, and prominent nucleoi, arranged in nests or proliferated in a trabecular pattern. These features were highly suggestive of HAC of the gallbladder, and the tumor cells were negative for AFP immunohistochemical staining. The patient is doing well and has survived for 15 months postoperatively without any recurrence.     

Effect of nifedipine on interdigestive gallbladder volume and postprandial gallbladder emptying in man

The effect of two oral doses (10 and 20 mg) of nifedipine versus placebo on the fasted gallbladder volume and on the meal-induced gallbladder emptying was assessed according to a double-blind study protocol in 12 healthy volunteers. Eight subjects underwent three studies (with placebo and with both nifedipine doses), whereas in two subjects the effect of a 10-mg nifedipine dose, vs placebo and in two others the effect of a 20-mg nifedipine dose vs placebo was examined. The studies were performed on separate days, and the gallbladder volume was measured by means of real-time ultrasonography. Neither placebo nor 20 mg nifedipine per os elicited any significant change in the fasted gallbladder vlume. With 10 mg nifedipine per os a significant increase in the interdigestive gallbladder volume was observed: 22.9±2.9 cm³ before and 26.2±3.2 cm³ after the drug receipt (P<0.005). A trend towards an inhibition of the postprandial gallbladder emptying was observed with 10 mg nifedipineper os without, however, reaching the level of statistical significance. Following 20 mg nifedipineper os, a marked delay in the meal-stimulated gallbladder emptying occurred as reflected by a decrease in the gallbladder ejection fraction from 48.1±4.5% (placebo) to 26.4±5.0% (nifedipine) (P<0.02) at 30 min and from 54.0±3.6% (placebo) to 33.2±4.6% (nifedipine) (P<0.02) at 40 min after the test meal. We conclude that a therapeutic oral dosage of nifedipine has a significant relaxing effect on the human gallbladder.