Tumors of the gallbladder and bile ducts

Carcinosarcoma of Gallbladder with Osteosarcomatous Differentiation - a Case Report with Review of Literature

A 44-year-old female presented with dull upper abdominal pain. Contrast-enhanced computed tomography (CECT) of the abdomen revealed a well-distended gallbladder with multiple foci of minimally enhancing, intraluminal, soft tissue lesion, and hyperdensity on non-contrast scan measuring 4.3 × 3.5 cm in the fundus with few calculi embedded in it. There was no evidence of extraluminal extension. The patient underwent extended cholecystectomy with liver wedge resection. Histologically, the tumor showed both carcinomatous and sarcomatous components, with prominent osteosarcomatous differentiation. We report this unusual case and present a review of all cases of carcinosarcoma of the gallbladder with sarcomatous differentiation. Despite curative resection, CSGB prognosis remains poor, and thus, the authors recommend to focus their efforts to improve the surgical outcomes.

Trends in Primary Gallbladder Cancer Incidence and Incidence-based Mortality in the United States, 1973 to 2015

OBJECTIVES

Primary gallbladder cancer (GBC) is the most common biliary tract cancer with poor survival despite aggressive treatment. This study aimed to investigate the trends of GBC incidence and incidence-based mortality (IBM) over the last 4 decades.

MATERIALS AND METHODS

GBC cases diagnosed between 1973 and 2015 were retrieved from the Surveillance, Epidemiology, and End Results (SEER) database. Incidence rates, IBM rates, and annual percent changes (APCs) were calculated and stratified according to population and tumor characteristics.

RESULTS

The cohort consisted of 10,792 predominantly white (81%) and female (71%) GBC patients. The overall GBC incidence decreased by 1.65% (95% confidence interval [CI]: 1.45% to 1.84%) per year since 1973, but has plateaued since 2002. IBM decreased by 1.69% (95% CI: 1.22% to 2.16%) per year from 1980 to 2015; the rate of decrease in IBM rates was lower during 1997 to 2015 (APC: -1.19%, 95% CI: -1.68% to -0.71%) compared with 1980 to 1997 (APC: -3.13%, 95% CI: -3.68% to -2.58%).

CONCLUSIONS

The incidence and IBM rates of GBC have been decreasing over the last 40 years, but the decrease plateaued over the last 2 decades. The effects of treatment modalities, including laparoscopic cholecystectomy, adjuvant chemotherapy, and radiation on the incidence and IBM of GBC need to be further investigated.

Carcinosarcoma of the Gallbladder: A Rare Tumor

Malignant tumors of the gallbladder are rare, with adenocarcinoma being the most common histological subtype. Carcinosarcoma of the gallbladder, first described in 1907 by Landsteiner, is an extremely rare tumor which comprises less than 1% of the uncommon gallbladder cancers. This unique type of tumor can develop at any major organ, with the uterus being the most common one. Being a tumor that contains epithelial and mesenchymal components, histopathological diagnosis of such rare tumor is a challenging issue. Up to date, there are less than 100 cases of gallbladder carcinoasarocoma reported in the English literature. Therefore, experience and knowledge regarding this rare disease are very limited. Due to the fact that gallbladder carcinosarcoma is a rare and highly forgotten tumor, this article aims to review the English literature to increase awareness of the treating physician to improve diagnosis, management, as well as overall survival.

Surgical outcomes of primary carcinosarcoma of the gallbladder after curative resection: A rare case series

INTRODUCTION

Primary carcinosarcoma is a rare neoplasm of the gallbladder, and is characterized by collision elements of the adenocarcinomatous and sarcomatous components. The tumours comprise both malignant epithelial and mesenchymal elements, and are usually very aggressive, conferring poor prognosis. Adenocarcinomas are the most common neoplasms of the gall bladder, while carcinosarcoma are extremely rare, with a global prevalence rate of less than 1%. The low incidence of carcinosarcoma greatly hinders the understanding of its aetiology.

PRESENTATION OF CASE

Here, we report the surgical outcome of 3 rare cases of gallbladder carcinosarcomas, two of which had a IVB stage disease and in one case the staging was II. Following surgery, the survival in the former was less than 1 year, while in the latter, it extended up to 7 years (86 months), and the patient is alive till date. This study aimed to elucidate the surgical outcomes and prognosis after curable resection for carcinosarcomas of the gallbladder.

DISCUSSION

The findings suggest that carcinosarcomas are associated with a poor prognosis and short survival, particularly in those with tumours of >5 cm. In the absence of effective adjuvant treatment, surgery remains the mainstay of treatment.

CONCLUSION

Complete surgical resection may improve prognosis and extend survival in patients with this rare and aggressive form of gallbladder cancer.

Ovarian metastases from gallbladder mimics primary ovarian neoplasm in young patient: a case report

Background

Gallbladder cancer is unusually seen but can result in highly mortality rate. It makes challenge to diagnose for clinicians due to present asymptomatic or non-specific clinical presentation including abdominal pain, anorexia. It usually also accompanies with cholelithiasis (incidence is 1–2%) and incidentally detected by radiologic examination such as ultrasound, computed tomography or intra-operative intervention accidentally. Gallbladder cancer results in highly fatal malignancy because it is difficult to early detect. The ovarian metastases from gallbladder mimics primary neoplasm isn’t seen before and mentioned in English literatures before.

Case presentation

A 28-year-old woman suffered from intermittently lower abdominal tenderness and nausea after meals for 3 years. The abdominal ultrasound revealed a right ovarian mass with fluid accumulation and the contrast CT of abdomen revealed a gallbladder fundus mass and liver tumor lesion located at segment 4. We arranged surgical intervention with radical cholecystectomy and debulking operation with salpingo-oophorectomy. The pathologic report revealed adenocarcinoma of gallbladder with liver, peritoneum, and right ovarian invasion. After surgical intervention, she also received adjuvant chemotherapy with Gemcitabine, Cetuximab, Cisplatin and Cyberknife.

Conclusion

The non-specific symptoms make the challenge to difference the primary malignant neoplasm. The rarely diagnosis must take in consider if the gastrointestinal tract tumours coexist with ovarian tumours.

Conditional survival in patients with gallbladder cancer

Background

Conditional survival (CS) has been established as a clinically relevant prognostic factor for cancer survivors, and the CS in gallbladder (GB) cancer has not yet been fully evaluated. In this study, we evaluated the cancer-specific CS rate and cancer-specific survival (CSS) rate in patients with GB cancer at multiple time points and investigated prognostic factors which affect cancer-specific CS rate to provide more accurate survival information.

Methods

Between 2004 and 2013, a total of 9760 patients with GB cancer were identified from the Surveillance, Epidemiology, and End Results (SEER) data. The 3-year cancer-specific CS rate was calculated using the covariate-adjusted survival function in the Cox model for each year since diagnosis, and the results were analyzed together with the adjusted CSS rates at the same time points. Cox proportional hazards regression was performed to ascertain the individual contribution of factors associated with CSS rate at diagnosis and cancer-specific CS rates at 1, 3, and 5 years after diagnosis.

Results

The adjusted 5-year CSS rate was 26.1%. The adjusted 3-year cancer-specific CS rates at 1, 2, 3, 4, and 5 years after diagnosis were 55.5, 72.2, 81.5, 86.8, and 90.5%, respectively. At the time of diagnosis, age, race, histology, grade, T, N, and M categories, surgery, radiotherapy, insurance status, and marriage status were significant prognostic factors of CSS. Five years after diagnosis, however, T and M categories were significant prognostic factors for survivors (P = 0.007 and P = 0.009, respectively), whereas surgery and radiotherapy were not.

Conclusions

T and M categories were significant prognostic factors even 5 years after the initial diagnosis, whereas local treatments at the time of diagnosis were not, suggesting that patients with GB cancer at high risks might need further adjuvant therapy after primary treatments. The combined analysis of CSS and cancer-specific CS rates offered more accurate survival information for patients who have already survived a certain period of time after diagnosis.

Primary carcinosarcoma of the gallbladder

Carcinosarcoma of gallbladder (CSGB) is a rare malignancy characterized by malignant epithelial and mesenchymal components. Its pathogenesis is unknown and most CSGBs are associated with poor survival because the disease normally presents at an advanced stage, and as a result, curative resection is uncommon. This report describes a case that underwent curative resection. A 77-year-old woman presented with right upper quadrant pain. The preoperative diagnosis was gallbladder (GB) cancer, and thus, curative radical cholecystectomy was performed. However, pathologic examination of the surgical specimen revealed that the tumor was composed of two histologic components of squamous cell carcinoma and spindle cell sarcoma, which was consistent with a diagnosis of carcinosarcoma. The tumor was found to extend to the perimuscular connective tissue and to have metastasized to one lymph node (LN). The prognosis of CSGB remains poor despite curative resection, and thus, the authors recommend that effort be made to improve surgical outcomes.

Image-guided intensity-modulated radiotherapy (IG-IMRT) for biliary adenocarcinomas: Initial clinical results

PURPOSE

Biliary tract lesions are comparatively rare neoplasms, with ambiguous indications for radiotherapy. The specific aim of this study was to report the clinical results of a single-institution biliary tract series treated with modern radiotherapeutic techniques, and detail results using both conventional and image-guided intensity-modulated radiation therapy (IG-IMRT).

METHODS AND MATERIALS

From 2001 to 2005, 24 patients with primary adenocarcinoma of the biliary tract (gallbladder and extrahepatic bile ducts) were treated by IG-IMRT. To compare outcomes, data from a sequential series of 24 patients treated between 1995 and 2005 with conventional radiotherapy (CRT) techniques were collected as a comparator set. Demographic and treatment parameters were collected. Endpoints analyzed included treatment-related acute toxicity and survival.

RESULTS

Median estimated survival for all patients completing treatment was 13.9 months. A statistically significant higher mean dose was given to patients receiving IG-IMRT compared to CRT, 59 vs. 48Gy. IG-IMRT and CRT cohorts had a median survival of 17.6 and 9.0 months, respectively. Surgical resection was associated with improved survival. Two patients (4%) experienced an RTOG acute toxicity score>2. The most commonly reported GI toxicities (RTOG Grade 2) were nausea or diarrhea requiring oral medication, experienced by 46% of patients.

CONCLUSION

This series presents the first clinical outcomes of biliary tract cancers treated with IG-IMRT. In comparison to a cohort of patients treated by conventional radiation techniques, IG-IMRT was feasible for biliary tract tumors, warranting further investigation in prospective clinical trials.

[CT evaluation of locoregional spread of carcinoma of the gallbladder]

OBJECTIVE

This study aims to assess the diagnostic capability of CT to preoperatively detect evidence of locoregional spread of gallbladder cancer.

PATIENTS AND METHODS

Two radiologists independently performed retrospective review of CT scans on 20 patients who had undergone surgical resection for carcinoma of the gallbladder. Local spread was categorized by the TNM system and the results were correlated with surgical and pathologic findings.

RESULTS

All cases of hepatic spread (14 cases), common bile duct extension (four cases), pancreatic spread (three cases) and duodenal spread (three cases) were correctly diagnosed by helical CT. One of three cases of peritoneal spread and two of three cases of gastric spread were misdiagnosed. CT evaluation of T stage (T1: one case [5%]; T2: four cases [20%]; T3: four cases [20%], and T4: 11 cases [55%]) was accurate in 85%. The sensitivity and positive predictive value (PPV) of T1-T2 lesions were 80%. The specificity and negative predictive value (NPV) were 93%. For T4 lesions sensitivity, specificity, PPV and NPV were 100%.

CONCLUSION

Helical CT provided 85% accuracy in the diagnosis of the locoregional extent of gallbladder cancer. It allows an acceptable classification according to the TNM staging system and predicts prognosis.

Bilateral ovarian metastases from carcinoma of the gallbladder

BACKGROUND

Metastasis of carcinoma of the gallbladder to other intra-abdominal organs is recognised, but is rare. Ovarian metastases can mimic the clinical and morphological appearances of primary ovarian tumours, making the diagnosis difficult particularly when the primary source is not apparent.

CASE

A patient presented with abdominal pain and was found to have gallstones and bilateral ovarian masses. Tumour markers were all normal. The patient developed jaundice and was subsequently operated on for the gallstones and ovarian masses. Histology showed these to be metastases from a gallbladder carcinoma.

CONCLUSION

Presentation of ovarian metastases can cause diagnostic difficulty. Careful evaluation of the digestive tract should be considered in patients presenting with ovarian masses of uncertain origin.

Image-guided intensity-modulated radiation therapy for gallbladder carcinoma

PURPOSE

Clinical and technical parameter analysis of patients treated with ultrasound-based image-guided tomotherapeutic IMRT for gallbladder cancer.

METHODS AND MATERIALS

Between 8/2001 and 5/2005, 10 patients with primary tumors of the gallbladder were treated by image-guided IMRT to median doses of 59 Gy. To analyze normal tissue radiation exposure reduction using this novel approach, a virtual plan comparison between actually delivered IMRT plans and re-computed plans with identical inverse planning parameters but more conventional PTV safety margins was conducted.

RESULTS

Average CTV was 379 cm(3), with a mean initial PTV of 834 cm(3). In 9/10 patients, a boost was delivered to a mean CTV(boost) of 171 cm(3) and average PTV(boost) of 241 cm(3). One patient reported RTOG grade 3 acute toxicity. All other patients exhibited Grade 2 or lower acute toxicity. Preliminary median overall survival was 16.7 months (range 3.2-34.9 months), with 5/10 patients alive at analysis. Virtual plan comparison revealed significant organ-at-risk sparing by the enabled PTV margin reduction.

CONCLUSION

Ultrasound-based image-guided IMRT is a feasible mechanism of delivering conformal radiation doses to tumors of the gallbladder with acceptable toxicity. Early outcome data with this novel radiation planning and delivery technique are encouraging and comparable to previously reported literature.

Cavernous hemangioma of the gallbladder. Case report and review of the literature

Hemangiomas are common benign tumors; they frequently occur in the liver but very rarely in the gallbladder, with only seven cases reported in the scientific literature to date. We here report an additional patient, a 49-year-old white woman presenting with an echogenic lesion of the gallbladder that was incidentally discovered. Cholecystectomy was performed after computed tomography had revealed a gallbladder neoplasm; pathological examination showed the mass to be a cavernous hemangioma. No postoperative complications occurred and the patient is alive and free of recurrence five years after the operation. We present a review of the literature on this topic with special emphasis on the diagnostic and therapeutic challenges these lesions may entail. Hemangiomas of the gallbladder may have extremely variable presentations (from non-specific abdominal pain to acute syndromes resembling cholangitis or choledocholithiasis) and can mimic different lesions (liver tumors, sarcoma). Only surgical exploration can provide a correct diagnosis. Excision is indicated as these lesions may grow to huge sizes, compress adjacent structures or bleed.

CONCLUSIONS

Gallbladder hemangiomas are uncommon benign tumors. A preoperative diagnosis is difficult to make. Surgical excision is mandatory both in reaching a final diagnosis and in preventing bleeding or compression of vital structures.

[Biliary adenocarcinoma arising from atypical benign lesions]

Tumors of the biliary tract have a poor prognosis. When these tumors arise from a prior benign lesion the prognosis improves. We present two cases of carcinoma developing from atypical benign lesions. Aggressive surgical treatment was provided.

Cholangiocarcinome secondaire à une cholangite radique associée à une pancréatite chronique radique

There are no reports of cholangiocarcinoma complicating post radiotherapy cholangitis. We report the case of a 40 year old patient who had undergone thoracoabdominal radiotherapy for Hodgkin's disease, 22 years ago. This radiotherapy was complicated, many years later, by chronic pancreatitis and cholangitis. Recurrent angiocholangitis led us to schedule a biliodigestive anastomosis. During surgery, cholangiocarcinoma was discovered. The patient died from his carcinoma some months later.

Endosonographic and histopathological staging of extrahepatic bile duct cancer: time to leave the present TNM-classification?

OBJECTIVES

The discrepancy between high rates of sensitivity, specificity, and accuracy for intraductal ultrasonography (IDUS) in extrahepatic bile duct carcinoma and the failure to depict different wall layers as defined by the TNM classification have not yet been elucidated sufficiently.

METHODS

In a prospective study, endosonographic images were correlated with histomorphology including immunohistochemistry. Using IDUS, we examined fresh resection specimens of patients who had undergone pancreato-duodenectomy. For histological analysis, the formalin-fixed and paraffin-embedded specimens were stained by hematoxylin-eosin, elastica-van-Gieson, and immunohistochemically by smooth muscle-actin. To confirm our hypothesis, further cases from the archives were analyzed histopathologically and immunohistochemically.

RESULTS

The various wall layers of the extrahepatic bile duct as described by the International Union Against Cancer are neither histomorphologically nor immunohistochemically consistently demonstrable. Especially, a clear differentiation between tumor invasion beyond the wall of the bile duct (T2) and invasion of the pancreas (T3) by histopathological means is often not possible. Endosonographic images using high-resolution miniprobes similarly confirm the difficulty in imaging various layers in the bile duct wall.

CONCLUSIONS

Most adaptations made by the sixth edition of the TNM classification accommodate to the endosonographic and most of the histopathological findings as demonstrated in our study. In contrast to the new edition, however, our findings suggest to combine T2- and T3-staged tumors into one single class leading to clarification, and improved reproducibility of histopathological staging.

Molecular and immunohistochemical analysis of intraductal papillary neoplasms of the biliary tract

Intraductal papillary neoplasms (IPNs) of the biliary tract are uncommon lesions that may be solitary or may spread extensively along the biliary tree. Some biliary IPNs are histologically and radiologically similar to intraductal papillary mucinous tumors (IPMNs) of the pancreas and present a risk for progression to invasive cholangiocarcinoma. Unlike pancreatic IPMNs, little is known about their molecular pathogenesis. We studied 14 biliary IPNs (including 5 cases with associated invasive cholangiocarcinoma) for genetic alterations in the APC/beta-catenin pathway, K-ras oncogene mutations, p53/chromosome 17p alterations, and Dpc4/18q alterations. Immunohistochemistry was performed for beta-catenin, p53, and Dpc4, and microdissected tissue was analyzed using direct DNA sequencing for exon 1 of K-ras and exon 3 of beta-catenin and allelic loss assays on chromosomes 5q, 17p, and 18q. Activating mutations in codon 12 of the K-ras oncogene were present in 4 of 14 (29%) biliary IPNs. Of these 4 cases, 2 patients had associated invasive cholangiocarcinoma, and identical K-ras mutations were present in both the intraductal and invasive components. Allelic loss on chromosome 18q was present in 4 of 13 informative cases (31%); however, no loss of normal Dpc4 expression was detected by immunohistochemistry. Nuclear accumulation of beta-catenin protein was demonstrated in 3 of 12 cases (25%); however, there were no beta-catenin gene mutations, and allelic loss on 5q was present in only 1 of 10 informative cases (10%). Both immunohistochemistry for p53 and 17p allelic loss assays were negative. Biliary IPNs therefore demonstrate a K-ras gene mutation frequency that is lower than that previously reported for pancreatic IPMNs, but similar to that reported for hepatic cholangiocarcinomas. The presence of K-ras mutations in 2 purely intraductal neoplasms, and identical K-ras mutations in 2 cases with both intraductal and invasive components, suggests that these mutations arise early in tumorigenesis. Finally, the frequency of allelic loss on 18q suggests that a locus on 18q is involved in the molecular pathogenesis of biliary IPNs, but this locus is not DPC4.

Significant correlations of E-cadherin, catenin, and CD44 variant form expression with carcinoma cell differentiation and prognosis of extrahepatic bile duct carcinomas

To clarify the relation between alteration of expression of cell adhesion molecules and progression of extrahepatic bile duct carcinomas. 55 cases were immunohistochemically examined for E-cadherin, alpha-catenin, beta-catenin, and CD44, with additional reverse transcription-polymerase chain reaction and Southern blotting hybridization (RT-PCR/SBH) assays. Levels of E-cadherin, alpha-catenin, and beta-catenin proteins were lower in carcinomas than in normal mucosa, while CD44 variants 3 and 6 were upregulated. Well-differentiated carcinoma showed higher expression of E-cadherin and alpha-catenin than moderately to poorly differentiated types. Macroscopically papillary lesions had higher expression of E-cadherin than their nonpapillary counterparts. RT-PCR/SBH for CD44 revealed the CD44 variant form to be more prevalent in carcinoma than in normal mucosa, correlating with the immunohistochemical results, and with more exon variety. The Cox proportional hazards test identified histologic type and E-cadherin expression as prognostic factors. Among the examined molecules, E-cadherin was especially related to papillary mass formation and a good prognosis.

[Prognostic factors in gallbladder cancer]

BACKGROUND AND AIM

Carcinoma of the gallbladder is the most frequent biliary tract lesion but the 5-year survival is less than 5%. The aim of this study was to analyze the influence of several clinico-pathological variables on survival in a series of 226 carcinomas of the gallbladder.

PATIENTS AND METHODS

The results were retrospectively analyzed and prognostic factors were identified by univariate statistical analysis and Cox regression model. All patients underwent surgery and in 67 of these (29.6%), surgery was potentially curative. In 63 patients (27.9%) diagnosis was made when the resected gallbladder was studied for benign disease. Tumor node metastasis (TNM) stage was 0 in 7 patients (3.1%), stage I in 19 patients (8.4%), stage II in 21 patients (9.3%), stage III in 61 patients (27%) and stage IV in 118 patients (52%).

RESULTS

Overall 5-year survival was 17.3%. In the univariate analysis, significant variables were the presence of jaundice, weight loss, palpation of abdominal tumors at diagnosis, surgical technique, TNM stage and the three variables of this system (T: size, N: adenopathies; M: distant metastasis). In the multivariate analysis, the three variables of the TNM system and surgical technique were significantly associated with survival.

CONCLUSIONS

The most important prognostic factor was TNM stage. Currently, radical cholecystectomy in stages II and III has become another important prognostic factor.

Sclerosing cholangitis

Primary sclerosing cholangitis is a chronic cholestatic liver disease of unknown etiology. Immunogenetic factors are considered important in its pathogenesis. The genetic susceptibility to primary sclerosing cholangitis is associated, in part, with the HLA HLA-DRB1, DQA1, DQB1 haplotype. Liver histology in primary sclerosing cholangitis is characterized by a portal inflammatory infiltrate mostly composed of memory T cells. Many patients eventually will develop cholangiocarcinoma, and inactivation of the p16 tumor-suppressor gene might be involved in neoplastic transformation. Alcohol consumption might be a risk factor for cholangiocarcinoma, and, in some patients, elevation of serum CA19-9 marks the neoplastic transformation. To date, no medical treatment has been proven effective. Endoscopic therapy might be useful in some patients, but controlled studies are lacking. Liver transplantation remains the only effective treatment. Posttransplant survival and quality of life are continuously improving despite the fact that the disease may recur in some patients after transplantation. Nevertheless, patient selection and timing of indication for liver transplantation remain uncertain.