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Carcinoma involving the gallbladder: a retrospective review of 23 cases - pitfalls in diagnosis of gallbladder carcinoma.

Giang TH, Ngoc TT, Hassell LA - Diagn Pathol (2012)

Bottom Line: Misinterpretation of subtle microscopic abnormalities contributes diagnostic failures in early cases.Careful attention to any evidence of mural thickening, thorough sampling, particularly in older patients, and close examination of any deeply situated glandular structures are critical.Correlations with radiographic and clinical findings are important helps to avoid misdiagnosis in this commonly resected organ.

View Article: PubMed Central - HTML - PubMed

Affiliation: University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA.

ABSTRACT

Background: Carcinoma of the gallbladder (GBC) clinically mimics benign gallbladder diseases and often escapes detection until advanced stage. Despite the frequency of cholecystectomy, diagnosis of GBC remains problematic in many situations. We sought to identify pathologic features that contribute to the difficulty in recognition of GBC.

Methods: We identified 23 patients (ranged from 45 to 86 years, male to female ratio 1:4.5) with carcinoma involving the gallbladder referred to an academic medical center over a period of 10 years for study. This includes 10 cases of primary GBC, 6 cases of metastatic tumor to gallbladder, 6 cases of directly invasive adenocarcinoma arising elsewhere in the biliary tree, and one case of unidentified origin adenocarcinoma. Primary tumors include adenocarcinoma not otherwise specified (NOS) in 6 cases, papillary adenocarcinoma in 2 cases, and single cases of undifferentiated carcinoma and combined adenocarcinoma and neuroendocrine carcinoma (NEC). Metastatic tumors to gallbladder were from a wide range of primary sites, predominantly the gastrointestinal tract.

Results: These cases illustrate seven potential pitfalls which can be encountered. These include: 1) mistakenly making a diagnosis of adenocarcinoma of gallbladder when only benign lesions such as deeply penetrating Rokitansky-Aschoff sinuses are present (overdiagnosis), 2) misdiagnosing well-differentiated invasive carcinoma with minimal disease as benign disease (underdiagnosis), 3) differentiating between primary NEC of gallbladder and metastasis, 4) confusing primary mucinous adenocarcinoma of gallbladder with pseudomyxoma peritonei from a low grade appendiceal neoplasm disseminated to gallbladder, 5) confusing gangrenous necrosis related to cholecystitis with geographic tumoral necrosis, 6) undersampling early, grossly occult disease, and 7) misinterpreting extracellular mucin pools.

Conclusions: Clinical history and a high index of suspicion are prerequisite to detecting GBC. Detection of GBC at an early stage is difficult because the symptoms mimic benign gallbladder diseases. Misinterpretation of subtle microscopic abnormalities contributes diagnostic failures in early cases. Careful attention to any evidence of mural thickening, thorough sampling, particularly in older patients, and close examination of any deeply situated glandular structures are critical. Correlations with radiographic and clinical findings are important helps to avoid misdiagnosis in this commonly resected organ.

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Extracellular mucin can originate from mucinous metaplasia, GBC or metastasis. A: Expansile pools of mucin with scattered glands, the mucinous epithelium exhibited cytologic atypia (H&E stain, X100), B: Neoplastic glands within the wall of gallbladder (H&E stain, X100).
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Figure 4: Extracellular mucin can originate from mucinous metaplasia, GBC or metastasis. A: Expansile pools of mucin with scattered glands, the mucinous epithelium exhibited cytologic atypia (H&E stain, X100), B: Neoplastic glands within the wall of gallbladder (H&E stain, X100).

Mentions: Another potentially confusing factor is extracellular mucin. Mucinous carcinoma of gallbladder is uncommon, representing only 4% of all malignancies. It is characterized by small clusters of malignant epithelial cells surrounded by large deposits of extracellular mucin. In general, there are few epithelial glandular elements and when present, they are often distended with mucin [4]. In case D above (See Table 2), radiographic study suggested the possibility of a primary gallbladder neoplasm or a gynecologic neoplasm. At exploration, extensive peritoneal mucinous tumor was present which was removed as much as possible, along with the appendix, gallbladder, and pelvic mass. The appendix showed a villiform mucinous epithelial proliferation replacing the normal appendiceal mucosa. The peritoneal and gallbladder samples were characterized by abundant pools of mucin containing scattered single infiltrating glands and cellular proliferations lined by mucinous epithelium with moderate to occasional high grade cytologic atypia (See Figure 4). The mucinous epithelium in the peritoneal lesions and gallbladder were the same as in the appendiceal lesion.


Carcinoma involving the gallbladder: a retrospective review of 23 cases - pitfalls in diagnosis of gallbladder carcinoma.

Giang TH, Ngoc TT, Hassell LA - Diagn Pathol (2012)

Extracellular mucin can originate from mucinous metaplasia, GBC or metastasis. A: Expansile pools of mucin with scattered glands, the mucinous epithelium exhibited cytologic atypia (H&E stain, X100), B: Neoplastic glands within the wall of gallbladder (H&E stain, X100).
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC3285085&req=5

Figure 4: Extracellular mucin can originate from mucinous metaplasia, GBC or metastasis. A: Expansile pools of mucin with scattered glands, the mucinous epithelium exhibited cytologic atypia (H&E stain, X100), B: Neoplastic glands within the wall of gallbladder (H&E stain, X100).
Mentions: Another potentially confusing factor is extracellular mucin. Mucinous carcinoma of gallbladder is uncommon, representing only 4% of all malignancies. It is characterized by small clusters of malignant epithelial cells surrounded by large deposits of extracellular mucin. In general, there are few epithelial glandular elements and when present, they are often distended with mucin [4]. In case D above (See Table 2), radiographic study suggested the possibility of a primary gallbladder neoplasm or a gynecologic neoplasm. At exploration, extensive peritoneal mucinous tumor was present which was removed as much as possible, along with the appendix, gallbladder, and pelvic mass. The appendix showed a villiform mucinous epithelial proliferation replacing the normal appendiceal mucosa. The peritoneal and gallbladder samples were characterized by abundant pools of mucin containing scattered single infiltrating glands and cellular proliferations lined by mucinous epithelium with moderate to occasional high grade cytologic atypia (See Figure 4). The mucinous epithelium in the peritoneal lesions and gallbladder were the same as in the appendiceal lesion.

Bottom Line: Misinterpretation of subtle microscopic abnormalities contributes diagnostic failures in early cases.Careful attention to any evidence of mural thickening, thorough sampling, particularly in older patients, and close examination of any deeply situated glandular structures are critical.Correlations with radiographic and clinical findings are important helps to avoid misdiagnosis in this commonly resected organ.

View Article: PubMed Central - HTML - PubMed

Affiliation: University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA.

ABSTRACT

Background: Carcinoma of the gallbladder (GBC) clinically mimics benign gallbladder diseases and often escapes detection until advanced stage. Despite the frequency of cholecystectomy, diagnosis of GBC remains problematic in many situations. We sought to identify pathologic features that contribute to the difficulty in recognition of GBC.

Methods: We identified 23 patients (ranged from 45 to 86 years, male to female ratio 1:4.5) with carcinoma involving the gallbladder referred to an academic medical center over a period of 10 years for study. This includes 10 cases of primary GBC, 6 cases of metastatic tumor to gallbladder, 6 cases of directly invasive adenocarcinoma arising elsewhere in the biliary tree, and one case of unidentified origin adenocarcinoma. Primary tumors include adenocarcinoma not otherwise specified (NOS) in 6 cases, papillary adenocarcinoma in 2 cases, and single cases of undifferentiated carcinoma and combined adenocarcinoma and neuroendocrine carcinoma (NEC). Metastatic tumors to gallbladder were from a wide range of primary sites, predominantly the gastrointestinal tract.

Results: These cases illustrate seven potential pitfalls which can be encountered. These include: 1) mistakenly making a diagnosis of adenocarcinoma of gallbladder when only benign lesions such as deeply penetrating Rokitansky-Aschoff sinuses are present (overdiagnosis), 2) misdiagnosing well-differentiated invasive carcinoma with minimal disease as benign disease (underdiagnosis), 3) differentiating between primary NEC of gallbladder and metastasis, 4) confusing primary mucinous adenocarcinoma of gallbladder with pseudomyxoma peritonei from a low grade appendiceal neoplasm disseminated to gallbladder, 5) confusing gangrenous necrosis related to cholecystitis with geographic tumoral necrosis, 6) undersampling early, grossly occult disease, and 7) misinterpreting extracellular mucin pools.

Conclusions: Clinical history and a high index of suspicion are prerequisite to detecting GBC. Detection of GBC at an early stage is difficult because the symptoms mimic benign gallbladder diseases. Misinterpretation of subtle microscopic abnormalities contributes diagnostic failures in early cases. Careful attention to any evidence of mural thickening, thorough sampling, particularly in older patients, and close examination of any deeply situated glandular structures are critical. Correlations with radiographic and clinical findings are important helps to avoid misdiagnosis in this commonly resected organ.

Show MeSH
Related in: MedlinePlus