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Gallbladder adenocarcinoma with sarcoid-like reaction in regional lymph nodes: report of a case.

Kawasaki Y, Maemura K, Kurahara H, Mataki Y, Iino S, Sakoda M, Ueno S, Shinchi H, Takao S, Natsugoe S - BMC Cancer (2014)

Bottom Line: Based on this histology, the swollen nodes were diagnosed as showing sarcoid reaction and therefore extended lymphadenectomy was avoided.The patient did not receive any adjuvant chemotherapy and has shown no recurrence of disease as of 4 years after surgery.Distinguishing between metastasis and sarcoid-like reaction in lymph nodes by preoperative imaging is still difficult.

View Article: PubMed Central - PubMed

Affiliation: Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical Sciences, Kagoshima University, Sakuragaoka 8-35-1, Kagoshima 890-8520, Japan. gekayota@gmail.com.

ABSTRACT

Background: Sarcoid-like reaction is often seen in various types of carcinoma, not only in the primary tumor, but also in regional lymph nodes, and can occur at any time, not only at the time of diagnosis, but also after treatment. However, few cases of hepatopancreatobiliary carcinoma, and no cases of gallbladder cancer with sarcoid-like reaction involving the lymph nodes have been described. This report is the first report of a sarcoid-like reaction involving the lymph nodes in a case of gallbladder cancer.

Case presentation: We encountered a rare case of gall bladder cancer with sarcoid-like reaction in the lymph nodes. Since regional lymph node swelling that was difficult to differentiate from metastasis was found preoperatively, swollen nodes were examined histologically using frozen sections. Based on this histology, the swollen nodes were diagnosed as showing sarcoid reaction and therefore extended lymphadenectomy was avoided. The patient did not receive any adjuvant chemotherapy and has shown no recurrence of disease as of 4 years after surgery.

Conclusion: Distinguishing between metastasis and sarcoid-like reaction in lymph nodes by preoperative imaging is still difficult. The present case shows that it is important to histologically examine swollen nodes by biopsy or by sampling before deciding on the treatment strategy for gall bladder cancer with swollen lymph nodes.

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Intraoperative findings. a) Macroscopically, no invasion to the serosa is evident. No shrinkage derived from invasion to the subserosa is seen. b,c) Swollen lymph nodes are easily dissected out, and the margins are clear. d) Frozen-section examination of swollen nodes shows only non-caseating epithelioid cell granuloma.
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Fig2: Intraoperative findings. a) Macroscopically, no invasion to the serosa is evident. No shrinkage derived from invasion to the subserosa is seen. b,c) Swollen lymph nodes are easily dissected out, and the margins are clear. d) Frozen-section examination of swollen nodes shows only non-caseating epithelioid cell granuloma.

Mentions: Based on the above evidence of gallbladder cancer, we planned to perform radical cholecystectomy involving removal of the gallbladder and extrahepatic biliary tract with en-bloc subsegmental resection of the adjacent hepatic parenchyma of segments 4B and 5, and regional lymphadenectomy involving complete removal of the hepatoduodenal ligament lymph nodes, common hepatic artery nodes and retropancreatic nodes [8]. During surgery, we detected swollen lymph nodes. Four of these lymph nodes were dissected and frozen sections were histologically examined. Unlike typical metastatic lymph nodes, these nodes showed a smooth, round shape with clear margins, and were easy to dissect (Figure 2). Histological frozen-section examination revealed that none of the lymph nodes showed tumor involvement but instead they showed non-caseating epithelioid cell granuloma (Figure 2). We therefore only performed simple cholecystectomy, and some of the swollen nodes in the hepatoduodenal ligament were not dissected. Histological examination of the resected gall bladder showed papillary carcinoma with invasion limited to the muscularis propria. None of the dissected lymph nodes showed tumor involvement and all were diagnosed as showing non-caseating epithelioid cell granuloma. Accordingly, the patient was diagnosed with papillary adenocarcinoma of the gall bladder, stage IA (pT1b, pN0, pM0) (Figure 3). Because of the early stage of gall bladder cancer, adjuvant chemotherapy was not performed. As of 4 years postoperatively, the patient has shown no disease recurrence. During follow-up examination, the size of swollen nodes remaining in the hepatoduodenal ligament has gradually decreased compared to the initial size at the time of surgery (Figure 4).Figure 2


Gallbladder adenocarcinoma with sarcoid-like reaction in regional lymph nodes: report of a case.

Kawasaki Y, Maemura K, Kurahara H, Mataki Y, Iino S, Sakoda M, Ueno S, Shinchi H, Takao S, Natsugoe S - BMC Cancer (2014)

Intraoperative findings. a) Macroscopically, no invasion to the serosa is evident. No shrinkage derived from invasion to the subserosa is seen. b,c) Swollen lymph nodes are easily dissected out, and the margins are clear. d) Frozen-section examination of swollen nodes shows only non-caseating epithelioid cell granuloma.
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4301567&req=5

Fig2: Intraoperative findings. a) Macroscopically, no invasion to the serosa is evident. No shrinkage derived from invasion to the subserosa is seen. b,c) Swollen lymph nodes are easily dissected out, and the margins are clear. d) Frozen-section examination of swollen nodes shows only non-caseating epithelioid cell granuloma.
Mentions: Based on the above evidence of gallbladder cancer, we planned to perform radical cholecystectomy involving removal of the gallbladder and extrahepatic biliary tract with en-bloc subsegmental resection of the adjacent hepatic parenchyma of segments 4B and 5, and regional lymphadenectomy involving complete removal of the hepatoduodenal ligament lymph nodes, common hepatic artery nodes and retropancreatic nodes [8]. During surgery, we detected swollen lymph nodes. Four of these lymph nodes were dissected and frozen sections were histologically examined. Unlike typical metastatic lymph nodes, these nodes showed a smooth, round shape with clear margins, and were easy to dissect (Figure 2). Histological frozen-section examination revealed that none of the lymph nodes showed tumor involvement but instead they showed non-caseating epithelioid cell granuloma (Figure 2). We therefore only performed simple cholecystectomy, and some of the swollen nodes in the hepatoduodenal ligament were not dissected. Histological examination of the resected gall bladder showed papillary carcinoma with invasion limited to the muscularis propria. None of the dissected lymph nodes showed tumor involvement and all were diagnosed as showing non-caseating epithelioid cell granuloma. Accordingly, the patient was diagnosed with papillary adenocarcinoma of the gall bladder, stage IA (pT1b, pN0, pM0) (Figure 3). Because of the early stage of gall bladder cancer, adjuvant chemotherapy was not performed. As of 4 years postoperatively, the patient has shown no disease recurrence. During follow-up examination, the size of swollen nodes remaining in the hepatoduodenal ligament has gradually decreased compared to the initial size at the time of surgery (Figure 4).Figure 2

Bottom Line: Based on this histology, the swollen nodes were diagnosed as showing sarcoid reaction and therefore extended lymphadenectomy was avoided.The patient did not receive any adjuvant chemotherapy and has shown no recurrence of disease as of 4 years after surgery.Distinguishing between metastasis and sarcoid-like reaction in lymph nodes by preoperative imaging is still difficult.

View Article: PubMed Central - PubMed

Affiliation: Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical Sciences, Kagoshima University, Sakuragaoka 8-35-1, Kagoshima 890-8520, Japan. gekayota@gmail.com.

ABSTRACT

Background: Sarcoid-like reaction is often seen in various types of carcinoma, not only in the primary tumor, but also in regional lymph nodes, and can occur at any time, not only at the time of diagnosis, but also after treatment. However, few cases of hepatopancreatobiliary carcinoma, and no cases of gallbladder cancer with sarcoid-like reaction involving the lymph nodes have been described. This report is the first report of a sarcoid-like reaction involving the lymph nodes in a case of gallbladder cancer.

Case presentation: We encountered a rare case of gall bladder cancer with sarcoid-like reaction in the lymph nodes. Since regional lymph node swelling that was difficult to differentiate from metastasis was found preoperatively, swollen nodes were examined histologically using frozen sections. Based on this histology, the swollen nodes were diagnosed as showing sarcoid reaction and therefore extended lymphadenectomy was avoided. The patient did not receive any adjuvant chemotherapy and has shown no recurrence of disease as of 4 years after surgery.

Conclusion: Distinguishing between metastasis and sarcoid-like reaction in lymph nodes by preoperative imaging is still difficult. The present case shows that it is important to histologically examine swollen nodes by biopsy or by sampling before deciding on the treatment strategy for gall bladder cancer with swollen lymph nodes.

Show MeSH
Related in: MedlinePlus