Challenges in Managing Delayed Port-Site Metastasis of Gallbladder Adenocarcinoma: A Case Report and Literature Review

Laparoscopic cholecystectomy is a gold standard procedure for gall stone disease. Incidence of gall bladder cancer is found in about 0.25-0.3% of patients undergoing cholecystectomy. Patients with a preoperatively undiagnosed adenocarcinoma of the gall bladder in situ have a high incidence of recurrence at the port site. Incidence increases when a gall bladder perforation occurs during its extraction. Incidence is as high about 14%. Here we report a case of a 35 yrs old female who presented with a swelling in the umbilical region after 18 months of laparoscopic cholecystectomy for gall bladder disease. We recommend retrieval of the gall bladder in a plastic bag and send all specimens for histopathological examination though metastasis in more than one port is very rare. Keywords: Histopathological examination, gall bladder carcinoma, laparoscopic cholecystectomy, metastasis, port site Cite this Article Mahinder Pal Kochar, K.M. Garg. Port Site Metastasis after Laparoscopic Cholecystectomy - Case Report. Research & Reviews Journal of Surgery . 2019; 8(3): 9–13p.

Myeloid sarcoma is a rare tumor composed of myeloid cells, localized in an extramedullary site, which may be associated with a concurrent myeloid neoplasm involving the bone marrow, although such an association is not required. Most patients present with acute myeloid leukemia and their prognosis is poor. We describe the case of a 76-year old woman with an adenocarcinoma of the right colon infiltrating the subserosa synchronous with a myeloid sarcoma at the same site; one pericolic lymph node was infiltrated by both tumors. The peculiarities of this case are the clinical presentation (as an acute abdomen due to subserosa infiltration by the myeloid sarcoma), the coexistence of a myeloid sarcoma with an adenocarcinoma of the right colon, and the absence of progression to acute leukemia. Coexistence of myeloid sarcoma and adenocarcinoma in the colon is probably incidental, and so it appears likely that the two different tumours arose from different mechanisms. However, a possible common background is conceivable. Some authors have found that p53 has a pivotal role in driving the maturation of myeloid stem cells and p53 is, also, involved in colon carcinogenesis. In our case, it may be hypothesized that synchronous heterogeneous mutations occurred in different types of committed cells or in stem cells secondary to p53 loss. Since only one case report has evaluated the correlation between myeloid sarcoma and adenocarcinoma of the large bowel, further immunohistochemical and molecular studies are needed to clarify the pathogenetic relationship between them.

Esophageal metastasis from a primary lesion is considered rare, especially when deriving from endometrial adenocarcinomas. Here, we describe a case of a 58-year-old woman presenting with a 3-month history of progressive dysphagia and lower abdominal pain. Subsequently, a poorly differentiated esophageal carcinoma was confirmed by endoscopic biopsy. The pathological and immunohistochemical analyses of the esophageal lesion were similar to that of the endometrial adenocarcinoma that had been removed 2 years earlier, suggesting that the esophageal tumor derived from her previous endometrial adenocarcinoma. The patient received 6 cycles of paclitaxel plus carboplatin first-line chemotherapy and 2 cycles of epirubicin plus cisplatin second-line chemotherapy, with continued disease progression. After switching to apatinib, computed tomography (CT) scans revealed stable disease after 2 months of treatment. Our goal in this case report was to increase the awareness of clinicians and pathologists regarding the possibility of esophageal metastasis originating from endometrial adenocarcinoma, although it is a rare occurrence. Apatinib may be effective for treating metastatic endometrial carcinoma. However, further investigations are warranted to determine the optimal targeted agent for this condition.

Objective To study the impact factors on prognosis of patients with gallbladder adenocarcinoma after surgery. Methods The clinicopathological data of 1 285 patients who underwent surgery and were histologically confirmed to have gallbladder adenocarcinoma from 2004 to 2014 was extracted from the SEER database of US National Cancer Institute. Life table was used to calculate the survival rate. Kaplan-Meier was used to construct the survival curves. Univariate and Cox multivariate regression analysis were applied to evaluate the prognostic factors. The univariate analysis was evaluated by the log-rank χ2 test. Results The median survival of 1 285 patients with gallbladder adenocarcinoma was 32 months. The 1-, 3- and 5-year survival rates were 77.5%, 46.8% and 36.5%, respectively. The 5-year survival rates of stage Ⅰ, Ⅱ, ⅢA, ⅢB, ⅣA, ⅣB were 72.7%, 63.2%, 24.6%, 20.5%, 0 and 5.1%, respectively. The median survival of stage ⅢA, ⅢB, ⅣA and ⅣB were 22 months, 19 months, 12 months and 16 months, respectively. The differences were statistically significant (P 0.05). Multivariate Cox regression analysis showed that sex (male), age (≥65 years), degree of differentiation, T staging, number of lymph nodes detected (<4) and AJCC staging were independent risk factors affecting prognosis of patients with gallbladder adenocarcinoma (P<0.05). Conclusions With increase in AJCC staging, the survival rates in patients with gallbladder adenocarcinoma after surgery decreased gradually. Parameters including sex, age, T staging, number of lymph nodes detected and AJCC staging were independent factors affecting prognosis of patients with gallbladder adenocarcinoma after surgery. Key words: Gallbladder neoplasms; Neoplasm staging; Gallbladder adenocarcinoma; Prognosis; Survival

Metastatic carcinoma to a lymph node with high grade lymphoma is very rare, particularly when high grade lymphoma is the first time diagnosis. Here we report a case where metastatic pancreatic ductal adenocarcinoma was found in a retroperitoneal lymph node with diffuse large B cell lymphoma (DLBCL). Histologically, the metastatic adenocarcinoma is located mainly in the subcapsular region. The lymph node architecture is diffusely effaced by proliferation of medium to large atypical lymphoid cells with prominent nucleoli, eosinophilic cytoplasm and eccentric nuclei. Immunohistochemical studies revealed these neoplastic lymphocytes are consistent with diffuse large B-cell lymphoma with immunoblastic morphology. Literatures on concomitant metastatic carcinoma with lymphoma in the same lymph node were reviewed. The significance and underline biological mechanisms were also discussed.

BackgroundTumor-to-tumor metastasis is a rare event. Rectal cancer to primary thyroid neoplasm metastasis is extremely rare. Herein, we reported a case of metastatic rectal adenocarcinoma to a papillary thyroid carcinoma. The incidence and clinicopathological characteristics of metastatic colorectal cancer to a thyroid gland neoplasm were described, and the pertinent literature was reviewed.Case presentationA 34-year-old female patient had curative treatment of initial rectal adenocarcinoma in 2012, and was found to have lung metastases by follow-up CT scan 3 years later. In 2018, she was found to have thyroid metastasis by imaging due to left neck pain and hoarseness. A fine-needle aspiration biopsy (FNAB) result suggested suspicious papillary thyroid carcinoma (PTC). The patient underwent a total thyroidectomy and bilateral cervical lymph nodes dissection. The histopathology of thyroidectomy specimen revealed a rectal adenocarcinoma metastatic to the thyroid concomitant with the papillary carcinoma in metastatic adenocarcinoma. The patient received levothyroxine supplementation therapy and palliative chemotherapy with irinotecan and anti-angiogenesis for the metastatic rectal adenocarcinoma. After 1 year of thyroidectomy, no newly developed lesion evidence of recurrent PTC was observed. The patient remains still alive.ConclusionThe possibility of metastases should be considered in patients with a history of rectal cancer and with a thyroid lesion, particularly in those with ageing, hereditary nonpolyposis colorectal cancer (HNPCC) or long-term survival. The diagnosis should be histologically confirmed for the presence of both primary thyroid lesions and secondary thyroid neoplasms. Thyroidectomy may be a feasible treatment for symptomatic thyroid metastasis or thyroid cancer. we need to gain more available evidence from large or multi-center clinical data to help clinicians to diagnose rectal cancer to thyroid neoplasm metastases and evaluate treatment.

Urothelial cancer is the most frequently diagnosed type of malignant tumor in the bladder, of which primary adenocarcinoma accounts for a small percentage. Secondary malignancies, in particular metastatic adenocarcinoma from the lung, are exceedingly rare, with only six cases previously reported in the literature. The present study describes the case of a 71-year-old Chinese male patient with known lung cancer for >2 years, who was diagnosed with metastatic adenocarcinoma to the bladder. The histopathological characteristics and immunohistochemical features of the patient are reported. It was proposed that pathologists should consider the possibility of metastatic adenocarcinoma from the lung, rather than assume a diagnosis of primary adenocarcinoma of the bladder or direct invasion of adenocarcinoma from the surrounding organs. Furthermore, it is essential to determine the medical history of each patient and observe the immunohistochemical features of all tumors prior to diagnosis.

We report an unusual case of prostatic carcinoma in a 47-year-old male that presented with generalized lymphadenopathy. He initially presented with metastatic lymphadenopathy. He underwent a battery of investigations to find the primary site of origin but to no avail. Thereafter, a complete and diligent physical examination revealed a hard and irregular normal-sized prostrate which was later confirmed as the primary site of tumor. This case report reiterates the significance of a precise and complete physical examination that may prove vital in avoiding superfluous expensive investigations and a delay in diagnosis.

DIFFUSE CYSTIC LUNG DISEASE SECONDARY TO METASTATIC COLON CANCER

Synchronous Primary Carcinosarcoma and Adenosquamous Carcinoma of the Esophagus

Lung cancer with gastrointestinal metastasis is uncommon; however, when such metastasis occurs, the small bowel is the most common metastatic site. There are few case reports of colonic metastasis developing from a primary lung adenocarcinoma. We report a case of metastatic adenocarcinoma in the colon, complicated by bowel obstruction and hydropneumothorax, in a 67-year-old woman. The primary cancer was highly suspected to have originated from the lung, based on immunohistochemistry assessments. Immunohistochemistry was positive for thyroid transcription factor-1 and cytokeratin 7, but negative for cytokeratin 20. The published literature, focusing on the differential diagnosis of the origin of the primary malignancy using immunohistochemistry, was reviewed.

So far as we know, the most metastatic site in lung cancer is brain and bone. Choroid metastases rarely occur in clinical diagnosis. We report a case of 57 yearold woman presenting as right blurred vision initially. She came to our hospital for further management due to deteriorating vision. Magnetic resonance (MR) revealed a homogeneous enhancing soft tissues mass occupied in the posterior surface of right eye. Under the impression of primary melanoma, enucleation was performed in June fifth, 2006. Pathologic report proved metastatic adenocarcinoma later. Chest computerized tomography (CT) displayed a spiculated mass at RUL and multiple mediastinal lymphadenopathies. Primary adenocarcinoma of lung with choroid metastases was final diagnosed. We also reviewed related literature and emphasized the importance of differentiating diagnosis in choroidal tumor, especially in cancer patients.

Objective To investigate the clinical efficacy of radical resection for stage T3 gallbladder cancer and prognostic factors. Methods The retrospective case-control study was conducted. The clinico-pathological data of 87 patients with T3 gallbladder cancer who were admitted to Tianjin Medical University Cancer Institute and Hospital from January 2005 to June 2016 were collected. There were 44 males and 43 females, aged 29-79 years, with a median age of 61 years. According to the different preoperative pathological classification and intraoperative exploration of gallbladder cancer, corresponding surgeries were performed. Observation indicators: (1) surgical and postoperative conditions; (2) clinical efficacy of stage T3 gallbladder cancer and prognostic factors analysis; (3) clinical efficacy of stage T3 gallbladder adenocarcinoma and prognostic factors analysis; (4) clinical efficacy of stage T3 gallbladder adenosquamous carcinoma and prognostic factors analysis. Follow-up by outpatient examination or telephone interview was performed to detect the postoperative survival of patients up to June 2018. Measurement data with skewed distribution were represented as M (range), and count data were described as absolute numbers. Survival curve, survival time and survival rate were drawn and calculated by the Kaplan-Meier method. Survival analysis was performed by the Log-rank test. Univariate analysis was performed using the Log-rank test and multivariate analysis using the COX proportional hazard model. Results (1) Surgical and postoperative conditions: all the 87 patients underwent radical resection of gallbladder cancer, including 29 cases of hepatic wedge resection and 58 cases of extended hepatectomy. Of the 87 patients, 42 underwent standard lymph node dissection and 45 underwent enlarged lymph node dissection. There were 27 cases receiving extrahepatic bile duct reconstruction. The postoperative pathological results of 87 patients showed that 64 were diagnosed with gallbladder adenocarcinoma and 23 were diagnosed with gallbladder adenosquamous carcinoma. There were 59 cases comorbid with liver invasion and 3 cases comorbid with vascular invasion. The marginal histopathological examination showed negative margin in 63 cases and positive margin in 24 cases. The degree of tumor differentiation: there were 23 patients with highly differentiated tumor and 64 with poorly differentiated tumor. Of the 87 patients, 43 received postoperative adjuvant therapy and 44 didn′t receive adjuvant therapy. (2) Clinical efficacy of stage T3 gallbladder cancer and prognostic factors analysis. ① All the 87 patients were followed up for 1.8-128.0 months, with a median follow-up time of 26.3 months. All the 87 patients had survived for 1.1-82.7 months, with a median time of 20.1 months. The 2-year overall survival rate of patients was 59.8%, and the 2-year disease-free survival rate was 49.4%. ② Univariate analysis showed that preoperative alkaline phosphatase (ALP) level, tumor diameter, pathological type of tumor, lymph node metastasis, and range of hepatectomy were associated factors for the postoperative 2-year overall survival rate of patients (χ2=5.451, 4.900, 8.256, 4.419, 5.858, P 0.05), but a significant difference in the postoperative 2-year disease-free survival rate between them (56.3% vs. 30.4%, χ2=5.828, P<0.05). (3) Clinical efficacy of stage T3 gallbladder adenocarcinoma and prognostic factors analysis. ① Sixty-four patients with gallbladder adenocarcinoma had the median survival time of 23.1 months, with a range from 3.2 to 82.7 months. The postoperative 2-year overall survival rate was 68.8%, and the postoperative 2-year disease-free survival rate was 56.3%. ② For the 64 patients with T3 stage gallbladder adenocarcinoma, univariate analysis showed that preoperative CA19-9 level and range of lymph node dissection were associated factors for the postoperative 2-year overall survival rate (χ2=4.012, 8.837, P<0.05). The range of lymph node dissection was an associated factor for the postoperative 2-year disease-free survival rate (χ2=6.361, P<0.05). Multivariate analysis showed that range of lymph node dissection was an independant factor for both the postoperative 2-year overall survival rate and postoperative 2-year disease-free survival rate (HR=0.244, 0.382, 95%CI: 0.088-0.674, 0.176-0.831, P<0.05). ③ Survival analysis: range of lymph node dissection was an associated factor for both the postoperative 2-year overall survival rate and postoperative 2-year disease-free survival rate of patients. Of the 64 patients with T3 stage gallbladder adenocarcinoma, the postoperative 2-year overall survival rate and disease-free survival rate of patients undergoing enlarged lymph node dissection were 84.8% and 69.7%, versus 51.6% and 41.9% of the patients undergoing standard lymph node dissection (χ2=8.837, 6.361, P<0.05). (4)Clinical efficacy of stage T3 gallbladder adenosquamous carcinoma and prognostic factors analysis. ① Twenty-three patients with gallbladder adenosquamous carcinoma had the median survival time of 13.2 months, with a range from 1.1 to 70.3 months. The postoperative 2-year overall survival rate was 34.8%, and the postoperative 2-year disease-free survival rate was 30.4%. ② For the 23 patients with T3 stage gallbladder adenosquamous carcinoma, univariate analysis showed that preoperative ALP level, lymph node metastasis, range of hepatectomy, and extrahepatic bile duct reconstruction were associated factors for the postoperative 2-year overall survival rate of patients (χ2=5.288, 4.574, 12.960, 4.106, P<0.05). The lymph node metastasis and range of hepatectomy were associated factors for the postoperative 2-year disease-free survival rate of patients (χ2=7.364, 10.582, P<0.05). Multivariate analysis showed that range of hepatectomy was an independant factor for both the postoperative 2-year overall survival rate and postoperative 2-year disease-free survival rate (HR=0.102, 0.153, 95%CI: 0.012-0.880, 0.033-0.718, P<0.05). ③ Survival analysis: range of hepatectomy was an independant factor for both the postoperative 2-year overall survival rate and postoperative 2-year disease-free survival rate of patients. Of the 23 patients with T3 stage gallbladder adenosquamous carcinoma, the postoperative 2-year overall survival rate and postoperative 2-year disease-free survival rate of patients undergoing extended hepatectomy were 87.5% and 75.0%, versus 6.7% and 6.7% of the patients undergoing hepatic wedge resection (χ2=12.960, 10.528, P<0.05). Conclusions Lymph node metastasis is an independent factor influencing the postoperative 2-year overall survival rate and postoperative 2-year disease-free survival rate of patients with T3 stage gallbladder cancer. The range of lymph node dissection is an independent factor for the postoperative 2-year overall survival rate and postoperative 2-year disease-free survival rate of patients with stage T3 gallbladder adenocarcinoma. Range of hepatectomy is an independent factor for the postoperative 2-year overall survival rate and postoperative 2-year disease-free survival rate of patients with stage T3 gallbladder adenosquamous carcinoma. Patients with gallbladder adenocarcinoma should undergo enlarged lymph node dissection, and patients with gallbladder adenosquamous carcinoma need to undergo extended hepatectomy. Key words: Biliary neoplasms; Gallbladder cancer, stage T3; Gallbladder adenocarcinoma; Gallbladder adenosquamous carcinoma; Lymph node dissection; Prognostic analysis

Adenocarcinoma, accounts for up to 14% of all vaginal cancer. In young patients, common histological feature is clear cell adenocarcinoma (CCA) while mesonephric adenocarcinoma (MA) is very rare. The authors report two patients in their early twenties with unilateral renal agenesis and vaginal adenocarcinoma not exposed to diethylstilbestrol (DES). Two patients with vaginal adenocarcinoma were treated, with external beam radiotherapy of pelvis combined with brachytherapy to a radical dose. In 2000, 25-year-old female, was admitted for radiotherapy after incomplete excision of the tumor localized in left vaginal apex and fornix. Histopathology confirmed CCA and classified as clinical Stage II. CT revealed left renal agenesis.The patient is alive and disease-free 15 years after therapy. Vaginal, urethral stenosis, and hydronephrosis occurred and ureteral stent was inserted. In the second patient, 22-year-old, in 2004, after biopsy of bulky tumor of vagina and histology, revealed MA in Stage III and CT scan also confirmed right renal agenesis. Radiotherapy was followed by chemotherapy. After 11 years, patient is disease-free with vaginal stenosis and incipient renal hydronephrosis. Radiotherapy is effective treatment in advance vaginal adenocarcinoma, however, with high morbidity. The authors advise rigorous gynecologic exams in young females with renal agenesis as there may be a risk of malignant changes in vagina.

Objective To study the expression levels of MK-1 antigen and regenerating gene Ⅳ (RegⅣ) and their clinicopathological significance in the benign and malignant lesions of gallbladder.Methods EnVisionTM immunohistochemical method for determining the expression of MK-1 and RegⅣ was used in routinely paraffin-embedded sections of surgically resected specimens from gallbladder adenocarcinoma ( n =108 ), peritumoral tissues ( n =46), adenomatous polyp ( n =15 ), and chronic cholecystitis (n =35). Results The positive rate of MK-1 or RegⅣ expression was significantly higher in gallbladder adenocarcinoma than that in peritumoral tissues (x2MK-1 =18.76, P ＜ 0. 01 ;x2RegⅣ =9.92, P ＜ 0. 01 ),adenomatous polyp (x2MK-1 =9. 49, P ＜ 0. 01 ;x2RegⅣ =8.59, P ＜ 0. 01 ) and chronic cholecystitis (x2MK-1 =24. 11,P ＜0. 01;x2RegⅣ =19. 24,P ＜ 0. 01 ). The positive cases of MK-1 and/or RegⅣ in the benign lesions showed moderate-or severe-atypical hyperplasia of gallbladder epithelia. The positive rate of MK-1 was significantly higher in the cases of well-differentiated adenocarcinoma, no-metastasis of lymph node,and no-invasiveness of regional tissues than that in the cases of low-differentiated adenocarcinoma, metastasis of lymph node, and invasiveness of regional tissues in gallbladder adenocarcinoma ( P ＜ 0. 05 or P ＜0. 01 ). The positive rate of RegⅣ was significantly lower in the cases of well-differentiated adenocarcinoma,no-metastasis of lymph node, and no-invasiveness of regional tissues than those in the cases of low-differentiated adenocarcinoma, metastasis of lymph node, and invasiveness of regional tissues in gallbladder adenocarcinoma (P ＜0. 05 or P ＜0. 01 ). Unitivariate Kaplan-Meier analysis revealed that the decreased expression of MK-1 (P ＜0. 01 ) or increased expression of RegⅣ (P ＜0. 01 ) was associated with decreased overall survival. Multivariate Cox regression analysis demonstrated that the decreased expression of MK-1 (P ＜ 0. 05 )and/or increased expression of RegⅣ (P ＜0. 01 ) was an independent bad-prognostic predictor in gallbladder adenocarcinoma. Conclusion The expression of MK-1 and/or RegⅣ might be closely related to the carcinogenesis, clinical biological behaviors, and prognosis of gallbladder adenocarcinoma. Key words: Gallbladder neoplasms; MK-1 ; Regenerating gene Ⅳ