Gallbladder Mass Research Articles

DIAGNOSIS AND MANAGEMENT OF GALLBLADDER PERFORATION: A SINGLE-CENTER EXPERIENCE

Background: Gall bladder perforation is one of the uncommon serious complications of cholelithiasis and cholecystitis with high morbidity and mortality. Presentation of gall bladder perforation may vary from that of similar to acute calculus cholecystitis, perforation peritonitis, palpable gall bladder mass to gall stone ileus. Here, we present our experience on the diagnosis and management of the case of gall bladder perforation. Methods: This is the retrospective review of the records of 24 patients who received medical and/or surgical treatment with the diagnosis of gall bladder perforation at Chitwan Medical College from January 2016 to December 2020. All the patients with suspicion of gall bladder perforation underwent contrast enhanced CT scan before an operation or prior intervention.The parameters including age, gender, type of perforation, comorbidities, symptoms, diagnostic procedures, treatment modalities, morbidity, and mortality were evaluated. Results: A total of 24 patients were included in the study during the study period. Among them 62.5% (n=15) were male and 37.5% (n=9) were female.The median age of presentation was 69 years. One patient (4.1%) had type I, 87.5% (n= 21) had type II, and 8.3 % (n=2) had type III gall bladder perforation. CT scan visualizes the defect in gall bladder wall and identifies perforation in all cases. Operative management was done in 12.5% (n=3) patients and percutaneous drainage of gallbladder was done in 87.5% (n=21). The comorbid disease was present in 83.3 % (n=20) of the cases. The median duration of hospital stay was 7 days and there was no mortality. Conclusions: Gall bladder perforation is commonly seen in patients with acute cholecystitis and associated comorbidities. Type II gall bladder perforation is the most common type. Contrast-enhanced CT has an important role in diagnosing gallbladder perforation. Early suspicion, diagnosis, and appropriate management are of crucial importance for a better outcome in patients with gall bladder perforation.

Adenocarcinoma of Gall Bladder, Imitator in Clinical Manifestations, Radiological and Histopathological Findings

Gall bladder adenocarcinoma is a rare malignancy with female predominance. Main patients are in the fifth to seventh decades. Clinical findings of gall bladder adenocarcinoma can be non-specific and the same as cholecystitis .The imaging is also non-specific with considerable overlap between benign and malignant lesions. Gall bladder adenocarcinoma may be overdiagnosed in histopathology by considering Rokitansky-Aschoff sinuses as malignant. It may be underdiagnosed in the cases of well-differentiated minimally invasive carcinoma. Incidental tumors are mainly in fundus and body of gall bladder. The first case was 80-year-old female with right upper quadrant pain, nausea and vomiting. Ultrasound was in favor of emphysematous cholecystitis. Postoperative diagnosis was acute gangrenous cholecystitis with tumor lesion suspicious for malignancy. Pathologist reported, moderately differentiated gall bladder adenocarcinoma extended to serosa in the neck of gall bladder. The second case was 58-year-old female with right upper quadrant severe pain, odynophagia, dysphagia, nausea and vomiting. Ultrasound examination showed gall bladder mass in the fundus and suggested gall bladder cancer. Pathologist reported, Poorly differentiated adenocarcinoma of gall bladder extended full wall thickness. Precise macroscopic evaluation is very important for finding of cases of gall bladder carcinoma even without clinical suspicion. For detection of malignancy, microscopic evaluation of all cholecystectomy samples is recommended. We suggest careful examination of cholecystectomy specimens especially in females more than forty with careful sampling of body and fundus.

English

BACKGROUND Cholecystectomy is a common surgical procedure done worldwide for both benign and neoplastic conditions. Cholecystectomy for benign conditions is performed based on clinical signs, symptoms, Ultrasound, CT. Hence there is fair chance of missing early malignant lesions like carcinoma-in-situ and other early carcinomas. Aim: The aim of the study is to analyse histopathological variations in post cholecystectomy specimens done for benign lesions. METHODS The study was conducted in Department of General Surgery, SVRRGGH, Tirupati, for a period of one year, from March 2019 to April 2020. This is a prospective Study conducted among 100 Patients, conducted over a period of one year from time of IEC approval from March 2019 to April 2020. All patients who underwent cholecystectomy for benign biliary disease and gall stone were included in the study. All patients with pre-diagnosed empyema gallbladder, gallbladder malignancy, gallbladder mass, and gallstones associated with obstructive jaundice are excluded from the study. RESULTS In our study, 100 cases of gall bladder disease were studied in the age group of 18 – 70 years, for a period of 1 year from March 2019 in the department of General surgery, SVRRGGH. Occurrence is high in patients of age group 18 – 45 years (65 %). The male to female ratio is 0.5:1 with female preponderance. The most common histopathologic finding was chronic calculus cholecystitis (59 %).Adenocarcinoma of gall bladder (2 %) of the cases with no preoperative suspicion of malignancy. CONCLUSIONS The occurrence of Incidental GBC found in my study is 2 %. Due to high estimate of residual disease, re-resection is still a curative option and is to be considered for pT2 & pT3, but not CBD removal. Prognosis usually is dismal, and five-year survival rates have been reported to be less than 5 % for more advanced stages. KEYWORDS Histopathology, Variations, Cholecystectomy, Specimen, Benign

The Role of Fine Needle Aspiration Cytology in the Diagnosis of Gallbladder Cancer: A Systematic Review.

Gallbladder cancer is the most common malignancy of the biliary tract. When diagnosed in an advanced stage it has a very poor prognosis. Therefore, early diagnosis and thorough assessment of a suspicious gallbladder polyp is essential to improve survival rate. The aim of this systematic review is to assess the role of fine needle aspiration cytology (FNAC) in the management of gallbladder cancer. For that purpose, a systematic review was carried out in the MEDLINE, EMBASE, Cochrane, Scopus and Google Scholar databases between 1 July 2004 and 22 April 2021. Six studies with 283 patients in total were included. Pooled sensitivity and specificity of FNAC were 0.85 and 0.94, respectively, while the area under the calculated summary receiver operating characteristic (SROC curve (AUC) was 0.98. No complications were reported. Based on the high diagnostic performance of FNAC in the assessment of gallbladder masses, we suggest that every suspicious mass should be evaluated further with FNAC to facilitate the most appropriate management.

Biliary Tract Malignancies Related to Gallbladder Polyps, Primary Sclerosing Cholangitis, and Choledochal Cysts.

Biliary Tract Malignancies Related to Gallbladder Polyps, Primary Sclerosing Cholangitis, and Choledochal Cysts.

Tuberculosis of the Gallbladder: An uncommon Case Report

Isolated gall bladder tuberculosis (GBTB) is exceedingly rare even in an endemic region and is usually found as a GB mass in association with cholelithiasis. Confirmed preoperative diagnosis is very difficult, and most cases are diagnosed after cholecystectomy. We present a case of a 45-years-old woman who came with symptoms of chronic cholecystitis. Computed tomography scan revealed intraluminal gallbladder mass and cholelithiasis. The patient underwent open cholecystectomy and GBTB was diagnosed after histopathological examination. Histopathological examination should be done after all cholecystectomy operations. Faridpur Med. Coll. J. 2020;15(2): 106-107

Effects of two Bisphenol A replacement compounds, 1,7-bis (4-hydroxyphenylthio)-3,5-dioxaheptane and Bisphenol AF, on development and mRNA expression in chicken embryos

Concerns about the estrogenic properties of Bisphenol A (BPA) have led to increased efforts to find BPA replacements. 1,7-bis(4-Hydroxyphenylthio)-3,5-dioxaheptane (DD-70) and 4,4′-(hexafluoroisopropylidene) diphenol (bisphenol AF, BPAF) are two potential chemical substitutes for BPA; however, toxicity data for these chemicals in avian species are limited. To determine effects on avian embryonic viability, development, and hepatic mRNA expression at two distinct developmental periods (mid-incubation [day 11] and term [day 20]), two egg injection studies were performed. Test chemicals were injected into the air cell of unincubated, fertilized chicken eggs at concentrations ranging from 0–88.2 µg/g for DD-70 and 0–114 µg/g egg for BPAF. Embryonic concentrations of DD-70 and BPAF decreased at mid-incubation and term compared to injected concentrations suggesting embryonic metabolism. Exposure to DD-70 (40.9 and 88.2 µg/g) and BPAF (114 µg/g) significantly decreased embryonic viability at mid-incubation. Exposure to DD-70 (88.2 µg/g) decreased embryo mass and increased gallbladder mass, while 114 µg/g BPAF resulted in increased gallbladder mass in term embryos. Expression of hepatic genes related to xenobiotic metabolism, lipid homeostasis, and response to estrogen were altered at both developmental stages. Given the importance of identifying suitable BPA replacements, the present study provides novel, whole animal avian toxicological data for two replacement compounds, DD-70 and BPAF. Data availabilityData, associated metadata, and calculation tools are available from the corresponding author (doug.crump@canada.ca).

Spontaneous cystic artery bleed presenting as hemoperitoneum and possible gallbladder cancer

Presenter: Karolin Ginting MD | The Jewish Hospital Background: Hemoperitoneum secondary to spontaneous rupture of cystic artery is extremely rare. When present, it is usually due to malignancy or ruptured pseudoaneurysm. Prompt intervention to control the hemorrhage and multidisciplinary evaluation for etiology is essential. Methods: We report a rare case of hemoperitoneum secondary to spontaneous rupture of cystic artery. The patient initially presented with acute onset abdominal pain. Imaging performed in the emergency department revealed large right upper quadrant hematoma with active extravasation, hemoperitoneum, and gallbladder mass. He underwent emergent embolization of the cystic artery. Follow-up work-up to elucidate the cause of bleeding included magnetic resonance cholangiopancreatography (MRCP), esophagogastroduodenoscopy (EGD) and endoscopic ultrasound (EUS) with biopsy. This showed a large gallstone, as well as possible solid tumor in the lumen of the gallbladder versus hematoma. Patient was discharged home with plans to follow up with us (surgical oncologist). However, three weeks later patient re-presented with acute onset abdominal pain and leukocytosis. Repeat imaging showed near resolution of right upper quadrant hematoma, extensive thickening of the gallbladder wall, pericholecystic stranding and omental masses. The patient consented for cholecystectomy, possible liver resection and lymphadenectomy. Results: Patient underwent diagnostic laparoscopy without any obvious evidence of metastatic disease. Frozen pathology on a small liver nodule came back as bile duct hamartoma. There were omental adhesions to gallbladder and on release of adhesions, a perforated gallbladder was noted. Three stones in right upper quadrant were initially noted but later on elevating the omentum, numerous gallstones throughout the omentum and lower pelvis were found. This explained the findings on the CT scan which were concerning for carcinomatosis. Robotic platform immensely helped to avoid conversion to open procedure. Indocyanine green (ICG) firefly imaging was used to identify cystic duct and common bile duct. Additionally, firefly imaging delineated the plane between gallbladder and liver bed. The gallbladder was removed and sent to pathology for review, which was grossly negative for cancer. All noted stones were meticulously retrieved and extracted from the abdominal cavity. The patient's postoperative course was unremarkable, and he was discharged home the next day. Final pathology showed chronic cholecystitis with bile duct hamartomas. Conclusion: Initial non-operative management of hemoperitoneum secondary to cystic artery rupture via emergent angioembolization is feasible. This is a temporary step to allow complete workup for malignancy and operative planning for interval cholecystectomy. Robotic surgery platform is very useful for difficult gallbladder procedures.

A Case Report on Chronic Xanthogranulomatous Cholecystitis

Xanthogranulomatous cholecystitis is an uncommon form of cholecystitis often being misdiagnosed as gallbladder carcinoma, hence poses as a diagnostic challenge for physicians. The proposed mechanism of the formation of this lesion is through mucosal ulceration or the rupture of Rokitansky-Aschoff sinuses due to increased intraluminal pressure. This causes granulomatous changes that lead to the formation of intramural nodules. Due to its nature of presenting as a gallbladder mass, certain surgical interventions can become unwarranted, which may diminish the patient’s quality of life. This paper presents a case of a 59-year-old male who presented with epigastric pain, initially treated as reflux disease, relieved by antacids, antispasmodics and opioid analgesics. The imaging studies revealed a mass in the gallbladder with signs of cholecystitis. The patient underwent intra-operative ultrasound, extended cholecystectomy and lymph node dissection with an unremarkable postoperative course. The final histopathology revealed chronic xanthogranulomatous cholecystitis and was negative for malignancy. This paper further reviews the presentation of the lesion under different imaging modalities. On ultrasound, it appears as a hypoechoic focus and marked or focal thickening of the gallbladder wall, while on computed tomography, it presents with hypoattenuating nodules in thickened walls, luminal surface enhancement with continuous mucosal lines. While on magnetic resonance imaging, it may appear as either a reduced signal intensity on out of phase images or slightly high signal intensity and slight enhancement on early phase and strong enhancement on the late phase. In general, the recommended treatment approach is through open cholecystectomy.

Expression and clinicopathological correlation of Ki-67 in gallbladder carcinoma.

INTRODUCTION:Gallbladder cancer is an aggressive cancer with short median survival from the time of diagnosis. Improved understanding of the pathological molecular mechanisms of gallbladder carcinogenesis is important to refine the diagnosis, prognosis, and also to develop novel targeted therapies for patients with advanced Gallbladder cancer (GBC) malignancy. Ki-67 is a marker of cell proliferation and its detection by immunohistochemistry is considered to be an effective method for the detection of prognosis in several tumors. In the present study, we have analyzed expression of immunohistochemical marker Ki-67 in gallbladder carcinoma and its correlation with clinicopathological and radiological parameters.MATERIALS AND METHODS:This prospective observational study was conducted from December 2017 to July 2020. The patients of newly diagnosed gallbladder cancer were enrolled as per the inclusion and exclusion criteria defined in the study protocol. Contrast-enhanced computer tomography of the chest and abdomen and serum tumor markers such as carbohydrate antigen (CA)-19.9, carcinoembryonic antigen, and CA 125 were done. Immunohistochemical expression of Ki-67 was evaluated on biopsy tissue from the gallbladder mass.RESULTS:Fifty newly diagnosed patients of carcinoma gallbladder were included in the present study. The correlation was studied between clinicodemographic parameters and Ki-67, but no association was found with age, gender, and symptoms. There was a weak positive correlation between Ki-67 and direct bilirubin, serum glutamic pyruvic transaminase, serum glutamic oxaloacetic transaminase, and alkaline phosphatase (P = 0.094; 0.126; 0.542; and 0.328, respectively). There was a weak positive correlation between body mass index (Kg/m2) and Ki-67, but this correlation was not statistically significant (P = 0.304).CONCLUSIONS:Ki-67 is a marker of proliferation and it correlated with histological differentiation, jaundice and liver function tests, presence of stones, and location of metastases but did not correlate with stage and extent of disease.

Meso-hepatectomy in a Locally Advanced Carcinoma Gallbladder in 21st Century: Is it Justified?

Introduction: Based on the 2017 systematic review and meta-analysis meso-hepatectomy appears to be safe and comparable in both peri-operative and long term outcomes while comparing patients undergoing extended hepatectomy. Majority included hepatocellular carcinomas(>95%), cholangiocarcinomas but none have carcinoma(ca) gallbladder(gb). Right extended hepatectomy after biliary drainage and portal vein embolisation is the treatment modality for advanced ca gb. It is common in low socioeconomic strata of India(South Asia). Majority(90%) of them don't achieve R0 resection due to disease progression and procedural complications. Chemotherapy can't be given unless bilirubin< 5. The main difference between cholangiocarcinoma and ca gb is that cholangiocarcinoma spreads along ducts but ca gb infiltrates locallly. Hence meso-hepatectomy is not an inferior oncologic surgery in advanced ca gb. Methods: 30 year old male presented with jaundice, weight loss. Scan showed gall bladder mass with hilar block and right hepatic artery(RHA) involvement. Maximum bilirubin was 24. He underwent biliary drainage and bilirubin came down to 14. Ultrasound doppler showed RHA block with good intra-hepatic flow. He underwent meso-hepatectomy with RHA excision and hepaticojejunostomy to right posterior sectoral duct and left duct. Blood loss was 1 litre with a duration of 10 hour. Post operatively neither there was liver failure nor bile leak. Histopathology report was T4N2Mx(ductal margins negative). He completed adjuvant chemotherapy and on follow up of 18 months found to have segment 6 metastasis and still on chemotherapy without jaundice. Conclusion: Meso-hepatectomy is a safer onco-surgical alternative to extended hepatectomy in selected cases of advanced gall bladder cancers.

Computed tomography texture-based radiomics analysis in gallbladder cancer: initial experience.

Aim of the studyTo investigate computed tomography (CT) texture parameters in suspected gallbladder cancer (GBC) and assess its utility in predicting histopathological grade and overall survival.Material and methodsThis retrospective pilot study included consecutive patients with clinically suspected GBC. CT images, clinical, and histological or cytological data were retrieved from the database. CT images were reviewed by two radiologists. A single axial CT section in the portal venous phase was selected for texture analysis. Radiomic feature extraction was done using commercially available research software.ResultsThirty-eight patients (31 females, mean age 53.1 years) were included. Malignancy was confirmed in 29 patients in histopathology or cytology analysis, and the rest had no features of malignancy. Exophytic gallbladder mass with associated gallbladder wall thickening was present in 22 (58%) patients. Lymph nodal, liver, and omental metastases were present in 10, 1, and 3 patients, respectively. The mean overall survival was 9.7 months. There were significant differences in mean and kurtosis at medium texture scales to differentiate moderately differentiated and poorly differentiated adenocarcinoma (p < 0.05). The only texture parameter that was significantly associated with survival was kurtosis (p = 0.020) at medium texture scales. In multivariate analysis, factors found to be significantly associated with length of overall survival were mean number of positive pixels (p = 0.02), skewness (p = –0.046), kurtosis (0.018), and standard deviation (p = 0.045).ConclusionsOur preliminary results highlight the potential utility of CT texture-based radiomics analysis in patients with GBC. Medium texture scale parameters including both mean and kurtosis, or kurtosis alone, may help predict the histological grade and survival, respectively.

Pure squamous cell carcinomas of gall bladder: A series of 4 cases

Introduction: Pure squamous cell carcinoma is an exceptional malignancy with a few case series available in literature. The overall clinical and pathological picture is highly variable and prognosis dismal. Our study describes a series of 4 patients who presented with squamous cell carcinoma of the gallbladder along with their clinico-pathological characteristics. Materials and Methods: The clinical presentation, laboratory investigations, radiological details were retrieved from the hospital records. The gross features and histopathological findings were collected from the departmental archival material and were analyzed by a single pathologist. Result: The clinical and pathological picture of the patients with pure squamous cell carcinoma was highly variable. The radiological features varied from a diffuse thickening of gall bladder wall, a exophytic intraluminal mass in the gall bladder to a large homogenous irregular mass in the right hypochondrium on ultrasonography. The gross features of gall bladder specimens varied from a diffuse infiltrating growth, a polypoid mass arising from the wall, to a large highly friable mass in right hypochondrium infiltrating into adjacent colon. The microscopic features varied from a tumor composed of groups, islands or nests of atypical squamous cells with dyskeratosis and keratin pearl formation to a tumor comprising of cells arranged in solid sheets with areas of comedo necrosis and keratin pearl formation. The prognosis was dismal. Conclusion: The clinical features and overall survival of patients with pure squamous cell carcinoma is more or less similar to the more common adenocarcinoma of gallbladder, however, the no. of cases studied is small to draw conclusions indicating the need for more extensive study. Keywords: Pure squamous cell carcinoma, Gall bladder mass, Adenocarcinoma gall bladder, Intraluminal mass gall bladder.

A rare cause of hemobilia: Metastatic melanoma of the gallbladder

Introduction: Gallbladder melanoma is an extremely rare entity, even more so in living patients, as many remain asymptomatic. Patients usually present with symptoms resembling acute cholecystitis, however here we present a case of metastatic melanoma of the gallbladder presenting with hemobilia. Case Report: An 82-year-old lady with a history of skin cancer excisions, including melanoma, many years ago, presented with anemia of unknown origin. A computed tomography (CT) scan was performed, demonstrating a gallbladder mass and hemobilia. She successfully underwent open cholecystectomy, partial liver resection, and lymph node dissection, which on histopathology, demonstrated metastatic melanoma. She remains disease free eight months later. Conclusion: Although melanoma of the gallbladder is rare, in patients with a past history of melanoma, a high index of suspicion should be maintained if there are concerning signs, such as anemia, without a clear cause. With early identification and surgical intervention, a patient’s survival rate can be optimized.

Progression to invasive cancer after snare polypectomy of intracholecystic papillary neoplasms during gallbladder stone removal by percutaneous transhepatic choledochoscopy: a case report

BackgroundIntracholecystic papillary neoplasms (ICPNs) of the gallbladder are rare, preinvasive lesions characterized by an intracholecystic papillary growth that may be associated with invasive adenocarcinoma. The natural history of ICPN is unknown. Here, we report a case of ICPN, highlighting its natural course.Case presentationA 79-year-old woman presented to the emergency department with perforated cholecystitis. After percutaneous transhepatic gallbladder drainage, due to the presence of surgical risk factors, we opted to perform gallstone removal through percutaneous transhepatic cholangioscopy instead of cholecystectomy. ICPN, which was accidentally detected after the removal of the gallbladder stones, was also endoscopically removed. After 4 years, the patient came back to the hospital with a large gallbladder mass. After cholecystectomy, pathological examination revealed ICPN with invasive adenocarcinoma.ConclusionThe current case showed endoscopic findings of ICPN and its natural progression, particularly its clinicopathological features and outcomes.

Clinicopathological study of carcinoma gallbladder and its management: a prospective study in a tertiary care hospital in Central India

Background: Gallbladder cancer is a highly aggressive malignancy of the biliary system having the shortest median survival rate. Being aggressive biological nature and lack of sensitive screening test for early detection it has a poor prognosis. Aim: The purpose is to study the relative frequency of gallbladder cancer in reference to age, sex, etiological factors, clinical signs and symptoms in relation to the stages and the outcomes of different treatment modalities. Methods: This study is observational and conducted in the Department of General Surgery Gandhi Medical College and Aassociated Hamidia Hospital, Bhopal, Madhya Pradesh, during the period of 2017-2019. all patients who came themselves to OPD were evaluated further. Results: This study shows that majority of the patients were elderly females. Most of them presented with pain in the right hypochondrium found in 78 patients (78%), nausea and vomiting in 36 patients (36%), and jaundice in 30 patients (30%). Tenderness in the right hypochondrium (85%), anemia (78%) followed by weight loss (68%) were the three commonest signs. In radiological investigations (USG and CECT) gallstones were observed in 74 patients (74%) and 75 patients (75%) have gallbladder mass, liver metastasis was seen in 56 patients (56%). Adenocarcinoma was the most common histopathological type reported in 92 patients (92%). Most of the patients (72%) have the disease at an advanced stage at the time of diagnosis which was inoperable. Conclusion: Gallbladder cancer is an aggressive malignancy of the biliary tract and has high case fatality with shortest median survival rates.

Frequency of Gall Bladder Carcinoma among Patients of Cholelithiasis at Tertiary Care Hospital

Objective: To determine the frequency of carcinoma of Gall Bladder in Hospitalized patients undergoing surgeries for cholelithiasis at tertiary care Hospital.&#x0D; Study Setting: General surgery department of Muhammad Medical College Mirpurkhas.&#x0D; Study Design: Descriptive. &#x0D; Study Duration: From 2018 to 2019.&#x0D; Methodology: All the patients of cholelithiasis diagnosed via trans-abdominal ultrasound, those who underwent cholecystectomies and either of gender were included. After surgeries, specimens immediately were sent to the Hospital diagnostic laboratory to evaluate the gall bladder carcinoma. The information obtained was noted on a pre-designed proforma.&#x0D; Results: A total 200 patient of gall bladder stone disease were observed who underwent cholecystectomies. Average age was 53.8+5.62 years and male to female ratio was 1:2.5. Incidence of carcinoma of gall bladder was 4%, which was significantly associated to gall bladder mass, chronic calculus cholecystitis and porcelain gall bladder (p=0.001). &#x0D; Conclusion: The incidence of the gall bladder cancer in the study population was 4% and its relationship with gall bladder diseases (chronic cholecystitis and porcelain) was found to be significant.

Diagnostic role of fine needle aspiration cytology (FNAC) in the evaluation of gall bladder lesions: an institutional experience.

Carcinoma of the gall bladder is the most common malignancy of the biliary tract. Ultrasonography guided Fine Needle Aspiration Cytology (FNAC) plays a crucial role in early detection of gall bladder (GB) lesions. Early diagnosis of GB lesions is a necessity in view of rising trend in GB carcinoma related mortality in India. The aim of this study is to determine the diagnostic accuracy of pre-operative ultrasonography guided FNAC in the diagnosis of GB masses. This was a retrospective observational study performed at a tertiary care university hospital over a period of one and a half years. A total of 47 patients with clinico-radiological suspicion of GB malignancy were subjected to USG guided FNA. 20 of these patients underwent diagnostic Trucut biopsy in addition to FNA. Forty-one out of 47 patients analyzed were positive for malignancy with female preponderance; MF ratio of 0.6:1. There were 29 females (61.8%) and 18 males (38.2%) in the range of 34 to 85 years. Cytomorphology was inconclusive for malignancy in two patients and unsatisfactory in one case. Two were labeled as chronic cholecystitis and one as acute cholecystitis. Adenocarcinoma was the most common malignancy found in 36 patients (76.6%). USG guided FNAC is a rapid, safe and successful diagnostic procedure with high sensitivity for diagnosis of GB lesions. In the present scenario of increasing incidence of GB malignancy, FNAC has proved to be a useful first choice of investigation in the detection of GB lesions.

MON-916 Pure Large Cell Neuroendocrine Carcinoma (LCNEC) of the Gall Bladder in a Patient with Down Syndrome - a Rare Case of an Aggressive Tumor of the Gall Bladder

Background: Pure large cell neuroendocrine carcinoma of the gall bladder (LCNEC-GB) is an extremely rare entity, with only 12 such cases reported in literature to date. None has been reported in a patient with genetic disorders. We describe the case of a patient with pure LCNEC-GB in the presence of Down syndrome and prior biliary atresia.Case:A 49-year-old female with Down Syndrome and history of neonatal surgery for congenital duodenal atresia presented with fever, vague abdominal discomfort and 6 month history of 15 pound weight loss. CT abdomen revealed a 5 X 4.2 cm exophytic, heterogeneously enhancing mass in the gall bladder fossa extending into segment 4B-5 of liver with mild intrahepatic biliary dilation, along with a 9 cm cystic lesion in continuity with the duodenum which was confirmed to a dilated duodenal anastomosis (from prior biliary surgery) on endoscopy. There was high suspicion for malignancy (gall bladder carcinoma versus intrahepatic cholangiocarcinoma) and subsequent metastatic workup including tumor markers, staging CT chest, MRI of the abdomen and diagnostic laparoscopy was negative.The patient underwent robotic converted to open en bloc resection of the gallbladder mass with segment 4B-5 liver resection and adherent loops of small bowel as well as resection of the dilated duodenal anastomosis followed by reconstruction with a gastrojejunostomy and Roux-en-Y/small bowel entero-enterostomy and closure of duodenotomy.Pathology demonstrated poorly differentiated “pure” large cell neuroendocrine carcinoma (G3), 6 cm in greatest dimension, with invasion of liver, duodenum and stomach, negative liver and gastric/small bowel margins. Lymphovascular invasion (LVI) was present with no perineural invasion (PNI), and 3/15 lymph nodes involved. Staging was determined to be pT4pN1.Patient was considered for adjuvant chemotherapy based on few case reports (platinum/etoposide) but unfortunately developed systemic complaints of fevers, fatigue, pain in bones and joints 2 months post operatively. Workup revealed metastatic disease which was confirmed on biopsy. Several small satellite liver lesions were also identified which was consistent with metastatic hepatic disease. Patient and family elected to proceed with hospice. Patient died within 4 months of surgery.Conclusion:Pure LCNEC-GB is an extremely rare and aggressive tumor with a poor prognosis as seen in our patient. This is the first reported case of pure LCNEC-GB in a patient with a genetic syndrome, although it is unknown if it had any causal relationship with the tumor. Prior biliary atresia/post -surgical inflammation may have also contributed to its pathogenesis by plausible development of metaplasia and expression of neuroendocrine cells which are normally absent in the gall bladder. Our case might help shed some light into pathogenesis and genetic basis if any of this rare entity.

Haemocholecyst related to gallbladder malignancy

A haemocholecyst is a clot-filled gallbladder caused by bleeding into its lumen. It is a rare entity with fewer than 50 cases reported in the English literature. Preoperative diagnosis is often not possible even with good quality cross-sectional imaging. Here, we present a case of a gallbladder mass, whose nature was only made clear at operation, where a hugely enlarged gallbladder was found filled with blood clots. There was neither liver infiltration nor regional lymphadenopathy. The clinical status of the patient demanded simple cholecystectomy. Histopathological examination, however, revealed a gallbladder adenocarcinoma, infiltrating the perimuscular connective tissue. Thus, more radical surgery was performed eight weeks later. At the 21-month follow-up, the patient was found to be well.