Gallbladder Mass Research Articles

Screening for malignancy in primary sclerosing cholangitis (PSC).

Primary sclerosing cholangitis (PSC) is a frequently progressive and fatal disease. Death from cancer occurs in a significant subset of patients with PSC. Patients with PSC have a 10 to 15% lifetime risk of developing cholangiocarcinoma (CCA). About one third of CCAs are present in the first year after a diagnosis of PSC; the remainder are present with a frequency of about 1.5% each year. Patients with concomitant PSC and inflammatory bowel disease (IBD) have a 4-fold higher risk of colorectal cancer (CRC) than patients with IBD alone and a 10-fold higher risk of CRC than the general population. The risk does not diminish with liver transplantation. This patient population also has a high frequency of carcinoma in gallbladder mass lesions. The risk for hepatocellular carcinoma (HCC) in the presence of cirrhosis is uncertain-two large cohort studies suggest that HCC is not as common as in other causes of cirrhosis. Although AASLD guidelines do not recommend routine screening for liver tumorsin patients with PSC, we recommend MRI/MRCP and serum CA 19-9 levels in patients with PSC every 6months to screen for CCA, HCC, pancreatic cancer, and gallbladder cancer. Screening colonoscopy at the diagnosis of PSC and surveillance colonoscopies every 1-2years should be performed in those with PSC and IBD.

Polypoid lesions of the gallbladder: disease spectrum with pathologic correlation.

Gallbladder polyps are seen on as many as 7% of gallbladder ultrasonographic images. The differential diagnosis for a polypoid gallbladder mass is wide and includes pseudotumors, as well as benign and malignant tumors. Tumefactive sludge may be mistaken for a gallbladder polyp. Pseudotumors include cholesterol polyps, adenomyomatosis, and inflammatory polyps, and they occur in that order of frequency. The most common benign and malignant tumors are adenomas and primary adenocarcinoma, respectively. Polyp size, shape, and other ancillary imaging findings, such as a wide base, wall thickening, and coexistent gallstones, are pertinent items to report when gallbladder polyps are discovered. These findings, as well as patient age and risk factors for gallbladder cancer, guide clinical decision making. Symptomatic polyps without other cause for symptoms, an age over 50 years, and the presence of gallstones are generally considered indications for cholecystectomy. Incidentally noted pedunculated polyps smaller than 5 mm generally do not require follow-up. Polyps that are 6-10 mm require follow-up, although neither the frequency nor the length of follow-up has been established. Polyps that are larger than 10 mm are typically excised, although lower size thresholds for cholecystectomy may be considered for patients with increased risk for gallbladder carcinoma, such as patients with primary sclerosing cholangitis.

Cytopathological diagnosis of gallbladder mass and mural thickening based on imaging findings: A prospective study of 51 cases.

Background:Image-guided fine-needle aspiration cytology (FNAC) serves as first-line diagnostic modalities for the assessment of mural thickening of the gallbladder (GB).Aim:The main objective of the present study was to correlate the diagnostic accuracy of preoperative image-guided FNAC of the thickened GB wall based on imaging findings to arrive at a final diagnosis in a tertiary care center.Materials and Methods:Fifty-seven image-guided fine-needle aspirations (FNAs) were performed from mural thickening of the GB over a period of 4 years and the smears prepared were stained with Leishman and Papanicolaou (Pap) stain. Out of 57 cases, 51 were included in the study for which follow-up histopathology was performed.Result:Out of 51 aspirations, 43 (84.3%) were adequate, 5 (9.8%) were inconclusive, and 3 (5.9%) were inadequate. Among the adequate aspirations, the most common was adenocarcinoma—36 (70.5%). The correlation between confirmatory cytological diagnosis and adequacy was significantly high (P = 0.0001). The overall diagnostic accuracy for adequate aspiration was 95.3%. The common diagnostic pitfalls were necrotic areas, aspiration of reactive hepatocytes adjacent to the GB mass, and mucus islands. No procedural complication was observed in any patient.Conclusions:Image-guided FNAC can be used as a safe, rapid, and successful diagnostic procedure with high sensitivity, specifically for supporting and confirming ultrasonography(USG)/computed tomography (CT) diagnosis of GB mass or mural thickening of the wall.

Exfoliative erythroderma as a paraneoplastic presentation of adenocarcinoma of the gallbladder.

We report a case of a 71-year-old Caucasian male presenting with an exfoliative skin rash all over his body. The patient was also found to have a huge gall bladder mass extending into the liver that turned out to be adenocarcinoma of the gall bladder on biopsy. Gall bladder cancer usually presents with abdominal pain, swelling or jaundice. We report only the second case in literature of a gall bladder adenocarcinoma presenting with exfoliative erythroderma as its paraneoplastic presentation.

Extramedullary plasmacytoma of the gallbladder diagnosed by endoscopic ultrasound fine needle aspiration (EUS-FNA).

Extramedullary plasmacytoma (EMP) is a rare entity that can exist independently or in conjunction with underlying plasma cell myeloma (PCM). When there is underlying multiple myeloma, the presence of EMP portends a poor prognosis. The most common locations for an EMP include the gastrointestinal tract, pleura, testis, skin, peritoneum, liver, endocrine glands and lymph nodes; involvement of the gallbladder is exceedingly rare with only five other cases reported and only one of which was associated with PCM. EMP of the gallbladder can manifest as acute cholecystitis, biliary obstruction, or may be asymptomatic. Treatment is traditionally surgical resection plus adjuvant chemotherapy or autologous stem cell transplant. We present a case of a 53-year-old man with PCM who was found to have a gallbladder mass on imaging and underwent endoscopic ultrasound (EUS) guided fine needle aspiration (FNA) of the mass, which was diagnostic of a plasma cell neoplasm.

Gallbladder Cancer Eroding Into the Duodenum Causing Gastric Outlet Obstruction

SymbolIntroduction: Gallbladder cancer (GBC) is an uncommon but fatal malignancy mostly because of its late presentation. The nonspecific symptoms and advanced stage at presentation contribute to the poor prognosis. We present a case of even rarer type of gall bladder cancer presenting in an uncommon way.SymbolCase Report: 66-year-old Korean male with no significant medical history presented to us with 4 week history of vague right upper quadrant abdominal pain along with nausea with progressive symptoms for past 5 days with now inability to tolerate PO due to post-prandial emesis. Labs on admission were remarkable for white blood cell count of 15 with a left shift; mild elevation in alkaline phosphatase at 181; the rest of the labs were normal. CT scan of the abdomen showed a large cavitary mass within the gallbladder with invasion of the surrounding portal vasculature and erosion into the second portion of the duodenum forming a fistula. An upper endoscopy showed a normal appearing duodenal bulb with the duodenal sweep leading into a cavity with exudative mucosa; the cavity contained bile. A large gallstone was noted in the cavity. The endoscope was unable to be advanced to the descending duodenum. This was thought to be the fistulous tract leading from the duodenum into the gallbladder mass. Biopsy of the cavity revealed invasive squamous carcinoma on histopathology. During the next few days, patient was not able to tolerate any PO intake. He underwent a palliative venting gastric tube along with a feeding jejunal tube and was discharged on home hospice. He subsequently expired 4 weeks later at home. Discussion: GBC is an uncommon GI malignancy with less than 5000 cases a year diagnosed in the US. More than 90% of cases GBC are adenocarcinoma. In our patient, the pathology showed squamous cell cancer, which although rare has been reported. Gallstones amongst other things appear to confer a risk factor for development of GBC especially when larger than 3 cm. Our patient had a gallstone seen on imaging and endoscopy measuring 1.8 cm. The nonspecific symptoms often lead to late diagnosis and despite advanced imaging, only 50% of GBC are recognized pre-operatively. Duodenal obstruction is rarely a presenting symptom, unlike in our patient where the GBC eroded into the duodenum and caused gastric outlet obstruction. Conclusion: GBC is an uncommon malignancy in the United States with variable presentation and vague non-specific symptoms. We describe a case of even rarer form of GBC (squamous cell cancer) presenting as gastric outlet obstruction from erosion of the cancer into the duodenum. The risk factor in our patient may have been presence of a gallstone.

Imaging of malignancies of the biliary tract- an update.

Malignancies of the biliary tract include cholangiocarcinoma, gallbladder cancers and carcinoma of the ampulla of Vater. Biliary tract adenocarcinomas are the second most common primary hepatobiliary cancer. Due to their slow growing nature, non-specific and late symptomatology, these malignancies are often diagnosed in advanced stages with poor prognosis. Apart from incidental discovery of gall bladder carcinoma upon cholecystectomy, early stage biliary tract cancers are now detected with computed tomography (CT) and magnetic resonance imaging (MRI) with magnetic resonance cholangiopancreatography (MRCP). Accurate characterization and staging of these indolent cancers will determine outcome as majority of the patients’ are inoperable at the time of presentation. Ultrasound is useful for initial evaluation of the biliary tract and gallbladder masses and in determining the next suitable modality for further evaluation. Multimodality imaging plays an integral role in the management of the biliary tract malignancies. The imaging techniques most useful are MRI with MRCP, endoscopic retrograde cholangiopancreatography (ERCP), endoscopic ultrasound (EUS) and positron emission tomography (PET). In this review we will discuss epidemiology and the role of imaging in detection, characterization and management of the biliary tract malignancies under the three broad categories of cholangiocarcinomas (intra- and extrahepatic), gallbladder cancers and ampullary carcinomas.

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AIMS & OBJECTIVES: To find out prevalence of gallbladder mass among the patients of gallbladder pathology & define morphological feature of gall bladder masses using real time gray scale ultrasonography and color Doppler flow imaging & power Doppler imaging to find out prevalence of gall stones among the patients of gall bladder mass. MATERIAL AND METHOD: 10424 patients were evaluated for gall bladder pathology with grey scale ultrasonography in between 1.10.12 to 30.09.2013 in Radiodiagnosis department of G.R.M.C. RESULT: 54 patients out of 10424 i.e. 0.5% were found to have gall bladder mass lesion. Among these 79.5% (43) of patients had gall bladder carcinoma, 9.3% (5) had gall bladder polyp, 87.4% (4) had mucocele of gall bladder 1.9% (1) had porcelain gall bladder and 1.9% (1) had gall bladder metastasis. The youngest patient in our study was 12 years old male presented with mucocele. Oldest patient in our study was 68 years old female presented with gallbladder carcinoma.7% of overall gall bladder mass lesion were encountered in females showing clear female preponderance. Gall Stone embedded in 70% of gall bladder mass. CONCLUSION: J.A. group of hospital and G.R. Medical College, Gwalior serve a good proportion of population of M.P. and adjoining area of U.P. and Rajasthan which is endemic for gall bladder pathology. The present study concludes that ultrasonography is a powerful readily available and cost effective tool in the diagnosis of gall bladder pathology.

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OBJECTIVES: To study the role of ultrasonography and computed tomography in the evaluation of abdominal masses, to compare their diagnostic accuracies, to evaluate the imaging features of lesions and to know the exact site of origin and extension into surrounding structures. MATERIALS AND METHODS:A prospective study of 104 patients with abdominal masses. USG was done with Toshiba SSA and Philips Envisor C machine and CT-Scan examination was performed in all patients on Philips brilliance 6-slice whole body CT scanner. RESULTS: There were 35(30.62%) cases of hepatobilliary masses, renal15(14.40%)cases, pancreatic 7(6.72%)cases, 5(4.80%) cases of splenic masses and 30(28.82%) cases of pelvic masses.8 cases with other abdominal masses. Hepatic SOL were detected in 6(5.76%) and 8(7.69%), 5(4.80%)cases of gall bladder masses and 4(3.85%), Omental caking was seen in 2(1.92%) cases and 4(3.85%), calcification was seen in 2(1.92%) cases and 4(3.85%) cases, renal calculi were seen in 4(3.84%) cases and6(5.77%) cases, on sonography and CT examination. Peritoneal deposits were seen in 3(2.88%) cases of ovarian carcinoma and unknown malignancy on US and in 5(4.88%) cases on CT. Ascites and lymphadenopathy was more accurately detected on CT as compared to US.CT detected splenicinfarcts which were missed on ultrasonography. CONCLUSION: CT is more sensitive in evaluation of site and size of lesion, detection of calcification, adjacent organ infiltration and regional lymphadenopathy. The limitations of CT are ionizing radiation, high cost and contrast administration. Hence ultrasound should be the primary screening modality and CT should be used for further characterizing the masses.

The Other Bladder: A Case of Prostatic Adenocarcinoma Metastasis to the Gallbladder

Prostate cancer metastasis to bone and lymph nodes is common, but metastasis to the gallbladder is rare. We report a case of a 72 year-old-male with a three month history of weight loss and nausea. On further evaluation he was found to have an elevated alkaline phosphatase and radiographic evidence of prostate cancer, skeletal metastases, and a gallbladder mass concerning for concomitant gallbladder carcinoma. Prostate biopsy confirmed high-grade prostatic adenocarcinoma. The patient underwent laparoscopic cholecystectomy and pathologic evaluation of the gallbladder revealed metastatic prostatic adenocarcinoma without evidence of gallbladder carcinoma. This case demonstrates a possible association between prostatic adenocarcinoma and the gallbladder.

Cushing's Syndrome Caused by an ACTH-Producing Neuroendocrine Carcinoma of the Gallbladder

Neuroendocrine tumors of the gallbladder are rare, and typically found incidentally after a cholecystectomy. Few data are available on adrenocorticotrophic hormone (ACTH)-producing neuroendocrine tumors originating specifically from the gallbladder. We experienced the case of a patient with a gallbladder mass who presented with Cushing’s syndrome, who was subsequently diagnosed as an ACTH-producing neuroendocrine carcinoma of the gallbladder. Despite being rare, hormoneproducing neuroendocrine tumors should be part of the differential diagnosis in patients with Cushing’s syndrome. (Korean J Med 2014;87:67-71)

Incidental gall bladder cancers: Are they truly incidental?

To seek and analyze features suggestive of gallbladder cancer (GBC) on preoperative imaging and intraoperative findings in patients diagnosed as having incidental GBC (IGBC). The study was conducted on 79 patients of IGBC managed in our department over a 10-year period (2003-2012). Review of preoperative imaging and operative notes was done to ascertain any suspicion of malignancy-in-retrospect. Of the 79 patients, Ultrasound abdomen showed diffuse thickening, not suspicious of malignancy in 5 patients, and diffuse suspicious thickening was seen in 4 patients. Focal thickening suspicious of malignancy was present in 24 patients. Preoperative computed tomography/magnetic resonance imaging was done in 9 patients for suspicion of malignancy. In 5 patients, difficult Cholecystectomy was encountered due to dense/inflammatory adhesions. Intraoperative findings showed focal thickening of the gallbladder and a gallbladder mass in 9 and 17 patients respectively. On overall analysis, 37 patients had preoperative imaging or intraoperative findings suggestive of malignancy, which was either a missed GBC or an unsuspected/unexpected GBC. In 42 (53.2%) patients, there was no evidence suggestive of malignancy and was an unanticipated diagnosis. Our study highlights a potential and not-so-rare pitfall of Laparoscopic Cholecystectomy. A greater awareness of this clinical entity along with a high index of suspicion and a low threshold for conversion to open procedure, especially in endemic areas may avert avoidable patient morbidity and mortality.

Neuroendocrine Neuroendocrine carcinoma of gallbladder: A rare case report

Primary neuroendocrine carcinoma of gallbladder is extremely rare, representing 0.2% of all neuroendocrine tumors, as normal gallbladder mucosa does not contain neuroendocrine cells. Little is known about its biological behavior. Diagnosis is incidental in most of the cases. We sought to give an overview of the current state of knowledge about gallbladder neuroendocrine tumors. We describe the case of a 55-year-old man who underwent cholecystectomy for the evaluation of a gallbladder mass that had been incidentally detected by ultrasonography. Histologically, the lesion was composed of monomorphic cells that contained round nuclei and were organized in small nests, nodules, trabeculae, and acini. Cells were positive for chromogranin A and a diagnosis of neuroendocrine carcinoma of the gallbladder was made. He is disease-free 8 months after surgical treatment. Characteristic pathological findings of the gallbladder neuroendocrine tumors predict the prognosis. Given the difficulty in distinguishing between benign and malignant lesions in the pre-surgical setting, we tend to emphasize the need for cholecystectomy in all cases, relying on the pathological and immunohistochemistry analyses for the final diagnosis. The biological behavior of the tumor is still not well defined. Thus, reporting every case is important and may contribute to the existing knowledge regarding the behavior and management of this rare tumor.

Duodenal lymphangitis carcinomatosa: A rare case

Duodenal lymphangitis carcinomatosa has been sporadically described, and little attention has been paid so far. To our knowledge, no data on radiological findings for this rare entity has been published. We report a case of duodenal lymphangitis carcinomatosa secondary to gallbladder mass in a 44-year-old Indian man to focus on the radiological diagnosis, which was further confirmed by endoscopic-guided biopsy and immunohistochemical analysis.

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Adenocarcinoma accounts for 75 - 85 % cases of primary carcinoma of gall bladder. The mucinous adenocarcinoma is a very common primary malignant neoplasm of GI tract, but this histological variant is nonexistent in gall bladder. Porcelain gall bladder is another rare finding in routine cholecystectomy specimen and regarded as precancerous lesion. We present a case of 50 years old female who came to OPD for yellowish discoloration of sclera and itching all over the body for three months. On USG there was a hetero echoic lesion approximately 3.8cmx2.7 in the neck region of gall bladder suggestive of gall bladder mass. The histological examination showed moderately differentiated mucinous adenocarcinoma with Adenomyomatosis in a porcelain gall bladder.

Safety of Nonanesthesiologist-administered Propofol Sedation in Endoscopic Ultrasound

Background: Sedation during complex endoscopic procedures is important for comfort and safety of patient and ensures smooth and efficient completion of the procedure. This article evaluates safety of nonanesthesiologist-administered propofol (NAAP) sedation during endoscopic ultrasound. Materials and methods: Patients undergoing endoscopic ultrasound (EUS) with propofol sedation at Center for Liver and Digestive diseases (CLD), Holy Family Hospital, Rawalpindi, Pakistan were included. The primary outcome variable was the frequency of any sedation-related complication. Results: One hundred and ten patients fulfilling the inclusion criteria were enrolled in the study. Sixty (54.5%) patients were male and 50 (45.5%) were females. The mean age of study patients was 49 ± 18 years. The mean propofol dose was 203 ± 119 mg. There were 41% (n = 45) in ASA class I, 40% (n = 44) in ASA class II and 19% (n = 21) in ASA class III. The most common endosonographic finding was mediastinal and/ or abdominal lymphadenopathy (30.9%, n = 34) followed by a pancreatic mass in 21.8% (n = 24) patients, and a space occupying lesion (SOL) in liver in 15.5% (n = 16) patients. There were three cases with gallbladder mass (2.7%), two cases with CBD mass (1.8%), three cases (2.7%) with esophageal growth and 10 (9.1%) cases with gastric masses. Most of the patients, i.e. 98.2% (n = 108) had no sedation-related complication. Only 1.8% (n = 2) patients developed sedation-related minor complications who only required bag mask ventilation and subsequently recovered without any sequel. Conclusion: NAAP for endoscopic sedation is safe in patients undergoing EUS.

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OBJECTIVE- To determine the prevalence of carcinoma of the gallbladder in the specimens following routine cholecystectomy. STUDY DESIGN- Observational case series study Place & Duration of study- Department of Surgery, Rama Medical college Hospital and Research center, from April 2009 to March 2013. MATERIALS AND METHOD-All patients with symptomatic gallstone disease of both sex having age range between 15 to 70 year were included. Patients with pre diagnosed Gallbladder malignancy, Gallbladder mass, Empyema Gallbladder and Gallstones associated with obstructive jaundice were excluded. All cholecystectomized gall bladder specimens were sent for histopathological examination. RESULTS-Five hundred and twenty patients (520) including 104 males and 416females (M: F ratio 1:4) aged15-70 year and having a mean age of 41.7 year (± SD 2.4), were included in this retrospective study. Commonest presentations were pain in the right hypochondrium and a positive Murphy's sign (87.71%) followed by dyspepsia (55%), nausea, vomiting (40%), pyrexia (31.92%) and weight loss (05%). Twenty two (4.23%) patients had a diagnosis of malignancy of gallbladder at histopathology examination. Mean age for patients with malignancy was 55.25 year with a male to female ratio of 01:10. Well differentiated adenocarcinoma was reported in 45.45% cases, moderately differentiated in 36.36%, poorly differentiated in 09.09% and undifferentiated in 09.09%patients CONCLUSION-Though early detection and treatment has declined the incidental Gall Bladder carcinoma occurrence, but routine histopathology of cholecystectomized Gall Bladder is necessary for early detection of Gall Bladder Cancer. KEY WORDS-Cholecystectomy, Gallstones, Histopathology.

Mass-forming Xanthogranulomatous Cholecystitis Masquerading as Gallbladder Cancer

BackgroundMass-forming xanthogranulomatous cholecystitis (XGC), an uncommon inflammatory pathology of gallbladder (GB), masquerades as gallbladder cancer (GBC) and diagnosis is often a histological surprise. MethodsA retrospective analysis of prospectively collected database of patients with GB mass operated between August 2009 and September 2012 was conducted to determine clinical, radiological, and intraoperative findings that might aid in the preoperative diagnosis of mass-forming XGC and ascertain their optimal management strategy. ResultsOf the 566 patients with GB mass and suspected GBC, 239 were found to be inoperable on preoperative workup and 129 patients had unresectable disease on staging laparoscopy/laparotomy. Of the 198 with resectable disease, 31 were reported as XGC on final histopathology (Group A), while 167 were GBC (Group B). Of these 31 patients, six with an intraoperative suspicion of benign pathology underwent cholecystectomy with segments IVb and V resection, and frozen section histopathology. Twenty-five underwent radical cholecystectomy, with (n = 10) or without (n = 15) adjacent organ resection. In comparison, anorexia and weight loss were significantly more in Group B (p = 0.001 and <0.001). Intraoperatively, empyema and associated gallstones were more common in Group A (p = 0.011 and <0.001). On computed tomography (CT) of the abdomen, continuous mucosal line enhancement and intramural hypodense bands were significantly more in Group A (p < 0.001 and 0.025). While CT abdomen revealed one or more features suggestive of XGC in 64.5 % (20/31) of patients in Group A, 11(35.5 %) did not have any findings suggestive of XGC on imaging. ConclusionMass-forming XGC mimics GBC, making preoperative and intraoperative distinction difficult. While imaging findings can help in suspecting XGC, definitive diagnosis require histopathological examination. Presence of typical radiological findings, however, can help in avoiding extended radical resection in selected cases.

Intense FDG Activity in a Case of Xanthogranulomatous Cholecystitis Without Elevated Fluorothymidine Activity

F-FDG PET/CT is a useful imaging modality to detect malignant gall bladder lesions. We present an image of a patient with a gall bladder mass that was found to be FDG avid but negative on F-fluorothymidine PET/CT imaging. This was later confirmed to be a case of xanthogranulomatous cholecystitis.

Selective Laparoscopic Approach in Suspected Gallbladder Malignancy

We examined patients with clinical findings that are concerning for gallbladder malignancy to determine the incidence of pathology-confirmed malignancy and to discover factors that may be used to determine which patients may be initially treated with a laparoscopic approach. All patients referred to a surgical oncologist with preoperative findings that are concerning for gallbladder malignancy who had not undergone previous surgical resection from 2005 to 2011 were reviewed. Variables collected included demographics, imaging, operative findings, and final pathology. Patients were grouped into 3 categories based on preoperative findings: gallbladder mass, irregular wall thickening, and abnormal intraoperative findings on previous diagnostic laparoscopy. Twenty-nine of 4474 patients evaluated for gallbladder pathology during the study period met the inclusion criteria. Preoperative imaging included computed tomography, ultrasonography, and magnetic resonance imaging. Twelve patients had multiple imaging studies. Eight patients were initially treated with a laparoscopic approach with 3 conversions to an open procedure. Forty-eight percent of patients had pathology-confirmed malignancy. Patients without a discrete mass on imaging were more likely to have benign disease (P = .04). Our results demonstrate that >50% of patients with suspicious preoperative findings had benign pathology, suggesting that the initial laparoscopic approach in selected patients may be appropriate.