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

Abstract

BackgroundCarcinoma of the gallbladder (GBC) clinically mimics benign gallbladder diseases and often escapes detection until advanced stage. Despite the frequency of cholecystectomy, diagnosis of GBC remains problematic in many situations. We sought to identify pathologic features that contribute to the difficulty in recognition of GBC.MethodsWe identified 23 patients (ranged from 45 to 86 years, male to female ratio 1:4.5) with carcinoma involving the gallbladder referred to an academic medical center over a period of 10 years for study. This includes 10 cases of primary GBC, 6 cases of metastatic tumor to gallbladder, 6 cases of directly invasive adenocarcinoma arising elsewhere in the biliary tree, and one case of unidentified origin adenocarcinoma. Primary tumors include adenocarcinoma not otherwise specified (NOS) in 6 cases, papillary adenocarcinoma in 2 cases, and single cases of undifferentiated carcinoma and combined adenocarcinoma and neuroendocrine carcinoma (NEC). Metastatic tumors to gallbladder were from a wide range of primary sites, predominantly the gastrointestinal tract.ResultsThese cases illustrate seven potential pitfalls which can be encountered. These include: 1) mistakenly making a diagnosis of adenocarcinoma of gallbladder when only benign lesions such as deeply penetrating Rokitansky-Aschoff sinuses are present (overdiagnosis), 2) misdiagnosing well-differentiated invasive carcinoma with minimal disease as benign disease (underdiagnosis), 3) differentiating between primary NEC of gallbladder and metastasis, 4) confusing primary mucinous adenocarcinoma of gallbladder with pseudomyxoma peritonei from a low grade appendiceal neoplasm disseminated to gallbladder, 5) confusing gangrenous necrosis related to cholecystitis with geographic tumoral necrosis, 6) undersampling early, grossly occult disease, and 7) misinterpreting extracellular mucin pools.ConclusionsClinical history and a high index of suspicion are prerequisite to detecting GBC. Detection of GBC at an early stage is difficult because the symptoms mimic benign gallbladder diseases. Misinterpretation of subtle microscopic abnormalities contributes diagnostic failures in early cases. Careful attention to any evidence of mural thickening, thorough sampling, particularly in older patients, and close examination of any deeply situated glandular structures are critical. Correlations with radiographic and clinical findings are important helps to avoid misdiagnosis in this commonly resected organ.

Impact of Routine Histopathological Examination of Gall Bladder Specimens on Early Detection of Malignancy - A Study of 4,115 Cholecystectomy Specimens

“…Underdiagnosis and overdiagnosis -both are not uncommon in gall bladder cancer (Giang et al, 2012). Marked necrosis, extensive fibrosis with few tumor cells, limited invasion with dysplastic glands-are some difficult situations which we encountered especially in unsuspected cases.…”

Evaluation of Surgical Procedures for T2 Gallbladder Cancer in Terms of Recurrence and Prognosis

“…The gallbladder is anatomically characterized by its location in relation to the surrounding organs, the absence of a musclaris mucosae, presence of Rokitansk-Aschoff sinuses [1,2], presence of a very thin muscularis propria composed of a network of smooth muscle cells, and abundance of blood and lymph vessels in the subserosa. Therefore, once gallbladder cancer crosses the mucosal layer, it easily penetrates the muscular coat to invade the subserosa and spread into the abundant blood and lymph vessels, leading to increased invasion and metastasis.…”

Gallbladder Carcinoma and Its Mimics

“…Dysplasia extending to Rokitansky-Aschoff sinuses (RAS) can mimic adenocarcinoma [22] . Giang et al [23] reported two cases of surface dysplasia which on further evaluation demonstrated numerous areas in which dysplasia was Annals of Pathology and Laboratory Medicine, Vol. 5, Issue 1, January, 2018 seen extending into RAS, mimicking transmural invasion of carcinoma.…”

“…Giang et al [23] reported adenomyosis can be confused with adenocarcinoma. It can be differentiated from adenocarcinoma by noting cytology of glands which are usually benign in cases of adenomyomatosis.…”