Gallbladder carcinoma - mural thickening

Case contributed by Dr Bruno Di Muzio

Presentation

Right upper quadrant pain, nausea, and vomiting. Murphy's positive. Elevated white cell count. Deranged LFTs.

Patient Data

Age: 70 years
Gender: Female

Pancreas poorly visualized due to overlying bowel gas. Two mobile gallstones identified measuring 1.5 cm and 1.3 cm. The gallbladder wall is thickened up to 6 mm and there is mild hypervascularity and trace pericholecystic fluid. The gallbladder is focally tender while examination.  The extrahepatic biliary tree is mildly dilated with the mid common bile duct measuring 10 mm.  No choledocholithiasis seen.  The liver is of normal size and has a smooth contour.  Mild increased echogenicity of the liver suggesting mild fatty infiltration.  No focal hepatic lesion identified although the entirety of the liver was not able to be visualized.  Normal main portal vein diameter and flow.  Right kidney measures 10.6 cm in bipolar length and the left measures 11.7 cm.  Normal cortical thickness.  No hydronephrosis or focal renal lesion.  Spleen is not enlarged.  No ascites.

Conclusion: Tender gallbladder containing mobile stones with mildly thickened and hyperemic wall suggestive of acute cholecystitis in this clinical setting.  The common bile duct is mildly dilated up to 10 mm without an obstructing stone or lesion seen.

Gallbladder calculi measuring up to 14 mm.  Gallbladder wall thickening and pericholecystic inflammatory changes compatible with the stated picture of cholelithiasis.  A note is made that the gallbladder is not abnormally distended and there is funnelling of its infundibular region, where the wall is slightly more thickened and there is diffusion restriction. The mid-portion of the cystic duct is difficult to visualize. Dilated common bile duct measuring up to 9 mm in diameter.  No choledocholithiasis.  No obstructing lesion identified.  No pancreatic duct dilatation.

Macroscopy:  Labeled "Gallbladder". A gallbladder received unopened 70 x 40 mm (length × diameter) with a hemorrhagic, dull serosa, an irregularly thickened wall up to 10 mm, a hemorrhagic, and patchily polypoid/cobblestone mucosa, with a vague ovoid swelling 15 x 12 mm.  The lumen contains hemorrhagic material, and 2 green gallstones 11-15 mm.  There is a cholecystic lymph node 7mm. Black ink marks the margin immediately adjacent the proximal margin.

Microscopy: Gallbladder, shows surface columnar epithelium, focally showing dysplasia and also showing an area within which there is surface ulceration deep to which there are islands and glands of varying sizes lined by moderately pleomorphic epithelial cells, associated with reduction of mucin, infiltrating through the gallbladder wall and into the serosal tissues in association with a reactive inflammatory process. Focally, the tumor is seen to extend to the diathermy fatty tissues, surrounding the gallbladder wall lymphovascular invasion is seen. Tumor is also present in the connective tissues at the gallbladder neck. Adjacent gallbladder shows hemorrhage and reactive fibroblasts within the gallbladder wall in addition to this muscle hypertrophy. Lymph node shows sinus histiocytosis with no evidence of metastatic malignancy.

Conclusion:  Gallbladder – poorly differentiated adenocarcinoma of the gallbladder extending full thickness through the gallbladder wall through fatty tissues and present at a determined margin of the omental fatty tissue surrounding the gallbladder, the tumor is also present in the fat tissues of the proximal gallbladder neck. Lymphovascular invasion is seen. No involvement of the cholecystic lymph node (0/1). Adjacent gallbladder shows acute on chronic inflammation.  

Gallbladder has a funnelling of its infundibular region, where the wall is slightly more thickened and there is diffusion restriction. 

Case Discussion

This case illustrates an incidental gallbladder adenocarcinoma that has been missed on imaging and during the cholecystectomy, only picked later on the histopathology assessment and review of the images. The clinical presentation with acute symptoms and picture mimicking acute cholecystitis, together with a more discrete and not mass-like tumor appearance, lead it to be missed. 

As such in this case, gallbladder carcinomas predominantly affect older persons with long-standing cholelithiasis, and as such is most common in elderly women. On imaging, the gallbladder is not abnormally distended and narrows with a funnelling appearance at its infundibulum, where there is focal restricted diffusion of its wall. This type of tumor presentation is the most frequently missed and mistaken for cholecystitis. 

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