Does gallbladder cancer divide India?

Incidental Gallbladder Neoplasms: A Growing Global Burden

Background

The increasing trend of laparoscopic procedures has made cholecystectomies one of the most common surgical specimens received for histopathological evaluation. This has also led to an increasing trend of finding incidental gallbladder malignancies for a presumed benign disease. The present study describes the histopathological spectrum of neoplastic lesions of the gallbladder along with the historadiological correlation with special emphasis on incidental gallbladder carcinomas (IGBC).

Materials and methods

All the cholecystectomies received over a span of two and a half years were studied. Demographic details, imaging findings, gross features, and microscopic findings of premalignant and malignant lesions were noted. Special stains were done as and when required.

Results

Of the 1253 cholecystectomies received during the study period, 50 gallbladders (3.9%) showed neoplastic pathology and were included in the present study. The age range was 40 to 60 years with female predominance. Ultrasonography revealed nonspecific wall thickness in both premalignant and incidental gallbladder carcinomas. Gallstones were seen in 74% of the cases (37/50). Gross and imaging findings in 17 (34%) of the malignant cases were in concordance with microscopic features, whereas the dysplastic lesions (21) and IGBC cases showed evidence of chronic cholecystitis on the same. Microscopic examination revealed focal dysplasia (low and high grade) in 21/50 (42%) cases. Invasive malignancy was seen in 28/50 (56%) of the cases, of which 11 cases (22%) were IGBC. Pancreaticobiliary type of adenocarcinoma was the most common morphology seen in almost all the cases. There was also one case each of intracholecystic papillary neoplasm (ICPN) and carcinosarcoma.

Conclusion

GBC is an unusual malignancy and its preoperative diagnosis is not so definitive. The incidental form of GBC presents as a radiological disguise and a histopathological surprise. Hence, the present study warrants a complete and scrupulous histopathological examination of all the cholecystectomy specimens for proper and further management of the case.

Routine examination of gallbladder specimens after cholecystectomy: a single-centre analysis of the incidence, clinical and histopathological aspects of incidental gallbladder carcinoma

BACKGROUND

Gallbladder carcinoma is often found incidentally on histopathologic examination after cholecystectomy-this is referred as incidental gallbladder carcinoma (IGC). Routine vs selective histopathological assessment of gallbladders is under debate and this study evaluates the role of regular specimens' examination, based on a single-centre analysis of incidence, clinical and histopathological aspects of IGC.

METHODS

Patients who underwent cholecystectomy, between July 2010 and January 2020, were considered. Exclusion criteria were age under 18 and preoperative diagnosis of GB carcinoma. Demographic, clinical and histopathological data were retrospectively collected, continuous variables with a normal distribution were evaluated with Student's t-test and ANOVA.

RESULTS

Some 5779 patients were included. The female/male ratio was 2.5:1. Chronic cholecystitis (CC) was the most common finding on specimens (99.3%), IGC was found in six cases (0.1%). In the latter group, there were 5 women and patients were older than those with benign disease-73.7 [Formula: see text] 5.38 years vs 55.8 [Formula: see text] 0.79 years (p < 0.05). In all the cases, the GB was abnormal on intraoperative inspection and beside cancer, histopathology showed associated CC and/or dysplasia. Upon diagnosis, disease was at advanced stage-one stage II, one stage IIIA, one stage IIIB, three stage IVA. Two patients are alive, three died of disease progression-median survival was 7 months (range 2-14).

CONCLUSIONS

In this series, ICG was rare, occurred most commonly in old adult women and was diagnosed at an advanced stage. In all the cases, the GB was abnormal intraoperatively, therefore macroscopic GB anomalies demand histopathological assessment of the specimen.

Cost-effectiveness of gallbladder histopathology after cholecystectomy for benign disease

Background

The prevalence of incidental gallbladder cancer is low when performing cholecystectomy for benign disease. The performance of routine or selective histological examination of the gallbladder is still a subject for discussion. The aim of this study was to assess the cost‐effectiveness of these different approaches.

Methods

Four management strategies were evaluated using decision‐analytical modelling: no histology, current selective histology as practised in Sweden, macroscopic selective histology, and routine histology. Healthcare costs and life‐years were estimated for a lifetime perspective and combined into incremental cost‐effectiveness ratios (ICERs) to assess the additional cost of achieving an additional life‐year for each management strategy.

Results

In the analysis of the four strategies, current selective histology was ruled out due to a higher ICER compared with macroscopic selective histology, which showed better health outcomes (extended dominance). Comparison of routine histology with macroscopic selective histology resulted in a gain of 12 life‐years and an incremental healthcare cost of approximately €1 000 000 in a cohort of 10 000 patients, yielding an estimated ICER of €76 508. When comparing a macroscopic selective strategy with no histological assessment, 50 life‐years would be saved and the ICER was estimated to be €20 708 in a cohort of 10 000 patients undergoing cholecystectomy.

Conclusion

A macroscopic selective strategy appears to be the most cost‐effective approach.

Squamous Cell and Adenosquamous Carcinoma of Gall Bladder: a Clinicopathological Study of 8 Cases Isolated in 94 Cancers

Adenosquamous/squamous cell carcinoma (AS/SCC) of the gall bladder is a rare histopathologic subtype that accounts for 1 to 12% of all the gall bladder carcinomas (GBC). Literature on these malignancies is limited. A retrospective analysis of 8 cases (study group) of pathologically proven AS/SCC of the gallbladder among 94 patients who underwent surgery for GBC from January 2001 to December 2014 was done. Twenty-four conventional gall bladder adenocarcinoma cases were selected as control group after matching for age and gender. Mean patient age was 57.8 years and six were females. Clinical presentation did not seem to be too different among the study and control group. Average tumor thickness was significantly higher in AS/SCC cases as compared to the control group (mean 3.1 versus 1.44 cm; p = 0.001). Immunohistochemistry for Ki-67 in adenosquamous carcinoma of the gall bladder showed much higher proliferative index in squamoid area than the adenocarcinoma areas (mean 31.3 versus 16.8%; p = 0.0004). Study group showed 87.5% patients were in higher stage whereas only 37.5% of the patients in control group presented at a higher stage. AS/SCC of the gall bladder presented at an advanced stage. Higher proliferation index in squamous component of adenosquamous carcinomas may account for higher T stage in these malignancies.

Incidental findings during routine pathological evaluation of gallbladder specimens: review of 1,747 elective laparoscopic cholecystectomy cases

Introduction Cholecystectomy for benign gallbladder diseases can lead to previously undiagnosed gallbladder cancer during histopathological evaluation. Despite some controversy over its usefulness, histopathological evaluation of all gallbladder specimens is common in most hospitals. We evaluated the results of routine pathology of the gallbladder after cholecystectomy for benign gallbladder diseases with regard to unexpected primary gallbladder cancer (UPGC). Methods Patients undergoing cholecystectomy because of benign gallbladder diseases between 2009 and 2013 were enrolled in this study. All gallbladder specimens were sent to the pathology department, and histopathological reports were examined in detail. The impact of demographic features on pathological diagnoses and prevalence of UPGC assessed. Data on additional interventions and postoperative survival for patients with UPGC were collected. Results We enrolled 1,747 patients (mean age, 48.7±13.6 years). Chronic cholecystitis was the most common diagnosis (96.3%) and was associated significantly with being female (p=0.001). Four patients had UPGC (0.23%); one was stage T3 at the time of surgery, and the remaining three cases were stage T2. Conclusions Routine histopathological examination of the gallbladder is valuable for identification of cancer that requires further postoperative management.

Need for Prophylactic Cholecystectomy in Silent Gall Stones in North India

One of the criteria for recommending cholecystectomy for silent gall stones, is gall stones in regions with high incidence of gall bladder cancer. Both gall stones and gall bladder cancer are common in North India. All tertiary care centres in India report high rates of gall bladder cancer (GBC) incidence and poor treatment outcomes in the majority of cases due to advanced stage of presentation. Csendes of Chile has reported very high incidence of gallbladder cancer in Chile and Bolivia and advocated prophylactic cholecystectomy in asymptomatic patients. Incidence rate of gall bladder cancer in Indian males is equal to that of Chile, whereas in females, the rates are almost double the rates of Chile. Indians have also been found to have high concentrations of heavy metals in gall bladder wall, and antibodies to tumor suppressor genes. In India, gall bladder cancer is the commonest GI cancer in women and fourth commonest cancer overall in the female population. In view of the epidemiology and clinical scenario of gall bladder cancer and proven safety of laparoscopic cholecystectomy, there is a need to act before it is too late in the current rates of gall bladder cancer. This study looks at the evidence correlating gall stones and gall bladder cancer, in relation to India. There is pressing evidence today to justify a strategy of prophylactic cholecystectomy in silent gall stones in North India. Data for this study was selected through an internet based search for literature concerning gall stones and gall bladder cancer in India, and for prophylactic cholecystectomy.

Histological assessment of cholecystectomy specimens performed for symptomatic cholelithiasis: routine or selective?

Traditionally, all cholecystectomy specimens resected for symptomatic cholelithiasis were sent for histological evaluation. The objectives of such evaluation are to confirm the clinicoradiological diagnosis, identification of unsuspected findings including incidental gallbladder malignancy, audit and research purposes, and quality control issues. Currently, there is a developing trend to consider selective histological evaluation of surgical specimens removed for clinically benign disease. This article discusses the need for routine or selective histopathological evaluation of gallbladder specimens following cholecystectomy. Although several retrospective studies have suggested selective histological evaluation of cholecystectomy specimens performed for symptomatic cholelithiasis, the evidence is not adequate at present to recommend selective histological evaluation globally. However, it may be appropriate to consider selective histological evaluation on a regional basis in areas of extremely low incidence of gallbladder cancer only after unanimous agreement between the governing bodies of surgical and histopathological expertise.