Characteristics of gallbladder cancer in South India

Expression Pattern of Estrogen Receptor Alpha and Progesterone Receptor in Gallbladder Carcinoma and Their Association with Clinicopathological Parameters and Overall Survival

BACKGROUND

Gallbladder cancer (GBC) is a highly aggressive malignant tumor with a poor prognosis. Despite being first described two centuries ago, there are no targeted therapies available beyond conventional cytotoxic therapy. Epidemiological studies have shown that the incidence of gallbladder cancer is higher in females than males. This suggests that the gallbladder may be a female sex hormone-responsive organ, and these hormones might be involved in the pathogenesis of gallbladder cancer. Therefore, we aimed to analyze the expression of ERα and PR in GBC and correlate their expression with clinicopathological variables and overall survival.

PATIENTS AND METHODS

A total of 235 histopathologically diagnosed GBC cases were included in this hospital-based cross-sectional study. Clinicopathological data were collected, and the expression of ERα and PR was evaluated by immunohistochemistry.

RESULTS

The mean age of this study population was 55.47 ± 8.45 with range 28-87 years. Females were predominated over male with a male-to-female ratio of 1:3.5. Positive nuclear expression of the ERα and PR was found in 13 (5.5%) and eight (3.4%) cases, respectively. Apart from nuclear staining, cytoplasmic expression of ERα and PR was found in three (1.2%) and 31 (13.2%) cases, respectively. Higher percentage of positive nuclear expression of ER was found in < 50 years age (p value = 0.04), parity > 4 (p value = 0.02), advanced pT stage (T3) (p value = 0.01), lymphovascular invasion (p value = 0.02), and liver invasion (p value = 0.04) which were statistically significant. Higher percentage of PR expression was also observed in < 50 years age (p value = 0.01), and tumor associated with gallstone (p value = 0.04). There was no significant correlation between cytoplasmic expression of ER, PR, and clinicopathological variables. In multivariate analysis, there was no significant correlation between ER or PR positive expression and overall survival.

CONCLUSION

Although nuclear expression of ERα was significantly associated with progressive disease factors but the positive expression was found in very small percentage of GBC cases. So anti-hormone therapy might be an option in patient with ER α positive gallbladder carcinoma.

Small-cell carcinoma of the gall bladder: Report of three cases and review of the literature

Gallbladder (GB) Small Cell Carcinoma (SCC) is an uncommon entity with very poor prognosis. There is a paucity of literature regarding its natural history and management, with only 73 prior cases reported in the world literature. In this case report, we present three cases of SCC of the GB with varied presentations, clinical course, management, and outcomes along with a brief review of the available literature on this subject.

Outcome of routine histopathological examination of gallbladder specimen following elective laparoscopic cholecystectomy

BACKGROUND:

Gallstone disease is one of the commonest surgical ailments encountered in our setup. Its prevalence in India varies from 2% to 29%. Although cholelithiasis accounts for more than 95% of gall bladder related disease, routine histopathological examination (HPE) is vital. It reveals a myriad of benign as well as the malignant surgical pathology of the gallbladder (GB). This part of the world is considered as an endemic region for GB carcinoma as well as gallstone disease. This study intends to evaluate the outcome of the routine HPE of laparoscopic cholecystectomy specimens.

METHODS:

This retrospective observational study evaluated the results of the routine HPE of elective laparoscopic cholecystectomy specimens of single tertiary care center. Patients suspected or diagnosed with carcinoma gall bladder were excluded. Demographic data such as age, sex, and pathology results were recorded.

RESULTS:

From January 2017 to December 2019, HPEs of 921 patients who had undergone laparoscopic cholecystectomy specimens were analyzed. 97.6% specimens had benign lesion of which chronic calculus cholecystitis was predominantly high (95.01%) followed by cholesterosis (9.9%) and xanthogranulomatous cholecystitis (6.51%). Incidental carcinoma gall bladder was observed in 17 specimens accounting for 1.85%. Mean age of patients who underwent cholecystectomy was 43.10 ± 13.90 with female to male ratio of 3.23:1.

CONCLUSION:

Chronic calculus cholecystitis was the most common gall bladder disease with high female preponderance to all GB pathologies. This study affirms the importance of routine HPE after cholecystectomy as early incidental detection of carcinoma gall bladder alters the postoperative management approach and patients are expected to have a better outcome with it.

Differences in cancer incidence and pattern between urban and rural Nepal: one-year experience from two population-based cancer registries

Variations in cancer incidence, mortality and pattern exist in rural and urban areas. Understanding these differences helps in developing targeted cancer prevention and control strategies. However, no previous studies have explored the differences in cancer demographics between the rural and urban areas of Nepal. The data of Kathmandu Valley (urban area) Population-Based Cancer Registry (PBCR) and Rukum (rural area) PBCR were analysed to identify the differences in cancer pattern in rural and urban areas. The age-adjusted incidence rate (AAR) in Kathmandu was higher than that in Rukum (1.6 times among males and 1.9 times among females). The top two leading sites in males were lungs and stomach in both the regions; however, the rates were higher in Kathmandu. The incidence rate for cancer of the urinary bladder among males in Kathmandu was particularly higher - 4.4 times that of Rukum. In females, the leading site of cancer in Kathmandu was breast, which was eight times higher compared to Rukum, whereas the incidence rate of cervix cancer in Kathmandu is 30% less than in Rukum. The incidence of tobacco-related cancer was found to be higher in Kathmandu compared to Rukum. These findings reveal the need for different policy priorities for cancer control in the urban versus rural regions of Nepal, based on the different demographics of cancer in the two areas. Similar studies from other regions of Nepal are needed to develop a targeted cancer control strategy.

A Comparative Analysis of Clinical Characteristics and Histomorphologic and Immunohistochemical Spectrum of Gallbladder Carcinoma in Young Adults (< 45 Years) and Elderly Adults (> 60 Years)

Gallbladder carcinoma (GBC) is more frequent after 60 years of age; its behavior in young adults has not been much studied. A retrospective analysis was performed in patients who underwent a cholecystectomy procedure between the years 2001 to 2016. A group of young patients (< 45) were compared with elderly patients (> 60 years) with reference to various clinical, histomorphologic, and immunohistochemical parameters. Statistical analysis was performed using t test and Fisher's test. Survival curves were calculated by Kaplan-Meier actuarial survival curves and log-rank tests. One hundred and one patients with GBC were observed during the study period. Of these, 14 patients (13.9%) belonged to the study group (age range 20 to 45 years) and 43 patients (42.6%) constituted the comparison elderly control group (age range 60 to 80 years). Forty-four pts. were in the middle-aged group (46 to 59 years) and were thus excluded from the study. With reference to age (< 45 and > 60), no significant difference was found in sex (females 64.3% vs 69.8%, p = 0.7), presence of gall stones (64% vs 60%, p = 0.8), advanced disease at presentation (T4) (14.3% vs 7%, p = 0.40), incidental detection of gallbladder carcinoma (28.5% vs 28%, p = 0.9), tumor stage at presentation (stage I/II) (35.7% vs 49%, p = 0.39), and poor differentiation (tumor grades G3) (14% vs 12%, p = 0.79). Full-length involvement (28.5% vs 11.6%, p = 0.015) of the gallbladder and abundant tumor necrosis (43% vs 14%, p = 0.021) were more common in the younger patients group whereas adenosquamous and pure squamous cell carcinoma were predominantly observed in elderly patients. Immunohistochemical studies showed higher percentage of overexpression of p53 and Ki-67 proliferation indices in the younger population. Overall survival in younger patients was 48 months whereas in elderly patients it was 36 months. Histological markers denoting aggressive tumor behavior were observed in gallbladder carcinomas of younger individuals; further studies are needed to delineate the differences in molecular mechanisms involved in progression of the tumor in the two groups.

Oxidative stress and deregulations in base excision repair pathway as contributors to gallbladder anomalies and carcinoma - a study involving North-East Indian population

Gallbladder cancer (GBC) is a fatal condition with dismal prognosis and aggressive local invasiveness; and with uncharacterised molecular pathology relating to non-specific therapeutic modalities. Given the importance of oxidative stress in chronic diseases and carcinogenesis, and the lacunae in literature regarding its role in gallbladder diseases, this study aimed to study the involvement of oxidative stress and deregulation in the base excision repair (BER) pathway in the pathogenesis of gallbladder diseases including GBC. This study involved patients from the North-East Indian population, where the numbers of reported cases are increasing rapidly and alarmingly. Oxidative stress, based on 8-OH-dG levels, was found to be significantly higher in gallbladder anomalies (cholelithiasis [CL] and cholecystitis [CS]) and GBC at the plasma and DNA level, and was associated with GBC severity. The expressions of key BER pathway genes were downregulated in gallbladder anomalies and GBC compared to controls, and in GBC compared to both non-neoplastic controls and gallbladder anomalies. Expression of XRCC1 and hOGG1 was significantly associated with both susceptibility and severity of GBC. The XRCC1 codon280 polymorphism was associated with disease susceptibility; and significantly higher oxidative stress was observed in hOGG1 genotypic variants. The genomes of GBC patients were found to be more hypermethylated compared to controls, with the promoters of XRCC1 and hOGG1 being hypermethylated and, therefore, being silenced. This study underlined the prognostic significance of the oxidative stress marker 8-OH-dG and BER pathway genes, especially hOGG1 and XRCC1, in gallbladder anomalies and GBC, as well as stated their potential for therapeutic targeting.

Gallbladder cancer incidence in Delhi urban: A 25-year trend analysis

INTRODUCTION

Gallbladder cancer (GBC) falls into the top ten leading cancer sites in urban Delhi. The incidence of GBC in females is more than that among males worldwide. The present study evaluates the temporal variation of GBC incidence in an urban Delhi population.

MATERIALS AND METHODS

The 25-year GBC incidence data were obtained from Population-Based Cancer Registry (PBCR) of Delhi which covered nearly 97.5% of the population and 75% of Delhi. We applied joinpoint regression method to determine the trend of GBC incidence from 1988 to 2012. The estimated cumulative risk (0-74) and lifetime risk of developing GBC were also calculated.

RESULTS

GBC contributed 6% of total cancer cases in Delhi during the year 2012. In the past 25 years, 12,410 GBC cases (4010 males and 8400 females) were registered and contributed approximately 3% of male cancer cases and 6.5% of female cancer cases. The median age at diagnosis of GBC was 60.13 years and 57.22 years in males and females, respectively. Joinpoint analysis showed an overall increasing trend of age-adjusted rates of GBC incidence over 25 years. In females, a downward trend was observed during 1992-2004, whereas in males, the trend remained consistent during 1991-2005; however, thereafter, it started significant increasing for both the genders. Age-specific trend of GBC also reflects an increasing trend among males and females after 2004.

CONCLUSION

The total and age-specific GBC cases have show an increasing trend in the past 25 years in urban Delhi. Stringent steps are required to control the modifiable risk factors for reducing the incidence of GBC in Delhi. In addition, individuals should also practice a healthy lifestyle to reduce the likelihood of GBC as well as other diseases.

Role of Multidetector Computed Tomography (MDCT) in Evaluation of Gallbladder Malignancy and its Pathological Correlation in an Indian Rural Center

OBJECTIVES

Clinically or sonographically suspected gallbladder carcinoma was evaluated on multidetector computed tomography. Based on the spectrum of multidetector computed tomography findings, staging of gallbladder carcinoma was done. Multidetector computed tomography diagnosis was compared with pathological diagnosis.

MATERIAL AND METHODS

This is a prospective study carried out in 100 patients at a rural Indian center between May 2012 and June 2015. Multidetector computed tomography was performed in all the cases and the findings were observed. Based on the radiological spectrum, staging of gallbladder carcinoma was done. The diagnosis was confirmed by ultrasound guided fine needle aspiration cytology/histopathological examination of surgical specimens.

RESULTS

The most common multidetector computed tomography findings noted by us were mass replacing gallbladder, followed by diffuse/focal gallbladder wall thickening and polypoidal mass. Other findings noted were cholelithiasis, liver infiltration, intra hepatic biliary dilatation, liver metastases, portal vein invasion, antroduodenal and hepatic flexure involvement. Ultrasonography guided fine needle aspiration cytology done in all cases was positive in 92 cases and inconclusive in eight cases. Surgery was performed in only 22 patients, and histopathological findings were correlated with multidetector computed tomography findings.

CONCLUSION

Multidetector computed tomography is also reliable in detection of extension of tumor and lymph nodes. multidetector computed tomography plays a major role in evaluating and staging of carcinoma gallbladder. It also guides the surgeons for operatibility and resectability of tumour.

Trends in Gallbladder Cancer Incidence and Survival in Korea

Purpose

The current study was undertaken to examine the trend in gallbladder cancer (GBC) incidenceand survival in Korea.

Materials and Methods

GBC incidence data by histologic typewere obtained from the Korea Central Cancer Registry.Age-standardized incidence rates were calculated using the mid-year Korean population of2000 as a standard population, and a joinpoint regression model was used to calculate theannual percent change (APC) in incidence rates. Incidence by Surveillance, Epidemiology and End Results (SEER) summary stage and by geographical areas and female-to-male incidencerate ratios was also described.

Results

The number of new GBC cases increased between 1999 and 2013. Nevertheless, the agestandardizedincidence rate decreased by 0.5% per year in men (p < 0.01), whereas theincidence rate in women did not change significantly over the same period (APC, –0.2;p=0.59). The most common histologic type was adenocarcinoma in both sexes. Based onthe SEER stage, the distant stage was the most frequent stage (41%), followed by theregional stage (37%). Ulsan (4.31/100,000 for men and 4.09/100,000 forwomen in 2009-2013) and Gyeongsangnam-do (4.15/100,000 for men and 3.54/100,000 for women)showed the highest GBC incidence, whereas the lowest incidence was observed in Seouland Gyeonggi-do. There were no significant sex differences in the incidence of GBC (femaleto-maleincidence rate ratio, 0.96).

Conclusion

The overall incidence of GBC in Korea did not change significantly over the 15-year period.Incidence for men and women was similar. However, geographical variation was found.

Predictors of incidental gallbladder cancer in elderly patients

BACKGROUND

At the time of diagnosis, most patients with gallbladder cancer are in advanced stage and the cancer is unresectable. Long-term survivors are usually seen in a small number of patients with incidental gallbladder cancer. This study aimed to identify preoperative predictors of incidental gallbladder cancer in elderly patients.

METHODS

A total of 4014 patients of more than 44 years old who had undergone cholecystectomy at our department from January 2000 to December 2010 were retrospectively reviewed. Univariate and multivariate modalities were used to identify the predictive factors of incidental gallbladder cancer.

RESULTS

Twenty-nine of the 4014 patients who had undergone cholecystectomy for benign gallbladder diseases were histologically diagnosed as having incidental gallbladder cancer. Multivariate analysis identified that elevated carbohydrate antigen 19-9 combined with carcinoembryonic antigen and/or carbohydrate antigen 125 (P=0.045), a gallbladder polyp greater than or equal to 1.2 cm (P=0.043) and focal gallbladder wall thickening of more than or equal to 5 mm (P=0.002) were predictive factors of incidental gallbladder cancer.

CONCLUSION

Cholecystectomy is suggested for patients with these predictive factors and intraoperative frozen section should be considered to rule out carcinoma.

Incidental detection of carcinoma gall bladder in laparoscopic cholecystectomy specimens: a thirteen year study of 23 cases and literature review

Carcinoma of gall bladder is the most common malignancy of the biliary tract worldwide and is usually associated with poor prognosis. In this era of laparoscopic cholecystectomy, there has been increase in detection of early stage incidental gall bladder carcinoma in cholecystectomy specimens. A retrospective study was carried out in tertiary care hospital in central India. A total of 2990 patients underwent laparoscopic cholecystectomy during the year 2001-2013. Hospital records and histopathology reports of these patients were studied in detail. Twenty three cases of gall bladder carcinoma were detected incidentally accounting for an incidence of 0.76 %. It was more common in females with an M: F ratio of 1:1.9. Mean age of presentation was 57.8 years. Gall stones were present in 22 cases and one patient presented with features of acute cholecystitis. Three patients had associated xanthogranulomatous inflammation and 10 had associated intestinal metaplasia. It is not uncommon to encounter incidental malignancies of gall bladder in laparoscopic cholecystectomy specimens sent to histopathology for presumably benign disease. Histopathology reports must include comments on extent of infiltration, perineural invasion, tumor differentiation and nodal involvement for oncologist information and subsequent management of patients.