Pathology of the gallbladder: a concise review

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.

Do histopathologic findings improve by increasing the sample size in cholecystectomies?

BACKGROUND

Gallbladder diseases present with cholelithiasis in a wide spectrum of adenomas and cancers. Two or three specimens are sampled in cholecystectomies in routine pathology practice. The aim of this study was to investigate the increase in frequency of histologic alterations in cholecystectomies, particularly precancerous lesions, by increasing the sample size to understand the carcinoma pathway.

METHODS

Cholecystectomies of 432 patients with pathology records and materials from two medical centers were collected, and two groups were created. Initial data with two or three samples were allocated to Group 1 and the new six samples with the initial ones were allocated to Group 2. Hematoxylin and eosin (HandE) sections were examined for histopathologic alterations, and periodic acid-Schiff (PAS) Alcian blue (pH 2.5) and high iron diamine (pH 2.5) stains were used to signify the mucin profile in case of metaplasias. For the comparison of findings, non-parametric tests, McNemar's tests, chi-squared tests and Fisher's exact test were performed.

RESULTS

Of the 432 patients, 308 (71.3%) patients were female and 124 (28.7%) patients were male. The mean age of patients was 47.9±14.6 years. Cholesterolosis was observed in 95 (22%) patients in Group 1 and 108 (25%) patients in Group 2. Gallstones were detected in 255 (59%) of the cholecystectomies. There was a significant difference between Group 1 and Group 2 by increasing the sample size when we compared cholesterolosis, metaplasia and polyps (P<0.05). Cholecystitis and dysplasia rates were the same in both of the groups. There was no cancer determined.

CONCLUSION

Increasing the sample size in cholecystectomies increased the diagnosis of some histologic alterations, but further studies with a larger number of samples over a longer period time might increase the ability to determine precancerous lesions and concomitants.

Primary Sclerosing Cholangitis: Current and Future Management Strategies

Primary sclerosing cholangitis (PSC) is a chronic cholestatic liver disease. The etiology of this disorder is unknown and there are no effective medical therapies. PSC is associated with inflammatory bowel disease and an increased risk for hepatobiliary and colorectal malignancies. The aim of this review is to highlight the clinical features and diagnostic approach to patients with suspected PSC, characterize associated comorbidities, review screening strategies for PSC associated malignancies and review contemporary and future therapies.

Antilithiasic and hypolipidaemic effects of Raphanus sativus L. var. niger on mice fed with a lithogenic diet

In Mexico, Raphanus sativus L. var. niger (black radish) has uses for the treatment of gallstones and for decreasing lipids serum levels. We evaluate the effect of juice squeezed from black radish root in cholesterol gallstones and serum lipids of mice. The toxicity of juice was analyzed according to the OECD guidelines. We used female C57BL/6 mice fed with a lithogenic diet. We performed histopathological studies of gallbladder and liver, and measured concentrations of cholesterol, HDL cholesterol and triglycerides. The juice can be considered bioactive and non-toxic; the lithogenic diet significantly induced cholesterol gallstones; increased cholesterol and triglycerides levels, and decreased HDL levels; gallbladder wall thickness increased markedly, showing epithelial hyperplasia and increased liver weight. After treatment with juice for 6 days, cholesterol gallstones were eradicated significantly in the gallbladder of mice; cholesterol and triglycerides levels decreased too, and there was also an increase in levels of HDL (P < 0.05). Gallbladder tissue continued to show epithelial hyperplasia and granulocyte infiltration; liver tissue showed vacuolar degeneration. The juice of black radish root has properties for treatment of cholesterol gallstones and for decreasing serum lipids levels; therefore, we confirm in a preclinical study the utility that people give it in traditional medicine.

Likelihood of malignancy in gallbladder polyps and outcomes following cholecystectomy in primary sclerosing cholangitis

OBJECTIVES

Patients with primary sclerosing cholangitis (PSC) have an increased risk for gallbladder cancer. We aimed to define the postoperative outcomes in PSC patients after cholecystectomy and determine if size of a gallbladder lesion on imaging predicts the presence of neoplasia.

METHODS

We conducted a retrospective review of patients with PSC who underwent cholecystectomy at Mayo Clinic between 1 January 1995 and 31 December 2008. Patients with a prior history of a liver transplant or cholangiocarcinoma were excluded.

RESULTS

A total of 57 patients were included in our primary analysis during the early postoperative period. The most common indication for undergoing a cholecystectomy was the presence of a gallbladder polyp or mass. The sensitivity and specificity of a gallbladder lesion of 0.80 cm and the presence of gallbladder neoplasia was 100% (95% confidence interval (CI) 77-100%) and 70% (95% CI 35-93%), respectively. Of the patients, 23 (40%) had an early postoperative complication. The Child-Pugh score was the only predictor of postoperative outcomes in the multivariate model (odds ratio 1.78, 95% CI 1.11-3.12, P=0.02).

CONCLUSIONS

Cholecystectomy in patients with PSC is associated with a high morbidity. Gallbladder polyps <0.80 cm are unlikely to be malignant and observation of these small polyps should be considered. A higher Child-Pugh score was associated with early postoperative complications.

Prevalence and Risk Factors for Gallbladder Neoplasia in Patients With Primary Sclerosing Cholangitis: Evidence for a Metaplasia-Dysplasia-Carcinoma Sequence

Primary sclerosing cholangitis (PSC) carries an increased risk (10% to 20%) of hepatobiliary malignancy, especially cholangiocarcinoma (CC). Dysplasia, adenomas, and carcinomas of the gallbladder have been described in PSC but are less common than bile duct carcinomas. However, the prevalence and risk factors for gallbladder neoplasia among patients with PSC undergoing orthotopic liver transplantation (OLT) have not been well studied. We evaluated 72 gallbladders from 100 consecutive liver explants for PSC, including 66 cholecystectomies performed at the time of OLT and 6 performed before OLT. All specimens were totally embedded for histologic examination. We evaluated the following histologic features: presence of diffuse lymphoplasmacytic chronic cholecystitis, pyloric metaplasia, intestinal metaplasia, dysplasia (low-grade or high-grade), and adenocarcinoma. Gallbladder dysplasia and adenocarcinoma were correlated with several clinicopathologic parameters using Fisher exact test and t test, including: (1) sex, (2) age, (3) PSC duration, (4) inflammatory bowel disease (IBD) at time of OLT, and (5) concomitant bile duct dysplasia or carcinoma. Lymphoplasmacytic chronic cholecystitis was present in 35 (49%), pyloric metaplasia in 69 (96%), intestinal metaplasia in 36 (50%), dysplasia in 27 (37%; low-grade in 12 and high-grade in 15), and adenocarcinoma in 10 (14%; 2 with lamina propria invasion and 8 with invasion into muscularis or adventitia). Gallbladder carcinoma was associated with intrahepatic bile duct dysplasia (P=0.001), CC (P=0.023), and IBD (P=0.03). Gallbladder dysplasia was associated with hilar/intrahepatic bile duct dysplasia (P=0.0006), CC (P=0.028), IBD (P=0.0014), and older age at OLT (P=0.007). Neither gallbladder carcinoma nor dysplasia had a significant association with sex or PSC duration. These results indicate that complete histologic evaluation of gallbladders in patients undergoing transplantation for PSC yields high frequencies of inflammatory, metaplastic, and neoplastic changes. The strong correlation between gallbladder dysplasia/adenocarcinoma and bile duct dysplasia/CC supports the concept of a neoplastic "field effect" along the intrahepatic and extrahepatic biliary tract in PSC.