Simultaneous gallbladder and bile duct cancers: revisiting the pathological possibilities

Intraductal Implantation of Biliary Neoplasms: A Potential Cause of "Multifocal" Tumors

Multiple biliary tumors rarely develop in patients without underlying chronic hepatobiliary disease. Those lesions are regarded as multifocal neoplasms if there is no interconnecting dysplasia. This study aimed to determine whether 2 separate tumors in the biliary tract represent true multifocal independent tumorigenesis or intraluminal implantation of a single neoplasm. Two separate biliary tumors without intervening dysplasia were identified in 9 cases: biliary intraductal papillary neoplasm (IPNB; n=5) and extrahepatic cholangiocarcinoma (n=4). The 2 tumors were histologically similar in all cases. In 5 metachronous cases, the second tumor developed 2 to 13 years after the complete resection of the first tumor. In 4 synchronous cases, 2 separate neoplasms were identified in a surgical specimen. The metachronous presentation was more common in IPNB cases, whereas the synchronous development was more frequent in cholangiocarcinoma cases. The second tumors in 4 metachronous cases (4/5; 80%) and smaller lesions in all synchronous cases (4/4; 100%) were located in a lower part of the biliary. Immunophenotypes of cytokeratins and mucin core proteins were almost identical between the 2 lesions. Next-generation sequencing also confirmed that the 2 neoplasms shared gene mutations involving KRAS, GNAS, APC, BRAF, CTNNB1, SMAD4, TP53, or ARID1A in all cases. In conclusion, multiple biliary tumors without underlying chronic biliary disease are most likely due to intraductal implantation of a single neoplasm. Thick mucinous bile in IPNB and increasing use of trans-ampullary biliary interventions may contribute to this unique form of tumor extension.

Double trouble: synchronous extrahepatic cholangiocarcinoma and gallbladder cancer in a Caucasian woman with no pancreaticobiliary maljunction

Synchronous malignancies of the bile duct and the gallbladder are rare. These cases are often associated with pancreaticobiliary maljunction which is characterized by a long common shared pancreatobiliary channel leading to the Sphincter of Oddi. This predisposes the biliary epithelium to pancreatic enzyme reflux and makes the development of neoplasia more likely. We describe the case of a 64-year-old Caucasian female who presented with new jaundice and severe cholecystitis secondary to an impacted gallstone which was seen on ultrasound. Magnetic resonance cholangiopancreatography was organized with suspicion of a possible Mirizzi syndrome. This revealed a mid-distal bile duct cancer in addition to cholecystitis from an impacted gallstone. She was treated with intravenous antibiotics for her cholecystitis and underwent an urgent endoscopic retrograde cholangiopancreatography procedure for biliary decompression and stenting for her obstructive jaundice. The patient proceeded to pancreaticoduodenectomy with final histopathology revealing a synchronous primary gallbladder malignancy in addition to the known bile duct cancer.

Triple cancer of gallbladder, common bile duct and papilla of Vater: Report of a case and review of literature

INTRODUCTION AND IMPORTANCE

Synchronous malignancies of gallbladder and biliary tree are together rare entity whose pathogenesis is yet unknown. We report the case of a triple synchronous cancer of 3 distinct location: gallbladder, common bile duct (CBD) and papilla of Vater.

CASE PRESENTATION

An 84-years-old woman, was admitted to our Hospital with clinics features of obstructive jaundice. Dilatation of the biliary tree and CBD without evidence of gallstones was seen at US. CT scan confirmed distal CBD obstruction. An endo-US showed a nodule of the head of pancreas infiltrating the lower CBD. Finally, hepatic-MRI displayed a gallbladder malignancy with invasion of CBD. Preoperative staging showed 3 diagnostic suspicions: carcinoma of CBD on CT, pancreatic carcinoma on endo-US and malignancy of gallbladder on MRI. A cephalic duodenopancreatectomy and radical gallbladder resection was performed. Final pathology revealed 3 distinct location of moderately differentiated adenocarcinomas: Gallbladder, CBD and Vater's papilla. Microscopic examination didn't detect any direct continuity between the 3 tumors. Metastases were identified in the pancreaticoduodenal, peri-hepatic and peri-gastric lymph nodes.

CLINICAL DISCUSSION

Literature displayed 22 cases of synchronous malignancies of gallbladder and CBD and 1 case of triple cancer with associated Vater's papilla carcinoma. In most of these cases, an association with an anomalous pancreatic-bile duct junction was reported. Although the real incidence remain unknown, it was reported to occur in 5-10% of CBD cancers.

CONCLUSION

Suspicion of such combination of cancer should be remembered, especially when preoperative investigations don't allow a precise localization of tumor in the biliary tree.

Anomalous Pancreaticobiliary Duct Junction in an Unusual Case of Synchronous Gallbladder and Bile Duct Malignancy

Synchronous malignancies involving the gallbladder and the bile duct are exceedingly rare. Moreover, their association with anomalous pancreaticobiliary duct junction (APBDJ) has been reported mostly from the Far Eastern countries. Over time, many studies have suggested the definite risk of malignancy attributable to the ‘carcinogenic anatomical configuration’ of the long common biliopancreatic channel, allowing reflux of pancreatic juices in the biliary tract. In this report, we present a case of an elderly man from South India who was initially diagnosed with synchronous gall bladder with bile duct malignancy; the patient turned out to have an APBDJ on further evaluation.

Genetic Tracing of Clonal Expansion and Progression of Pancreatic Ductal Adenocarcinoma: A Case Report and Multi-Region Sequencing Analysis

Pancreatobiliary tumors frequently contain multiple malignant and precancerous lesions; however, the origin of the driver mutations and the mechanisms that underlie the generation of distinct clones within an organ field remain unclear. Herein, we describe a 76-year-old male suffering from moderately differentiated adenocarcinomas of the pancreas that primarily involved the distal bile duct and multiple “dispersing” invasive lesions in the pancreatic head. The patient underwent pylorus-preserving pancreaticoduodenectomy with superior mesenteric vein resection, and targeted sequencing of 18 genes associated with pancreatic tumorigenesis and immunohistochemical analysis of RNF43 and ARID1A were performed on each tumor compartment, including the invasive and non-invasive areas. Multi-region sequencing revealed shared KRAS and TGFBR1 mutations in all invasive foci, including those involving the distal bile duct. Distinct KRAS variants were found to be present in other non-continuous and non-invasive lesions in the pancreas. Intraductal lesions with KRAS G12D and RNF43 V50R mutations were evident in the main pancreatic duct. This appeared to be a founder clone, given that the mutation profile was common to the invasive foci as well as the additional high-grade dysplasia harboring ARID1A mutations, thereby suggesting a clonal branch-off during tumor evolution. In addition, we also observed independent intraductal papillary mucinous neoplasms with KRAS G12V and GNAS R201H mutations. Our theory, learned from this patient, was that lesions skipped dissemination and wide-spread movement potentially through the pancreatic ductal system as a process of pancreatic cancer development.

Utility of multiple endoscopic techniques in differential diagnosis of gallbladder adenomyomatosis from gallbladder malignancy with bile duct invasion: A case report

BACKGROUND

Gallbladder adenomyomatosis (GAM) is a benign lesion, characterized by thickening of the gallbladder wall and a focal mass, which overlap with the features of gallbladder malignancy. Consequently, differential diagnosis of GAM from gallbladder cancer is difficult and approximately 20% of suspected malignant biliary strictures are postoperatively confirmed as benign lesions. Herein, we report a case in which a preoperative diagnosis of GAM was made by a combination of endoscopic and imaging techniques.

CASE SUMMARY

A 40-year-old man was referred to our hospital chiefly for a fever and right upper abdominal pain with dark urine. Enhanced computed tomography showed thickening of the gallbladder wall and a mass in the gallbladder neck with involvement of the hepatic bile ducts, which was suspected to be malignant. Gallbladder malignancy with bile duct invasion was ruled out by subsequent endoscopic examinations, including endoscopic retrograde cholangio-pancreatography, intraductal ultrasound, and SpyGlass. Endoscopic examinations showed a homogeneous hyperechoic lesion with smooth margins of benign bile duct stricture suggestive of inflammatory stenosis of the bile duct. The patient underwent laparoscopic cholecystectomy. GAM was postoperatively diagnosed and confirmed based on the histopathology results, which are consistent with the preoperative diagnosis. Notably, no malignant event occurred in the patient during a 12-mo follow-up period.

CONCLUSION

A combination of endoscopic techniques may help in the differential diagnosis of GAM from gallbladder cancer.

Gallbladder cancer: a journey of a thousand steps

This article traces the journey of one of the teams from India that has been actively managing and researching gallbladder cancer for more than a decade, providing insights into the work carried out and highlighting areas that warrant future research in this cancer traditionally known for its dismal outcomes.

Synchronous gallbladder squamous cell carcinoma and adenocarcinoma, both as primary tumors in one patient

INTRODUCTION

Synchronous primary carcinomas of gallbladder are extremely rare. In this paper, we report a case of double primary carcinomas in gallbladder CASE REPORT: A 65 year old male was admitted to the hospital for surgical removal of gallbladder, which was diagnosed as cholecystitis in ultrasonography. Macroscopic examination disclosed a single whitish mass in gallbladder neck and another distinct mass in the fundus as wall thickening. Pathologic findings revealed squamous cell carcinoma of the neck and adenocarcinoma in the fundus.

DISCUSSION

This study represents an example of misdiagnosis. Being cautious is mandatory in order to manage the patient properly.

CONCLUSION

Synchronous primary carcinomas of gallbladder are rare. However this diagnosis should be taken into account in patients with cholecystitis features in order to seeking for the best surgical approach.

Synchronous Gall Bladder and Bile Duct Cancer: A Short Series of Seven Cases and a Brief Review of Literature

BACKGROUND

Simultaneous presence of cancer in the gall bladder and in the biliary tree could be due to local spread, metastases, de novo multifocal origin, or as part of a field change. In the past, such an association has been described in patients with anomalous pancreatico-biliary ductal junction.

AIMS

We studied seven consecutive patients with simultaneous gall bladder and bile duct malignancy with a view to identify the best way to treat them, and if possible to hypothesize the etiopathogenesis.

METHODS

Over a period of 24 months, there were seven cases, with synchronous gall bladder and extra-hepatic bile duct cancer.

RESULTS

None of our patients had anomalous pancreatico-biliary ductal junction. Three patients were found to have inoperable disease, three other underwent curative resection, and one patient had a complete response to chemotherapy. Herein, we describe these patients and our lessons learnt from these patients with synchronous bile duct and gall bladder cancer. Of the seven patients, we were able to complete a curative resection in three patients, and the three patients were found to have inoperable disease. One patient had an excellent response to chemotherapy.

CONCLUSION

Thus aggressive therapy in such patients with gall bladder cancer may be warranted in select cases. Also, the gall bladder specimens in patients undergoing surgery for cholangiocarcinoma should be analyzed in detail to identify foci of dysplasia or change in the epithelium. The pathogenesis may be due to a common field change in the biliary epithelium.

Synchronous malignancies of the gall bladder and common bile duct: a case report

BACKGROUND

Synchronous malignancies of the gall bladder and common bile duct are a rare entity. Much of our knowledge on this topic comes from Japanese literature. Most of the synchronous carcinomas described in Japanese literature are associated with the presence of an anomalous pancreatic-bile duct junction (APBDJ).

CASE PRESENTATION

We report a case of synchronous malignancy of the extrahepatic biliary tree involving the fundus of the gall bladder and the intrapancreatic portion of the common bile duct (CBD). A 50-year-old female patient presented to us with clinical features of obstructive jaundice and on radiological evaluation was diagnosed to have a periampullary carcinoma; the patient underwent a pancreaticoduodenectomy, and histopathological examination revealed adenocarcinoma of the gall bladder and the intrapancreatic portion of the CBD.

CONCLUSIONS

Synchronous malignancies have been rarely reported from the Indian subcontinent; therefore, it is essential for the clinician as well as the pathologist to maintain a high index of suspicion while evaluating such lesions and to look for the presence of an anamolous pancreatic-bile duct junction whenever indicated.

Gallbladder carcinoma: causes of misdiagnosis at CT

Gallbladder carcinomas can present with varied imaging features on computed tomography. The three major imaging features include (1) focal or diffuse wall thickening with or without irregularity of the gallbladder; (2) polypoidal intraluminal mass; and (3) large mass obscuring and replacing the gallbladder, often extending to the liver. Patterns of wall thickening or polypoid growth are often confused with various benign gallbladder diseases due to overlap of imaging findings. Moreover, gallbladder carcinomas that coexist with benign gallbladder diseases make accurate preoperative diagnosis more difficult. Recently, high-resolution ultrasound (HRUS) has been regarded as a problem-solving tool for gallbladder diseases. In this article, we will illustrate various imaging presentations of gallbladder cancer, along with imaging pitfalls and recently updated HRUS findings.

A genetic model for gallbladder carcinogenesis and its dissemination

Gallbladder cancer, although regarded as the most common malignancy of the biliary tract, continues to be associated with a dismal overall survival even in the present day. While complete surgical removal of the tumour offers a good chance of cure, only a fraction of the patients are amenable to curative surgery owing to their delayed presentation. Moreover, the current contribution of adjuvant therapies towards prolonging survival is marginal, at best. Thus, understanding the biology of the disease will not only enable a better appreciation of the pathways of progression but also facilitate the development of an accurate genetic model for gallbladder carcinogenesis and dissemination. This review provides an updated, evidence-based model of the pathways of carcinogenesis in gallbladder cancer and its dissemination. The model proposed could serve as the scaffolding for elucidation of the molecular mechanisms involved in gallbladder carcinogenesis. A better understanding of the pathways involved in gallbladder tumorigenesis will serve to identify patients at risk for the cancer (and who thus could be offered prophylactic cholecystectomy) as well as aid oncologists in planning the most suitable treatment for a particular patient, thereby setting us on the vanguard of transforming the current treatment paradigm for gallbladder cancer.

Extent of resection for T2N0 gallbladder carcinoma regarding concurrent extrahepatic bile duct resection

Backgrounds/Aims

Gallbladder carcinoma (GBCa) T2 lesions are considered to be advanced tumors showing diverse features in tumor extent. When this T2 lesion does not involve the cystic duct and there is no evidence of lymph node metastasis, we have to consider what is the most reasonable extent of resection - that is, whether to perform concurrent extra-hepatic bile duct resection (EHBD) resection or not. This study intends to evaluate the adequacy of EHBD resection in patients undergoing resection for T2N0 GBCa.

Methods

From our institutional database of GBCa, 48 cases of T2N0 GBCa who underwent R0 resection during November 1995 and August 2008 were selected. Patients who underwent prior laparoscopic cholecystectomy were excluded. Their medical records were reviewed retrospectively.

Results

Their mean age was 63.2±83.3 years and females were 25. The mean serum CA19-9 level was 37.3±89.3 ng/ml. The extents of liver resection were wedge resection (n=36) and segment 4a+5 resection (n=12). Concurrent EHBD resection was performed in 16 (33.3%) patients. No fatal surgical complication occurred. The majority of tumor pathology was adenocarcinoma (n=42), with additional unusual types as papillary (n=3), saromatoid (n=1), signet ring cell (n=1) and adenosquamous (n=1) cancers. The overall survival rate was 87.1% at 1 year, 69.5% at 3 years and 61.7% at 5 years. After exclusion of mortalities not related to cancer, the overall patient survival rate was 89.6% at 1 year, 72.9% at 3 years and 64.7% at 5 years, with 3-year survival rates of 72% in the EHBD resection group and 69.2% in the non-resection group (p=0.661).

Conclusions

The results of this study indicate that concurrent EHBD resection did not improve patient survival when R0 resection was achieved in patients with T2N0 GBCa. Therefore, routine EHBD resection may not be indicated for T2N0 GBCa unless the tumor is close to the cystic duct.

Systematic review: should routine resection of the extra-hepatic bile duct be performed in gallbladder cancer?

BACKGROUND/AIM

Complete surgical resection is associated with improved outcomes in gallbladder cancer. Whether the extra-hepatic bile duct (EHBD) should be routinely excised for gallbladder cancer is unclear.

OBJECTIVE

To analyze literature concerning EHBD excision to determine if it is associated with survival advantage and hence can be routinely recommended.

MATERIALS AND METHODS

A systematic search using Medline, Embase, and Cochrane Central Register of Controlled Trials for the years 1988-2008.

RESULTS

EHBD excision was reported to be performed routinely for T1-4 in some studies, while others reported resection to facilitate lymph node clearance or if the EHBD was grossly involved by disease that remained otherwise resectable. While one study demonstrated 100% survival in T1 disease, other reports do not demonstrate any survival benefit of EHBD excision in T1 disease. Four studies (level IV-V) demonstrated 60% to 90% five-year survival for routine excision in T2 disease, while three other studies demonstrated no survival advantage but increased morbidity due to the procedure. In T3/4 disease, one study (level IV-V) demonstrated a benefit in T4 disease only, and another study (level IV-V) reported a survival advantage in patients in whom the bile duct was not involved; five other studies showed no impact of routine EHBD excision on survival but reported morbidity following anastomotic leaks.

CONCLUSIONS

Available evidence does not support routine resection of EHBD in gallbladder cancer. EHBD excision should be performed in the presence of specific indications, viz., to achieve an R0 resection of the primary tumor and/ or to aid complete lymph node dissection that would compromise the EHBD by devascularization.