Clinicopathological features of gallbladder papillary adenocarcinoma

Development and validation of a prognostic nomogram for gallbladder papillary adenocarcinoma

Background

Gallbladder papillary adenocarcinoma (GBPA) is an uncharacteristically gallbladder cancer subtype. Although some studies have shown that the prognosis of GBPA patients is significantly better than that of gallbladder adenocarcinoma (GBA) and gallbladder mucinous adenocarcinoma (GBMA) due to its rarity, there is a lack of large sample studies necessary to confirm the clinical characteristics and survival rate of GBPA. Therefore, this study aimed to describe the clinicopathological characteristics affecting survival in GBPA. This data was then used to establish a prognostic nomogram for GBPA.

Methods

The data of patients diagnosed with gallbladder cancer between 2004 to 2015 were extracted from the Surveillance, Epidemiology, and End Results (SEER) database. The clinical features and survival of patients with GBPA were compared with those of GBA and GBMA after balancing the baseline characteristics using propensity score matching (PSM). Univariate and multivariate Cox analyses were used to identify the prognostic factors for GBPA. Subsequently, the overall survival (OS) and cancer-specific survival (CSS) nomograms were established to predict GBPA prognosis. The performance and discrimination of the nomogram were measured using concordance index (C-index), calibration curves, receptor operating characteristic curves(ROC), and decision curve analysis (DCA) was applied to examine the net benefit of tients with GBPA, 5798 patients with GBA, and 223 patients with GBMA. The mean 1-, 3- and 5-year OS rates for GBPA were 81.3%, 58.8%, and 49.1%, respectively, while the mean 1-, 3- and 5-year CSS rates were 85.0%, 68.1%, and 61.0%, respectively. The median OS rates was 58 months (95% CI: 43-88), while the median CSS was not reached. The PSM analysis showed a differ statistically significantly in the OS between GBPA and GBA. However, there has no statistically difference in CSS. Conversely, the OS and CSS between GBPA and GBMA have statistically significant differences. Age, marital, T stage, and M stage were strongly linked to the prognosis for OS, while T-stage, M-stage, and surgery were significantly associated with the prognosis for CSS in GBPA patients. The AUC for the 1-, 3-, and 5-year OS were 0.722 (95%CI: 0.630-0.813), 0.728 (95%CI: 0.665-0.790), and 0.706 (95%CI: 0.641-0.771), respectively. The AUC for the 1-, 3-, and 5-year CSS were 0.749 (95%CI: 0.659-0.840), 0.698 (95%CI: 0.627-0.770), and 0.665 (95%CI: 0.594-0.735), respectively. The C-indices for the OS and CSS nomograms were 0.701 (95% CI: 0.634-0.744) and 0.651 (95% CI: 0.598-0.703), respectively. The calibration curves showed that the nomograms were well consistency. The DCA showed that compared with the TNM system, the nomogram models had a significant positive net benefit in survival prediction.

Conclusion

GBPA has distinct clinicopathological characteristics and survival compared to other gallbladder carcinomas. The established nomogram provided a better prediction of survival for GBPA patients than the traditional TNM models.

Intraepithelial involvement of non-neoplastic glands in papillary preinvasive neoplasms of the biliary tract: a potential diagnostic pitfall

Intracholecystic papillary neoplasms of the gallbladder (ICPN) and intraductal papillary neoplasms of the bile duct (IPNB) show intramural neoplastic growths in addition to intraluminal papillary or polypoid neoplastic growth. Such intramural growths include intraepithelial involvement of non-neoplastic glands by preinvasive neoplastic epithelia (glandular involvement) as well as stromal invasive carcinoma. A total of 29 ICPN cases and 84 IPNB cases were pathologically examined for their glandular involvement. Glandular involvement was characterized by intramural neoplastic glands (1) showing cytological and phenotypical similarities to intraluminal preinvasive papillary neoplasms and (2) showing reminiscent configurations of non-neoplastic glands, such as (i) a mixture of preinvasive neoplastic epithelia and non-neoplastic epithelia within the same glands, (ii) neoplastic glands close to or within clustered non-neoplastic glands, or (iii) continuous growth of intraluminal preinvasive neoplastic glands into the walls. Such glandular involvement was found in 16 of 29 ICPN and 48 of 84 IPNB, and 15 of the former and 28 of the latter were not associated with invasive carcinoma. Non-invasive ICPN and IPNB with glandular involvement showed a favorable postoperative overall survival (OS). Glandular involvement by preinvasive neoplastic epithelia was frequently found in ICPN and IPNB. Such lesions may be diagnostic pitfalls in ICPN and IPNB referring to invasion. Glandular involvement without invasive carcinoma was not associated with an unfavorable postoperative OS in ICPN and IPNB. Recognition of glandular involvement may thus prevent overestimation of invasive carcinoma in ICPN and IPNB.

Polypoid invasive carcinoma of the gallbladder-Another challenging polypoid neoplasm

BACKGROUND

Invasive gallbladder carcinoma generally presents as nodular-sclerosing growth. Recently, "polypoid invasive carcinoma (PICA)" showing grossly visible polypoid neoplasm and histologically invasive carcinoma with no adenomatous components was proposed as a neoplastic polyp of the gallbladder.

METHODS

We herein report five cases of PICA collected from 49 cases of invasive gallbladder carcinoma in comparison with another polypoid preinvasive neoplasm of gallbladder, intracholecystic papillary neoplasm (ICPN).

RESULTS

Polypoid invasive carcinomas were composed of four males and one female with an average age of 74 years. Polypoid lesions were sessile (height ranging from 6 to 10 mm and the largest diameter ranging from 12 to 40 mm), and histologically, polypoid neoplasms presented papillary configuration containing tubular and cribriform components with thin inflammatory, fibrotic stroma. Polypoid carcinoma invaded directly and continuously into the gallbladder wall with destruction of the muscle layer. These patterns of PICA were different from ICPN, showing papillary patterns containing tubular components with fine fibrovascular stalks and with occasional focal stromal invasion but with preserved muscle layer. Post-operative outcome was not favorable in PICA but was favorable in ICPN.

CONCLUSIONS

Polypoid invasive carcinoma shared several pathological features with ICPN, such as intraluminal polypoid pattern with papillary configurations, but PICAs were invasive adenocarcinoma with destruction of muscle layer while ICPNs were preinvasive neoplasm with occasional focal stromal invasion, thus both should be differentiated from each other.

Characterization of high-grade biliary intraepithelial neoplasm of the gallbladder in comparison with intracholecystic papillary neoplasm

Biliary intraepithelial neoplasm (BilIN) is characterized by a microscopically identifiable preinvasive neoplasm of the biliary tract. In this study, the high-grade BilIN of gallbladder was examined pathologically and compared with the intracholecystic papillary neoplasm (ICPN) of gallbladder. Sixteen high-grade BilINs (height <0.5 cm) collected from 2297 cholecystectomies (0.7%) and another three cases (19 cases total) were examined and compared with 34 cases of ICPN (greatest diameter ≥1 cm and height ≥0.5 cm). High-grade BilINs were incidentally found in 11 cholecystectomies, and the remaining eight were cholecystectomized in cases with a preoperative diagnosis of carcinoma. The largest diameter ranged from 0.5 to 6 cm. While 13 cases were recognized grossly as clustered granular and rough mucosa, the remaining were almost unrecognizable. Histologically, the high-grade BilINs showed intraepithelial neoplastic growth. Furthermore, they frequently showed intraepithelial replacement growth to non-neoplastic glands and cystic lesions in the gallbladder. The lesions presented with flat, wave or fold-like patterns, including tubular components. Short papillary components were also found in 13 cases. Gastric and biliary subtypes were frequent. Several foci of stromal invasion were found in the short papillary components in three cases. The lower polypoid or granular parts of conglomerated ICPNs showed intraepithelial neoplastic lesions sharing many features with high-grade BilINs with short papillary components. In conclusion, high-grade BilINs showed intraepithelial growth of neoplastic epithelia involving the mucosa. A morphologic continuum was noted between high-grade BilINs with short papillary components and conglomerated ICPNs, suggesting that conglomerated ICPNs may arise from high-grade BilINs with short papillary components.

Port-site metastasis of unsuspected gallbladder carcinoma with ossification after laparoscopic cholecystectomy: A case report

BACKGROUND

Unsuspected gallbladder carcinoma (UGC) refers to cholecystectomy due to benign gallbladder disease, which is pathologically confirmed as gallbladder cancer during or after surgery. Port-site metastasis (PSM) of UGC following laparoscopic cholecystectomy is rare, especially after several years.

CASE SUMMARY

A 55-year-old man presenting with acute cholecystitis and gallstones was treated by laparoscopic cholecystectomy in July 2008. Histological analysis revealed unexpected papillary adenocarcinoma of the gallbladder with gallstones, which indicated that the tumor had spread to the muscular space (pT1b). Radical resection of gallbladder carcinoma was performed 10 d later. In January 2018, the patient was admitted to our hospital for a mass in the upper abdominal wall after surgery for gallbladder cancer 10 years ago. Laparoscopic exploration and complete resection of the abdominal wall tumor were successfully performed. Pathological diagnosis showed metastatic or invasive, moderately differentiated adenocarcinoma in fibrous tissue with massive ossification. Immuno-histochemistry and medical history were consistent with invasion or metastasis of gallbladder carcinoma. His general condition was well at follow-up of 31 mo. No recurrence was found by ultrasound and epigastric enhanced computed tomography.

CONCLUSION

PSM of gallbladder cancer is often accompanied by peritoneal metastasis, which indicates poor prognosis. Once PSM occurs after surgery, laparoscopic exploration is recommended to rule out abdominal metastasis to avoid unnecessary surgery.

Clinicopathological features and survival outcomes of rare histologic variants of gallbladder cancer

BACKGROUND

Adenocarcinoma (AC) is the most common histological type in gallbladder carcinoma (GBC). Squamous cell carcinoma (SCC), adenosquamous carcinoma (ASC), and papillary carcinoma (PC) are rare histologic variants of GBC.

METHODS

Patients with AC, SCC, ASC, and PC of the gallbladder between 2004 and 2013 were identified from the National Cancer Database. Univariate and multivariate analyses were performed, and Kaplan-Meier curves were used to compare overall survival (OS) based on histological subtype.

RESULTS

A total of 5956 patients ≥18 years of age were included in the final analysis. Most patients (n = 5398; 90.6%) had AC compared with variant histologies. PC (n = 227; 3.8%) was the most common variant, followed by ASC (n = 216; 3.6%) and SCC (n = 115; 1.9%); 70.3% were female and 78.9% Caucasian. The median age was 70 (range, 25-90) years. Surgical resection was performed in 77.7% of AC, 53.0% of SCC, 88.9% of ASC, and 96.9% of PC (P < .001). Systemic therapy after surgery was administered in 25.1% of AC, 18.3% of SCC, 35.7% of ASC, and 19.4% of PC (P = .001). In multivariate analysis, multiagent chemotherapy was associated with improved OS in all histologies except for SCC and PC (p < .001), and adjuvant systemic therapy was associated with improved OS in ASC and AC (P < .001).

CONCLUSION

Survival differs between the gallbladder variants. Except for SCC, GBC variants underwent surgical resection more often than AC. Adjuvant systemic therapy was associated with improved OS in ASC and AC.

A Case of Acute Pancreatitis Associated with Early-Stage Adenocarcinoma of the Gallbladder

Patient: Female, 55

Final Diagnosis: Gallbladder adenocarcinoma

Symptoms: Abdominal pain

Medication: —

Clinical Procedure: Cholecystectomy • pancreatic necrosectomy

Specialty: Surgery

Clinicopathological characteristics and outcomes of rare histologic subtypes of gallbladder cancer over two decades: A population-based study

Background

There is limited literature about the clinicopathological characteristics and outcomes of rare histologic variants of gallbladder cancer (GBC).

Methods

Using SEER database, surgically managed GBC patients with microscopically confirmed adenocarcinoma, adenosquamous/squamous cell carcinoma and papillary carcinoma were identified from 1988 to 2009. Patients with second primary cancer and distant metastasis at presentation were excluded. The effect of clinicopathological variables on overall survival (OS) and disease specific survival (DSS) were analyzed using univariate and multivariate proportional hazards modeling. All associations were considered statistically significant at an alpha error of 0.01.

Results

Out of 4738 cases, 217 adenosquamous/squamous (4.6%), 367 papillary (7.7%), and 4154 adenocarcinomas (87.7%) were identified. Median age was 72 years. Higher tumor grade (grade 2, 3, 4 versus grade 1), higher T stage (T2, T3, T4 versus T1), lymph node positivity (N1 versus N0) and adenosquamous/squamous histology (versus adenocarcinoma) had worse OS and DSS (p < .001). Papillary GBC had better OS and DSS than adenocarcinoma (HR = 0.7; p < .001). Radical surgery (versus simple cholecystectomy) had better OS (HR = 0.83, p = 0.002) in multivariate analysis. OS rates at 3 and 5 years were 0.56 and 0.44 for papillary, 0.3 and 0.22 for adenocarcinoma, and 0.14 and 0.12 for adenosquamous/squamous histology, while DSS rates at 3 and 5 years were 0.67 and 0.61 for papillary, 0.38 and 0.31 for adenocarcinoma, and 0.17 and 0.16 for adenosquamous/squamous subtypes respectively.

Conclusion

Papillary GBC had better survival outcomes while adenosquamous/squamous GBC had worse survival outcomes compared to gallbladder adenocarcinoma.

Gallbladder papillary neoplasms share pathological features with intraductal papillary neoplasm of the bile duct

Intraductal papillary neoplasm of the bile duct (IPNB) has been widely recognized. However, the knowledge of intracystic papillary neoplasm of the gallbladder (IPNG) including papillary adenoma and adenocarcinoma is not well defined. In this study, we compared the clinicopathological and immunohistochemical features between 32 IPNG cases and 32 IPNB cases. IPNG-1 (low-high grade dysplasia) exhibited an earlier onset age, smaller tumor size and lower level of CK20 expression compared to IPNG-2 (invasive carcinoma). Histologically, pancreaticobiliary and intestinal subtype accounted for nearly half of IPNG or IPNB (44.4% and 48.1% vs. 44.0% and 44.0%), respectively. Immunohistochemically, 88.9% of IPNG and 92.0% of IPNB cases were positive for MUC1, and 96.3% and 92.0% for CK7, respectively. CDX2 and MUC2 were more highly expressed in the intestinal subtype than in other subtypes. CK20 expression increased in parallel with tumor progression. In addition, 53.1% of IPNG cases and 68.6% of IPNB cases exhibited invasive carcinoma, and showed significant survival advantages to conventional gallbladder adenocarcinoma and cholangiocarcinoma, respectively. In conclusion, papillary adenoma and adenocarcinoma of the gallbladder can be recognized as different pathological stages of IPNG, and they share pathological features with IPNB.

HDAC1 promoted migration and invasion binding with TCF12 by promoting EMT progress in gallbladder cancer

The identification of prognostic markers for gallbladder cancer is needed for clinical practice. Histone deacetylases (HDACs) play an important role in tumor development and progression by modifying histone and non-histone proteins. However, the expression of HDAC1 in patients with gallbladder cancer is still unknown. Here, we reported that HDAC1 expression was elevated in cancerous tissue and correlated with lymph node metastasis and poorer overall survival in patients with GBC. Knockdown of HDAC1 using lentivirus delivery of HDAC1-specific shRNA abrogated the migration and invasion of GBC cells in vitro. TCF-12, as the HDAC1 binding protein, has also correlates with poor prognosis in GBC patients. And there is a positive correlation between HDAC1 and TCF-12 which leading the high invasion and migration ability of GBC cells. Taken together, our data suggested that HDAC1 and TCF-12 are a potential prognostic maker and may be a molecular target for inhibiting invasion and metastasis in GBC.

Relationship between gallstones and local invasion of gallbladder carcinoma

AIM: To explore the relationship between the local invasion of gallbladder carcinoma and the features of gallstones, such as quantity and diameter.

METHODS: One hundred fifty patients with pathologically confirmed gallbladder carcinoma were analyzed. The relationship between gallstones and the Nevin stage of gallbladder carcinoma was analyzed.

RESULTS: Stages Ⅳ and Ⅴ gallbladder carcinoma was more commonly seen in patients with gallbladder stones (χ² = 6.15, P < 0.05), especially those with stones greater than 2 cm in diameter (χ² = 5.79, P < 0.05). However, the number of stones (single or multiple) showed no significant correlation with the Nevin stage of gallbladder carcinoma (χ² = 0.13, P > 0.05).

CONCLUSION: Gallbladder carcinoma patients with gallbladder stones, especially those greater than 2 cm in diameter, tend to have a more serious disease.