Is there any justification for the routine histological examination of straightforward cholecystectomy specimens?

Reconsidering Routine Histopathological Examination of Gallbladder Specimens in Cholecystectomy: Optimizing Clinical Practice and Resource Management

Introduction Cholecystectomy, the surgical removal of the gallbladder, is a common procedure worldwide. Despite no visible anomalies, routine histopathological examination (HPE) of gallbladder specimens post-surgery is standard practice to exclude pathologies, notably gallbladder cancer (GBC). Incidence rates of GBC vary geographically and ethnically. Surgical intervention is recommended for advanced GBC stages, while early stages may require cholecystectomy alone. Although rare, GBC and bile duct cancers pose increased risks in certain demographics, such as women and individuals over 65. Routine HPE practices vary globally based on resource availability and GBC incidence. This study assesses the necessity of routine HPE by evaluating the selective processing of gallbladder specimens suspected of GBC, prioritizing patient safety. Materials and methods This retrospective cohort study conducted at Redland Hospital, a district general hospital in Australia, investigated the necessity of routine HPE for excised gallbladder specimens. Adhering to routine HPE policy, the study encompassed all elective and emergency cholecystectomies performed from January 2023 to December 2023, excluding pediatric cases, concurrent surgical procedures, and those with suspected malignancy. Demographic data, surgery indications, intraoperative findings, histopathological results, and incidental gallbladder cancer (IGC) outcomes were analyzed. Pathology reports and case documentation were reviewed for cancerous pathology indicators. Results Over the one-year study period from January 2023 to December 2023, a total of 266 gallbladder specimens were subjected to HPE post-cholecystectomy. Of these, 201 were female and 65 were male, yielding a male-to-female ratio of 3:1. Elective cholecystectomy was performed on 56.4% (150) of patients, while 43.6% (116) underwent emergency procedures. Laparoscopic cholecystectomy (LC) was the primary surgical approach, except for one case requiring conversion to an open procedure. None of the patients exhibited GBC; however, 3.3% (9) displayed premalignant histopathological features in their specimens. Conclusion In conclusion, adopting a selective approach, where only gallbladder specimens with macroscopic abnormalities undergo HPE, seems prudent, especially in regions with low GBC incidence. Our study, which revealed no cases of GBC, supports this approach. It not only reduces the risk of missing incidental carcinoma in clinically unsuspected cases but also proves cost-effective and reduces the histopathology department workload without compromising patient outcomes. Therefore, we advocate for routine macroscopic examination of gallbladder specimens for abnormalities before HPE submission, particularly in cholecystectomy patients with gallstone disease.

Misdiagnosis of carcinoma gall bladder in endemic regions

Background

Incidental carcinoma gall bladder and benign disease in radical cholecystectomy specimen is the cause of concern. We attempted to find out the incidence and reasons thereof in the present study.

Methods

Present study is a retrospective analysis of a prospectively maintained database between July 2002 and July 2019. All patients with a diagnosis of carcinoma gall bladder admitted for surgery were included.

Results

Out of 148 patients, 110 patients had carcinoma gall bladder (CAGB), while 38 patients (25.7%) had incidental carcinoma (under-diagnosis). Radical resection was done in 61/110 (55.4%) patients with clinical CAGB, where 15 (24.6%) patients had benign pathology (“over-diagnosis”). Overdiagnosis was due to xanthogranulomatous cholecystitis (n = 9), chronic cholecystitis (n = 2), tuberculosis (n = 2) and IgG4 related cholecystitis (n = 2). Among 61 patients, a history of weight loss and anorexia were significantly associated with malignancy. Asymmetrical wall thickness was significantly more common in benign mimickers.

Among patients with incidental carcinoma, preoperative ultrasonography reported normal wall thickness of gall bladder in 28 (73.7%), thickened gall bladder wall in 6, and polyp in 3 patients. The resectability rate among incidental carcinoma was 27/38 (71.05%).

Conclusion

Over-diagnosis of the carcinoma gall bladder was present in 24.6%. On the other hand, incidental carcinoma comprised 25.7% of all admissions for carcinoma gall bladder with resectability of 71%.

Retrospective histopathologic findings of routine cholecystectomy specimens in a teaching hospital in North East India

Background

Cholecystectomy is one of the most common general surgical operations performed worldwide. Limited data is available about the histopathological diagnoses of various gallbladder diseases in North Eastern part of India even though a higher incidence of gallbladder cancer has been reported from this part of the Country. Hence, a retrospective review of the histopathological findings of routine cholecystectomy specimens was done to assess the incidence of gallbladder cancer and other gallbladder pathologies.

Aims and Objective

To study the incidence of gallbladder cancer and other pathologic findings in routine cholecystectomy specimens.

Methodology

A retrospective study of the histopathological findings of cholecystectomy specimens with presumed benign gallbladder diseases who had undergone cholecystectomy from June 2013 till October 2021.

Results

A total of 1683 patients had undergone cholecystectomy during the study period. In total, 1354 patients underwent laparoscopic cholecystectomy and 339 patients underwent open cholecystectomy. Gallstones were present in 1631 patients. Chronic cholecystitis and cholesterosis were the most common histopathologic findings, followed by pyloric metaplasia. Unsuspected gallbladder cancer was detected in eight patients (0.48%).

Conclusion

Chronic cholecystitis was the most common histopathologic finding followed by pyloric metaplasia. Gallstones were found in most patients. Incidental gallbladder cancer was detected in 0.48% of patients.

Incidental Gallbladder Carcinoma in North Indian Population: Importance of Routine Histopathological Examination of All Benign Gallbladder Specimens

AIM

To evaluate the incidence of incidental gallbladder carcinoma in specimens of cholecystectomy performed for benign gallbladder diseases and to establish the utility of routine histopathological examination of all gallbladder specimens obtained following cholecystectomy done for benign diseases.

MATERIAL AND METHODS

 This was a hospital-based three years prospective and retrospective study done at a tertiary care centre in North India. Gallbladder specimens from laparoscopic and open cholecystectomies done for benign gallbladder diseases without any clinico-radiological evidence of malignancy were included in the study. Routine histopathological evaluation of 1,268 such gallbladder specimens was carried out to get the incidence of incidental gallbladder carcinoma and pathological staging of carcinoma was done according to American Joint Committee recommendations for cancer staging (AJCC). All the diagnosed cases of Incidental gallbladder carcinoma (IGBC) were analysed in terms of demographics, radiology findings, and gross and microscopic pathology findings.

RESULTS

Out of 1,268 gallbladder specimens of clinically benign diseases, 16 cases (1.26%) were diagnosed as cases of IGBC with female predominance with a male to female ratio of 1:7. Mean gallbladder thickness in these cases was 0.77±0.20 cm, and 98.30% cases of IGBC were associated with gall stone disease. However, no correlation was observed between the age, gallbladder thickness and pathological stages of these IGBC.

CONCLUSION

 IGBC is an occult disastrous malignancy of the gallbladder, which can be missed in the pre and intraoperative periods despite careful clinical and radiological evaluation and comes as a surprise for pathologists the first time. We recommend that all specimens of gallbladder obtained from its surgical resection for benign diseases should be subjected to histopathological examination.

Selective or Routine Histology of Cholecystectomy Specimens for Diagnosing Incidental Carcinoma of Gallbladder and Correlation with Careful Intraoperative Macroscopic Examination? A Systematic Review

BACKGROUND

Selective or Routine histology of cholecystectomy specimens for benign gallbladder disease has always been a matter of debate because of the low prevalence and bad prognosis associated with gall bladder carcinoma. The objective of this study is to ascertain whether selective histology can be preferred over Routine histology without any harm.

METHODS

This systematic review is conducted according to PRISMA's checklist; relevant articles were searched in the database until September 1 2020 in PubMed, Scopus, Science Direct, and Web of Science databases, manually, with search queries and without date restrictions. Studies included in this systematic review involved patients who underwent cholecystectomy for benign gallbladder disease and were diagnosed with gallbladder carcinoma incidentally either after selective or routine histology of the gallbladder.

RESULTS

A total of 24 routine or selective histology recommending studies were selected for the systematic review after following the inclusion and exclusion criteria. These studies comprised 77,213 numbers of patients and 486 numbers of Malignancies. These studies correlate the number of IGBC diagnosed histologically with the number of IGBC's that were suspected by the surgeons intraoperative by macroscopy. Routine recommending studies show a significant number of IGBC diagnosed histologically as missed by surgeons whereas the selective recommending studies show most of the histologically diagnosed IGBC already suspected by the surgeons intraoperative. When comparing the macroscopic details of the IGBC's between routine and selective studies, we found that there was significant overlap. Most of the findings missed by the surgeons as suspicious in routine studies were suspected by the surgeons involved in selective histology recommending studies. Thereby, favouring selective histology and emphasizing the need for careful intraoperative macroscopy for suspecting IGBC.

CONCLUSION

Selective Histological examination of cholecystectomy specimens can be preferred if a careful intraoperative macroscopic examination is done and patient risk factors are taken into consideration.

T2 gallbladder cancer shows substantial survival variation between continents and this is not due to histopathologic criteria or pathologic sampling differences

Published data on survival of T2 gallbladder carcinoma (GBC) from different countries show a wide range of 5-year survival rates from 30-> 70%. Recently, studies have demonstrated substantial variation between countries in terms of their approach to sampling gallbladders, and furthermore, that pathologists from different continents apply highly variable criteria in determining stage of invasion in this organ. These findings raised the question of whether these variations in pathologic evaluation could account for the vastly different survival rates of T2 GBC reported in the literature. In this study, survival of 316 GBCs from three countries (Chile n = 137, South Korea n = 105, USA n = 74), all adequately sampled (with a minimum of five tumor sections examined) and histopathologically verified as pT2 (after consensus examination by expert pathologists from three continents), was analyzed. Chilean patients had a significantly worse prognosis based on 5-year all-cause mortality (HR: 1.89, 95% CI: 1.27-2.83, p = 0.002) and disease-specific mortality (HR: 2.41, 95% CI: 1.51-3.84, p < 0.001), compared to their South Korean counterparts, even when controlled for age and sex. Comparing the USA to South Korea, the survival differences in all-cause mortality (HR: 1.75, 95% CI: 1.12-2.75, p = 0.015) and disease-specific mortality (HR: 1.94, 95% CI: 1.14-3.31, p = 0.015) were also pronounced. The 3-year disease-specific survival rates in South Korea, the USA, and Chile were 75%, 65%, and 55%, respectively, the 5-year disease-specific survival rates were 60%, 50%, and 50%, respectively, and the overall 5-year survival rates were 55%, 45%, and 35%, respectively. In conclusion, the survival of true T2 GBC in properly classified cases is neither as good nor as bad as previously documented in the literature and shows notable geographic differences even in well-sampled cases with consensus histopathologic criteria. Future studies should focus on other potential reasons including biologic, etiopathogenetic, management-related, populational, or healthcare practice-related factors that may influence the survival differences of T2 GBC in different regions.

Incidental gallbladder carcinoma: Utility of histopathological evaluation of routine cholecystectomy specimens

Background

Incidental gallbladder carcinoma (IGBC) is rare cancer diagnosed during or after cholecystectomy done for benign gallbladder disease. The concern whether routine histopathological examination is needed for all cholecystectomy specimens still remains debatable.

Materials and Methods

Twenty patients diagnosed with IGBC over a period of 2 years were retrospectively reviewed. Clinical details including clinical presentation, preoperative ultrasound (USG) findings, and macroscopic features were retrieved. Diagnosis of IGBC was confirmed on microscopic examination, and staging was done using the tumor node metastasis staging system.

Results

Of the 4800 cholecystectomy specimens retrieved, diagnosis of IGBC was rendered in twenty cases (0.41%). Mean patient age was 50.65 years with a female preponderance. Preoperative USG detected an increase in wall thickness in six cases (30%) in contrast to gross examination which revealed the same in 55% (11/20) cases. Mucosal ulceration was observed in two cases (10%) of IGBC and seven cases (35%) did not reveal any preoperative or macroscopic findings suggestive of malignancy. Associated cholelithiasis was observed in 14 cases. Final diagnosis of IGBC was made on histomorphological assessment with tumor cells infiltrating the lamina propria in three cases (pT1b), muscularis propria in 15 cases (pT1b), and serosa in the remaining 2 cases (pT2).

Conclusion

IGBC is a clinical masquerader which often evades the eye of a radiologist and comes as pathological surprise. Histopathological examination of cholecystectomy specimens remains the gold standard for the detection of this occult, yet notorious malignancy and assessment of the depth of invasion in IGBC guide further management.

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.

Chronic calculus cholecystitis: Is histopathology essential post-cholecystectomy?

Background

Carcinoma of the gall bladder (GB) is the most common malignancy of the gastrointestinal tract. One percent of cholecystectomy specimens show incidental gall bladder cancers (GBCs).

Aim

Our aim of the study to was evaluate the utility of routine histopathology of cholecystectomy specimens removed with a diagnosis of gall bladder diseases (GBD).

Materials and Methods

A retrospective study was done reviewing the histopathological records of 906 patients who underwent cholecystectomy. Demographic details, gross findings, and microscopic findings noted. All the cases were categorized into two groups, A and B. Group A included the cases with any gross abnormality including wall thickness ≥4 mm and group B included rest of the cases.

Results

Majority of the patients were in the age group of 31-40 years of age. Out of 906 patients studied, majority of them were females with F:M ratio of 6.14:1. Of the 47 cases which were included in group A (with macroscopic abnormality), six cases had gall bladder carcinoma on microscopy. One case from group B with macroscopically normal-appearing GB had invasive carcinoma on microscopy. In our study, we found a sensitivity of 85.71% and specificity of 95.44%, while positive predictive value (PPV) was 91.11% and negative predictive value (NPV) was 99.65% of macroscopic abnormality in the diagnosis of invasive carcinoma.

Conclusion

All cholecystectomy specimens must be examined by histopathologists who must decide whether processing for microscopy is needed. Microscopic examination may be reserved for the specimen with a macroscopic lesion. This will result in a reduction of costs and pathology workload without compromising patient management.

Safe, selective histopathological examination of gallbladder specimens: a systematic review

Background

Routine histopathological examination after cholecystectomy is costly, but the prevalence of unsuspected gallbladder cancer (incidental GBC) is low. This study determined whether selective histopathological examination is safe.

Methods

A comprehensive search of PubMed, Embase, Web of Science and the Cochrane Library was performed. Pooled incidences of incidental and truly incidental GBC (GBC detected during histopathological examination without preoperative or intraoperative suspicion) were estimated using a random‐effects model. The clinical consequences of truly incidental GBC were assessed.

Results

Seventy‐three studies (232 155 patients) were included. In low‐incidence countries, the pooled incidence was 0·32 (95 per cent c.i. 0·25 to 0·42) per cent for incidental GBC and 0·18 (0·10 to 0·35) per cent for truly incidental GBC. Subgroup analysis of studies in which surgeons systematically examined the gallbladder revealed a pooled incidence of 0·04 (0·01 to 0·14) per cent. In high‐incidence countries, corresponding pooled incidences were 0·83 (0·58 to 1·18), 0·44 (0·21 to 0·91) and 0·08 (0·02 to 0·39) per cent respectively. Clinical consequences were reported for 176 (39·3 per cent) of 448 patients with truly incidental GBC. Thirty‐three patients (18·8 per cent) underwent secondary surgery. Subgroup analysis showed that at least half of GBC not detected during the surgeon's systematic examination of the gallbladder was early stage (T1a status or below) and of no clinical consequence.

Conclusion

Selective histopathological examination of the gallbladder after initial macroscopic assessment by the surgeon seems safe and could reduce costs.

Indiscriminate Pathologic Examination of Pediatric Supraglottoplasty Specimens: An Evidence-Based Approach toward Exempt Status

OBJECTIVE

The primary aim of this study was to demonstrate that indiscriminate pathologic evaluation of supraglottoplasty specimens is unnecessary and does not influence postoperative management. The secondary objective was to determine the costs associated with pathologic evaluation of supraglottoplasty specimens.

METHODS

A planned chart review was conducted to evaluate data from consecutive patients undergoing supraglottoplasty. Demographic data were extracted and pathology reports were reviewed. Projected cost savings were estimated based on 2018 Centers for Medicare & Medicaid Services reimbursement rates for Current Procedural Terminology code 88304 (surgical pathology, gross and microscopic examination).

RESULTS

A total of 1417 consecutive patients were identified. All specimens underwent gross and microscopic examination. Pathologic outcomes were categorized into 3 major categories: no diagnostic abnormality (n = 1069), chronic inflammation (n = 346), and other (n = 2). Pathologic evaluation did not alter postoperative management in any patient. Projected yearly and 5-year cost- savings totaled $11,818.08 and $59,173.92, respectively.

DISCUSSION

These findings demonstrate that pathologic examination of supraglottoplasty specimens adds no value to patient management. A more selective approach to pathologic examination of certain surgical specimens is an improvement opportunity to enhance the value of patient care by eliminating direct financial costs and "hidden costs" associated with unnecessarily increased workload.

IMPLICATIONS FOR PRACTICE

Addressing inappropriate, indiscriminate pathologic examination of certain surgical specimens is a potential quality improvement opportunity that has a meaningful impact on the value of patient care and reduces strains on the workload of surgical and pathology department personnel.

Laparoscopic Cholecystectomy for Symptomatic Cholecystic Disease in Children: Defining Surgical Timing

Background: Laparoscopic cholecystectomy (LC) is the standard of care for gallbladder (GB) pathologies. We evaluated clinical, ultrasonographic (US) data as well as histopathological findings in children affected with symptomatic cholecystic disease (SCD) who underwent LC, with the aim of defining surgical timing. Methods: We reviewed our cases who underwent elective LC (ELC) or urgent LC (ULC). Clinical, US, surgical and histological features were used to create different risk scores. Results: We considered 26 children (17 ELC/9 ULC). US signs were not different in the two groups (p > 0.05). Operating times were longer in ELC than in ULC (p = 0.01). Histopathological evaluation revealed fibrosis and atrophy in both ELC and ULC. The clinical risk score was higher in ELC compared to ULC (p < 0.001). An increased operative risk score was noted in patients with systemic inflammatory signs (OR1.98), lithotherapy (OR1.4.3) and wall thickening ≥3 mm (OR2.6). An increased histopathological risk score was detected in children with symptom duration >7 days (OR3.61), concomitant hematological disease (OR1.23) and lithotherapy (OR3.61). Conclusion: Criteria adopted in adults cannot be adopted to detect the severity of GB damage in children. A dedicated clinical and US score is mandatory to define the most appropriate surgical timing.

Histopathological Examination of Gallbladder Specimens in Kumaon Region of Uttarakhand

Gall stones are one of the major causes of morbidity and mortality all over the world and common health problems throughout in developing countries. Cholecystectomy is one of the most common surgical practices and postoperative analysis of cholecystectomy specimen has a great value since histopathological reports may document some entities with significant clinical significances. Gallbladder carcinomas in cholecystectomy specimens are received in our histopathology laboratory to analyse their clinicopathological features. This was a descriptive study carried out at the histopathology section of the Department of Pathology at our hospital over a period of two years ranging from November 2016 to October 2018. Both intraoperative and postoperative histological examinations of the excised gallbladder facilitated the diagnosis of gallbladder cancer. Surgery-related variables and surgical approaches were evaluated according to the extent of tumor invasion. Twenty five cholecystectomy specimens of the acute and symptomatic chronic cholecystitis patients were analyzed. Standardization of the reporting were examined. Age, gender, presence of gall stone, cholesterolosis, adenomatous hyperplasia, gastric or intestinal metaplasia, dysplasia, histopathological type of gallbladder carcinoma, cellular differentiation, grading, lympho vascular invision, perineural invasion, lymph node invasion, involvement of cystic duct end margin, liver invasion, omental tissue invasion and T.N.M. staging were investigated. Reported rates of histopathological findings were comparable between patients aged twenty six years to seventy six years. Epithelial hyperplasia and metaplasia were found to be related to age. The correlation between cholesterolosis and gender or metaplasia was noted. We suggest that in India and other nations, high incidences of gallbladder carcinoma, all cholecystectomy specimens must be submitted to routine macroscopic and histopathology examination in the laboratory, as this is the only capability through which malignancies can be detected at an early, potentially curable stage. This incidental finding has altered the management and outcome of this dreadful disease.

Routine histopathological examination of gallbladder specimens after cholecystectomy: Is it time to change the current practice?

Objectives

Routine histopathological examination of all gallbladder specimens, regardless of the clinical characteristics of the patient or macroscopic aspect of the gallbladder, is the current approach to detect the presence of gallbladder carcinoma. The aim of the present study was to assess whether or not it would be safe to adopt a policy of processing only gallbladder specimens with preoperative or intraoperative suspicion for malignancy without compromising patient safety.

Material and Methods

From January 2009 to June 2017, all histopathology reports of 3423 consecutive gallbladder specimens after elective and emergency cholecystectomies were retrospectively analyzed in two university hospitals.

Results

A total of 3423 gallbladder specimens submitted for histopathological examination during the study period were included into the study. The results of histopathological examination of these gallbladder specimens showed that chronic cholecystitis was found in 2792 (81.6%), acute cholecystitis in 237 (6.9%), and cholesterolosis in 223 (6.5%) patients. Dysplasia was found in 5 (0.14%) patients, and gallbladder carcinoma was detected in 4 (0.11%) patients. All patients with gallbladder carcinoma were diagnosed either preoperatively or intraoperatively, and none of the patients with gallbladder carcinoma were diagnosed from the histopathological examination.

Conclusion

A strategy of selective approach for histopathological examination of gallbladder specimens may be safe in areas with very low incidence of gallbladder carcinoma. Such selective strategy is more cost-effective, reduces the workload of pathologists, and does not appear to compromise patient outcome.

Histopathological findings in cholecystectomies specimens: A single institution study of 20 584 cases

BACKGROUND

The histopathological examination of cholecystectomy specimens has not been standardized with a debate concerning the routine and the selective approach. The aim of this study was to assess the information obtained from routine histopathological examination of cholecystectomy specimens.

METHODS

All histopathological reports of cholecystectomy specimens between January 2003 and December 2016 were analyzed, including a clinical diagnosis of benign gallstone disease or cholecystitis.

RESULTS

A total of 20,584 reports were examined. The mean age of patients was 54.2 years. Patients aged more than 60 years represent 37.6% of the study population. Of all patients, 15,973 (77.6%) were females. Incidental gallbladder cancers (GBC) were present in 155 cholecystectomies specimens (0.8%). 67.1% of GBC are at T2 and T3 stage. Granulomatous cholecystitis was diagnosed in only 19 cases (0.1%). GBC were more prevalent in older patients (P < 10^-6) and cholesterolosis was more prevalent in young patients (P < 10^-6). There was no gender predilection for GBC (P = 0.739).

CONCLUSIONS

The rate of incidental gallbladder carcinoma in our study is low, yet, we found a higher proportion of T2 and T3 carcinomas stage. Granulomatous cholecystitis may need further investigations and treatments. When a selective approch of histopathological examination of cholecystectomy specimens is used, it is important to take into account that clinical parameters are significantly associated with gallbladder cancer.

The risk of incidental gallbladder cancer is negligible in macroscopically normal cholecystectomy specimens

BACKGROUND

Cholecystectomy is usually carried out for benign indications. Most perform routine histopathologic examination to detect incidental gallbladder cancer (GBC).

METHODS

Cholecystectomies performed at four hospitals in the Helsinki Metropolitan Area during 2010-2012 were analyzed retrospectively. Patients with preoperative suspicion of neoplasia, active malignancy, or in whom cholecystectomy was performed as a secondary procedure were excluded.

RESULTS

A total of 2034 cholecystectomies were included. In ten patients (0.5%), GBC was identified, each with an associated macroscopic finding, including local hardness (n = 1), a thickened wall (n = 5), acute inflammation and necrosis (n = 1), or suspected neoplasia (n = 3). No GBC was found in macroscopically normal gallbladders (n = 1464). Of the ten patients with GBC, five underwent subsequent liver resection, four had metastatic disease, and one had locally advanced inoperable disease. Three of the five patients who underwent liver resection were alive and disease-free at final follow-up (median 48 months). The remaining seven patients with GBC died of the disease, with a median survival of 14 months (range 10-48 months).

CONCLUSIONS

Routine histopathologic examination of a macroscopically normal gallbladder does not improve diagnosis of GBC. A histopathological examination is, however, mandatory when a macroscopic abnormality is present.

Unexpected pathological findings after laparoscopic cholecystectomy - analysis of 1131 cases

Introduction

Gallbladder specimens are routinely sent for histopathological examination after cholecystectomy in order to rule out the presence of unexpected pathological findings.

Aim

To establish the overall incidence of unexpected pathological findings in patients who underwent laparoscopic cholecystectomy for symptomatic gallbladder disease and determine whether the macroscopic appearance of the gallbladder in ultrasound examination could be a valid method for identifying patients with gallbladder malignancy.

Material and methods

A retrospective study was conducted between 2013 and 2015. All histological reports (n = 1131) after cholecystectomy were searched for unexpected pathological findings. In cases where unexpected pathological findings were identified the additional analysis of preoperative abdominal ultrasound examination (USG) was done to determine the usefulness of USG in diagnosis of gallbladder malignancy.

Results

Of the 1131 patients included in the study, 356 (31.47%) were male and 774 (68.43%) were female. Unexpected pathological findings were present in 21 cases. The overall incidence of unexpected pathological findings was 1.86%. Only in 5 patients were suspicious appearances of gallbladder observed in preoperative ultrasound examination. In 16 patients there was no suspicion of malignancy. The positive predictive value of USG was 0.238.

Conclusions

The incidence of unexpected pathological findings after laparoscopic cholecystectomy was 1.86%. Ultrasonography has low positive predictive value for identifying patients with malignant findings in a gallbladder specimen.

An Unusual Case of Primary Extranodal Lymphoma of the Gallbladder

Primary gallbladder lymphoma is an extremely rare disease. We report a case of a 63 year-old woman who has been admitted with gradual onset abdominal pain in the upper right quadrant and in the suprapubic region, nausea and malaise. According to the computed tomography scan of the abdomen, which was suggestive of chronic cholecystitis, she was treated conservatively. A laparoscopic cholecystectomy was performed 5 months later and the histological examination of the gallbladder showed a low grade small lymphocytic lymphoma. The patient has been taken over by the hematology team who kept her under surveillance as no further treatment was deemed as necessary. The purpose of this paper is to report a rare case of primary gallbladder lymphoma and to demonstrate that a laparoscopic cholecystectomy may be a valid treatment for this disease.

Incidental non-benign gallbladder histopathology after cholecystectomy in an United Kingdom population: Need for routine histological analysis?

AIM

To analyse the range of histopathology detected in the largest published United Kingdom series of cholecystectomy specimens and to evaluate the rational for selective histopathological analysis.

METHODS

Incidental gallbladder malignancy is rare in the United Kingdom with recent literature supporting selective histological assessment of gallbladders after routine cholecystectomy. All cholecystectomy gallbladder specimens examined by the histopathology department at our hospital during a five year period between March 2008 and March 2013 were retrospectively analysed. Further data was collected on all specimens demonstrating carcinoma, dysplasia and polypoid growths.

RESULTS

The study included 4027 patients. The majority (97%) of specimens exhibited gallstone or cholecystitis related disease. Polyps were demonstrated in 44 (1.09%), the majority of which were cholesterol based (41/44). Dysplasia, ranging from low to multifocal high-grade was demonstrated in 55 (1.37%). Incidental primary gallbladder adenocarcinoma was detected in 6 specimens (0.15%, 5 female and 1 male), and a single gallbladder revealed carcinoma in situ (0.02%). This large single centre study demonstrated a full range of gallbladder disease from cholecystectomy specimens, including more than 1% neoplastic histology and two cases of macroscopically occult gallbladder malignancies.

CONCLUSION

Routine histological evaluation of all elective and emergency cholecystectomies is justified in a United Kingdom population as selective analysis has potential to miss potentially curable life threatening pathology.

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.

Surgically Resected Gall Bladder: Is Histopathology Needed for All?

Background. Laparoscopic cholecystectomy is considered to be gold standard for symptomatic gall stones. As a routine every specimen is sent for histopathological examination postoperatively. Incidentally finding gall bladder cancers in those specimens is around 0.5-1.1%. The aim of this study is to identify those preoperative and intraoperative factors in patients with incidental gall bladder cancer to reduce unnecessary work load on pathologist and cost of investigation particularly in a developing world. Methods. Retrospective records were analyzed from January 2005 to February 2015 in a surgical unit. Demographic data, preoperative imaging, peroperative findings, macroscopic appearance, and histopathological findings were noted. Gall bladder wall was considered to be thickened if ≥3 mm on preoperative imaging or surgeons comment (on operative findings) and histopathology report. AJCC TNM system was used to stage gall bladder cancer. Results. 973 patients underwent cholecystectomy for symptomatic gallstone disease. Gallbladder carcinoma was incidentally found in 11 cases. Macroscopic abnormalities of the gallbladder were found in all those 11 patients. In patients with a macroscopically normal gallbladder, there were no cases of gallbladder carcinoma. Conclusion. Preoperative and operative findings play a pivotal role in determining incidental chances of gall bladder malignancy.

Routine versus selective histological examination after cholecystectomy to exclude incidental gallbladder carcinoma

Introduction Gallstone disease is treated commonly with cholecystectomy. Malignant disease of the gallbladder may present similarly and has a poor prognosis. It is common for cholecystectomy specimens to be sent for histological examination to exclude malignancy. However, the incidence of incidental gallbladder carcinoma (IGBC) is low and it has therefore been suggested that macroscopic inspection of the gallbladder by the surgeon, followed by selective histological examination of abnormal specimens, may be safe and cost saving. Methods All cholecystectomies performed between 1 May 2003 and 1 September 2009 were identified from clinical coding. Pathology records were used to identify gallbladder malignancies; these were searched manually to identify IGBC. Pathology reports and case notes were cross-referenced to determine whether there were macroscopic abnormalities present. Annual cost savings were estimated by comparing the number of gallbladder specimens over one year (May 2013 - April 2014) with the total number of cholecystectomies performed in that time. Results Of 4,776 cholecystectomies identified, 12 (0.25%) were cases of IGBC. These cases had a higher median age (68 vs 54 years, p<0.001) and a higher proportion were emergency operations (50% vs 12%, p<0.001). All cases had some form of macroscopic abnormality, most commonly wall thickening (n=6, 50%). Only two cases (17%) had a visible tumour present. Conclusions All cases of IGBC in this study had a macroscopically abnormal gallbladder. Our findings suggest it is safe to adopt a selective approach to histological examination. Savings of almost £20,500 per annum have been achieved.

The surgical management of gallbladder cancer

Among biliary tract cancers, gallbladder cancer (GBC) is a potentially lethal malignancy with abysmal long-term survival. Surgery is central to the management of GBC, and presently, provides the only ray of hope for long-term survival. Radical cholecystectomy, which includes cholecystectomy with a limited hepatic resection, regional lymphadenectomy and adjacent organ resection if required is used to encompass the tumor with negative margins - R'0' resection is the standard surgical treatment for the management of GBC. Absence of randomized controlled trials to address various surgical controversies due to rarity of disease in western world, advanced disease at presentation, high frequency of unresectability/inoperability at surgery, deficient neoadjuvant/adjuvant strategies and nihilistic views of oncologists due to aggressive disease biology has resulted in marked heterogeneity in surgical strategies employed to manage GBC across the surgical centers globally.

Impact of routine histopathological examination of gall bladder specimens on early detection of malignancy - a study of 4,115 cholecystectomy specimens

Gall bladder carcinoma is the most common cancer of biliary tree, characterized by rapid progression and a very high mortality rate. Detection at an early stage, however, is indicative of a very good prognosis and prolonged survival. The practice of histopathological examination of gall bladder specimens removed for clinically benign conditions and its usefulness has been a subject of controversy. The present prospective study was carried out over a period of four years in order to find out the incidence of unsuspected gallbladder carcinoma in cholecystectomy specimens received in our histopathology laboratory and to analyze their clinico-pathological features. A total of 4,115 cases were examined. Incidentally detected cases comprised 0.44%, which accounted for 72% of all gall bladder carcinomas detected. The majority were in an early, surgically resectable stage. From the results of this study we recommend that in India and other countries with relatively high incidences of gall bladder carcinoma, all cholecystectomy specimens should be submitted to histopathology laboratory, as this is the only means by which malignancies can be detected at an early, potentially curable stage.

Selective histology of cholecystectomy specimens--is it justified?

BACKGROUND

Gallbladder cancer (GBC) is rare but the most common malignancy of biliary tract with a dismal prognosis. The early diagnosis and surgical treatment of GBC offers the only chance of long-term survival. Despite advances in radiological imaging, early diagnosis of GBC is still rarely achieved without histopathology. In our hospital, routine histologic examination of all resected gallbladder specimens has been standard practice. This study seeks to define whether selective histologic examination for gallbladder specimens based on preoperative imaging or intraoperative findings is justified.

MATERIALS AND METHODS

From September 2008-September 2013, all histopathology reports of gallbladder specimens after elective cholecystectomy were retrospectively analyzed in a single surgical unit. Preoperative imaging, intraoperative findings, and histology notes were analyzed in all cases.

RESULTS

Out of 14,369 (60% female and 40% male) patients undergoing cholecystectomy, GBC was found in only 46 cases (0.32%). More than one fifth (10/46) of GBC patients presented with acute cholecutitis (AC). All 10 AC patients coexisted with GBC harbored "significantly inflamed' gallbladders, and about 83.49% AC patients were judged with "significant inflammation." Carcinoma in situ and early GBC (T1a, T1b) accounted for 61% of all cases. Only two patients with Tis and T1a respectively did not show suspicious lesion on preoperative and intraoperative findings, but for the remaining cases (44/46), GBC was suspected either by preoperative imaging and/or intraoperative findings.

CONCLUSIONS

Almost all cases of invasive GBC will show macroscopic abnormalities following examination by a simple procedure-a full dissection, inspection, and palpation of the gallbladder. Any patient with early GBCs "missed" on macroscopic examination can still receive the appropriate treatment by the cholecystectomy alone. The gallbladder should be sent for histology only if macroscopic examination raises suspicion. This selective policy is more cost-effective, and does not appear to compromise patients outcome.

Routine histological analysis of a macroscopically normal gallbladder--a review of the literature

BACKGROUND

70,000 cholecystectomies were performed in the United Kingdom in 2011-2012. Currently it is standard practice to submit all gallbladder specimens for routine histology to exclude malignancy. The aim of this systematic review was to establish whether a normal macroscopic appearance to the gallbladder at the time of cholecystectomy is sufficient to rule out malignancy and therefore negate the need for routine histology.

METHODS

Relevant articles that were published between 1966 and January 2013 were identified through electronic databases.

RESULTS

21 studies reported on 34,499 histologically analysed specimens. 172/187 (92%) of gallbladder cancers demonstrated intra-operative macroscopic abnormality. Studies that opened the specimens intra-operatively identified all cancers, whereas gross macroscopic visualization resulted in 15 potentially missed cancers (p = 0.10). In patients of European ethnicity, gallbladder cancer in a macroscopically normal looking gallbladder was identified in only one study; however all of these patients were above the age of 60. The incidence of gallbladder cancer was significantly raised in ethnic groups from high risk areas (p = 0.0001).

CONCLUSIONS

A macroscopically normal gallbladder in patients of European ethnicity under the age of 60 may not require formal histopathology. The best method for intra-operative examination may involve opening the specimen to allow inspection of the mucosa and wall, however this needs further investigation. In the context of the volume of gallbladder surgery being performed there is the potential for significant cost and time savings.

Uveitis and T cell lymphoma: a rare but notable relationship

Uveitis is an autoimmune disease of the eye that refers to a number of intraocular inflammatory conditions. We identified three rare cases of T cell lymphoma diagnosed following an initial presentation of uveitis. This study summarized the clinical features of these rare cases and evaluated the association between uveitis and lymphoma. We analyzed the etiology of uveitis diagnosed in the Department of Pediatrics and Internal Medicine at our hospital. Five patients were diagnosed with uveitis and lymphoma. We present case reports of three patients who were diagnosed with T cell lymphoma following an initial presentation of uveitis. From January 1985 to June 2013, there were 80 cases of uveitis and 1,900 cases of lymphoma in the Department of Pediatrics and Internal Medicine at our hospital. We found five patients that were diagnosed with uveitis and lymphoma; of these, three had a definite pathologic diagnosis of T cell lymphoma. The odds ratio (OR) was 6.08 (95 % confidence interval [CI] of 1.93-14.94, P = 0.002) for the five patients with uveitis and lymphoma, suggesting a significant association. The OR was 3.67 (95 % CI of 1.16-11.65, P = 0.053) for the three patients with uveitis and T cell lymphoma. Uveitis may be a rare presentation of malignant disease, such as lymphoma. Ophthalmologists and general practitioners should be familiar with the differential diagnosis of uveitis.

Primary gallbladder small lymphocytic lymphoma as a rare postcholecystectomy finding

Introduction. Primary lymphoma of the gallbladder is an extremely rare entity with approximately 50 cases reported so far. In many of these cases the presenting symptoms were mimicking symptomatic gallstone disease and the diagnosis was made postoperatively, especially when the preoperative imaging results were far from suspicious for malignant disease. Patients and Methods. We report a case of primary lymphoma of the gallbladder in an 85-year-old man with gallstone disease, who was admitted for elective cholecystectomy 2 months after an episode of acute cholecystitis and pancreatitis. Histological evaluation of the specimen revealed a small lymphocytic lymphoma of the gallbladder. This type of primary gallbladder lymphoma has not been previously reported. Discussion. The most common primary lymphomas of the gallbladder are MALT lymphomas and diffuse large B-cell lymphomas, although a variety of other histological types have been reported. The association of these lesions with chronic inflammation is the most convincing theory for their pathogenesis. For lesions confined to the gallbladder, cholecystectomy is considered to be sufficient, while supplementary chemotherapy significantly improves prognosis in more advanced disease.

Primary B-lymphoblastic lymphoma of gallbladder involving mandibular bone

We report the case of a 75-year-old man who presented for evaluation of painless hematuria persisting for more than 1 month. At the time of presentation, the patient did not report any systemic symptoms and had no fever, weight loss, or dysuria. Computed tomography showed several enhancing, sessile polyps in the gall bladder (1.5 cm or smaller). There was no associated stone or biliary dilation. Since no other abnormality was evident, we performed laparoscopic cholecystectomy. He was diagnosed as having B-cell lymphoblastic lymphoma (B-LBL) after surgical resection of the gall bladder (GB). As the left mandibular swelling was developed after the diagnosis of the B-LBL involving GB, facial magnetic resonance imaging (MRI) was added to the imaging scan. Facial MRI revealed mass formation in the left mandible, left medial pterygoid, masticator, and buccinator muscles. The biopsy samples from the mandibular bone were also diagnosed as B-LBL. The definitive pathological diagnosis was B-LBL, stage IV. Systemic chemotherapy was done with subsequent response in size of the left mandible mass.

Routine versus selective histologic analysis of gallbladder specimens for the detection of incidental gallbladder cancers. A retrospective review over 9 years of activity with a special focus on patients' age

BACKGROUND

Incidental gallbladder cancer (IGC) is an infrequent possibility in patients undergoing cholecystectomies. Routine histologic examination of all gallbladder specimens is the current approach to detect this disease. Our study presents the influence of age to perform a selective histologic analysis.

METHODS

A retrospective review was conducted of all gallbladder specimens during the last 9 years in our hospital. The medical notes were retrieved for cases of IGC or dysplasia and perioperative data were collected.

RESULTS

A total of 3,330 cholecystectomies were conducted over the study period, 3,041 for gallstone disease. Twelve patients were found with dysplasia and 13 patients with IGC, all of them occurred in gallbladders removed for gallstone diseases. There were 18 men with a median age of 65 years (range 18 to 85). Median age for cancer patients was 70 years (range 51 to 85) and 54 years for dysplasia (range 18 to 75). No patient below the age of 51 years (n = 1,464) experienced IGCs.

CONCLUSION

Age should be considered as an additional factor for a selective approach to the histologic analysis of all gallbladder specimens following cholecystectomies.

Predictive factors for incidental gallbladder dysplasia and carcinoma

BACKGROUND

This study aims to analyze clinical characteristics and demographics of all patients admitted for cholecystectomy in a tertiary referral center to determine predictors of incidental gallbladder dysplasia (IGBD) and incidental gallbladder carcinoma (IGBC).

METHODS

A retrospective analyses of clinical, demographic, and histologic features of patients undergoing cholecystectomy in a single tertiary institution from 2005-2012 were performed using a logistic regression model to determine the predictors of IGBD and IGBC.

RESULTS

Some 771 (28 conversions to open surgery [3.6%]) and 93 patients (10.7%) underwent laparoscopic and open cholecystectomies for gallstone disease, respectively. At final pathology, IGBD (low-grade [n = 10], high-grade [n = 2], mixed-grade [n = 1], and adenoma-associated [n = 5] dysplasia) was found in 18 patients (2%; median age, 45 y; interquartile range, 42.5-63.5; male-to-female ratio, 1:2; six Caucasian; and 12 Asian). IGBC was found in seven patients (0.8%; median age, 69 y; interquartile range, 69-72; one Afro-Caribbean; four Caucasian; and two Asian). Logistic regression analysis revealed Asian patients to be at a higher risk of IGBD (odds ratio [OR], 2.9; 95% confidence interval [CI], 1.1-8.0; P = 0.02). Only age (OR, 1.12; 95% CI, 1.04-1.2; P < 0.01) and polypoid lesions (OR, 37.4; 95% CI, 2.97-470.6; P = 0.01) were significantly associated with IGBC. Receiver operating characteristic curve analysis demonstrated that age >68 y correlated positively to IGBC.

CONCLUSIONS

IGBD and IGBC are fairly common incidental histologic finding after cholecystectomy for gallstone disease. When considering cholecystectomy, patients' demographics, in particular age and race, should always be considered as this might help the surgeon and the pathologist to institute the appropriate treatment.

Routine histopathology for carcinoma in cholecystectomy specimens not evidence based: a systematic review

BACKGROUND

Routine histopathological examination of gallbladder specimens is mainly performed to identify unexpected gallbladder carcinoma (GBC). This systematic review assesses the prevalence and characteristics of GBC in cholecystectomy specimens.

METHODS

PubMed, EMBASE, Web of Science, and the Cochrane Library were searched for all articles reporting on the finding of GBC in cholecystectomy specimens.

RESULTS

Of the 30 articles included, 20 were from Europe and the United States, and 10 were of Asian origin. In the Western studies, 276 cases of GBC were found in 61,542 specimens (median prevalence 0.4%, 95% confidence interval [CI] 0.3-0.6). Of these, 65% were expected pre- or intraoperatively. In the Asian studies, 344 cases of GBC were found in 37,365 specimens (median prevalence 1.2%, 95% CI 0.8-1.7). Of these, 45% were expected pre- or intraoperatively. In a subgroup analysis, identification of previously unexpected GBC affected treatment in only a minority of patients. In total, 72% of the patients received no further treatment and 32 patients (22%) received secondary surgery, of whom 15 patients survived at least 1 year.

CONCLUSIONS

The histopathological finding of GBC after cholecystectomy appears to be a rare event. The prevalence of unexpected GBC was higher in Asian studies than in Western studies. The pre- and intraoperative sensitivity for this carcinoma is low. Moreover, the diagnosis of GBC at the time of histopathology is usually inconsequential. The results of this systematic review do not support routine histopathology of cholecystectomy specimens in clinical practice.

Routine histopathology of gallbladder after elective cholecystectomy for gallstones: waste of resources or a justified act?

Background

Selective approach for sending cholecystectomy specimens for histopathology results in missing discrete pathologies such as premalignant benign lesions such as porcelain gallbladder, carcinoma-in-situ, and early carcinomas. To avoid such blunders therefore, every cholecystectomy specimen should be routinely examined histologically. Unfortunately, the practice of discarding gallbladder specimen is standard in most tertiary care hospitals of Pakistan including the primary investigators’ own institution. This study was conducted to assess the feasibility or otherwise of performing histopathology in every specimen of gallbladder.

Methods

This cohort study included 220 patients with gallstones for cholecystectomy. All cases with known secondaries from gallbladder, local invasion from other viscera, traumatic rupture of gallbladder, gross malignancy of gallbladder found during surgery was excluded from the study. Laparoscopic cholecystectomy was performed in majority of cases except in those cases where anatomical distortion and dense adhesions prevented laparoscopy. All gallbladder specimens were sent for histopathology, irrespective of their gross appearance.

Results

Over a period of two years, 220 patients with symptomatic gallstones were admitted for cholecystectomy. Most of the patients were females (88%). Ninety two per cent patients presented with upper abdominal pain of varying duration. All specimens were sent for histopathology. Two hundred and three of the specimens showed evidence chronic cholecystitis, 7 acute cholecystitis with mucocele, 3 acute cholecystitis with empyema and one chronic cholecystitis associated with poly. Six gallbladders (2.8%) showed adenocarcinoma of varying differentiation along with cholelithiasis.

Conclusion

The histopathological spectrum of gallbladder is extremely variable. Incidental diagnosis of carcinoma gall bladder is not rare; if the protocol of routine histopathology of all gallbladder specimens is not followed, subclinical malignancies would fail to be identified with disastrous results. We strongly recommend routine histopathology of all cholecystectomy specimens.

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.

Routine histopathologic examination of two common surgical specimens-appendix and gallbladder: is it a waste of expertise and hospital resources?

This study was undertaken to assess whether a routine histopathologic examination of two common surgical specimens (appendix and gallbladder) is needed and whether routine histopathologic examination has an impact on further management of patients. Histopathology reports of patients who had undergone appendicectomy and cholecystectomy, between 2006 and 2010, were analyzed retrospectively in the department of pathology of a tertiary care hospital. The case notes were retrieved in all cases of malignancies. Patients having a clinical diagnosis or suspicion of malignancy were excluded. The incidence and impact of unexpected pathologic diagnosis on postoperative management were noted. The study period included a total of 1,123 and 711 appendicectomy and cholecystectomy specimens, respectively. Fifteen (1.336 %) cases of appendicectomy specimens revealed incidental unexpected pathological diagnoses, which included tubercular appendicitis (n = 2), parasite (n = 8), neuroma (n = 1), carcinoid (n = 2), pseudomyxoma (n = 1), and adenocarcinoma (n = 1). About 88 % of such unexpected appendiceal findings had an impact on postoperative treatment. Unexpected pathologic gallbladder findings were found in 12 (1.68 %) of 711 cholecystectomy specimens. In 6 (0.84 %) cases, gallbladder cancer (GBC) was detected. Additional further management was required in 50 % of patients with unexpected gallbladder findings. Twenty of the total 1,834 specimens (1.090 %) had an impact on patient management or outcome and were not suspected on macroscopic examination at the time of surgery. These would have been missed had the specimens not been examined microscopically. The intraoperative diagnosis of the surgeon is therefore sometimes doubtful in detecting abnormalities of the appendix and gallbladder. This study supports the sending of all appendicectomy and cholecystectomy specimens for routine histopathological examination. Appendix and gallbladder should undergo routine histopathological examination. This is important in patients with advanced age and gallstones. Also, it is of great value in identifying unsuspected conditions which require further postoperative management. Selectively sending specimens for histopathological examination can result in reduced workload on the histopathology department without compromising patient safety.

The impact of routine histopathological examination on cholecystectomy specimens from an Asian demographic

INTRODUCTION

Most gallbladder carcinoma cases are suspected pre-operatively or intra-operatively. In Malaysia histopathological examination of cholecystectomy specimens has become routine practice. The aim of this study was to assess the impact of routine histological examinations on cholecystectomy specimens from an Asian demographic, which may differ from a Caucasian demographic.

METHODS

A retrospective study was performed of all histopathology reports for cholecystectomies (laparoscopic and open) undertaken over a period of 12 years (1997-2008) in a single teaching hospital.

RESULTS

A total of 1,375 gallbladder specimens were sent for histopathological analysis, with 7 (0.5%) being reported as malignant while only three (0.2%) were found to contain primary gallbladder carcinoma. Other premalignant findings included two specimens with dysplastic changes of the mucosa and one tubulovillous adenoma with a dysplastic epithelium. From the ten malignant and premalignant specimens, seven were diagnosed pre-operatively, two were suspected intra-operatively and one was diagnosed with dysplastic changes on the histopathology report post-operatively.

CONCLUSIONS

This study supports earlier research carried out in the UK and the demographic difference does not affect the impact of the histology examination on cholecystectomy specimens in diagnosing this disease. A selective policy is recommended in Malaysia.

All cholecystectomy specimens must be sent for histopathology to detect inapparent gallbladder cancer

OBJECTIVES

Traditionally, a gallbladder removed for presumed benign disease has been sent for histopathological examination (HPE), but this practice has been the subject of controversy. This study was undertaken to compare patients in whom gallbladder cancer (GBC) was diagnosed after cholecystectomy on HPE with GBC patients in whom the gallbladder was not sent for HPE and who therefore presented late with symptoms.

METHODS

A retrospective analysis of prospectively collected data for 170 GBC patients diagnosed after cholecystectomy was conducted. All patients presented to one centre during 2000-2011. These patients were divided into two groups based on the availability of histopathology reports: Group A included patients who presented early with HPE reports (n = 93), and Group B comprised patients who presented late with symptoms and without HPE reports (n = 77).

RESULTS

The median time to presentation in Group A was significantly lower than in Group B (29 days vs. 152 days; P < 0.001). Signs or symptoms suggestive of recurrence (pain, jaundice or gastric outlet obstruction) were present in four (4.3%) patients in Group A and all (100%) patients in Group B (P < 0.001). Patients deemed operable on preoperative evaluation included all (100%) patients in Group A and 38 (49.4%) patients in Group B (P < 0.0001). The overall resectability rate (69.9% vs. 7.8%) and median survival (54 months vs. 10 months) were significantly higher in Group A compared with Group B (P < 0.0001).

CONCLUSIONS

Patients in whom a cholecystectomy specimen was sent for HPE presented early, had a better R0 resection rate and longer overall survival. Hence, routine HPE of all cholecystectomy specimens should be performed.

Gallbladder selection for histopathological analysis based on a simple method: a prospective comparative study

INTRODUCTION

After a cholecystectomy, the current and traditional practice is to send each resected gallbladder to the pathologist for analysis. Some reports have suggested the possibility of selecting only those gallbladders that need to be analysed. The purpose of this study was to show a simple method for selecting which gallbladders should be sent to the pathologist.

METHODS

A prospective comparative study was carried out. Two 'tests' were performed in 150 patients to detect or rule out gallbladder cancer. The first test included the patient's variables and a macroscopic gallbladder analysis performed by the surgeon (MGAS). The second test was the analysis performed by the pathologist. The results were compared.

RESULTS

Of the 150 patients, 132 were women and 18 men; 130 were under 60 years old. One patient had inflammatory bowel disease, seven had changes on ultrasonography and in four cases intra-operative disturbances were observed. During the MGAS, disturbances were found in 30 patients. Eighty-one cases (54%) had at least one or more risk factors for gallbladder cancer.

Leukaemic infiltration of gall bladder - unusual presentation of occult chronic lymphocytic leukaemia

Extramedullary involvement in early stage chronic lymphocytic leukaemia (CLL) is rare. We report the first case of an incidental finding of gall bladder infiltration in a patient who underwent a cholecystectomy for gallstone pancreatitis with no preceding history of CLL. This case reiterates the importance of subjecting even routine cholecystectomy specimens for histopathology examination in the context of this unusual presentation.

Gall bladder and extrahepatic bile duct lymphomas: clinicopathological observations and biological implications

Lymphomas of the gall bladder and extrahepatic bile ducts are exceedingly rare. We present the clinicopathological features of 19 cases from our files; 14 patients had primary lymphoma (13 involving gall bladder and 1 involving common hepatic duct), while 5 had systemic lymphoma on further work-up. Most patients presented with symptoms mimicking cholecystitis. The most common primary lymphoma types were diffuse large B-cell lymphoma, extranodal marginal zone lymphoma, B-lymphoblastic lymphoma, and follicular lymphoma. Two cases had features of lymphomatous polyposis, one a case of follicular lymphoma and the second a case of mantle cell lymphoma, with disease limited to the mantle zones, so-called in situ mantle cell lymphoma. Other rare lymphoma subtypes not described earlier in this site included the extracavitary variant of primary effusion lymphoma and plasmablastic lymphoma. Patients with diffuse large B-cell lymphoma and extranodal marginal zone lymphoma were older (mean age 75.8 y) than those with other subtypes (mean age 47 y) and more likely to have gallstones (60% vs. 12.5%). A comprehensive literature review revealed 36 primary gall bladder and 16 primary extrahepatic bile duct lymphomas. When compared with primary gall bladder lymphomas, those involving the extrahepatic bile ducts present at a younger age (47 y vs. 63 y) usually with obstructive jaundice, and are less often associated with gallstones (17% vs. 50%) or regional lymph node involvement (6% vs. 31%). In conclusion, primary lymphomas of the gall bladder and extrahepatic bile ducts show a broad spectrum of disease types, but in many respects mirror the spectrum of primary lymphomas of the gastrointestinal tract.

Indications for routine pathologic examination of specimens removed during trauma operations

BACKGROUND

Surgical specimens removed during trauma operations are routinely submitted for examination by pathology. This practice has not been systematically evaluated and the incidence of abnormal results from these examinations remains unknown. The objective of this study was to identify the incidence and management implications of abnormal findings at pathology review of trauma specimens.

METHODS

This is a retrospective chart and pathology review of all surgical specimens obtained during laparotomy or thoracotomy for trauma between January 1, 1993 and December 31, 2005. Reports were assessed for significant abnormal findings, including malignancy, infectious processes, and chronic inflammation. Additional clinical and demographic data were obtained. The main outcome measure was any change in management due to the pathology result.

RESULTS

A total of 1686 specimens were obtained from 1307 trauma patients. Ten patients (0.8%) were identified as having clinically significant abnormal findings on pathology. Six findings (0.5%) were evidence of malignancy. The pathology reports did not alter care in any patients. In all instances malignancy was known or highly suspected prior to specimen examination based on other diagnostic modalities or gross examination during surgery. Patients with an abnormal finding were significantly older than the patients with normal pathology reports (70.5 vs. 30.4, P < 0.0001).

CONCLUSIONS

The routine pathology review of specimens obtained during trauma operations did not alter patient care and should not continue. In all instances of abnormal pathology, preoperative imaging or gross intraoperative findings led to increased suspicion of occult disease. The suggestion of abnormalities on imaging or intraoperatively warrants pathologic examination, especially in older patients.