Neuroendocrine tumors of the gallbladder

Examination of Gallbladders at Military Treatment Facilities: Is Histologic Analysis Necessary?

INTRODUCTION

Gallbladder specimens from cholecystectomy procedures are a common specimen evaluated by military pathologists. These are often removed for inflammatory causes. Previous studies show that the incidence of gallbladder carcinoma (GBC) is around 3%. Incidentally identified GBC is even less common at 0.36%. Incidentally found GBCs are of little clinical consequence as most are treated by cholecystectomy alone. We hypothesize that a selective approach to histologic evaluation of gallbladders could save time for pathologists to focus on more complex cancer cases and save money for the Defense Health Agency. We propose that for patients under 50 years of age with no clinical or macroscopic concern for neoplasia, histologic evaluation may be omitted with negligible risk of missing a clinically relevant diagnosis.

MATERIALS AND METHODS

This protocol was determined to be institutional review board exempt. All pathology reports from cholecystectomies from January 1, 1998, to August 11, 2023 were pulled. Key data from these reports were extracted. These data include age, gender, and if there was a clinical or macroscopic concern for neoplasia, macroscopic findings, and histologic findings. Additionally, the patient's active duty status was pulled from Military Health Systems Genesis and the Joint Longitudinal Viewer and included for demographic data.

RESULTS

Of 9,774 cases pulled, 2,063 of these reports underwent data extraction. In total, 63 cases were excluded, and 2,000 cases were sent to the 59th Medical Wing biostatistics department for analysis. In this dataset, there were 8 instances of malignancy, 5 of which were GBC (1 of these 5 arose from an intracholecystic papillary neoplasm), 2 of which were metastatic disease, and 1 a neuroendocrine tumor. The incidence of GBC in our dataset is 0.20%, lower than that of other studies. The sensitivity of a clinical/macroscopic concern to identify malignancy in a patient aged under 50 years is 66.67%. In the 187 cases from the active duty population, there were zero instances of dysplasia or malignancy.

CONCLUSIONS

The sensitivity of a clinical/macroscopic concern for neoplasia in a patient aged under 50 years is low, identifying only 2 of 3 malignancies in our dataset. However, the case that would have been missed under our proposed guidelines was from metastatic disease of a previously known metastatic malignancy. We consider that if a selective histologic evaluation is established, a history of malignancy should be a qualifier for evaluation regardless of any other factors. A selective approach to histologic evaluation of gallbladders could save our institution $4,716 to $5,240 annually. Additional studies, incorporating prior malignancy as a qualifier, are warranted to further evaluate the potential for harm in patients aged under 50 years and a number needed to harm should be established prior to any changes in practice.

Clinical diagnosis and treatment of 37 cases of gallbladder neuroendocrine carcinoma

OBJECTIVE

This study aims to investigate the clinical and pathological characteristics, treatment approaches, and prognosis of gallbladder neuroendocrine carcinoma (GB-NEC).

METHODS

Retrospective analysis was conducted on the clinical data of 37 patients with GB-NEC admitted to Shanxi Cancer Hospital from January 2010 to June 2023. The study included an examination of their general information, treatment regimens, and overall prognosis.

RESULTS

Twelve cases, either due to distant metastasis or other reasons, did not undergo surgical treatment and received palliative chemotherapy (Group 1). Two cases underwent simple cholecystectomy (Group 2); four patients underwent palliative tumor resection surgery (Group 3), and nineteen patients underwent radical resection surgery (Group 4). Among the 37 GB-NEC patients, the average pre-surgery CA19-9 level was 113.29 ± 138.45 U/mL, and the median overall survival time was 19 months (range 7.89-30.11 months). Of these, 28 cases (75.7%) received systemic treatment, 25 cases (67.6%) underwent surgical intervention, and 16 cases (64.0%) received postoperative adjuvant treatment, including combined radiochemotherapy or chemotherapy alone. The median overall survival time was 4 months (0.61-7.40 months) for Group 1 (n = 12), 8 months for Group 2 (n = 2), 21 months (14.67-43.33 months) for Group 3 (n = 4), and 19 months (range 7.89-30.11 months) for Group 4 (n = 19). A significant difference in median overall survival time was observed between Group 1 and Group 4 (P = 0.004).

CONCLUSION

Surgery remains the primary treatment for GB-NEC, with radical resection potentially offering greater benefits to patient survival compared to other therapeutic options. Postoperative adjuvant therapy has the potential to extend patient survival, although the overall prognosis remains challenging.

Neuroendocrine tumor of the gall bladder: A rare case report with review of literature

Neuroendocrine tumor of the gall bladder is an extremely rare malignancy, accounting for only 0.2% of all neuroendocrine tumors. Gall Bladder-Neuroendocrine Tumors (GB-NETs) are mainly diagnosed on histological examination of GB samples after cholecystectomy or after any biliary pathology surgery since it is very difficult to diagnose based on imaging. The overall outcome of gallbladder NET is worse than the adenocarcinoma of the gallbladder. No focused approach towards its treatment is available in literature due to its rarity. We share our experience of gall bladder NET in a 37-year-old female who was successfully managed at our institution.

Successful management of a rare case of gallbladder neuroendocrine carcinoma with tumor thrombi

A gallbladder neuroendocrine neoplasm (GB‑NEN) is a bizarre heterogeneous neoplasm arising from neuroendocrine cells, which are present in minimal amounts on the GB mucosa either due to conversion of undifferentiated stem cells, chronic inflammation and resulting in pathological metaplasia or switching of GB adenocarcinoma to neuroendocrine one. Among all the GB malignancies, GB-NEN accounts for approximately 2.1%. A 41-year-old lady presented with right upper abdomen pain and distension for 2 weeks. Contrast CT showed heterogeneously enhancing wall thickening involving fundus-body of the GB with large exophytic component involving segments IV/V of liver, peripheral enhancement and central low attenuating necrotic areas. Middle hepatic and left branch of portal vein was filled with enhancing lesion, tumor thrombi. She underwent left trisectionectomy followed by adjuvant chemotherapy. Postoperative biopsy reported as poorly differentiated unifocal small cell GB-neuroendocrine carcinomas (GB-NEC). Resected margins were free of tumor with periportal lymph nodes negative for tumor. Follow-up PET-CT after six months of treatment completion shows no tumor recurrence or metastases. She has completed 12 months following the surgery and is asymptomatic. As the occurrence of GB-NEC is rare, there are little data regarding etiology, pathogenesis, treatment and prognosis of it. Even though metastasis is early and most frequent to lymph nodes, liver, lung and peritoneum, the presence of tumor thrombus in GB-NEC is rarely reported. Though most reports suggest very poor outcomes, radical surgery followed by adjuvant chemotherapy can yield good short-term results as seen in this case.

Relation between WHO Classification and Location- and Functionality-Based Classifications of Neuroendocrine Neoplasms of the Digestive Tract

Practice of neuroendocrine neoplasms (NENs) of the digestive tract, which comprise of a highly diverse group of tumors with a rising incidence, faces multiple biological, diagnostic, and therapeutic issues. Part of these issues is due to misuse and misinterpretation of the classification and terminology of NENs of the digestive tract, which make it increasingly challenging to evaluate and compare the literature. For instance, grade 3 neuroendocrine tumors (NETs) are frequently referred to as neuroendocrine carcinomas (NECs) and vice versa, while NECs are, by definition, high grade and therefore constitute a separate entity from NETs. Moreover, the term NET is regularly misused to describe NENs in general, and NETs are frequently referred to as benign, while they should always be considered malignancies as they do have metastatic potential. To prevent misconceptions in future NEN-related research, we reviewed the most recent terminology used to classify NENs of the digestive tract and created an overview that combines the classification of these NENs according to the World Health Organization (WHO) with location- and functionality-based classifications. This overview may help clinicians and researchers in understanding the current literature and could serve as a guide in the clinic as well as for writing future studies on NENs of the digestive tract. In this way, we aim for the universal use of terminology, thereby providing an efficient foundation for future NEN-related research.

Progress in immunotherapy for neuroendocrine neoplasm of the digestive system

Neuroendocrine neoplasms (NENs) are rare heterogeneous tumors that can develop in almost any organ, with the digestive organs, including the gastrointestinal tract and pancreas being the most commonly affected sites. Despite the fact that advances in initial therapies have progressed, there is presently no recognized effective treatment for advanced NEN. Immune checkpoint inhibitors (ICIs) have shown superior efficacy in treating several types of solid tumors. Despite their successful role in the treatment of partial NENs, such as small cell lung cancer, and Merkel cell carcinoma, the role of ICIs in most of the NENs remains limited. Nevertheless, due to their specific anti-tumor mechanisms and acceptable safety profile, ICIs are a promising avenue for further study in NENs therapy. Recent clinical trials have illustrated that combination therapy with ICI is more efficient than monotherapy, and multiple clinical trials are constantly ongoing to evaluate the efficacy and safety of these combination therapies. Therefore, the purpose of this review is to provide a comprehensive summary of the clinical progress of immunotherapy in NENs affecting the digestive system, with a specific emphasis on the application of programmed cell death protein 1/programmed death receptor ligand 1 inhibitor. Furthermore, this review has an exploration of the potential beneficiary population and the inherent value of utilizing immunotherapy in the management of NENs.

Gallbladder neuroendocrine carcinoma: A report of two cases and literature review

Gallbladder neuroendocrine carcinoma (GB-NEC) is a rare, aggressive neuroendocrine carcinoma that arises from the gallbladder. Patients with GB-NEC usually have a poor prognosis. The present study described two cases diagnosed with GB-NEC and reviewed the literature to improve knowledge of GB-NEC. The present study reported on two cases of GB-NEC in male patients aged 65 and 66 years, respectively. Both patients underwent surgical resection. Postoperative pathology confirmed that one case had mixed adeno-neuroendocrine carcinoma and the other had large cell neuroendocrine carcinoma. In addition, both patients had uneventful recoveries following surgery and received cisplatin-etoposide combination chemotherapy. The present study summarized the two cases and reviewed the literature to improve understanding of GB-NEC. The results revealed that radiological findings of GB-NEC are non-specific. The present study demonstrated that surgical resection was still the most effective therapy and that postoperative adjuvant chemotherapy could markedly improve the prognosis of patients with GB-NEC.

Small Cell Carcinoma of the Gallbladder

Primary neuroendocrine carcinoma of the gallbladder (GB) is a rare, highly dismal lethal disease with a fatal prognosis. A 45-year-old female presented with right upper abdomen pain and multiple vomiting episodes. Imaging studies showed diffuse thickening of the wall of the GB with locoregional invasion into the nearby structures with extensive abdominal lymph node metastasis and arteriovenous encasements. Ultrasound-guided fine-needle aspiration was done, which was diagnostic of small cell carcinoma of the GB. The patient was planned for palliative chemotherapy. A small cell variant of neuroendocrine carcinoma of the GB is a rare entity with a moribund lethality associated with it. Patients are diagnosed in advanced stages with not many treatment modalities to offer. Usually, patients are treated with palliative chemotherapy.

An Unusual Case of Large Cell Neuroendocrine Cancer of the Gallbladder With Mixed Adenocarcinoma Component in a Patient With Pancreatobiliary Maljunction

Gallbladder neuroendocrine tumors (GB-NETs) and gallbladder neuroendocrine carcinomas (GB-NECs) are rare forms of neuroendocrine neoplasms (NENs). Most GB-NENs present as incidental findings or as gallbladder polyps in the course of investigation of nonspecific symptoms such as upper abdominal pain and nausea. Given the rarity of GB-NENs, only a few small case series are currently available describing this entity, and even fewer guiding consensus on standard treatment and the role of adjuvant therapy.  We present the case of a 65-year-old South American female referred for a chronic history of intermittent post-prandial epigastric pain, bloating, nausea, and occasional diarrhea. Pancreaticobiliary maljunction with dilation was present and she was diagnosed with primary gallbladder large cell neuroendocrine carcinoma (GB-LCNEC) mixed with a minor component of gallbladder adenocarcinoma.

Mixed neuroendocrine-non-neuroendocrine carcinoma (MiNEN) in gallbladder with liver metastasis of neuroendocrine carcinoma component: a case report

Mixed neuroendocrine-non-neuroendocrine neoplasms of the gallbladder are rare with a lack of established standardized therapeutic strategies. We report a case of gallbladder mixed neuroendocrine-non-neuroendocrine neoplasm with liver metastasis of neuroendocrine carcinoma. A patient who underwent radical cholecystectomy for gallbladder adenocarcinoma was detected with increasing liver mass, and hepatectomy was performed. Pathological report revealed neuroendocrine carcinoma. To find primary origin, pathological review of the old specimen from previous cholecystectomy with a slightly different perspective was conducted, where the neuroendocrine component was positively dyed. In conclusion, though it might be impossible to review every pathological result in cases with ambiguous findings, reviewing the previous specimen can be a useful option in diagnosis.

Gallbladder Neuroendocrine Tumors: Is There a Need for a Specific Approach?

Neuroendocrine tumors (NETs) of the gallbladder or the biliary tree are rare. Most of the current guidelines and protocols are derived from the experience of managing lung small cell neuroendocrine carcinoma or gastrointestinal NETs. But, the overall outcome of gallbladder NETs (GB-NETs) seems worse than similarly staged lung NETs and adenocarcinoma of the gallbladder. This may be due to its rarity and lack of literature for a focused approach toward its treatment. Hence, the need for a specifically designed approach might help improve results of treatment for these rare tumors. We share our experience of 2 patients with GB-NETs and their 5-year outcome.

Gallbladder Cancer: Current Insights in Genetic Alterations and Their Possible Therapeutic Implications

Due to the fast progression in molecular technologies such as next-generation sequencing, knowledge of genetic alterations in gallbladder cancer (GBC) increases. This systematic review provides an overview of frequently occurring genetic alterations occurring in GBC and their possible therapeutic implications. A literature search was performed utilizing PubMed, EMBASE, Cochrane Library, and Web of Science. Only studies reporting genetic alterations in human GBC were included. In total, data were extracted from 62 articles, describing a total of 3893 GBC samples. Frequently detected genetic alterations (>5% in >5 samples across all studies) in GBC for which targeted therapies are available in other cancer types included mutations in ATM, ERBB2, and PIK3CA, and ERBB2 amplifications. High tumor mutational burden (TMB-H) and microsatellite instability (MSI-H) were infrequently observed in GBC (1.7% and 3.5%, respectively). For solid cancers with TMB-H or MSI-H pembrolizumab is FDA-approved and shows an objective response rates of 50% for TMB-H GBC and 41% for MSI-H biliary tract cancer. Only nine clinical trials evaluated targeted therapies in GBC directed at frequently altered genes (ERBB2, ARID1A, ATM, and KRAS). This underlines the challenges to perform such clinical trials in this rare, heterogeneous cancer type and emphasizes the need for multicenter clinical trials.

Primary Small Cell Neuroendocrine Tumour of Gallbladder Presenting as Pyrexia of Unknown Origin

Herein, we report a case of primary small cell neuroendocrine tumor (NET) of the gallbladder in a 45-year-old female who presented with complaints of fever accompanied by abdominal pain on the right upper quadrant for one month. Contrast-enhanced computed tomography abdomen showed a large gallbladder mass. It was infiltrating the segments IVa, IVb, and V of the liver. Ultrasound-guided fine-needle-aspiration-cytology was performed. Based on preoperative pathological and immunohistochemical investigations, it was diagnosed to be a primary small cell NET of the gallbladder. The patient underwent radical cholecystectomy after three cycles of cisplatin-based neoadjuvant chemotherapy. She had an uneventful recovery and received adjuvant chemo-radiotherapy. The patient was well at the 18-month follow-up.

Neuroendocrine neoplasms of the biliary tree, liver and pancreas: a pathological approach

Neuroendocrine neoplasms of the pancreatobiliary tract and liver are a heterogeneous group that encompass a spectrum of entities with distinct morphological, biological and clinical features. Although in the various anatomical sub-sites of this region they show specific characteristics, these tumors, as a whole, share several etiological and clinical aspects. This review systematically addresses NENs arising in the extrahepatic bile ducts, gallbladder, liver and pancreas, with the principal aim of pinpointing essential diagnostic and classification issues. In addition, the section on hepatic NENs has been expanded to include metastatic disease of unknown primary site.

Small cell carcinoma of gall bladder: An uncommon histologic entity

<b>Introduction:</b> Gall bladder (GB) small cell carcinoma (SCC) comprises 0.5% of all gall bladder cancers. It carries a poor prognosis in view of its aggressive nature. <br><b>Case report:</b> We here report a case of small cell carcinoma of GB in a female who presented with obstructive jaundice. Examination revealed a hard lump in the right upper abdomen. Tumour markers showed raised CA 19-9. Staging CECT of the thorax and abdomen reported polypoidal enhancing wall thickening of the gall bladder with multiple metastatic deposits close to the pancreatic head encasing the main portal vein and common bile duct. Histopathology report was suggestive of small cell carcinoma, which was confirmed by immunohistochemistry. Patient was referred to the Oncology Department for palliative chemotherapy.