Calcified carcinoma of the gallbladder with calcified nodal metastasis presenting as a porcelain gallbladder: a case report

A porcelain gallbladder and a rapid tumor dissemination

Introduction

Porcelain gallbladder is a very rare entity that consists of a calcification of the gallbladder wall, and is associated with carcinoma in 12.5–62% of patients, although recent studies suggest weaker association.

Case report

We describe an 80-year-old woman who presented with colicky abdominal pain in the right upper quadrant, radiating to the back and associated with vomiting. Physical examination revealed jaundice, murphy's sign was negative.

Hepatic-biliary tract ultrasound revealed porcelain gallbladder, she was referred to the surgical team for a scheduled cholecystectomy. A month later, she presented diffuse abdominal pain. Imaging studies showed a disseminated process affecting liver's segments, capsule, and hilum; and lungs. An aggressive surgical treatment was dismissed, and was referred to the oncology department.

Discussion

There is controversy in the harboring risk of malignancy of the porcelain gallbladder. While it seems that the current data points towards a lower risk of degeneration, it is also demonstrated that patients with gallbladder wall calcifications are indeed statistically at risk of gallbladder cancer. Laparoscopic cholecystectomy has become a safe and efficient approach recommended for patients with gallbladder symptoms directly related or unrelated to gallbladder wall calcifications. In this case, a pathological gallbladder, very quickly evolved into an inoperable tumor with a poor prognosis.

Conclusion

This report heightens that with US evidence of porcelain gallbladder, an urgent CT scan should be carried out to assess an underlying malignancy, and a simple cholecystectomy should be done urgently rather than on a routine elective list to prevent possible malignant change if possible.

•

We report a patient with advanced gallbladder porcelain.

•

Porcelain gallbladder is a very rare entity found in <1% of cholecystectomies.

•

It consists of calcification of the gallbladder wall.

•

The rapid progression of cancer in a porcelain gallbladder is more unusual.

Porcelain gallbladder: a benign process or concern for malignancy?

BACKGROUND

Gallbladder wall calcifications, otherwise known as porcelain gallbladder, have received considerable attention due to its perceived association with gallbladder carcinoma. While the perception of a strong correlation persists, more recent reports raise conceivable doubts.

STUDY DESIGN

A systematic literature search was conducted of human studies describing gallbladder wall calcification and its association with gallbladder malignancy.

RESULTS

The 111 articles which met inclusion criteria identified 340 patients with gallbladder wall calcification. Of the 340 patients, 72 (21 %) were diagnosed with malignancy of the gallbladder. When examining a subgroup of 13 studies (n = 124) without obvious selection bias, the rate of gallbladder malignancy was only 6 % (0-33 %) compared to 1 % (0-4 %) in a matched cohort of patients without gallbladder wall calcification (p = 0.036, relative risk 8.0 (95%CI 1.0-63.0)). Multivariate analysis identified the presence of symptoms typical for gallbladder cancer (odds ratio 83.6, 95%CI 2.3-2979.1, p = 0.015) and the presence of a gallbladder mass (odds ratio 3226.6, 95%CI 17.2-603884.8, p = 0.003) as the only independent prognostic factors for harboring gallbladder malignancy.

CONCLUSIONS

The risk of harboring gallbladder cancer in patients with gallbladder wall calcifications is lower than recently anticipated. The risk factors identified have only limited clinical value, since they are stigmatic for advanced gallbladder cancer. In the absence of better risk stratification and in the presence of a relative low rate of associated malignancy, prophylactic cholecystectomy appears appropriate for otherwise healthy patients; whereas a non-operative approach should be considered in patients with significant co-morbidity.