Gallbladder carcinoma cells in cerebrospinal fluid as the first manifestation of a tumor. A case report

BACKGROUND: Meningeal carcinomatosis (MC) rarely occurs as the first evidence of a tumor. In such cases cytology of the cerebrospinal fluid is crucial to the diagnosis. The most frequent primary MCs are lung and breast cancers. MC from a gallbladder carcinoma is uncommon. CASE: A 58-year-old woman presented with paroxysmal headaches, seizures and coma. Analysis of the cerebrospinal fluid revealed carcinoma cells and a low protein concentration. Only postmortem examination discovered gallbladder adenocarcinoma to be the source of the tumor cells. CONCLUSION: A case with the onset of MC secondary to rare mucinous adenocarcinoma of the gallbladder is presented. Cytology of the cerebrospinal fluid was the only examination that uncovered malignancy. Nine similar cases were found in the literature. Low cerebrospinal fluid protein seems to be of diagnostic value.     

X-ray and ultrasonic diagnosis of noninflammatory benign diseases of the gallbladder]

The author analyzes the results of x-ray (cholecystography) and ultrasonic examinations carried out in patients with noninflammatory benign diseases of the gallbladder (71 with cholesterosis and 28 with adenomyomatosis). X-ray and ultrasonic symptoms of these conditions are presented and the diagnostic potentialities of both methods in the detection of such diseases assessed. The author considers ultrasonic scanning the method of choice for the diagnosis of any forms of gallbladder cholesterosis, whereas an x-ray examination appears to be informative only in a polypous form of the disease. X-ray contrast examination is preferable for the recognition of gallbladder adenomyomatosis, for it presents a clear-cut pattern characteristic of each form of this condition, whereas ultrasonic symptoms of such involvement are nonspecific.     

Cytologic diagnosis of suppurative cholecystitis due to Candida albicans and actinomyces. A report of 2 cases

BACKGROUND: Cholecystitis is a common inflammatory disease of the gallbladder. Actinomycosis and candidiasis of the gallbladder are uncommon causes of acute cholecystitis. There has been no previous report on the cytologic diagnosis of actinomycosis and candidiasis from aspirated gallbladder bile intraoperatively. CASES: Purulent bile was intraoperatively aspirated from the gallbladder of 71-year-old Indian and a 30-year-old Australian woman. The specimens were sent for cytologic examination. The first case revealed sulphur granules characteristic of Actinomyces spp. The second case showed budding spores and pseudohyphae of Candida spp. Pure colonies of Candida albicans grew from the bile culture. CONCLUSION: Actinomycosis and candidiasis rarely cause acute suppurative cholecystitis. Initial diagnosis can be made by cytologic examination of the aspirated purulent bile intraoperatively.     

黄色肉芽肿性胆囊炎与胆囊癌的临床特征分析及螺旋CT检查的鉴别诊断价值

目的:研究黄色肉芽肿性胆囊炎(XGC)与胆囊癌的临床特征分析及螺旋CT检查的鉴别诊断价值。方法:选取从2018年1月-2020年12月于我院接受腹部螺旋CT检查的41例XGC患者纳入研究,记作XGC组,另取同期医院接受腹部螺旋CT检查的45例胆囊癌患者作为胆囊癌组。分析两组临床特征、螺旋CT检查结果表现,比较两组血清血管内皮生长因子(VEGF)、糖类抗原19-9(CA19-9)水平的差异。并以病理检查为金标准,分析螺旋CT检查用作XGC与胆囊癌鉴别诊断的价值。结果:XGC组患者食欲下降、体重下降人数占比均低于胆囊癌组(均P<0.05);而两组腹痛、黄疸、发热、白细胞(WBC)升高、谷丙转氨酶(ALT)升高、谷草转氨酶(AST)升高、胆囊扩张发生率对比差异无统计学意义(均P>0.05)。XGC组囊壁增厚均匀、壁内有低密度结节人数占比均低于胆囊癌组,而有肿大淋巴结人数占比高于胆囊癌组(均P<0.05)。螺旋CT检查诊断XGC的灵敏度、特异度、准确度分别为95.12(39/41)、95.56%(43/45)、95.35%(82/86)。XGC组患者血清VEGF、CA19-9水平均低于胆囊癌组,差异均有统计学意义(均P<0.05)。结论:XGC患者食欲下降、体重下降发生率低于胆囊癌患者,螺旋CT检查鉴别诊断XGC与胆囊癌的价值较高,值得临床关注。     

Diagnostic capabilities of the x-ray endoscopic method of study in cholelithiasis]

The developed variants of the roentgenoendoscopic method for the examination of the pancreatobiliary system were employed in 256 patients with various diseases of the gallbladder and biliary duct. The results of application of these methods in 85 patients with cholelithiasis are presented. Different potentialities of the roentgenoendoscopic method and ultrasonic scanning for the assessment of the biliary system status in cholelithiasis were revealed. The findings recommend supplementing ultrasonic examinations with an optimal variant of the roentgenoendoscopic examination.     

Gallbladder carcinoma: a retrospective analysis of twenty-two years experience of a single teaching hospital

BACKGROUND: The purpose of this study was to retrospectively evaluate our experience with gallbladder cancer since the establishment of a tumour registry in our institute. METHODS: Between 1975 and 1998, 23 consecutive patients with gallbladder cancer were identified using the tumour registry database. There were 18 females (78%) and 5 (22%) males. The mean age at diagnosis was 70.6 (range 42-85) years. The diagnosis was achieved either intra-operatively or following the histological analysis of the gallbladder (n = 17), following gallbladder or liver biopsy (n = 4) or at autopsy (n = 2). Presenting symptoms included upper abdominal pain, weight loss, nausea, vomiting, fever, painless jaundice, hepatomegaly, upper abdominal mass, upper abdominal tenderness, and gastrointestinal haemorrhage. RESULTS: Histological examination revealed 20 adenocarcinomas (87%), 2 squamous cell carcinomas (9%) and one spindle cell sarcoma (4%). At presentation, 14 (61%) gallbladder cancers were stage IV, 5 (22%) were stage III and 4 (17%) were stage II. Kaplan Meier analysis revealed a mean survival of 3.2, 7.8 and 8.2 months for stage IV, III, and II disease respectively. Out of 14 patients with stage IV disease, 8 patients received adjuvant chemotherapy and survived for 4.6 months whereas six patients who did not receive adjuvant chemotherapy survived for 1.3 months. This difference was statistically significant (p = 0.04). CONCLUSION: The majority of patients with gallbladder cancer presented with advanced stage disease (stage IV) which carries a dismal prognosis. Patients who received chemotherapy with stage IV disease, however, did better than those who did not, but this is probably a reflection of patient selection.     

Histopathological study on inflammation in cholecystoses

At present, according to the unanimously accepted data, cholecystoses are noninflammatory, nonlithiasic, gallbladder diseases. However the authors' experience has proved that the inflammatory process is much more frequent than it is believed and often associated also with lithiasis, a fact which, in the authors' opinion, would justify a reconsideration of this group of diseases. This study, based on histopathologic examination, was carried out in 1,630 gallbladder specimens, surgically removed. Out of these, 278 (17.05 per cent) were identified as cholecystoses; 156 out of them were cholesteroloses and 122 diverticular diseases of the gallbladder. Inflammation as a well defined morphologic process was found in 104 cases (66.67 per cent) of cholesterolosis and in 119 cases (97.54 per cent) of diverticular disease, therefore 80.21 per cent of the cases of cholecystosis examined were associated with inflammation. As regards lithiasis, it was present in 131 of the cases (46.76 per cent). The inflammatory process presented a chronic aspect with no other particular morphologic characteristics. By correlating the histopathologic data with the clinical evolutive ones, it was observed that the presence of inflammation corresponded with a clinical evolution of the disease of about three years. The authors believed that the group of cholecystoses should be reconsidered bearing in mind that inflammation is present in most of the cases and in almost half of them it is associated with lithiases. Under these conditions the sphere of chronic nonlithiasic, noninflammatory gallbladder diseases becomes considerably reduced today.     

Diagnosis and Treatment of Xanthogranulomatous Cholecystitis: A Report of 39 Cases

This study focuses on providing diagnosis and treatment for xanthogranulomatous cholecystitis (XGC). Clinical data from 39 patients diagnosed with XGC by pathological examination between 2002 and 2010 were analyzed retrospectively. As a result, in this group of patients, the male to female ratio was 30:9 and the average age of XGC onset was 62.2?years. Clinical manifestation of the disease was similar to general cholecystitis and preoperative CT examination showed that there were only 4 XGC cases, while the others were possibly misdiagnosed. Intraoperative observations showed that all the patients had gallbladder wall thickening. This was associated with gallbladder stones in 37 patients (94.9?%), choledocholith in 11 patients (28.2?%), and Mirizzi syndrome in 5 patients (12.8?%). In this study, intraoperative frozen section pathology was conducted in 14 patients and no gallbladder cancer was found. Laparoscopic cholecystectomy was performed on 7 patients, of which two were transferred to laparotomy. Of the remaining 32 cases, 25 were subjected to open cholecystectomy, 3 to partial cholecystectomy, and 4 to the cholecystectomy and partial liver wedge resection. It was concluded that XGC is a unique type of cholecystitis with atypical clinical manifestations and is often difficult to diagnose preoperatively. Pathological examination is a key to diagnose XGC and cholecystectomy is the primary surgical treatment. In patients with choledochectasia or jaundice, for whom we cannot exclude calculus of common bile duct, common bile duct exploration should be considered. The prognosis of XGC appears to be good with the above approaches.     

RADIOGRAPHIC SIGNS OF ACUTE SUPPURATIVE CHOLECYSTITIS

In a recent series of 26 pathologically proven cases of acute cholecystitis, preoperative radiographic examination of the abdomen confirmed the presence of an inflammatory process in 17.The radiographic signs associated with acute suppurative cholecystitis are:1. Enlargement of the gallbladder, as indicated by separation or alteration in position of opaque calculi or indentation of adjacent bowel.2. Localized peritoneal irritation, manifested by (a) ileus of hepatic flexure of colon; (b) ileus of duodenal loop; (c) effacement of haustra of the hepatic flexure or valvulae conniventes of the duodenum; (d) obscuration of fat line marking inferior border of liver.3. Cholecystitis emphysematosa.4. Perforation of gallbladder, which if localized (retroperitoneal) is manifested by bubbles of gas in the gallbladder bed. If generalized (intraperitoneal) the signs are adynamic ileus of small and large bowel, increased intraperitoneal fluid, subdiaphragmatic abscess and plate atelectasis of right lung base.Visualization of the gallbladder and biliary tree after intravenous cholecystography rarely occurred in the presence of acute cholecystitis.Plain film examination of the abdomen aids in establishing the diagnosis of an acute cholecstitis and leads to the early recognition of complications such as perforation and peritonitis.     

Extramedullary plasmacytoma imitating neoplasm of the gallbladder fossa after cholecystectomy

Extramedullary plasmacytomas are plasma cell tumors that arise outside of the bone marrow. They account for approximately 3% of plasma cell neoplasms and are most frequently located in the head and neck region. Five months after undergoing cholecystectomy, a 69-year-old patient presented with the pain under the right costal margin and a 12 kg weight loss. Computed tomography of the abdomen demonstrated irregular, vascular mass in the gallbladder fossa that dents towards the duodenum and the pylorus and lowers caudally to the hepatic flexure. His laboratory tests indicated normocytic anemia and showed elevated sedimentation rate. During operative procedure, a tumorous mass in the gallbladder fossa was found, inseparable of the peritoneum of the hepatoduodenal ligament and the IVb liver segment. Histopathological examination and immunohistochemical staining determined the diagnosis of the plasmacytoma. Total resection of the tumor was achieved and after 24-month follow-up patient showed no signs of local recurrence or dissemination of the disease.     

Evaluation d'un nouveau cholécystocinétique

Boyden''s test meal (egg yolk beaten with cream), used during cholecystography, remains in the stomach for a long time and could interfere with the radiological findings on barium meal examination performed after cholecystography.A new preparation based on corn oil emulsion (G.P. Prep) was evaluated in 33 patients with and without symptoms of gallbladder disease. The criteria used in the evaluation of results were three: reduction in the gallbladder dimensions, variations in the cholecystovertebral angle, and visualization of the extrahepatic bile ducts.The gallbladder dimensions were determined before and after contraction with the aid of a metallic perforated ruler (Colcher''s) placed at the estimated level of the gallbladder at the time of exposure.     

“One-off” Complete Radiofrequency Ablation of Hepatocellular Carcinoma Adjacent to the Gallbladder by a Novel Laparoscopic Technique Without Gallbladder Isolation

The main objective of this study is to assess the feasibility and safety of treating hepatocellular carcinoma (HCC) proximal to the gallbladder using laparoscopic radiofrequency ablation (RFA). Surgical ablation of tumor located adjacent to the gallbladder may damage the gallbladder wall, even with a laparoscope and this ablation method is not precise and incomplete and is frequently combined with alcohol injections with need for further RFA treatment. Four patients were included in this study, with typical HCC where the tumor was present on the left, right, or bed side surrounding the gallbladder. The gallbladder was not separated or removed during larascopic inspection. In the RFA treatment procedure, the tumor lesion was pre-heated for 10 min, and heating was continued for 20 min. The integrity of the gallbladder wall was properly maintained. A follow-up to check for possible local recurrence was carried out 1 year after the RFA. The goal of “one-off” tumor complete RFA is to achieve thorough ablation of the tumor in a single treatment and limiting the possibility of recurrence within 6 months. Seven days after RFA, liver functions of all the patients returned to near-preoperative levels. The patients experienced slight pain in the upper right abdomen, which disappeared in 2–3 days. Results of B ultrasound on days 3–5 showed thickening of the periphery of the ablation area, without significant effusion. Enhanced CT on day 3 showed that RFA low-density area completely covered the lesions. No significant abnormality was observed in the gallbladder and its vicinity. One month after the surgery, B ultrasound and CT examination revealed no significant abnormalities. All patients had an intact gallbladder, and no extrahepatic or intrahepatic bile duct dilatation occurred. There was no evidence of damage to the bile duct or the vessels. Follow-up for 18–32 months found that all patients were in good condition. “One-off” complete RFA can be safely implemented to ablate HCC close to the gallbladder with the assistance of a laparoscope while maintaining integrity and continuity of the gallbladder, and without the need for secondary treatments.     

Diagnosis of xanthogranulomatous cholecystitis by fine needle aspiration biopsy. A case report

Xanthogranulomatous cholecystitis is an uncommon benign thickening of the gallbladder wall characterized histopathologically by extensive histiocytic infiltration. A case is presented in which a 62-year-old woman with clinical cholecystitis was found at surgery to have a markedly thick-walled, adherent gallbladder, raising the differential diagnosis of an inflammatory versus an infiltrating neoplastic process. Intraoperative fine needle aspiration (FNA) biopsy revealed abundant foamy histiocytes ("xanthoma cells"), both dispersed and in clusters associated with capillaries suggestive of organization. Occasional multinucleated giant cells and columnar epithelial cells were also present. The differential diagnosis of histiocytic processes sampled by FNA biopsy is reviewed.     

Meningeal Carcinomatosis

Meningeal carcinomatosis without gross tumour in the substance of the brain or spinal cord has been reported rarely. Two cases observed at the Victoria General Hospital, Halifax, presented a bizarre clinical picture consisting of signs of meningeal irritation without fever, and psychotic behaviour. Examination of the cerebrospinal fluid revealed low sugar concentration and increased pressure, protein and cells. In one case these cells were readily identified as malignant on stained smears. At autopsy the surfaces of the cerebral hemispheres, cerebellum and brain stem were covered by an opalescent film and on section the subarachnoid space was densely packed with malignant cells. Both primary tumours were adenocarcinomas, one originating in the gallbladder and one in the rectum. The diagnosis of meningeal carcinomatosis must be considered in patients presenting with profound mental changes and meningeal irritation without fever. Diagnosis may be confirmed by cytological examination of the cerebrospinal fluid. The primary tumour is most commonly an adenocarcinoma. There is no satisfactory treatment available.     

Dedifferentiated liposarcoma of the gallbladder: first reported case

Background

Liposarcoma of the gallbladder is an extremely rare sarcoma, with only five cases reported in the literature according to our knowledge.

Case presentation

A 71-year-old woman was referred to the Surgical Oncology Division of Napoleão Laureano Hospital (João Pessoa, PB, Brazil) due to a solid mass at the right side of the abdomen and fever, with no signs of jaundice. Abdominal ultrasonography and computed tomography (CT) evidenced an extensive gallbladder lobular formation adhered to the inferior border of the right hepatic lobe and cholelithiasis. The CT report suggested gallbladder liposarcoma. A cholecystectomy associated with resection of segments IV-B and V of the liver were performed. Intraoperative frozen sections were compatible with gallbladder sarcoma. Anatomopathological examination and immunohistochemistry confirmed dedifferentiated liposarcoma with foci of heterologous leiomyosarcomatous differentiation and undifferentiated fusocellular areas of high histological grade.

Conclusion

This is the first case of dedifferentiated liposarcoma of the gallbladder to be reported.

     

1H NMR metabolic profiling of human serum associated with benign and malignant gallstone diseases

Proton NMR based metabolic profile of serum associated with different gallbladder pathologies is presented. Quantitative and qualitative variations in the metabolic profile of serum in control samples and three different pathologies of gallbladder, chronic cholecystitis, xanthogranulomatous cholecystitis and carcinoma of gallbladder has been evaluated by use of ¹H NMR based metabonomics and multivariate chemometric methods. Multivariate partial least square discriminant analysis of ¹H NMR spectra showed a clear discrimination between control and diseased groups on the basis of quantitative and qualitative metabolic variations. Increased levels of lactate and pyruvate whereas decreased levels of glucose, some amino acids and low density lipoprotein/very low density lipoprotein (LDL/VLDL) were observed. These metabolites, responsible for class discrimination, from different metabolic pathways could be considered as the signatures of the carcinoma of gallbladder.     

Synthetic pathways of gallbladder mucosal prostanoids: the role of cyclooxygenase-1 and 2.

Acute cholecystitis is associated with increased gallbladder prostanoid formation and the inflammatory changes and prostanoid increases can be inhibited by nonsteroidal anti-inflammatory agents. Recent information indicates that prostanoids are produced by two cyclooxygenase (COX) enzymes, COX-1 and COX-2. The purpose of this study was to determine the COX enzymatic pathway in gallbladder mucosal cells involved in the production of prostanoids stimulated by inflammatory agents. Human gallbladder mucosal cells were isolated from cholecystectomy specimens and maintained in cell culture and studied in comparison with cells from a well differentiated gallbladder mucosal carcinoma cell line. COX enzymes were evaluated by Western immunoblotting and prostanoids were measured by ELISA. Unstimulated and stimulated cells were exposed to specific COX-1 and COX-2 inhibitors. In both normal and transformed cells constitutive COX-1 was evident and in gallbladder cancer cells lysophosphatidyl choline (LPC) induced the formation of constitutive COX-1 enzyme. While not detected in unstimulated normal mucosal cells and cancer cells, COX-2 protein was induced by both lipopolysaccharide (LPS) and LPC. Unstimulated gallbladder mucosal cells and cancer cells produced prostaglandin E2 (PGE2) and prostacyclin (6-keto prostaglandin F1alpha, 6-keto PGF1alpha) continuously. In freshly isolated normal gallbladder mucosal cells, continuously produced 6 keto PGF1alpha was inhibited by both COX-1 and COX-2 inhibitors while PGE2 levels were not affected. Both LPS and LPC stimulated PGE2 and 6 keto PGF1alpha formation were blocked by COX-2 inhibitors in freshly isolated, normal human gallbladder mucosal cells and in the gallbladder cancer cells. The prostanoid response of gallbladder cells stimulated by proinflammatory agents is inhibited by COX-2 inhibitors suggesting that these agents may be effective in treating the pain and inflammation of gallbladder disease.     

Ischemic electrocardiographic pattern secondary to gallbladder disease: Evaluation of possible mechanisms

A case of gallbladder disease that caused severe electrocardiographic changes resembling those seen with myocardial ischemia is presented. Normal coronary artery anatomy was documented by means of arteriography, and the patient's symptoms were relieved after cholecystectomy. Various theories concerning the cause of such electrocardiographic changes are discussed.     

Cholelithiasis and Cholecystitis in Childhood

Six cases of cholecystitis and cholelithiasis confirmed by x-ray examination and surgical operation were observed in a ten-year period. Due to the wide variability in signs and symptoms in children, cholecystitis and cholelithiasis can be diagnosed only with a high degree of clinical suspicion and roentgenological examination. Gallbladder disease is uncommon in childhood but should be considered in children with vague abdominal pains or bouts of unexplained jaundice. If a normal appendix is found at laparotomy in the “acute abdomen,” the surgeon would be wise to palpate other specific organs within the abdomen, including the liver and gallbladder.The treatment of choice is cholecystectomy. The prognosis for recovery is excellent if there is no complicating systemic disease.     

Characterization of a monoclonal antibody to human sex hormone binding globulin

The occurrence and distribution of PHI-like immunoreactivity in the guinea pig gallbladder has been analysed by radioimmunoassay and immunocytochemistry. Chromatography of gallbladder extracts by gel permeation and high-performance liquid chromatography revealed that guinea pig PHI-like immunoreactivity is of a similar size to that of porcine PHI but may differ in its amino acid sequence. Immunocytochemistry showed PHI-immunoreactivity to be localised to nerves found predominantly in the ganglionated plexus and the mucosal plexus of the gallbladder. Pure natural porcine PHI induced a dose-dependent relaxation of the isolated guinea pig gallbladder muscle which was not blocked by antagonists to acetylcholine, catecholamines, histamine, and 5-hydroxytryptamine. PHI may thus be one of the local factors involved in controlling gallbladder function.