Saudi Journal of Gastroenterology
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CASE REPORT Table of Contents   
Year : 2002  |  Volume : 8  |  Issue : 1  |  Page : 22-24
Carcinosarcoma of the gallbladder : A case report and review of literature


Department of Surgery and Pathology, Royal Victoria Hospital and McGill University, Montreal, Quebec, Canada

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Date of Submission06-Jul-2000
Date of Acceptance27-Oct-2001
 

How to cite this article:
Al-Sheneber IF, Jaber T, Huttner I, Arseneau J, Loutfi A. Carcinosarcoma of the gallbladder : A case report and review of literature. Saudi J Gastroenterol 2002;8:22-4

How to cite this URL:
Al-Sheneber IF, Jaber T, Huttner I, Arseneau J, Loutfi A. Carcinosarcoma of the gallbladder : A case report and review of literature. Saudi J Gastroenterol [serial online] 2002 [cited 2020 Sep 29];8:22-4. Available from: http://www.saudijgastro.com/text.asp?2002/8/1/22/33380



   Introduction Top


Carcinomasarcoma is a rare tumor and as the name implies, is characterized by malignant epithelial and sarcomatous components. It has been described in many locations of the body and the most common site is the uterus [1] . There are fewer than 30 cases reported in the literature on carcinosarcoma arising in the gallbladder [2] . In this report, we add another case that was associated with acute cholecystits and the diagnosis was made later when the patient presented with widespread metastases. The clinical and histological features are presented with a literature review.


   Case Report Top


A 68-year old woman presented to the Emergency Room with right upper quadrant pain and fever. She had recently lost some weight but denied any other relevant symptoms. On clinical examination, she wasn't jaundiced but had a temperature of 38.6° and a pulse rate of 105 beats/minute. A tender mass was felt in the right upper quadrant of the abdomen and the rest of the physical examination was normal. Complete blood count, serum bilirubin and liver enzymes were normal. The ultrasound and the Hida scan confirmed the diagnosis of acute cholecystitis. At laparoscopy, the gallbladder was found to be inflamed, edematous and in some parts gangrenous and the procedure was converted to an open cholecystectomy because of technical difficulties. Inspection of the gallbladder and liver showed no abnormalities suggestive of malignancy. She had an uneventful postoperative course and went home in the 5 th postoperative day in good condition.

The pathology report was consistent with acute cholecystitis and cholelithiasis with no other remarks. The patient returned to the hospital nine months later because of severe pain in the right upper quadrant of the abdomen radiating to the back, was associated with nausea and bloating. She was afebrile and non-icteric, but a large non tender mass was palpalable in the right upper abdomen. Another smaller mass was also felt in the umbilical trocar site. Blood tests revealed mild anaemia and a serum carcinoembryonic antigen (CEA) of 49.26ug/L (normal 0-4.9). Ultrasound and CT scan of the abdomen showed ascites, bilateral pleural effusion, large mass in the subhepatic area (14.8x8cm), a pelvic mass and multiple nodules in the transverse mesocolon, peripancreatic area, portahepatis and in both lobes of the liver. A CT guided needle biopsy of the upper abdominal mass revealed a high-grade sarcoma. She received symptomatic and supportive treatment and expired seven weeks later.

Histological Examination: The fine needle biopsy taken from the large upper abdominal mass showed histological features of high grade spindle cell sarcoma [Figure - 1] positive for vimentin by immunohistochemistry.

The histology of the previous cholecystectomy specimen was examined and revealed foci of malignant mixed tumor (carcinosarcoma) in the gallbladder wall. These were consisting of biphasic pattern showing adenocarcinoma component positive for cytokeratin and mesenchymal sarcomatous component positive for vimentin [Figure - 2]. The latter is identical to the findings in the needle biopsy of the abdominal mass. Other areas of the gallbladder mucosa revealed focal areas of clear cell dysplasia and carcinoma in situ [Figure - 3], which indicates that the carcinosarcoma arose primarily in the gallbladder wall mucosa.


   Discussion Top


The first case of carcinosarcoma of the gallbladder was described in 1907 [2] . The tumor is rare and Born et al reported one case of carcinosarcoma of the gallbladder among 99 cases of primary gallbladder malignancies admitted to St Luke's Hospital in Nvw York City over an 18-year period from 1964 to 1981 [3] . The clinical characteristics. treatment and outcome of carcinosarcoma of the gallbladder are similar to the more common carcinoma and thus the same management guidelines are followed [3],[4] . Most patients with carcinosarcoma of the gallbladder are females in their sixth or seventh decade and present with abdominal pain and right upper quadrant mass with or without jaundice [2],[5] . In 74% of cases, gallstones were also present, which is similar to carcinoma of the gallbladder [2],[6] . The tumor is usually a polypoidal mass that may be seen pre­operatively on ultrasonography [5] . Serum ca 19-9 may be elevated but the diagnosis requires high index of suspicion [7],[8] . The tumor spreads to lymph nodes along the cystic duct and common bile duct and other distant lymph nodes and the liver may be involved from direct extension or venous metastases [6] . The treatment is stage dependent and the same staging system used for carcinoma of the gallbladder maybe applied [6] . Stage I is in situ carcinoma and in Stage II and III invasion includes the muscularis and serosa respectively. In Stage IV, the tumor extends to lymph nodes and if other distant sites are involved, then it is Stage V disease. Cholecystectomy alone is sufficient for Stage I disease while other advanced stages require resection of 3-5cm wedge of liver tissue at the gallbladder bed, combined with lymph node dissection if there is no evidence of distant metastases [8],[9],[10] . More extensive procedures like right hepatectomy will probably increase the risk and add no benefit to survival"". 5 Fu-based chemotherapy has been used both as adjuvant therapy and in advanced disease but the response is minimal"'. The prognosis is dismal with most patients dying within few months of the diagnosis. Only two cases were reported to have survived for one year or more [2] . Our patient had gallstones and presented with acute cholecystitis, the ultrasound didn't show any suspicion of tumor, both when reported initially or in retrospect. Actually, the tumor was so small that it was missed on the initial histological examination, yet it had very aggressive behavior with widespread metastases. The histogenesis of carcinoma is unclear, whether it is due to concurrent transformation of ephithelial and mesenchymal cell lines in the same organ or that the spindle cell component represent sarcomatous metaplasia in a poorly differentiated carcinoma is debatable [1],[5] . The diagnosis of carcinoma requires the presence of both malignant epithelial and mesenchymal elements that may be intimately admixed often with a transition between the two cell types.

The mesenchymal component may differentiate toward tissue indigenous to the site such as stroma, fibrous tissue or smooth muscle (homologous) or to tissue foreign to the site such as bone, cartillage, fat and skeletal muscle (heterologous) [1] . In our case, the sarcomatous component of the tumor was homologous stromal sarcoma, while the epithelial component was clear cell adenocarcinoma. Some studies have shown that laparoscopic cholecystectomy does not worsen the outcome of cases with gallbladder cancer [12],[13]. Others have claimed that laparoscopy has adverse effect on cancer spread [14],[15] . This is mainly due to the extraction of the cancerous gallbladder through the port site but other hypothetical factors include: vasodilatory effects of CO2, dissemination of cancer cells by C02 convection and passage of the instrument through the port site [14] . Fong et al described four patients who had gallbladder cancer removed laparoscopically and on subsequent laparotomy were found to have new intraperitoneal dissemination of tumor despite the short interval to re-operation [16] . The treatment for isolated port site metastasis is wide local excision and or external beam radiation [12] . In addition to the intra-abdominal metastases in our patient, the umbilical port site but not the open scar incision, was involved. Recently, a similar case was described where the Laparoscopic cholecystectomy was converted to open, the final diagnosis was adencarcinoma of the gallbladder and the patient developed metastasis at the port site but not at the open incision [17] . While this is an interesting observation, it remains to be explained.

 
   References Top

1.Wick MR, Swanson PE: Carcinosarcoma: Current Perspectives and Historical Review of Nosological Concepts. Seminars in Diagnostic Pathology 1993, 10:118­-27  Back to cited text no. 1    
2.Fagot H, Fabre JM, Ramos J et al: Carcinosarcoma of the Gallbladder: A Case Report and Review of the Literature. J Clin, Gastroenterol 1994; 18:314-6  Back to cited text no. 2    
3.Born MW, Ramey, WG, Ryan SF, Gordon PE: Carcinosarcoma and Carcinoma of the Gallbladder. Cancer; Indonesia 1984; 53:2171-77  Back to cited text no. 3    
4.Inoshita S, Iwashita A, Enjoji M: Carcinosarcoma of the Gallbladder. Report of a Case and Review of the Literature, Acta Pathol jpn 1986; 36: 913-20.  Back to cited text no. 4    
5.lezzoni JC, Mills SE: Sarcomatoid Carcinomas (carcinosarcomas) of the gastrointestinal tract: A Review: Seminars in Diagnostic Pathology 1993, 10:176-87.  Back to cited text no. 5    
6.Way LW, Altman DF: Neoplasms of the Gallbladder and Bile Ducts; Gastrointestinal Disease Pathophysiology Diagnosis Management 1989; 4: 1734-40  Back to cited text no. 6    
7.Rumalla A, Petersen BT: Diagnosis and Therapy of Biliary Tract Malignancy, Semin Gastrointest Dis 2000, 11 168-73  Back to cited text no. 7    
8.Bartlett DL, Gallbladder cancer; Semin Sur-, Oncol 2000; 19: 145-55.  Back to cited text no. 8    
9.Piehler JM, Crichlow RW: Primary carcinoma of the gallbladder: Surg Gynecol. Obstet 1978, 147: 929-42.  Back to cited text no. 9    
10.Albores-Saavedra J, Manrique J, de J et al: carcinoma in situ of the gallbladder. A clinicopathologic study of 18 cases, Am J Surg Pathol 1984, 8: 323-33  Back to cited text no. 10    
11.Roberts JW, Daugherty SF; Primary carcinoma of the gallbladder; Surg Clin North Am 1986, 66: 743-9.  Back to cited text no. 11    
12.Whalen GF, Bird 1. Tanski W et al. Laparoscopic cholecystectomy does not demonstrably decrease survival of patients with serendipitously treated gallbladder cancer; J Am Coll Surg 2001, 192:189-95  Back to cited text no. 12    
13.Suzuki K, Kimura T, Ogawa H: Long term prognosis of gallbladder cancer diagnosed after laparoscopic cholecystectomy. Surg Endosc 2000; 14: 712-6  Back to cited text no. 13    
14.Cushieri A: Laparoscopic management of cancer patients: JR Coll Surg Edinb 1995; 40:1-9  Back to cited text no. 14    
15.Winston CB, Chen JW, Fong Y et al: Recurrent gallbladder carcinoma along laparoscopic cholecystectomy port tracks: CT demonstrations: Radiology 1999; 212: 439-44  Back to cited text no. 15    
16.Fing Y, Brennan ME. Turnbull A et al: Gallbladder Cancer Discovered during Laparoscopic Surgery, Arch Surg.1993, 128:1054-6.  Back to cited text no. 16    
17.Jacobi C, Keller HW, Said S: Implantation metastasis of unsuspected gallbladder carcinoma after laparoscopy. Br J Surg.1994; 81 (Suppl) 82 (abstract)  Back to cited text no. 17    

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Correspondence Address:
Antione Loutfi
Royal Victoria Hospital S10.22, 687 Pine Ave. West, Montreal, Quebec, H3A 1A1
Canada
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Source of Support: None, Conflict of Interest: None


PMID: 19861787

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    Figures

  [Figure - 1], [Figure - 2], [Figure - 3]



 

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