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Gallbladder calcification leads to discovery of carcinosarcoma of the gallbladder
Gallbladder calcification leads to discovery of carcinosarcoma of the gallbladder Jun Ishida, MD,a Tetsuo Ajiki, MD,a Shigeo Hara, MD,b and Yonson Ku, MD,a Kobe, Japan
From the Department of Surgery, Division of Hepato-Biliary-Pancreatic Surgery,a and Department of Pathology,b Kobe University Graduate School of Medicine, Kobe, Japan
A 62-year-old woman was referred to our hospital for gallbladder resection. An abdominal radiograph performed for follow-up of percutaneous pinning of a fracture to her left calcaneus revealed unexpected calcification in the right upper abdomen. Although she had no abdominal complaints and her blood tumor markers were all within normal limits, computed tomographic (CT) scans revealed a protruding mass measuring 52 3 38 mm with calcification that occupied the entire gallbladder (Fig 1). Because of possible malignancy, the patient was treated with open cholecystectomy, and the hard mass in the gallbladder revealed no invasion into the liver, common bile duct, or duodenum. There were no lymph node enlargements along the hepatoduodenal ligament, and macroscopic examination of the opened gallbladder identified 3 elastic hard polypoid lesions (Fig 2). Histologic analysis of frozen sections from 1 lesion indicated a sarcomatous tumor, and the final histologic diagnosis was carcinosarcoma. The tumor was composed of 2 types of carcinoma: most tissue was sarcomatous and included disarrayed spindle cells with high-grade nuclear atypia and no apparent differentiation, whereas a small part of the tumor was adenocarcinoma. The postoperative course was uneventful, and the patient had no evidence of recurrence 10 months postsurgery. A recent review reports carcinosarcoma of the gallbladder to be rare, occurring in <1% of all
Fig 1. Computed tomographic scans of the abdomen revealing evidence of calcification of the gall bladder.
Accepted for publication July 8, 2011. Reprint requests: Tetsuo Ajiki, MD, Division of Hepato-BiliaryPancreatic Surgery, Department of Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe 650-0017, Japan. E-mail: [email protected]. Surgery 2012;152:934-5. 0039-6060/$ - see front matter Ó 2012 Mosby, Inc. All rights reserved. doi:10.1016/j.surg.2011.07.033
934 SURGERY
Fig 2. Macroscopic findings of the gall bladder revealing 3 polypoid lesions (arrows).
Ishida et al 935
Surgery Volume 152, Number 5 malignant gallbladder neoplasms.1 Although mesenchymal components do sometimes have apparent sarcomatous characteristics (chondroid, osteoid, or rhabdomyosarcomatous differentiation), there exists a distinct type of carcinosarcoma composed of anaplastic spindle cells as mesenchymal tissue.2 Although this case had no clear differentiation in the mesenchymal component, the obvious calcification within the tumor was distinctive. In general, CT scans of a gallbladder tumor with speckled calcification are diagnosed as gallbladder carcinoma with calcification, calcified gallstones, porcelain gallbladder, or gallbladder carcinosarcoma. Preoperative diagnosis of this type of tumor is difficult, and in most cases resection of the gallbladder is performed. Because carcinosarcoma
of the gallbladder is typically present as a single polypoid mass, this case was rare because of the presence of a multicentric tumor. Prognosis after resection of a gallbladder carcinosarcoma is shorter than with a carcinoma, with a recent review citing a 3-year survival rate of 31%.1 Appropriate radiation or chemotherapy should be promptly established to improve the prognosis of patients with this type of tumor. REFERENCES 1. Okabayashi T, Sun ZL, Montgomey RA, Hanazaki K. Surgical outcome of carcinosarcoma of the gall bladder: a review. World J Gastroenterol 2009;15:4877-82. 2. Ajiki T, Nakamura T, Fujino Y, Suzuki Y, Takeyama Y, Ku Y, et al. Carcinosarcoma of the gallbladder with chondroid differentiation. J Gastroenterol 2002;37:966-71.
From the Department of Surgery, Division of Hepato-Biliary-Pancreatic Surgery,a and Department of Pathology,b Kobe University Graduate School of Medicine, Kobe, Japan
A 62-year-old woman was referred to our hospital for gallbladder resection. An abdominal radiograph performed for follow-up of percutaneous pinning of a fracture to her left calcaneus revealed unexpected calcification in the right upper abdomen. Although she had no abdominal complaints and her blood tumor markers were all within normal limits, computed tomographic (CT) scans revealed a protruding mass measuring 52 3 38 mm with calcification that occupied the entire gallbladder (Fig 1). Because of possible malignancy, the patient was treated with open cholecystectomy, and the hard mass in the gallbladder revealed no invasion into the liver, common bile duct, or duodenum. There were no lymph node enlargements along the hepatoduodenal ligament, and macroscopic examination of the opened gallbladder identified 3 elastic hard polypoid lesions (Fig 2). Histologic analysis of frozen sections from 1 lesion indicated a sarcomatous tumor, and the final histologic diagnosis was carcinosarcoma. The tumor was composed of 2 types of carcinoma: most tissue was sarcomatous and included disarrayed spindle cells with high-grade nuclear atypia and no apparent differentiation, whereas a small part of the tumor was adenocarcinoma. The postoperative course was uneventful, and the patient had no evidence of recurrence 10 months postsurgery. A recent review reports carcinosarcoma of the gallbladder to be rare, occurring in <1% of all
Fig 1. Computed tomographic scans of the abdomen revealing evidence of calcification of the gall bladder.
Accepted for publication July 8, 2011. Reprint requests: Tetsuo Ajiki, MD, Division of Hepato-BiliaryPancreatic Surgery, Department of Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe 650-0017, Japan. E-mail: [email protected]. Surgery 2012;152:934-5. 0039-6060/$ - see front matter Ó 2012 Mosby, Inc. All rights reserved. doi:10.1016/j.surg.2011.07.033
934 SURGERY
Fig 2. Macroscopic findings of the gall bladder revealing 3 polypoid lesions (arrows).
Ishida et al 935
Surgery Volume 152, Number 5 malignant gallbladder neoplasms.1 Although mesenchymal components do sometimes have apparent sarcomatous characteristics (chondroid, osteoid, or rhabdomyosarcomatous differentiation), there exists a distinct type of carcinosarcoma composed of anaplastic spindle cells as mesenchymal tissue.2 Although this case had no clear differentiation in the mesenchymal component, the obvious calcification within the tumor was distinctive. In general, CT scans of a gallbladder tumor with speckled calcification are diagnosed as gallbladder carcinoma with calcification, calcified gallstones, porcelain gallbladder, or gallbladder carcinosarcoma. Preoperative diagnosis of this type of tumor is difficult, and in most cases resection of the gallbladder is performed. Because carcinosarcoma
of the gallbladder is typically present as a single polypoid mass, this case was rare because of the presence of a multicentric tumor. Prognosis after resection of a gallbladder carcinosarcoma is shorter than with a carcinoma, with a recent review citing a 3-year survival rate of 31%.1 Appropriate radiation or chemotherapy should be promptly established to improve the prognosis of patients with this type of tumor. REFERENCES 1. Okabayashi T, Sun ZL, Montgomey RA, Hanazaki K. Surgical outcome of carcinosarcoma of the gall bladder: a review. World J Gastroenterol 2009;15:4877-82. 2. Ajiki T, Nakamura T, Fujino Y, Suzuki Y, Takeyama Y, Ku Y, et al. Carcinosarcoma of the gallbladder with chondroid differentiation. J Gastroenterol 2002;37:966-71.