INTRODUCTION-
Mucinous Carcinoma
of gall bladder is a rare variant of gall bladder carcinoma, constitutes 2.5%
of gallbladder carcinomas. Mucinous carcinoma of gallbladder is characterized
by extracellular mucin comprising > 50% of tumor volume [1]. When
mucinous component exceeds 90% of the tumour is labeled
as pure mucinous
carcinoma [2-4]. We reported a case of mucinous adenocarcinoma
of gallbladder. Mucinous cell carcinoma is a very uncommon neoplasm of
gallbladder, most of them displaying a mixed–mucinous histological picture.
Most
carcinomas arise in the fund us (60%), body (30%) and neck (10%) [5].
Tumor has a poor prognosis because of its tendency toward invasive growth
[5]. Approximately 3:1 ratio between female: male occur
and most patients are older than 50 years [6].
Carcinomas with copious mucin production are now thought to form distinct category
among malignancies of gall bladder [6].
It’s
incidence increases with age [6].
Risk factor for gall bladder carcinoma is well known but a definite
epidemiologic parallel between gall bladder carcinoma and cholelithiasis occur [6].
MATERIALS
AND METHOD- Cholecystectomy
specimen and the hysterectomy specimen of the same patient were sent for
histopathological examination in our Department of Pathology, GSVM Medical
College, Kanpur, India from a private hospital in the year of 2018. Both the
specimens were fixed in 10% buffered formalin for 24 – 48 hours. After that the
tissues were processed and stained by
hematoxylin and eosin staining and then mounted with DPX.
CASE
REPORT- A 50 years old female was presented with complaints of pain in the
right hypochondriac
region, vomiting, and weight loss since 45 days along with the history of loss
of appetite and indigestion for 20 days.
On examination, her vital parameters
were within normal limits. Renal function test was within the
normal limit.
Hematological parameters revealed mildly raised. TLC was found the 13,300 cells/mm3. Biochemical
investigation (liver function test) were showed deranged parameters as-
Table 1: Liver
function test
|
Biochemical parameters |
Obtained value |
Normal reference Range |
|
S. Bilirubin Total Direct Indirect |
13.1 mg/dl 2.0 mg/dl 11.1 mg/dl |
0.3
– 1.0 mg/dl 0.0
to 0.2 mg/dl 0.4
to 0.8 mg/dl |
|
S.G.P.T. |
108 U/L |
5 – 42 U/L |
|
S.G.O.T. |
130 U/L |
5 – 40 U/L |
|
S.
Alkaline phosphatase |
1485 U/L |
25 - 120 U/L |
USG findings
of the patient revealed markedly distended gall bladder with thickened and
edematous gallbladder wall and lumen was filled with
multiple calculi. The proximal part of
common bile duct not adequately visualized due to theedematous gallbladder
wall. A Liver was mildly enlarged with intra-hepatic
biliary channels slightly dilated. One month after cholecystectomy, CECT whole
abdomen was performed which revealed multiple lymphnodesin periportal,
peripancreatic, coeliac, pre-aortic, para-aortic, aorto-cavallymphnodesupto 1.5
cm- Lymphnodalsecondaries. Also, there were mild as
cites with mild
hepatosplenomegaly.
* CA
19.9 cancer marker was also done, which was found within normal limit.
Gross- Cholecystectomy and hysterectomy
specimen of the same patient were sent to pathology department of GSVM Medical
College, Kanpur, in two separate jars for histopathological examination.
JAR I was labeled gall bladder as, Cholecystectomy
specimen measured 8x4 and 5x2 cm. The outer surface showed
few fibro fatty adhesions. On cut section inner surface showed glistening
mucosa with a greyish white area. Wall thickness varies from 1.5 to 2 cm. There
were multiple stones inside the jar shown in Fig. 1 (A,B).
.jpg)
Fig. 1 (A, B): Cholecystectomy specimen shows a greyish white area and the
inner surface shows a glistening mucosa
JAR II was labeled total abdominal hysterectomy. The
specimen consisted of
the uterus, cervix with bilateral adnexa.
Microscopy
examination- Multiple H & E stained sections from gall bladder were
examined showing marked thickening of gallbladder wall comprising of mucosa,
muscular layer and serosa. Numerous well demarcated mucin pools with atypical
cells (floating into the mucin pools) having a
high nucleocytoplasmic
ratio, moderate
amount of vacuolated cytoplasm, were seen on the mucosal surface (Fig. 2 to
Fig. 5).
These
mucin pools were surrounded by inflammatory cells infiltrate comprising of
mature lymphocytes, macrophages and fibroblasts along
with few congested and dilated blood vessels. These atypical cells and mucin
pools were also in filtrating the muscle layer with similar picture and were also involving upto the serosa.
Findings were suggestive of primary mucinous adenocarcinoma of gallbladder.
Microscopic findings of received hysterectomy specimen were histopathologically
normal.
.jpg)
DISCUSSIONS-
Gallbladder carcinoma is the fifth
most common G. I. malignancy [7]. It is a disease of elderly, more
common in females than in males (3:1) and there are various types of gall
bladder carcinoma such as adenocarcinoma, squamous
cell carcinoma, adenosquamous carcinoma and very rare mucinous adenocarcinoma [5].
Mucinous carcinoma has two histologic variants. One with large
pool of extracellular mucin with groups of tumour cells and other type with
cystically dilated mucin filled glands. These may be present either alone or in
combination [1]. In the
majority of cases
mucinous adenocarcinoma was frequently well differentiated and admixed with
conventional adenocarcinoma but poorly differentiated mucinous adenocarcinoma
with distant metastasis can be found. Focal mucinous differentiation and
well-differentiated adenocarcinoma with intra glandular mucin also occur [8]. Mucinous carcinoma constitutes only 2.5%. This was rather uncommon
in gall bladder and is noted in the literature mostly as individual case
reports or small handful of cases [6].
Presence
of gall stones is one of the major risk factors for gallbladder adenocarcinoma,
as in our case report but 10 - 25% of patients with
gall bladder carcinoma. They do not have associated cholelithiasis [9]. We can differentiate mucinous carcinoma from conventional gall
bladder adenocarcinoma by MUC 2 positivity and from intestinal carcinoma by an
inverse CK7/CK20 profiles [10] CK7(+) and CK20(-) [11].
It was CDX2 (Negative) so can be differentiated from pancreatic
mucinous carcinoma [12]. It was MUC6 (Negative)
so can be differentiated from mammary colloid carcinoma [13]. Owing to the location of gallbladder, dissemination of tumour to
adjacent tissue is usually present at the time of diagnosis. Most patients were
not suitable for curative surgery
because of advanced stage of the disease [7].
CONCLUSIONS-
Mucinous
adenocarcinoma is a rare variant of gall bladder carcinoma. It has more
aggressive behavior and worse prognosis than that of conventional
adenocarcinoma of gall bladder. Most mucinous carcinoma is
a mixed-mucinous, not
pure colloid type. It is very essential to differentiate a primary mucinous
adenocarcinoma from metastatic mucinous adenocarcinoma arising from other
sites/organs because
of different modes of treatment and different prognosis.
Tumour markers have the increasing significance in the
diagnosis and evaluation of gall bladder carcinoma. Assay of carbohydrate
antigen (CA) 242, carbohydrate antigen (CA) 15-3, carbohydrate antigen (CA)
19-9 and carbohydrate antigen (CA) 125 are fairly good markers for
discriminating patients of carcinoma of the gall bladder from cholelithiasis.
CA242 and CA125 when used together achieved best sensitivity and specificity.
Serum markers seem to be less sensitive when used individually in carcinoma of
the gall bladder but may prove useful in combination.
CONTRIBUTION
OF AUTHORS
Research
concept- Dr. Anveksha Sachan
Research
design- Dr. Neelima Verma
Supervision-
Dr.
Anita Omhare
Materials- Dr. Anita
Omhare
Data
collection- Dr. Anita Omhare
Data
analysis and interpretation- Dr. Anita Omhare
Literature
search- Dr. Swetlana Sachan
Writing
article- Dr. Anveksha Sachan
Critical
review- Dr. Mahendra Singh
Article
editing- Dr. Anveksha Sachan
Final approval- Dr.
Anveksha Sachan
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