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Acute Cholecystitis and Cholelithiasis Concurrence with Mucinous Adenocarcinoma.

Dear Editor,

Mucinous adenocarcinoma (MA) of the gallbladder (GB) is a less common histological type of carcinoma with an incidence of 2.5% in gallbladder tumors. It displays the presence of extracellular mucin that makes over 50% of the tumor volume. Tumors that have less than 50% of stromal mucin are classified as adenocarcinoma that have focal mucinous differentiation. When the mucinous content is greater than 90%, the tumor is classified as pure mucinous/colloid carcinoma. Patients with mucin that is limited to the lumina of the infiltrating glandular units, but not present in the stroma, are not diagnosed with MA. Cholelithiasis, choledochal cysts, porcelain GB, polyps, etc. are common risk factors for the advancement of GB carcinoma (1-3). We report a case with primary MA of GB as an unexpected histopathological finding and coexistent cholelithiasis in an elective cholecystectomy material.

A 67-years-old woman showed the symptoms of acute cholecystitis and cholelithiasis. Laparoscopic cholecystectomy was performed in the general surgery clinic. She had a history of poorly controlled type 2 diabetes mellitus and was diagnosed with hypercholesterolemia. A complete blood count revealed a total leukocyte count of 9000/m[m.sup.3] with 61% of polymorphs. The level of serum alkaline phosphatase (913 IU/L), gamma-glutamyl transpeptidase (1109 U/L), aspartate transaminase (178 U/L), alanine transaminase (280 U/L), and C-reactive protein (2.2 mg/dL) were markedly elevated. The total bilirubin (1.3 mg/dL) and direct bilirubin (0.41 mg/dL) were mildly elevated. The viral markers for hepatitis B and C were negative (HBsAg, AntiHBs, AntiHCV). An abdominal ultrasound showed that the gallbladder was fully filled with stone and mud. During the surgical procedure, the gallbladder was excised easily. The gallbladder material was sent to a pathology laboratory with preliminary diagnosis of acute cholecystitis and cholelithiasis. The macroscopic examination showed that the GB was distended, and it measured 10x9 cm. Inside the lumen, multiple stones (max. diameter, 1.5 cm) were discovered. A nodular mass that was 4x4x2.5 cm in size was found in the corpus. The cut surface of the mass was friable, shiny, and soft (Figure 1).The slides of the mass showed a tumor consisting of tumor cells in the extracellular mucin pools, and cells similar to a signet ring are observed in clusters or individually in mucin (Figure 2). The tumor infiltrated the muscle. There was no perineural or vascular invasion. Surgical margins were free of the tumor. Dysplasia, intestinal metaplasia, calcification, and chronic active inflammation were also found (Figure 3). The tumor cells were immunoreactive for CK7, CK19, CEA, and EMA but were nonimmunoreactive for CK20 and CDX2. A diagnosis of MA of the GB was made.

According to the literature, MA exhibits a different clinicopathologic behavior and prognosis than the usual adenocarcinoma. Although ordinary GB adenocarcinomas typically present with chronic cholecystitis, MA presents with an acute cholecystitis type picture. Calcification may be observed in the GB MAs. MAs are typically large and present at a very advanced stage at the time of diagnosis, and they therefore show a more aggressive behavior compared to usual GB carcinoma. MA can be distinguished from conventional GB adenocarcinomas by the MUC2 positivity. MA has a poor prognosis compared to that of conventional adenocarcinomas because of its tendency toward invasive growth (1).

Mucinous adenocarcinoma shows the CK7 positivity and CK20 negativity opposed to intestinal adenocarcinomas. It can be diagnostically challenging to recognize a primary MA of the GB vs. pseudomyxoma peritonei disseminated to gallbladder, particularly in cases in which only the gallbladder is removed (I, 4).

Primary MA of the GB is a rare variant and unexpected histopathological finding in a cholecystectomy specimen examined for cholecystitis or cholelithiasis. Despite a growing awareness and improved diagnostic modalities, correct pre-operative diagnosis of gallbladder carcinoma is uncommon. Therefore, careful attention to any evidence of mural thickening and exact sampling of gallbladder specimens, particularly in older patients, are required so that any invasive malignancy would not be missed.

Informed Consent: Written informed consent was obtained from patient who participated in this study.

Peer-review: Externally peer-reviewed.

Author contributions: Concept - A.K., R.E.; Design - A.K., R.E.; Supervision- A.K., R.E.; Data 17 Collection and/or Processing - A.K.; Analysis and/or Interpretation - A.K., R.E.; Literature 18 Search - A.K.; Writing - A.K; Critical Reviews - A.K.

Conflict of Interest: The authors have no conflicts of interest to declare.

Financial Disclosure: The author declared that this study has received no financial support.

REFERENCES

(1.) Dursun N, Escalona OT, Roa JC, Basturk O, Bagci P, Cakir A, et al. Mucinous carcinomas of the gallbladder: Clinicopathologic analysis of 15 cases identified in 606 carcinomas. Arch Pathol Lab Med 2012; 136:1347-58. [CrossRef]

(2.) Joo YE, Kim HS, Choi SK, Rew JS, Kim HJ, Kang HK, et al. Case of mucinous adenocarcinoma with porcelain gallbladder. J Gastoenterol Hepatol 2003; 18: 995-8. [CrossRef]

(3.) Yamamoto A, Ozeki Y, Ito Y, Horita R, Saji S, Sugiyama H, et al. A case of well differentiated mucinous carcinoma of the gallbladder. Nihon Shokakibyo Gakkai Zasshi 2010; 107:1821-7.

(4.) Giang TH, Ngoc TT, Hassell LA. Carcinoma involving the gallbladder:a retrospective review of 23 cases-pitfalls in diagnosis of gallbladder carcinoma. Diagn Pathol 2012; 7:10. [CrossRef]

Asuman Kilitci (1), Rasim Ergul (2)

(1) Department of Pathology, Ahi Evran University School of Medicine, Kirsehir, Turkey

(2) Department of General Surgery Ahi Evran University Education and Research Hospital, Kirsehir, Turkey

ORCID IDs of the Author: A.K.: 0000-0002-5489-2222

This study was presented at the International Congress of the International Academy of Pathology and 28th Congress of European Society of Pathology September 25-29, 2016, Koln, Germany.

Corresponding Author: Asuman Kilitci

E-mail: dr.asuk@gmail.com

Received: 20.04.2018

Accepted: 10.05.2018

DOI: 10.5152/cjms.2018.511
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Author:Kilitci, Asuman; Ergul, Rasim
Publication:Cyprus Journal of Medical Sciences
Article Type:Letter to the editor
Date:Aug 1, 2018
Words:964
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