Printer Friendly

FREQUENCY OF INCIDENTAL CARCINOMA GALL BLADDER IN CHOLECYSTECTOMY.

Byline: Arifa Manzoor and Faran Khan

ABSTRACT

Objective: To determine the frequency of incidental gall bladder carcinoma in patients of a tertiary care hospital undergoing cholecystectomy.

Methodology: This descriptive case series was carried out at Department of General Surgery, Pakistan Institute of Medical Sciences (PIMS), Islamabad from 1st January, 2012 to 30th June, 2014. The histopathology reports of 1003 patients undergoing cholecystectomy (either by laparoscopic or open) were reviewed retrospectively and 940 patients fulfilling our criteria were included.

Results: Gall bladder adenocarcinoma was detected in only two patients (0.21%) undergoing cholecystectomy. Male to Female ratio was 1:1 and the mean age was 68.5 years for incidental carcinoma patients. One patient had a pre-malignant porcelain gall bladder while the rest of 937 histopathology results were benign.

Conclusion: In this single institute study, the frequency of incidental gall bladder carcinoma was found to be 0.21 % and that too in elderly patients.

Key Words: Incidental carcinoma gall bladder, Cholecystectomy, Cholelithiasis, Histopathology

INTRODUCTION

Cholelithiasis is a significant health problem affecting 10-15% population of the developed world1-3. Cholelithiasis and its complications are the most frequent indication for performing cholecystectomy4,5.85% of the cases of carcinoma gall bladder are associated with cholelithiasis1,2 and is thought to arise due to chronic irritation caused by the presence of gallstones2.

Other risk factors for developing carcinoma gall bladder include genetic susceptibility, advancing age, female gender, chronic biliary infections, some dietary factors and anatomical anomalies3. Women have two to six times more incidence of carcinoma gall bladder as compared to men1,3.

Carcinoma gall bladder, though rare, is the most common malignancy of the biliary tract, accounting for 80%-95% of biliary tract carcinomas2. It is the fifth most common gastrointestinal malignancy2,3. An early diagnosis is essential as this malignancy progresses silently over 5 to 15 years but mostly presents late at an incurable stage1-3. Delay in diagnosis and aggressive nature leads to a median survival of less than six months while 5 years survival is less than 5%2. The stage of disease at the time of presentation determines the complete resection and thus outcome of the surgery4.

The frequency of carcinoma gall bladder is varied across the regions and between ethnicities1,2. Asians have a high risk of gall bladder carcinoma especially in northern Indian females, Pakistani females and Korean males2. According to an estimate the frequency of gall bladder cancer is 11/100,000 in Pakistan, 22/100,000 in North of India, 16-27/100,000 in Native American Indian females and 8-12/100,000 in Native American Indian males. The regions with low Frequency include Canada (1.6/100,000), USA (1.5/100,000) and New Zealand Marios (1.59/100,000 in females and 1.49 in males)2.

The frequency of finding intra or post operative incidental gall bladder carcinoma diagnosis is reported around 0.2 and 2.8%5. Our country is reported to have a high frequency of carcinoma gall bladder2 and our local studies have reported a high frequency of incidental carcinoma in cholecystectomy specimens. Introduction of ultrasonography has contributed to early diagnosis of gallstones 3,6 and accessibility to laparoscopic surgery had particularly increased the rate of operative management 2,3,7 .

Owing to availability of large number of gall bladder specimens and there histopathology reports, we undertook this study to determine the true frequency of incidental carcinoma gall bladder in our setup.

METHODOLOGY

This descriptive case series was carried out at the Department of General Surgery of Pakistan Institute of Medical Sciences (PIMS) Islamabad, Pakistan from 1st January 2012 to 30th June 2014 after taking approval from the hospital ethical committee. The histopathology of all the patients was carried out at the Department of Pathology PIMS. The data for the study was retrieved retrospectively from computerized histopathological records. Histopathology reports of patients of all ages and genders, who underwent cholecystectomy (by open or laparoscopic technique), were reviewed. Patients with suspicion of malignancy, diagnosis of malignancy, metastatic gall bladder disease, hepatic hilar lymphadenopathy, and gross mass formation or autolysed specimens were excluded from study.

Preoperative record, laboratory and radiological investigations and operation notes of the patients with malignancy were traced. The American Joint Committee on Cancer (AJCC) Tumor Node Metastasis (TNM) system was used as reference for staging carcinoma gall bladder8. The data were analyzed using IBM SPSS Statistics Version 20.0 with descriptive statistics to calculate percentages, frequencies, means and standard deviations. The numerical data such as age were expressed as mean and standard deviation while the categorical data such as the gender and histopathology reports were expressed as frequency and percentages.

RESULTS

In our study a total of 1003 histology reports of chOlecystectomy specimens were retrieved. There were 940 cases fulfilling our inclusion criteria. Gender distribution is shown in figure 1. 98.5 % (n=926) patients had cholelithiasis. The age of the patients ranged from 21 to 81 years. Overall mean age was 46.22 + 10.15 years. Mean age for the female patients was 46.70 + 10.38 years and mean age for male patients was 44.87 + 9.35 years.

Table 1 gives the summary of histopathology findings of all 940 specimens. Chronic cholecystitis is the predominant pathology in 89.15 % followed by acute on chronic cholecystitis in 4.25 % cases.

The hospital based frequency of adenocarcinoma gall bladder after cholecystectomy was 0.21% (n=2). Male to Female ratio was 1:1 and the mean age was 68.5 years for incidental carcinoma patients. A 61 years old male patient had his tumor staged as pT3 with a high grade papillary adenocarcinoma at the fundus of gall bladder. His pre-operative records showed that there were polyps greater than 1 cm along with multiple gallstones on ultrasonography while operation notes indicated difficulty in resection per-operatively due to hardening and thickened gall bladder. The other patient, 76 years old female had her gall bladder filled with multiple polyps and was staged pT1 on histopathology. She had multiple polyps visualized on pre-operative ultrasonography but without any gallstones. Only one case of pre-malignant lesion, porcelain gall bladder was reported. There were no cases of carcinoma in situ.

DISCUSSION

Incidental gall bladder carcinoma is defined as the gall bladder carcinoma diagnosed during or after the cholecystectomy done for benign gall bladder disease. The relative risk of developing carcinoma is 2-24 times for patients with cholelithiasis compared to those without gallstones7.

Table 1: Histopathological report (n=940)

Histopathology###Female###Male###Total (n)###%

Chronic cholecystitis###624###214###838###89.15

Acute on chronic cholecystitis###29###1###40###4.25

Chronic cholecystitis with cholesterolosis###23###6###29###3.08

Empyema gall bladder###6###6###12###1.27

Eosinophilic cholecystitis###3###4###7###0.74

Acute cholecystitis###1###1###2###0.21

Papillary adenocarcinoma###1###1###2###0.21

Acute cholecystitis with cholesterolosis###1###0###1###0.10

Chronic cholecystitis with pyloric metaplasia###1###0###1###0.10

Chronic granulomatous cholecystitis###1###0###1###0.10

Adenomyomatous hyperplasia###1###0###1###0.10

Follicular cholecystitis###0###1###1###0.10

Giant cell reaction against foreign body###0###1###1###0.10

Mucocele###1###0###1###0.10

Xanthogranulomatous cholecystitis###0###1###1###0.10

Porcelin gall bladder###1###0###1###0.10

Subacute cholecystitis###1###0###1###0.10

Total###694###246###940###100

Table 2: List of some local studies showing frequency of incidental carcinoma gall bladder

Studies###Duration###Place of###Sample size###Mean age###M:F###Frequency

###study###(yrs)###(%)

Our study###2012-2014###Islamabad###940###68.5###1:1###0.21

Khan et al3

###2008-2012###Rawalpindi###500###45###0:1###0.20

###Hyderabad/

Siddiqi et al9###2010-2012###220###32.3###1:7###2.8

###Jamshoro

Qazi et al10###2009-2011###Kohat###200###52.57###1:7###4.0

Shah et al11

###2008-2011###Peshawar###260###55.25###1:10###4.23

Junejo et al12

###2011###Jamshoro###138###49.3###1:2.36###10.86

Shaikh et al13

###1997-1998###Larkana###100###-###-###10.0

Abassi et al14

###2008###Rawalpindi###100###62.5###0:2###2.0

Soomro et al15

###2007-2008###Jamshoro###521###-###1:3.75###3.64

Lohana et al16

###2006-2008###Hyderabad###200###-###1:3###4.0

Iftikhar et al17

###2006-2008###Peshawar###107###58.5###-###4.67

Naqvi et al18

###1985-2004###Nawabshah###1,109###-###1:1.4###5.90

Malik KA19

###1998-2001###Nawabshah###260###-###1:3###6.15

Ahmed G20

###1995-1997###Bahawalpur###50###-###-###28.0

Ahmed I21

###1992-1993###Faisalabad###100###-###-###20.0

Table 3: List of some international studies showing frequency of incidental carcinoma gall bladder

Studies###Years of###Country###Sample size###Mean age###M:F###Frequency

###study###(yrs)###(%)

Yi et al22###2006-2013###China###14073###-###0.18

Kalita et al24

###2009-2012###India###4,115###54###0.87:1###0.44

Jetley et al25

###2007-2012###India###622###53###0:6###0.96

Ghnnam et al27

###2007-2012###Egypt###1,892###73.6###2:8###0.5

Genc et al23

###1999-2010###Turkey###5,164###66.2###1:4###0.09

Almuslamani et al28

###2008-2010###Jordan###1,984###64.4###1:1.2###0.55

Ghimire et al29

###1998-2008###Nepal###783###63.8###1:2.3###1.28

Mittal et al26

###1998-2007###India###1,305###45.3###1:4.5###0.99

It is aymptomatic in 15-30 % of cases or presents with atypical symptoms5. It is reported in 0.2-2.8 % of histopathological examinations in patients undergoing open or laparoscopic cholecystectomy5,7.

Literature search has demonstrated that our study had a very low frequency of incidental carcinoma as compared to other local studies. Frequency reported by our study (0.21 %) is comparable to only one local study by Khan et al3 who reported a frequency of 0.20 % for incidental carcinoma gall bladder. All the other studies from different regions of Pakistan have reported a higher frequency between 2.0 % to 28.0 %9-21. Table 2 gives a comparison of studies conducted in Pakistan along with the results of our study.

We reviewed international literature on the subject and found out that they have reported a lower frequency of incidental carcinoma gall bladder as compared to local literature. Study by Yi et al22 and Genc et al23 have reported a frequency of 0.18 and 0.09 % which is comparable to our study. India has also high frequency of gall bladder carcinoma like our country (2) but the Indian studies by Kalita et al24, Jetley et al25, and Mittal et al26, have also reported a lower frequency of 0.44, 0.96 and 0.99 % respectively as compared to the frequencies reported in our local studies between 2.0 to 28 %9-21. Table 3 has listed some international studies on the subject.

Curative management of gall bladder carcinoma by surgical resection is dependent on the stage at diagnosis i.e. the depth of invasion4,5,7. Incidental carcinomas are usually at an early stage, with rare vascular or venous invasion, which can be treated by a simple cholecystectomy5,7. Stage T1 is treated by cholecystectomy alone whereas higher stages need multimodality management or at times only palliative care.

Mean age of our carcinoma patients was 68.5 years. Male to female ratio was 1:1. Studies that we have compared with have indicated a female predominance and increasing age to be demographic risk factor1-3, 23-29. Our study had an equal gender distribution but advanced presenting age for incidental carcinoma so we should keep the suspicion of gall bladder carcinoma high on the list in aging population, especially in females in light of demographic evidence we have from other larger studies.

The significantly higher ratio of gall bladder carcinoma reported in our local literature as an incidental carcinoma is probably due to inadequate pre-operative evaluation. In our institute, a routine pre-operative work up includes laboratory and radiological investigations, especially ultrasonography, making pre-operative diagnosis of malignancy more likely. Ultrasonography has changed the management of cholelithiasis by early detection but malignancy is rarely picked before a solid intramural mass is present24. Low frequency of maligancy in our patients can also be attributed to increased and early acceptance of patients for laparoscopic cholecystectomy at our institution before development of carcinoma in diseased gall bladders. These strategies can account for the low frequency of incidental carcinoma in our operated cases compared to other local studies.

However we still believe that our study has certain limitations so we propose to carry out larger, longer, multi-centric and if possible prospective studies to establish with accuracy the true frequency of incidental carcinoma gall bladder in our country.

CONCLUSION

The frequency of incidental gall bladder carcinoma was found to be very low (0.21 %) and that too in elderly patients. Our findings are in contrast to the earlier published local literature on the frequency of incidental carcinoma gall bladder and calls for large scale and multi-centric studies to further authenticate our study.

PREFRENCES

1. Stinton LM, Shaffer EA. Epidemiology of Gall bladder Disease: Cholelithiasis and Cancer. Gut Liver 2012; 6:172-87.

2. Hundal R, Shaffer EA. Gall bladder cancer: epidemiology and outcome. Clinic Epid 2014; 6:99-109.

3. Khan JS, Ali Hassan I, Khan MM, Iqbal M. Frequency of incidental carcinoma gall bladder in laparoscopic cholecystectomy. J Rawalpindi Med Coll 2013; 17:36-8.

4. Cucinotta E, Lorenzini C, Melita G, Iapachino G, Curro G. Incidental gall bladder carcinoma: does the surgical approach influence the outcome. Aust NZ J Surg 2005; 75: 795-8.

5. Ferrarese AG, Solei M, Enrico S, Falcone A, Catalano S, Pozzi G, et al. Diagnosis of incidental gall bladder cancer after laparoscopic cholecystectomy: our experience. BMC Surg 2013; 13:S20.

6. Rathanaswamy S, Misra M, Kumar V, Pogal C, Pogal J, Agarwal A, et al. Incidentally Detected Gall bladder CancerThe Controversies and Algorithmic Approach to Management. Indian J Surg 2012; 74:248-54.

7. Cavallaro A, Piccolo G, Panebianco V, Menzo EL, Berretta M, ZanghA A, et al. Incidental gall bladder cancer during laparoscopic cholecystectomy: Managing an unexpected finding. World J Gastroenterol 2012; 18: 4019-27.

8. Edge SB, Byrd DR, Compton CC, Fritz AG, Green FL, Trotti A. Am Joint Comm Canc Cancer Staging Manual. 7th Ed. New York: Springer; 2010.

9. Siddiqui FG, Memon AA, Abro AH, Sasoli NA, Ahmad L. Routine histopathology of gall bladder after elective cholecystectomy for gallstones: waste of resources or a justified act? BMC Surg 2013; 13:26.

10. Qazi TU, Ahmad F, Tahir M, Tahir NB. Carcinoma of Gall bladder: Its frequency and clinical presentation in two hundred cases of cholelithiasis. Gomal J Med Sci 2013; 11: 37-41.

11. Shah FO, Hadi A, Khan SA, Zafar H, Ahmed B, Khan M, et al. Frequency of incidental gall bladder carcinoma following cholecystectomy for symptomatic gallstone disease. J Surg Pak 2012; 17:167-71.

12. Junejo A, Khatoon S, Balouch TA. Incidence of carcinoma of gall bladder in patients with cholilithiasis. Med Chan 2012; 18:7-10.

13. Shaikh SM, Shaikh IA, Mughal SA. Incidence of gall bladder malignancy in patients with cholelithiasis. J Surg Pak 1999; 4: 18-21.

14. Abassi A, Qasmi SA, Ghafoor A, Kiani F, Abassi H. Frequency of carcinoma gall bladder in cases of cholelithiasis undergoing cholecystectomy at tertiary care hospital. Rawal Med J 2012; 37:406-8.

15. Soomro AG, Jarwar M, Ali SA, Nizamani NB, Memon AS. Frequency of Carcinoma in Gall bladder Specimens sent for Histopathology in a University Hospital. J Liaqat Uni Med Hosp Sci 2013; 12:55-9.

16. Lohana D, Laghari MH, Memon RA, Khawaja MA, Kumar B, Memon A. Frequency of Gall bladder carcinoma in patients undergoing surgery for cholelithiasis. Isra Med J 2009; 1:13-8.

17. Iftikhar M, Hussain M, Ullah I, Iqbal Z. Frequency of carcinoma in cholecystectomies performed for symptomatic gall stones. Ann Pak Inst Med Sci 2011; 7: 75-8.

18. Naqvi SQH, Mangi IH, Dahri FJ, Khaskheli QA, Akhund AA. Frequency of carcinoma of gall bladder in patients with cholelithiasis. Gomal J Med Sci 2005; 3:41-3.

19. Malik KA, Jawaid M. Incidental gall bladder carcinoma in patients undergoing cholecystectomy for cholelithiasis. Pak J Surg 2009; 25:262-5.

20. Ahmed G. Carcinoma Gall bladder; Incidence in Cholelithiasis. The Professional 1998; 5: 437-44.

21. Ahmed I. Prevalence of Carcinoma Gall bladder in patients with Cholelithiasis. Pak J Med Sci 1995; 11: 213-7.

22. Yi X, Long X, Zai H, Xiao D, Li W, Li Y. Unsuspected gall bladder carcinoma discovered during or after cholecystectomy: focus on appropriate radical re-resection according to the T-stage. Clin Transl Oncol 2013; 15:652-8.

23. Genc V, Onur Kirimker E, Akyol C, Kocaay AF, Karabork A, Tuzuner A, et al. Incidental gall bladder cancer diagnosed during or after laparoscopic cholecystectomy in members of the Turkish population with gallstone disease. Turk J Gastroenterol. 2011; 22:513-6.

24. Kalita D, Pant L, Singh S, Jain G, Kudesia M, Gupta K, et al. Impact of Routine Histopathological Examination of Gall bladder Specimens on Early Detection of Malignancy A Study of 4,115 Cholecystectomy Specimens. Asian Pacific J Cancer Prev 2014; 14:3315-8.

25. Suiata J, S R, Sabina K, Mj H, Jairajpuri ZS. Incidental Gall bladder Carcinoma in Laparoscopic Cholecystectomy: A report of six cases and review of literature. J Clinic Diagn Res 2013; 7: 85-8.

26. Mittal R, Jesudason MR, Nayak S. Selective histopathology in cholecystectomy for gallstone disease. Indian J Gastroenterol 2010; 29:32-6.

27. Ghnnam WH, Al Bashrey TM, Malek JR. Incidental carcinoma gall bladder in laproscopic cholecystectomy: Five years local experience. El Med L 2014; 2:47-51.

28. Almuslamani AJ, Alsoude M, Alomari M, Mnazel T, Khasawana G. Histopathological examination on suspicious gall bladder specimens at Royal Medical Services Hospitals. Rawal Med J 2011; 36:93-6.

29. Ghimire P, Yogi N, Shrestha BB. Frequency of incidental carcinoma gall bladder in cases of routine cholecystectomy. Kathmandu Univ Med J 2011; 34:3-6.
COPYRIGHT 2016 Asianet-Pakistan
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 2016 Gale, Cengage Learning. All rights reserved.

Article Details
Printer friendly Cite/link Email Feedback
Publication:Journal of Postgraduate Medical Institute
Article Type:Report
Geographic Code:9PAKI
Date:Jun 30, 2016
Words:3230
Previous Article:POSTGRADUATE EDUCATION IN KHYBER PAKHTUNKHWA.
Next Article:UTERINE FIBROIDS GOING INTO THE HEART: INTRAVASCULAR AND INTRA-CARDIAC LEIOMYOMATOSIS: A VERY UNUSUAL PRESENTATION.
Topics:

Terms of use | Privacy policy | Copyright © 2019 Farlex, Inc. | Feedback | For webmasters