case presentation of adenosquamous cell carcinoma gall bladder

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Adenosquamous Ca is very rare tumor of gall bladder. it usually occurs in elderly women. in this case, patient was 60 yr old lady with history of colitis

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CASE PRESENTATION: ADENOSQUAMOUS CARCINOMA GALL BLADDER:

CASE PRESENTATION: ADENOSQUAMOUS CARCINOMA GALL BLADDER MODERATOR: DR O.P MOORJANI SPEAKER: DR RAVI JAIN

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PATIENT’S BIO DATA Name: Narmada Bai Age/Sex: 60 yr/F OPD Reg No: 39628/11 IPD Reg No: 39253/11

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A 60 year old woman presented in the Surgery OPD with complaints of : Pain in right hypochondrium since 4-5 days Loss of appetite Vomiting

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Past history: She had Amoebic liver abscess with Colitis On clinical examination: No icterus was visible Liver was mildly enlarged Spleen was not palpable

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Laboratory investigations: CBC – within normal limits Coagulation profile – Slightly increased Liver function tests – Moderately elevated

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Radiological investigations: CT abdomen – Soft tissue lesion in Gall Bladder fundus along with concentric wall thickening in the wall of Splenic flexure. ? Gall Bladder Neoplasm

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Provisional Diagnosis : ? Gall Bladder Neoplasm with Liver Abscess Patient was admitted in ward Exploratory laparatomy was done & whole Gall bladder including the mass was excised & sent to Pathology department for Histopathological examination

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GROSS EXAMINATION: Cholecystectomy specimen 6 X 3 X 2.5 cm On cut: A single grayish white growth identified at the neck & body of gall bladder measuring 4 X 2 X 1 cm Rest of the gall bladder was unremarkable.

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MICROSCOPIC EXAMINATION: Two components Adeno component – tumor cells arranged in the form of glands Squamous component – Malignant squamous cells arranged in form of sheets.

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DISCUSSION

ANATOMY OF GALL BLADDER:

ANATOMY OF GALL BLADDER

HISTOLOGY OF GALL BLADDER:

HISTOLOGY OF GALL BLADDER

TUMORS OF GALL BLADDER:

TUMORS OF GALL BLADDER

CLASSIFICATION OF TUMORS OF GALL BLADDER & EXTRAHEPATIC BILE DUCTS: EPITHELIAL TUMORS:

CLASSIFICATION OF TUMORS OF GALL BLADDER & EXTRAHEPATIC BILE DUCTS: EPITHELIAL TUMORS BENIGN Tubular Adenoma Papillary Adenoma Tubulopapillary Adenoma Cyst adenoma Papillomatosis (adenomatosis) MALIGNANT Carcinoma in situ Adenocarcinoma Papillary adenocarcinoma Adenocarcinoma, intestinal type Mucinous Adenocarcinoma Clear cell Adenocarcinoma Signet ring cell carcinoma Adenosquamous carcinoma Squamous cell carcinoma Small cell carcinoma (oat cell) Undifferentiated carcinoma

CLASSIFICATION OF TUMORS OF GALL BLADDER & EXTRAHEPATIC BILE DUCTS: NON EPITHELIAL TUMORS:

CLASSIFICATION OF TUMORS OF GALL BLADDER & EXTRAHEPATIC BILE DUCTS: NON EPITHELIAL TUMORS BENIGN Granular cell tumor Leiomyoma Lipoma Hemangioma Lymphangioma Neurofibroma Ganglioneurofibromatosis Neurofibromatosis MALIGNANT Rhabdomyosarcoma Kaposi’s sarcoma Leiomyosarcoma Malignant fibrous histiocytoma Angiosarcoma MISCELLANEOUS Carcinosarcoma Malignant melanoma Malignant lymphomas

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Ca gall bladder More frequent in females Incidence – 0.17% in Males & 0.49% in Females (US general population) Most common in middle age group More common in Latin American countries Definite epidemiological relation between gall bladder ca & gall stones Ca Gall Bladder

Ca Gall Bladder:

CONDITIONS WITH INCREASED RISK Cholecystoenteric fistula Porcelain gall bladder Ulcerative colitis Adenomyomatosis Polyposis coli Ca Gall Bladder

Ca Gall Bladder:

CLINICAL & LAB FEATURES: Right upper quadrant abdominal pain Anorexia Elevated alkaline phosphatase levels Ca Gall Bladder

Ca Gall Bladder:

GROSS FEATURES: DIFFUSELY GROWING(70 %) or POLYPOID MASS(30 %) Usually contain stones along with fibrosis of the wall Ca Gall Bladder

Ca Gall Bladder:

Papillary adenocarcinoma Adenocarcinoma in diffuse pattern Ca Gall Bladder

Ca Gall Bladder:

MICROSCOPIC FEATURES: Most common is Adenocarcinoma showing varying degree of differentiation Well formed glands with wide lumina lined by one or few rows of highly atypical cuboidal cells, surrounded by a cellular stroma often arranged concentrically Foci of intestinal differentiation are common, with appearance of goblet cells, endocrine cells & paneth cells Ca Gall Bladder

Ca Gall Bladder:

Well differentiated GB AdenoCa Well differentiated GB AdenoCa with papillary pattern Ca Gall Bladder

Ca Gall Bladder:

Ca Gall Bladder OTHER MICROSCOPIC TYPES: ADENOACANTHOMA – Squamous component well differentiated ADENOSQUAMOUS CARCINOMA - Squamous component poorly differentiated SQUAMOUS CELL CARCINOMA UNDIFFERENTIATED CARCINOMA SMALL CELL NEUROENDOCRINE CARCINOMA

Ca Gall Bladder:

Adenosquamous carcinoma Gall Bladder Sarcomatoid carcinoma Gall bladder Ca Gall Bladder

Ca Gall Bladder:

Ca Gall Bladder IMMUNOHISTOCHEMISTRY: Keratin stains are strongly +ve Usual profile is CK7+/CK20+ In intrahepatic cholangiocarcinoma, profile is CK7+/CK20- Other markers which are +ve - EMA & CEA

Ca Gall Bladder:

SPREAD & METASTASES: Great propensity to invade Liver directly Lesser extent to stomach & duodenum Also to cystic & pericholedochal lymph nodes in lesser omentum Ca Gall Bladder

Ca Gall Bladder:

Ca Gall Bladder TREATMENT : Surgery is main mode of treatment Cholecystectomy for stages I & II Radical surgery for stages III & IV Palliation alone for stage V PROGNOSTIC FACTORS: Stage Surgical margins Grading DNA content K – Ras C-erbB-2 oncogene Angiogenesis

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5 year survival rate: 90 % for Stage I & II 11 & for stage III & IV 0% for stage V

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THANK YOU Dr. Ravi Jain P.G. student- III yr