Port site and distant metastases of gallbladder cancer after laparoscopic cholecystectomy diagnosed by positron emission tomography

We report port site and distant metastases of unsuspected gallbladder cancer after laparoscopic cholecystectomy diagnosed by positron emission tomography （PET） in two patients. Patient 1, a 72-yearold woman was diagnosed as cholelithiasis and cholecystitis and received laparoscopic cholecystectomy. Unsuspected gallbladder cancer was discovered with histological result of well-differentiated squamous cell carcinoma of the gallbladder infiltrating the entire wall. A PET scan using F-18-fluorodeoxyglucose （FDG- PET） before radical resection revealed residual tumor in the gallbladder fossa and recurrence at port site and metastases in bilateral hilar lymph nodes. Patient 2, a 69-year-old woman underwent laparoscopic cholecystectomy more than one year ago with pathologically confirmed unsuspected adenosquamous carcinoma of stage pTlb. At 7-mo follow-up after surgery, the patient presented with nodules in the periumbilical incision. Excisional biopsy of the nodule revealed adenosquamous carcinoma. The patient was examined by FDG-PET, demonstrating increased FDG uptake in the right lobe of the liver and mediastinal lymph nodes consistent with metastatic disease. This report is followed by a discussion about the utility of FDG-PET in the gallbladder cancer.     

FDG-PET scanning in the diagnosis of gastrointestinal cancers

This review deals with the current, well-established indications for two-(18F)-fluoro-2-deoxy-D-glucose positron emission tomography (FDG-PET) scanning in patients with gastrointestinal cancers. FDG-PET is a non-invasive, functional imaging technique. FDG exploits the native glucose transporter to enter the cell. Since many tumours have enhanced glucose uptake, FDG is readily accumulated in malignant cells and can be detected by a PET camera. FDG-PET has been established as an important diagnostic tool in clinical oncology. This review deals with the current, well-established indications for FDG-PET scanning in patients with gastrointestinal cancers. In the current practice, FDG-PET is most commonly used to stage oesophageal carcinoma, to detect and stage recurrence of colorectal carcinoma and to differentiate between benign and malignant pancreatic lesions. The benefit of FDG-PET scanning in patients with oesophagus carcinoma is best established in stage IV disease, as the diagnostic accuracy to detect metastatic disease is higher compared to the combination of computed tomography (CT) and endoscopic ultrasound (EUS). In patients with a history of colorectal carcinoma, FDG-PET scanning is particularly effective in diagnosing recurrent disease, especially in those with a rising carcinoembryonic antigen without a suspect lesion on conventional imaging. Large series have indicated that the sensitivity and specificity for detecting recurrent colorectal carcinoma are in the range of 87%-100% and 66%-100%, respectively. Equally, FDG-PET has a high sensitivity (68%-96%) and specificity (78%-100%) in detecting pancreatic carcinoma in patients with a suspicious-looking pancreatic mass on CT scan. Lastly, we focus on the use of FDG-PET as a modality for early monitoring of treatment response in patients with gastrointestinal stromal cell tumours. Without doubt, future developments will further establish the diagnostic role of the FDG-PET scan in the care of patients with gastrointestinal cancers.     

A large inflammatory polyp of the gallbladder masquerading as gallbladder carcinoma

An inflammatory polyp of the gallbladder is a rare variant of benign gallbladder polyp. Differentiation between an inflammatory polyp and polypoid gallbladder carcinoma is difficult when the polyp is more than 1 cm in diameter. We report a rare case of a large inflammatory polyp of the gallbladder masquerading as gallbladder carcinoma in a 37-year-old Japanese woman who was incidentally diagnosed with a large gallbladder polyp, measuring 1 cm in diameter, by ultrasonography. She was asymptomatic and physical examination was unremarkable. Abdominal ultrasonography and endoscopic ultrasonography revealed three polypoid lesions in the gallbladder. One lesion was an isoechoic polyp, measuring 15 × 8 mm, showing a nodular surface and located in the fundus of the gallbladder. The other two lesions were hyperechoic polyps, measuring 5 × 5 mm, in the body of the gallbladder. Computed tomography and magnetic resonance imaging revealed marked enhancement of the largest polypoid lesion by dynamic study, and no lymph node enlargement was noted. Endoscopic retrograde cholangiography revealed a 12 × 8 mm polyp with an irregular surface in the fundus of the gallbladder. Superselective angiography of the cystic artery revealed neovascularity and a tumor stain in the fundus of the gallbladder. Cholecystectomy with lymph node dissection was performed. Intraoperative frozen section diagnosis of the largest polyp was an inflammatory polyp of the gallbladder. The other two polyps were cholesterol polyps. Inflammatory polyp should be considered as a differential diagnosis of hypervascular gallbladder polyps that measure more than 1 cm in diameter. Received Dec. 26, 1997; accepted Apr. 24, 1998     

Fluoro-deoxyglucose positron emission tomography imaging for the detection of occult disease in multiple myeloma

Positron emission tomography with 2-deoxy-2-[18]fluoro-D-glucose (FDG-PET) imaging has been extensively used to detect occult metastatic malignant lesions in patients with carcinoma. We describe its use in three patients with multiple myeloma, each representing a particular clinical situation in which this imaging modality offered advantages over plain radiography, computerized tomography or magnetic resonance imaging. FDG-PET provides a whole body image showing sites of occult disease. This is of particular value in patients with non-secretory myeloma, solitary plasmacytoma or for those that relapse with focal disease following autologous or allogeneic stem cell transplantation.     

Spontaneous necrosis of gallbladder carcinoma in patient with pancreaticobiliary maljunction

While gallbladder carcinoma is occasionally associated with pancreaticobiliary maljunction, spontaneous necrosis of carcinoma is extremely rare. We herein present a case of spontaneous necrosis of gallbladder carcinoma associated with direct invasion of viable cancer cell nests to the muscularis propria and subserosal layer located beneath the primary nodules. A 65-year-old Japanese man was admitted to a local hospital, complaining of repeated discomfort in the right hypochondrium. Ultrasonography and computed tomography scanning revealed cholecystitis associated with gallstones. Cholecystectomy was performed, and operative cholangiography demonstrated pancreaticobiliary maljunction. The resected gallbladder showed multiple mixed stones filled with necrotic debris and bile sludge. Scrutiny of the mucosal surface revealed multiple small necrotic nodules in the fundus, which were histologically confirmed to be necrotic remnants of a cancerous glandular structure. Small nests of papillary adenocarcinoma were found beneath the nodules in the muscularis propria and in the venous structure located in the connective tissues next to the divided margin of the gallbladder bed. Resection of S4a and S5 of the liver and resection of the extrahepatic bile duct was then performed to remove the remaining cancerous tissues and/or micrometastasis in the liver and bile duct. The biliary tree was reconstructed with a hepaticoduodenostomy. No cancer nests or any precancerous lesions were found in the additionally resected specimens. This case indicates a unique morphological feature of gallbladder carcinoma associated with pancreaticobiliary maljunction, which provides some insight into the pathogenesis of spontaneous necrosis of gallbladder carcinoma.     

Computed tomography of xanthogranulomatous cholecystitis

A case is presented of xanthogranulomatous cholecystitis that resembled carcinoma of the gallbladder on computed tomography. The large, infiltrating mass satisfied the criteria for massive carcinoma of the gallbladder.     

FDG positron emission tomography in the diagnosis of peripheral pulmonary focal lesions

Positron emission tomography (PET) using fluoride-18-marked fluoride deoxyglucose (FDG) represents a metabolically based imaging technique capable of providing information on the potential malignancy of peripheral pulmonary focal lesions. In the present prospective study, we investigated the effectiveness of FDG-PET in determining the dignities of 67 such lesions in 35 patients. Findings of FDG-PET were compared with those of computed tomography (CT), as well as with surgical and histological reports, and the value of FDG-PET as a diagnostic method evaluated. FDG-PET correctly identified 38 lesions as positive for malignancy, 18 correctly as negative, 7 incorrectly as negative, and 4 incorrectly as positive. Based on lesions, this yields a sensitivity of 84.4% and a specificity of 81.8%. All malignant focal lesions with a diameter of over 1.2 cm were correctly identified (sensitivity: 100%). In cases of intense FDG uptake, differentiation between a primary lesion, a metastasis, and an acute inflammation is often not possible.     

Carcinoma in adenoma of the gallbladder in a patient with anomalous pancreaticobiliary ductal junction

We present a case of carcinoma in adenoma of the gallbladder with anomalous pancreaticobiliary ductal junction (APBDJ) in a 60-year-old Japanese woman. The patient had no abdominal symptoms. Serum levels of carcinoembryonic antigen, carbohydrate antigen 19-9, elastase 1, and α-fetoprotein were all within normal limits. Ultrasonography demonstrated two irregular hyperechoic lesions of the gallbladder. Computed tomography showed two soft-tissue density masses in the gallbladder. Endoscopic retrograde cholangiopancreatography showed APBDJ and two protruding lesions in the gallbladder. Angiography displayed a hypervascular lesion fed by the cystic artery. The patient underwent total cholecystectomy; the diagnosis of the intraoperative frozen section was well differentiated adenocarcinoma with possible mucosal invasion. Amylase level in the gallbladder bile was 90600 IU/l. Macroscopically, there were two polyps in the gallbladder. The larger one, 3.5 cm in diameter, was adenocarcinoma in adenoma, and the smaller one, an inflammatory polyp. We briefly discuss the relationship among adenoma, adenocarcinoma of the gallbladder, and APBDJ.     

Apport de la tomographie par émission de positons dans la prise en charge de la sarcoïdose

FDG-PET, now hybrid positron emission tomography/computed tomography (PET-CT), has become an established diagnostic tool in oncology. Fluorodesoxyglucose (¹⁸F-FDG) is not specific for malignant lesions, as uptake of the tracer depends on its accumulation in cells with an increased glucose metabolism as it is also the case in infectious and inflammatory lesions, like sarcoidosis. Thus, FDG-PET has been proposed for internal medicine indications, one of whom is sarcoidosis. The main characteristics of FDG-PET are its better sensitivity compared to ⁶⁷Ga scintigraphy and its ability to be used as an earlier marker of therapeutic response as compared with anatomy-based and conventional scintigraphic imaging. However, FDG-PET should be used in atypical or advanced stage of the disease. Future prospective studies should be awaited before integrating FDG-PET in clinical routine for treatment outcome and disease activity assessment in sarcoidosis. New radiopharmaceutical probes are under development and will improve the performance of PET.     

Triple carcinomas of the biliary tract associated with congenital choledochal dilatation and pancreaticobiliary maljunction

We report a rare case of triple carcinomas of the biliary tract associated with congenital choledochal dilatation (CCD) and pancreaticobiliary maljunction (PBM). The patient was a 58-year-old Japanese man who complained of epigastralgia. Ultrasonography and computed tomography revealed an elevated lesion inside the markedly dilated extrahepatic bile duct, thickening of the gallbladder wall, and small polypoid lesions in the gallbladder. Magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography showed CCD and PBM. With a diagnosis of carcinoma of the bile duct and cholesterol polyps in the gallbladder, pylorus-preserving pancreaticoduodenectomy was performed. The resected specimen showed two elevated lesions in the dilated bile duct, cholesterol polyps, and an area of irregular mucosa in the gallbladder. Histopathological examination showed two carcinomas in the bile duct, an adenosquamous cell carcinoma, and a moderately differentiated tubular adenocarcinoma, and a well differentiated tubular adenocarcinoma of the gallbladder. Two years and 6 months after the operation, a solitary metastatic liver tumor was detected. Left hepatic lobectomy was performed. At present, 7 months after the second operation, the patient is doing well with no signs of recurrence. Multiple carcinomas in the biliary tract associated with CCD and PBM, including the details in the present patient, were reviewed. Received: March 31, 1999 / Accepted: October 22, 1999     

A large fibrous polyp of the gallbladder mimicking a polypoid carcinoma

Fibrous polyp of the gallbladder is a rare variant of benign gallbladder polyp. Differentiation between a benign polyp and polypoid carcinoma of the gallbladder is often difficult when the polyp is more than 1cm in diameter. We report a rare case of a large fibrous polyp of the gallbladder mimicking a carcinoma. A 44-year-old Korean woman who presented with abdominal pain was diagnosed with a large gallbladder polyp, measuring 1.26cm in diameter, by abdominal ultrasonography. The lesion was echogenic with a nodular surface on ultrasonography, and showed contrast enhancement on computed tomography. Neither evidence of infiltration into the gallbladder wall nor lymph node enlargement was shown. The resected gallbladder showed a 1.2 × 0.8-cm-sized polyp with a nodular surface. Histologically, it showed a leaf-like configuration and loose or cellular connective stroma containing scattered duct-like structures, varying-sized vessels, and patchy infiltration of chronic inflammatory cells. Stromal cells were immunoreactive for vimentin and smooth-muscle actin and negative for S-100 protein and desmin. Large fibrous polyps of the gallbladder should be considered in the differential diagnosis of benign and malignant polypoid lesions of the gallbladder.     

Neuro-Behçet’s Syndrome in a Patient not Fulfilling Criteria for Behçet’s Disease: Clinical Features and Value of Brain Imaging

Central nervous system involvement is rarely an initial presenting manifestation of Beh?et's disease (BD). We report the case of a 33-year-old man with recurrent attacks of fever, oral mucosal ulcers, deep venous thrombosis, diplopia, vertigo and headache. Sequential brain magnetic resonance imaging (MRI) scans showed fluctuating lesions of the brain stem, mesencephalon and thalamus. F-18-fluoro-2-deoxy-D-glucose positron emission tomography (FDG-PET) revealed hypometabolism at the parieto-occipital cortex at both sides and the brain stem. Treatment with prednisone and cyclosporine A led to a complete remission and normalisation of MRI and FDG-PET lesions. The present case illustrates the difficulty in the differential diagnosis of early neuro-BD.     

Intense PET signal in the degenerative necrosis superimposed on chronic pancreatitis

Although fluorine-18 deoxyglucose-positron emission tomography (FDG-PET) is a sensitive diagnostic modality in detecting malignant tumors, differential diagnosis of malignant tumors from inflammatory lesion is challenging. We experienced a case of acute degenerative necrosis superimposed on chronic pancreatitis, which was difficult to distinguish from pancreatic cancer. The patient was a 66-year-old man with a complaint of upper abdominal pain. Abdominal computed tomography revealed low-density masses in the head and body of the pancreas. FDG-PET revealed intense accumulations at the head and body of the pancreas (mean standard uptake value for the head and body pancreatic tumors was 4.1 and 6.7, respectively) corresponding to the 2 tumors detected by computed tomography. Because of a possible malignant pancreatic tumor, the patient underwent pylorus-preserving pancreatoduodenectomy. Histologic examination of the resected specimen revealed a characteristic of chronic pancreatitis in a nontumorous area. Two tumors detected by FDG-PET consisted of degenerative necrosis surrounded by granulation tissue. The amount of granulation tissue was correlated to the levels of standard uptake value. No malignant tumors were observed. This case suggests a limitation of FDG-PET in distinguishing malignant neoplastic lesions in the pancreas, especially from acute degenerative changes in chronic pancreatitis. Repetitive PET examination is recommended for the accurate diagnosis.     

Better yield of (18)fluorodeoxyglucose-positron emission tomography in patients with metastatic differentiated thyroid carcinoma during thyrotropin stimulation.

To determine whether (18)fluorodeoxyglucose-positron emission tomography (FDG-PET) for the detection of recurrences or metastases of differentiated thyroid carcinoma should be performed during thyrotropin (TSH) suppression or TSH stimulation, eight patients were studied sequentially. After the second FDG-PET scan, a therapeutic (131)I dose was administered with posttherapy scans obtained 10 days later. Both FDG-PET scans were compared with each other and with the (131)I posttherapy whole body scans by two independent observers. Findings were verified using other imaging modalities or biopsies. Median TSH was 0.04 mU/L during TSH suppression and 64 mU/L during TSH stimulation. The FDG-PET scans during TSH suppression showed abnormalities in four patients and the FDG-PET scan during TSH stimulation in five patients. One patient was only positive during TSH stimulation. In two other patients the FDG-PET scan during TSH stimulation clearly identified more lesions, and in all positive patients lesion contrast was better during TSH stimulation. In two patients FDG-PET findings during TSH stimulation led to a change in clinical management. Thus, the performance of FDG-PET during TSH stimulation was either superior or equal to FDG-PET during TSH suppression, but never inferior. To detect metastatic or recurrent differentiated thyroid carcinoma FDG-PET should be performed during hypothyroidism, leading to TSH stimulation.     

Gallbladder adenomyomatosis with tubercular portal lymphadenopathy masquerading as gallbladder carcinoma

Gallbladder carcinoma is more likely to occur in elderly females and the presence of periportal adenopathy often signifies advanced disease. Such patients are generally not taken up for surgery and are treated palliatively. Isolated periportal tuberculosis without the evidence of disease elsewhere is in itself a rarity. Here we present a case study of gallbladder mass suspected of being gallbladder carcinoma with portal lymphatic metastasis actually turning out to be that of gallbladder adenomyoma with periportal tuberculosis. This case illustrates how mass lesions of the gallbladder are commonly and falsely interpreted to be malignant.     

Clinical impact of 18F-FDG-PET in the suspicion of recurrent colorectal cancer based on asymptomatically elevated serum level of carcinoembryonic antigen (CEA) in Taiwan

BACKGROUND/AIMS: To retrospectively evaluate the impact of 18F-fluorodeoxy-glucose-positron emission tomography (FDG-PET) to detect recurrent colorectal cancer based on asymptomatically elevated tumor marker level of carcinoembryonic antigen (CEA). METHODOLOGY: Whole-body FDG-PET was performed in 50 patients suspected of having recurrent colorectal cancer and asymptomatically increased serum level of CEA (> 5 ng/mL), but other negative or equivocal imaging modality results. A blood sample was drawn in each case for CEA assay on the same day as the FDG-PET. The final diagnosis of recurrent colorectal cancer was established by operation/biopsy histopathological findings or clinical follow-up longer than 1 year by additional morphologic imaging techniques. RESULTS: Among the 50 patients, the final diagnosis of recurrent colorectal cancer was established in 64 lesions of 45 patients. FDG-PET could accurately detect 62 lesions but missed 2 false-negative lesions. In addition, there were 2 false-positive lesions. On a lesion-based analysis, the diagnostic sensitivity and positive predictive value of FDG-PET was 96.9%. There were 2 patients with false-negative lesions and 2 patients with false-positive lesions. Therefore, FDG-PET findings could lead to successful surgical resection in 41 (82.0%) patients. In addition, on a patient-based analysis, the diagnostic sensitivity and positive predictive value of FDG-PET was 95.3%. CONCLUSIONS: FDG-PET is a useful technique for detecting recurrent colorectal cancer suspected by asymptomatically elevated serum level of CEA and has an important clinical impact on the management in patients with suspected recurrent colorectal cancer.     

Mucin-producing carcinoma of the gallbladder associated with primary sclerosing cholangitis and ulcerative colitis

Mucin-producing carcinoma of the gallbladder is very rare. We report here a case of mucin-producing carcinoma of the gallbladder associated with primary sclerosing cholangitis (PSC) and ulcerative colitis (UC). A 74-year-old female had been treated with salazosulfapyridine and ursodesoxycholic acid becase of UC and PSC. After 7 years of treatment, laboratory data showed that the liver function took a turn for the worse, and the patient was admitted to our hospital for further examination. Enhanced computed tomography and ultrasonography showed an enlarged gallbladder associated with wall thickening and diffuse papillary protrusion. Endoscopic retrograde cholangiography showed stenosis and dilatation of the bile duct, which were compatible with PSC. Under the diagnosis of an early carcinoma of the gallbladder, we performed simple cholecystectomy. The tumor showed a papillary growth pattern located diffusely in the gallbladder with a massive amount of mucin filling the gallbladder. Histologically, it was diagnosed as a papillary adenocarcinoma localized in the mucosal layer. To the best of our knowledge, this is the first case of mucin-producing carcinoma of the gallbladder associated with PSC and UC. PSC and UC patients should be regarded as a high-risk group not only for cholangiocarcinoma but also carcinoma of the gallbladder.     

Cholecystocolic fistula caused by gallbladder carcinoma: Preoperatively misdiagnosed as hepatic colon carcinoma

Cholecystocolic fistula secondary to gallbladder carcinoma is extremely rare and has been reported in very few studies. Most cholecystocolic fistulae are late complications of gallstone disease, but can also develop following carcinoma of the gallbladder when the necrotic tumor penetrates into the adjacent colon. Although no currently available imaging technique has shown great accuracy in recognizing cholecystocolic fistula, abdominopelvic computed tomography may show fistulous communication and anatomical details. Herein we report an unusual case of cholecystocolic fistula caused by gallbladder carcinoma, which was preoperatively misdiagnosed as hepatic flexure colon carcinoma.     

Gallbladder cancer associated with cholesterosis

We report herein two cases of carcinoma in situ of the gallbladder associated with cholesterosis. The patient in case 1 was an 81-year-old man who underwent a cholecystectomy for cholelithiasis. The resected specimens revealed gallbladder cancer in the fundus which was diagnosed histologically as mucinous carcinoma. Other findings included 13-mm, 12-mm, and 5-mm poly-poid lesions in the neck of the gallbladder which macroscopically appeared to be cholesterol polyps, but histologically demonstrated carcinoma in situ with cholesterosis. The patient in case 2 was a 76-year-old man in whom ultrasonography revealed a highly echogenic, elevated lesion in the gallbladder. Cholecystectomy was performed, and a 33×28-mm papillary, elevated lesion with cholesterosis was resected from the neck of the gallbladder. Histologically, this was demonstrated to be papillary adenocarcinoma in situ with cholesterosis surrounded by glandular dysplasia. The distribution of the carcinomas and cholesterosis in both of these patients suggests that the adenoma or carcinoma of the gallbladder had occurred first. Then, the tumor epithelium absorbed cholesterol from the bile, and foamy cells were produced. Thus, when treating cholesterol polyps, it should be remembered that it is often difficult to distinguish between cholesterol polyp and gallbladder cancer with cholesterosis.     

Lymph node staging in lung cancer using [18F]FDG-PET

BACKGROUND: Mediastinal lymph node staging is essential to determine treatment options in patients with NSCLC. Positron emission tomography (PET) detects increased glucose uptake in malignant tissue using the glucose analogue 2-[(18)F]fluoro-2-deoxy-D-glucose (FDG). PATIENTS AND METHODS: In the present study were evaluated 155 patients with focal pulmonary tumors who underwent both preoperative computed tomography (CT) and FDG-PET scanning (116 malignant and 39 benign lesions). RESULTS: Findings in 155 patients included 116 malignant and 39 benign lesions. For N-staging, FDG-PET showed a sensitivity of 88%, a specificity of 91%, and an accuracy of 89%. Corresponding figures for CT were 77%, 76%, and 77%, respectively. CONCLUSIONS: FDG-PET is an effective, noninvasive method for staging thoracic lymph nodes in patients with lung cancer and is superior to CT scanning in the assessment of hilar and mediastinal nodal metastases. With regard to operability, FDG-PET could differentiate reliable between patients with N1/N2 disease and those with unresectable N3 disease.