Individualized nomogram improves diagnos-tic accuracy of stage I-II gallbladder cancer in chronic cholecystitis patients with gallbladder wall thickening

BACKGROUND: Early diagnosis of gallbladder cancer (GBC) can remarkably improve the prognosis of patients. This study aimed to develop a nomogram for individualized diagnosis of stage I-II GBC in chronic cholecystitis patients with gallblad-der wall thickening.
METHODS: The nomogram was developed using logistic re-gression analyses based on a retrospective cohort consisting of 89 consecutive patients with stage I-II GBC and 1240 patients with gallbladder wall thickening treated at one biliary surgery center in Shanghai between January 2009 and December 2011. The accuracy of the nomogram was validated by discrimina-tion, calibration and a prospective cohort treated at another center between January 2012 and December 2014 (n=928).
RESULTS: Factors included in the nomogram were advanced age, hazardous alcohol consumption, long-standing diagnosed gallstones, atrophic gallbladder, gallbladder wall calciifcation, intraluminal polypoid lesion, higher wall thickness ratio and mucosal line disruption. The nomogram had concordance indices of 0.889 and 0.856 for the two cohorts, respectively. Internal and external calibration curves iftted well. The area under the receiver-operating characteristic curves of the no-mogram was higher than that of multidetector row computed tomography in diagnosis of stage I-II GBC (P<0.001).
CONCLUSION: The proposed nomogram improves individu-alized diagnosis of stage I-II GBC in chronic cholecystitis pa-tients with gallbladder wall thickening, especially for those the imaging features alone do not allow to conifrm the diagnosis.     

Imaging-based algorithmic approach to gallbladder wall thickening

Gallbladder(GB) wall thickening is a frequent finding caused by a spectrum of conditions. It is observed in many extracholecystic as well as intrinsic GB conditions. GB wall thickening can either be diffuse or focal. Diffuse wall thickening is a secondary occurrence in both extrinsic and intrinsic pathologies of GB, whereas, focal wall thickening is mostly associated with intrinsic GB pathologies. In the absence of specific clinical features, accurate etiological diagnosis can be challenging. The survival rate in GB carcinoma(GBC) can be improved if it is diagnosed at an early stage, especially when the tumor is confined to the wall. The pattern of wall thickening in GBC is often confused with benign diseases, especially chronic cholecystitis, xanthogranulomatous cholecystitis, and adenomyomatosis. Early recognition and differentiation of these conditions can improve the prognosis. In this minireview, the authors describe the patterns of abnormalities on various imaging modalities(conventional as well as advanced) for the diagnosis of GB wall thickening. This paper also illustrates an algorithmic approach for the etiological diagnosis of GB wall thickening and suggests a formatted reporting for GB wall abnormalities.     

Contrast‐enhanced harmonic endoscopic ultrasonography for differential diagnosis of localized gallbladder lesions

Background and Aim

Differential diagnosis of localized gallbladder lesions is challenging. The aim of the present study was to evaluate the utility of contrast‐enhanced harmonic endoscopic ultrasonography (CH‐EUS) for diagnosis of localized gallbladder lesions.

Methods

One hundred and twenty‐five patients with localized gallbladder lesions were evaluated by CH‐EUS between March 2007 and February 2014. This was a single‐center retrospective study. Utilities of fundamental B‐mode EUS (FB‐EUS) and CH‐EUS in the differentiation of gallbladder lesions and sludge plug were initially compared. Thereafter, these two examinations were compared with respect to their accuracy in the diagnosis of malignant lesions. Five reviewers blinded to the clinicopathological results evaluated microcirculation patterns in the vascular and perfusion images.

Results

In the differentiation between gallbladder lesions and sludge plug, FB‐EUS had a sensitivity, specificity, and accuracy of 82%, 100%, and 95%, respectively, whereas CH‐EUS had a sensitivity, specificity, and accuracy of 100%, 99%, and 99%, respectively. FB‐EUS‐based diagnosis of carcinomas based on tumor size and/or shape had a sensitivity, specificity, and accuracy of 61–87%, 71–88%, and 74–86%, respectively. Additional information regarding irregular vessel patterns in the vascular image and/or heterogeneous enhancement in the perfusion image on CH‐EUS increased the sensitivity, specificity, and accuracy for the diagnosis of carcinomas to 90%, 98%, and 96%, respectively. There was a significant difference between FB‐EUS and CH‐EUS in terms of carcinoma diagnosis.

Conclusion

CH‐EUS was useful for the evaluation of localized gallbladder lesions.     

Endoscopic ultrasonography‐guided gallbladder drainage for acute cholecystitis: From evidence to practice

With the evolution of the linear echoendoscope and the improved ability to direct a needle within the field of interest, the therapeutic potential of endoscopic ultrasonography (EUS) has greatly expanded. Endoscopic ultrasonography‐guided transmural gallbladder drainage (EUS‐GBD) may be the next frontier for therapeutic EUS. Since EUS‐GBD was first described in 2007, recent reports have suggested it as an alternative to external gallbladder drainage for acute cholecystitis. EUS‐GBD includes EUS‐guided transmural nasogallbladder drainage, EUS‐guided gallbladder aspiration, and EUS‐guided transmural gallbladder stenting. Indications for the EUS‐GBD technique as currently practiced, including equipment, technical details, complications, and efficacy are herein reviewed.     

Usefulness and Limitations of Endoscopic Ultrasonography in Diagnosis of Adenomyomatosis of the Gallbladder

Abstract: Although endoscopic ultrasonography (EUS) is commonly used to examine lesions in the gallbladder, its ability to accurately diagnose adenomyomatosis (ADM) has not been evaluated. We compared the accuracy of EUS and various other imaging techniques in the diagnosis of ADM. Thirty-one patients undergoing cholecystectomy after elevated lesions were found in the gallbladder by various imaging techniques were studied retrospectively. Based on histopathologic examination, the sensitivity and specificity of EUS were evaluated in ADM. The sensitivity of abdominal ultrasonography, CT and ERCP in ADM were also evaluated. Of the 11 patients diagnosed with ADM by EUS, 9 cases were confirmed histologically (81.8%). Of the 11 patients with histologic diagnosis of ADM, 9 were accurately diagnosed preoperatively by EUS (81.8%). EUS proved more reliable for diagnosis of ADM than the other imaging techniques. Important diagnostic features include preservation of the three-layered structure of the gallbladder, wall-thickening exceeding 3 mm, and 2 or more Rokitansky-Aschoff sinuses occurring within a 1 cm area of the gallbladder.     

Superficial elevated-type early gallbladder carcinoma treated by laparoscopic cholecystectomy

A 60-year-old woman was admitted to our department for detailed examination of a polypoid lesion of the gallbladder detected at the time of a mass survey by ultrasound. Endoscopic ultrasonography (EUS) demonstrated a broad-based mass lesion, about 10 mm in size, with an irregular surface, at the peritoneal side of the body of the gallbladder. The layer structure of the gallbladder wall had not been destroyed by the mass. Computed tomography showed no direct invasion of the liver or other evidence of metastasis. Type-IIa (superficial elevated-type) early gallbladder cancer was suspected and laparoscopic cholecystectomy was performed. Histologically, the tumor proved to be a papillo-tubular adenocarcinoma, 9×8 mm in size, confined to the mucosa and without lymphatic permeation, vascular involvement, perineural invasion, or other signs of metastasis. Laparoscopic cholecystectomy for gallbladder cancer can be indicated only when a lesion is a pedunculated protruded-type (type-Ip) cancer, or a broad-based cancer 10 mm or less in size located on the peritoneal side with no destruction of the layer structure of the wall demonstrated by EUS. This strategy is justified only with precise evaluation of the lesion by EUS.     

Endoscopic naso-gallbladder drainage versus gallbladder stenting before cholecystectomy in patients with acute cholecystitis and a high suspicion of choledocholithiasis: a prospective randomised preliminary study

Objective Endoscopic transpapillary gallbladder drainage using a nasocystic tube or plastic stent has been attempted as an alternative to percutaneous drainage for patients with acute cholecystitis who are not candidates for urgent cholecystectomy. We aimed to assess the efficacy of single-step endoscopic drainage of the common bile duct and gallbladder, and to evaluate which endoscopic transpapillary gallbladder drainage method is ideal as a bridge before elective cholecystectomy. Materials and methods From July 2011 to December 2014, 35 patients with acute moderate-to-severe cholecystitis and a suspicion of choledocholithiasis were randomly assigned to the endoscopic naso-gallbladder drainage (ENGBD) (n?=?17) or endoscopic gallbladder stenting (EGBS) (n?=?18) group. Results Bile duct clearance was performed successfully in all cases. No significant differences were found between the ENGBD and EGBS groups in the technical success rates [82.4% (14/17) vs. 88.9% (16/18), p?=?0.658] and clinical success rates [by intention-to-treat analysis: 70.6% (12/17) vs. 83.3% (15/18), p?=?0.443; by per protocol analysis of technically feasible cases: 85.7% (12/14) vs. 93.8% (15/16), p?=?0.586]. Three ENGBD patients and two EGBS patients experienced adverse events (p?=?0.658). No significant differences were found in operation time or rate of conversion to open cholecystectomy. Conclusions Single-step endoscopic transpapillary drainage of the common bile duct and gallbladder seems to be an acceptable therapeutic modality in patients with acute cholecystitis and a suspicion of choledocholithiasis. There were no significant differences in the technical and clinical outcomes between ENGBD and EGBS as a bridge before cholecystectomy.     

Benign gallbladder lesions mimicking cancer infiltrating the liver

Considering the current improved resectability of advanced gallbladder cancers, differentiation from benign gallbladder lesions mimicking advanced cancer is now a significant problem to be overcome so that unnecessary extended operations can be avoided. During the 4 years from January 1989 to December 1992, we experienced 63 patients with elevated lesions of the gallbladder, including cancer. Among the 59 patients who underwent resection, preoperative imaging diagnostic procedures were suggestive of cancer in 27. In particular, the lesions of 14 patients appeared to be cancerous with hepatic infiltration. Frozen section histological examinations were performed on the specimens of 4 of these patients in whom the findings were inconsistent; all of them were shown non-cancerous. The final diagnoses in these 4 patients were: hyperplastic polyp with foreign body granuloma, xanthofibromatous granulation, localized type adenomyomatosis, and chronic cholecystitis. Resections were performed on the remaining 10 patients who had lesions suspected to be cancerous with infiltration to the liver. Nine lesions were confirmed as cancer by histological examination of the resected specimen. However, the lesion of the remaining patient, who underwent hepatopancreatoduodenectomy, proved after operation, to be a hamartoma with foreign body granuloma. Of the imaging diagnostic procedures, a combination of endoscopic or intraoperative ultrasonography and computerized tomography was most valuable for making the differential diagnosis between gallbladder cancer and benign gallbladder lesions mimicking cancer infiltrating the liver. However, frozen section histological examination should not be omitted before the extended operations are performed, even though en bloc resection is preferable because the procedures used to obtain the specimens have the potential to disseminate viable cancer cells.     

Amyloidosis of the gallbladder mimicking gallbladder cancer

We report a rare case of amyloidosis of the gallbladder in a 63-year-old woman with a history of primary amyloidosis. The patient was asymptomatic. Blood chemistry and hematologic laboratory levels, as well as values for tumor markers, were unremarkable. Ultrasonography (US) of the abdomen showed a focal echogenic lesion (22 × 15 mm) in the body of the gallbladder, and moderate enhancement was noted on contrast-enhanced US. Abdominal computed tomography revealed nodular wall thickening in the body of the gallbladder that was enhanced by contrast material. Although this patient was asymptomatic, the existence of gallbladder cancer could not be totally denied. Therefore, laparoscopic cholecystectomy was performed for total biopsy of the gallbladder. An intraoperative frozen-section examination revealed evidence of mild chronic cholecystitis with the appearance of hyalinal stroma. There was no malignant lesion. The final diagnosis, amyloidosis of the gallbladder, was obtained by alkaline alcoholic Congo red staining. Amyloid depositions were found in the walls of the vessels in the submucosa and the lamina propria mucosae, consistent with an elevated nodular lesion in the body of the gallbladder. To our knowledge, this is the first case of amyloidosis of the gallbladder mimicking gallbladder cancer that was diagnosed after laparoscopic cholecystectomy.     

Long-term follow up of gallbladder polyps

Background and Aim:  The management of gallbladder polyps (GBP) is directly linked to the early diagnosis of gallbladder cancer (GBC). This study aimed to evaluate the malignant risk of GBP.
Methods:  In total, 1558 patients diagnosed with GBP were followed. Neoplastic polyps were defined as GBC and its premalignant lesions. The risk for malignancy was estimated with the cumulative detection rate of neoplastic polyps.
Results:  Thirty-three cases (2.1%) were diagnosed with neoplastic polyps. The cumulative detection rates of neoplastic polyps were 1.7% at 1 year, 2.8% at 5 years, and 4% at 8 years after diagnosis. The size of GBP and the presence of gallstones were risk factors for neoplastic polyps. Polyps ≥ 10 mm had a 24.2 times greater risk of malignancy than polyps < 10 mm. However, 15 of 33 neoplastic polyps (45.5%) were < 10 mm at the time of diagnosis of GBP. During follow up in 36 (3.5%) of 1027 cases, an increase in size was detected; of these, nine (25%) had neoplastic polyps.
Conclusion:  Even small polyps have a risk of malignancy, and careful long-term follow up of GBP will help detect and treat early GBC.     

Case of mucinous adenocarcinoma with porcelain gallbladder

Histologically, the majority of gallbladder cancers are adenocarcinomas. Among the adenocarcinomas, the mucinous adenocarcinoma is relatively uncommon. Porcelain gallbladder is a rare finding and the risk of gallbladder cancer is significantly increased in porcelain gallbladder. We describe a rare case of mucinous adenocarcinoma with porcelain gallbladder. A 46-year-old man was admitted to Chonnam National University Hospital with a 2-week history of right upper quadrant pain. Three and 2 years previously, he had two episodes of cholecystitis with gallstones. An abdominal computed tomography revealed a contracted gallbladder with circumferential mural calcification, and the possibility of gallbladder cancer and porcelain gallbladder were considered. At laparotomy, cholecystectomy, liver wedge resection, and radical lymph node dissection were performed. The resected gallbladder showed thickened wall, luminal narrowing and mucosal irregularity. A histological examination of the resected gallbladder showed a mucinous adenocarcinoma composed of poorly differentiated glandular cells with mucin lakes. Porcelain gallbladder may be an end result of a chronic inflammatory reaction, and this change is associated with the development of gallbladder cancer.     

Endoscopic ultrasound‐guided endoluminal drainage of the gallbladder

For patients with acute cholecystitis who are not suitable for surgery, endoscopic ultrasound‐guided endoluminal drainage of the gallbladder (EUS‐GBD) has been developed to overcome the limitations of percutaneous transhepatic gallbladder drainage when endoscopic transpapillary gallbladder drainage is not feasible. In the present review we have summarized the studies describing EUS‐GBD. Indications, techniques, accessories, endoprostheses, limitations and complications reported in the different studies are discussed. There were 90 documented cases in the literature. The overall reported technical success rate was 87/90 (96.7%). All patients with technical success were clinically successful. A total of 11/90 (12.2%) patients had complications including pneumoperitoneum, bile peritonitis and stent migration. The advantage of EUS‐GBD is its ability to provide gallbladder drainage especially in situations where percutaneous or transpapillary drainage is not feasible or is technically challenging. It also provides the option of internal drainage and the ability to carry out therapeutic maneuvers via cholecystoscopy.     

A CASE OF PEDUNCULATED POLYPOID CANCER ASSOCIATED WITH FLAT‐TYPE CANCER OF THE GALLBLADDER

Pedunculated polypoid cancer of the gallbladder ordinarily shows cancer spread within the polyp consisting mainly of adenoma. We experienced a case of pedunculated mucosal cancer associated with flat‐type cancer of the gallbladder without an adenomatous component, the details of which are reported herein. The lesion was first detected by transabdominal ultrasonography (US) as a polypoid lesion of the gallbladder, 5 mm in size. Distinct growth of the lesion was revealed at follow‐up US after a year. Endoscopic ultrasonography showed not only a pedunculated polypoid lesion, 9 mm in size, with a solid internal echo pattern and a nodular surface, but also slight thickening of the surrounding gallbladder wall. Cholecystectomy was performed with a preoperative diagnosis of early gallbladder cancer, and a pedunculated polypoid lesion, 8 × 8 × 3 mm in size with a thin stalk and a nodular contour, surrounded by a widely spreading flat lesion with a coarse‐granular surface, was confirmed. Microscopically, the stalk was 700 µm in size, and both the pedunculated polypoid lesion and flat lesion consisted of well‐differentiated tubular adenocarcinoma limited to the mucosa, without an adenomatous component.     

Endoscopic ultrasonography-guided gallbladder drainage: actual technical presentations and review of the literature (with videos)

Background/purpose

Endoscopic ultrasonography-guided gallbladder drainage (EUS-GBD) has been developed as an alternative drainage method in patients with acute cholangitis. Here, we describe two successful EUS-GBD cases and review the literature on this topic.

Methods

EUS-GBD was conducted using a curved linear array echoendoscope and a 19-gauge needle.

Results

A 7-Fr double pigtail stent was successfully placed transgastrically in one patient and transduodenally in the other patient, without any serious early adverse events in either patient. No late complications or relapse of acute cholecystitis have been seen during the 3- to 6-month follow-up period.

Conclusions

EUS-GBD holds high potential as an alternative gallbladder decompression procedure. However, because current experience is limited, multicenter trials for the accurate evaluation of this procedure appear to be necessary in the near future.     

Sonographic demonstration of wall thickness of the gallbladder in pediatric patients with pancreatico-biliary maljunction

Background

Sonographic demonstration of extramural and intrapancreatic junction of the pancreatic and bile ducts, pathognomonic for pancreatico-biliary maljunction (PBM), is not easy in pediatric patients. We measured sonographic thickness of the gallbladder (GB) and retrospectively examined correlation of it with PBM.

Methods

Twenty-seven children with PBM were examined with conventional ultrasonography (US). All patients underwent hepaticojejunostomy, and resected GB were studied in histological examination. Preoperative extracorporeal US measured gallbladder wall thickness, and abnormal GB wall was defined 3?mm or more in thickness.

Results

They consisted of 8 males and 19 females, ranging in age from 2?months to 11?years. The thickness of the GB wall was more than 3?mm in 18: 10 with smooth thickness and 8 with non-uniform thickness. The thickness of GB wall was found in 16 (84.2%) of the 19 patients more than 1?year of age. The difference between sonographic and macroscopic measurements of the wall thickness was less than 1?mm in 24 (89%) of the 27 patients.

Conclusion

US measurement of gallbladder wall thickness can be a screening test more than 1?year of age for PBM.     

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.