Title
[症例報告]Sarcomatoid carcinoma (so-called carcinosarcoma)
of the gallbladder : A case report and review of the literature
Author(s)
Samura, Hironori; Isa, Tsutomu; Kuniyoshi, Shoichiro;
Shiraishi, Masayuki; Kusano, Toshiomi; Muto, Yoshihiro
Citation
琉球医学会誌 = Ryukyu Medical Journal, 19(1): 39-42
Issue Date
1999
URL
http://hdl.handle.net/20.500.12001/3319
Ryukyu Med.ォ/., 19(1)39-42, 1999
Sarcomatoid carcinoma (so-called carcinosarcoma) of the
gallbladder. A case report and review of the literature
Hironori Samura, Tsutomu Isa, Shoichiro Kuniyoshi, Masayuki Shiraishi,
Toshiomi Kusano and Yoshihiro Muto
The First Department of Surgery, Faculty of Medicine,
University of the Ryukyus, Okinawa, Japan
(Received on February 2, 1999, accepted on June 2, 1999)
AB STRACT
The case of a rare, peculiar tumor (sarcomatoid carcinoma, carcinosarcoma) in the gallbladder of an 82-year-old woman is herein described. The patient was admitted with right upper quadrant tenderness and mass. On admission, abdominal imaging modalities demon-strated a 10 cm-solid mass in the right upper quadrant with nonspecific features similar to those of carcinoma of the gallbladder. She was diagnosed to have carcinoma of the gallblad-der, and thereafter underwent an extirpation of the tumor together with a cholecystectomy and partial transverse colectomy. The tumor was relatively circumscribed with invasion into the transverse mesocolon, and measured 12cm in greatest dimension. On bisection, the tumor showed a massive intraluminal polypoid and exophytic growth in the gallbladder with a solid, gray-color, and fibrous appearance. Histologically, the tumor was composed of three different tumor cell types (tubular adenocarcinoma, giant cell and spindle cell types). The giant cell-type cells occupied the largest part of the tumor and were infiltrated with lym-phoid cells and leukocytes. Immunohistochemically, tubular adenocarcinoma was positive for cytokeratin while the remaining two components were negative for cytokeratin and vimentin. One month later, the patient developed local recurrence of the tumor at the primary site. The tumor grew rapidly and aggressively. As a result, she died 7 months after surgery.
Ryuわ・u Med. J., 19(1)39-42, 1999
Key words: sarcomatoid carcinoma, carcinosarcoma, gallbladder, case report
INTRODUCTION
The term "carcinosarcoma" refers to a group of rare malignant neoplasms that exhibit histologic fea-tures of epithelial and mesenchymal-like differentiation. This rare type of neoplasm tends to arise in the esopha-gus, stomach and gallbladder", and has attracted great interest because of uncertainty about its histogenesis,
differentiation and behavior. We herein report a case of
sarcomatoid carcinoma (carcinosarcoma) of the gallbladder and discuss its imaging features and immunohistochemical findings.
CASE REPORT
An 82-year-old Japanese woman was referred to the Ryukyu University Hospital with a 10-cm tumor in the right upper quadrant on December 16, 1997. About one month prior to this, she had visited a local clinic with complaint of appetite loss and general malaise, and
39
was found to have a tumor in the right upper quadrant. The physical examination on admission showed the pa-tient to be anemic and malnourished. A 10-cm tumor was observed with mild tenderness and no muscular ri-gidity in the right upper quadrant of the abdomen.
The laboratory data revealed the WBC to be ll,200, hemoglobin, 9.8 g/dl, and albumin, 2.9 g/dl. The carcinoembryonic antigen (CEA) level was 4.4 ng/dl, and
α-fetoprotein (AFP), 8 ng/dl. Diagnostic modalities
including ultrasonography (US), CT and MRI revealed a
10 cm-solid tumor with areas of necrosis in the gallbladder (Fig. 1) similar to the imaging features of a mass-forming carcinoma of the gallbladder. Angiography con-firmed a diagnosis of carcinoma of the gallbladder. To discriminate between a neoplastic mass and an inflamma-tory mass, a percutaneous fine-needle biopsy of the mass was performed, but failed because of poor tissue sam-phng. Following biopsy, she developed a spiked fever with leukocytosis (31,500) and abnormal CRP (21.2 mg /dl), resulting in critical conditions. Subsequently, she'At Sarcomatoid Carcinoma of th(ラ Gallbladder
Fig. 1 A contrasLenhanced CT scan demonstrating a hyperdense solid tumor with internal heterogeneity (top) and a comparable axial Tl-weighted MRI revealing a hypointense tumor (bottom).
underwent an emergency laparotomy on January 7, 1998. Surgery revealed a solid mass covered with the omentum measuring 12 cm at its greatest dimension which also showed involvement with the transverse colon. The mass was removed by a cholecystectomy and a partial resec-tion of the colon.
PATHOLOGICAL FINDINGS
The extirpated tumor measured 12×11× 7 cm in size and on bisection, the cut surface appeared grayish-white in color, while it was also fibrous and solid with areas of yellow-colored necrosis (Fig. 2). The gall-bladder was filled with an intraluminal and exophytic tumor mass. Only the neck of the gallbladder was not involved. Histologically, the tumor was composed of three different features: tubular adenocarcinoma, either a giant cell carcinoma or a sarcoma-like tumor and a spindle cell sarcoma-like tumor. The largest part of the tumor consisted of giant cells intermingled with lymphoid cells and leukocytes. The remaining two tumor types were found scattered throughout the tumor (Fig. 3). Immunohistochemically, cytokeratin (anti human keratin mouse monoclonal Ab; IMMUNOTECH)
Fig. 2 Macrophotographs of the tumor showing a rough
external surface with the surrounding structures (top) and its cut surface (bottom). The tumor shows intraluminal polypoid and exophyticexpansive growth. The neck por-tion of the gallbladder was not involved by the tumor (arrow).
showed positive staining in the adenocarcinoma, while reactivity for cytokeratin and vimentin (anti human vimentin mouse monoclonal Ab; DAKO) in the remain-ing components was only weakly and locally expressed. One month later, a local recurrence of the tumor occurred at the primary site. Two months after sur-gery, the pylorus and the proximal portion of the duo-denum were obstructed by compression of the recurrent tumor. Subsequently, her nourishment was managed by total parenteral nutrition with occasional jejunal nutri-tion. The recurrent tumor grew until reaching a size which was larger than that observed at the initial pres-entation. However, the tumor showed only locally ex-pansive and aggressive growth without any apparent
Samura H. et al.
Fig. 3 Microphotographs of the tumor showing tubular adenocarcinoma (top: HE, X 25) and a spindle cell-type tumor (bottom: HE, 50).
metastasis. Finally, the patient died due to clinical manifestations of recurrence 7 months after surgery. Ne-cropsy revealed local recurrence involving the adjacent organs (duodenum, colon and pancreas) without dis-tant metastasis.
DISCUSSION
Carcinosarcoma is composed of both carcinomatous and sarcomatous components. This peculiar tumor has beengiven a variety of namesl- and is divided into two morphologic types: the first type (so-called carcinosarcoma, pseudosarcoma or sarcomatoid carcinoma) is composed of typical carcinoma and mesechymal-like carcinoma, and the second type (carcinosarcoma or malignant mixed tumor) comprises epithelial (carcinoma) and mesenchymal
sarcoma) cells6-.
From an extensive analysis of the previously re-ported cases2∴ two morphologic typing may be diag-nostically convenient, but are not recommended because they convey little information as to the nature and poten-tial behavior of a given tumor. Regarding peculiarities in differentiation and behavior, many studies on these tu-mors using new analytic techniques have reported little
41
useful information regarding their histogenesis or type of differentiation. Therefore, the histogenesis and be-havior of these tumors remain unclear*
Moreover, both types are not significantly
differ-ent. Clinically, they commonly present with the same
manifestations. Morphologically, they are locally
ag-gressive, and grow in an expansive fashion, compress-ing the normal adjacent structures around them in a
concentric manner. We therefore believe that both
va-rieties should be discussed together rather than sepa-rately.
In clinical practice, the clinical features are nonspe-cific such as fever, abdominal pain and a right upper quadrant mass similar to those in cases of carcinoma of the gallbladder, and they are also usually related to cholelithiasis or extension of the tumor. However, most such cases show polypoid or exophytic growth which is the characteristic growth of this tumor in contrast to cases of carcinoma which grow rather diffusely. As aforementioned, our patient presented with right quad-rant tenderness and a mass. The tumor was a large solid tumor which was relatively welLcircumscribed, surrounded by and involving the adjacent structures. These clinical and pathological features in our case were more similar to those of carcinosarcoma than to carcinoma of the gallbladder. To our knowledge, little has been reported regarding the imaging features of
this rare tumor on US, CT or MRI. Consequently, this
was considered to be of interest regarding the imaging features of carcinosarcoma of the gallbladder. However, the imaging features of this tumor were not specific for carcinosarcoma, but common to carcinoma, especially a large polypoid carcinoma of the gallbladder7
Finally, no substantial differences were found in the clinical and pathological features among the cases reported in the literature. As for treatment and progno-sis, carcinosarcoma of the gallbladder are closely simi-lar to those of adenocarcinoma arising in this location. In both tumors, the extent of tumor invasion greatly influences prognosis. Both tumors typically manifest with advanced disease and also have an extremely poor clinical outcome.
However, if the tumor is detected and resected while it is still confined to thegallbladder or at an early stage, carcinosarcoma of the gallbladder therefore ap-pears to be curable and it also has a better long-term survival as that of carcinoma of the gallbladder"
ACKNOWLEDGEMENT
We are obliged to Mr. Brian Quinn for correcting English usage in the manuscript.
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