Giant Gallbladder Tumor, Unusual Cancer-Case Report and Short Review of Literature

Abstract

Background: Giant gallbladder is an uncommon condition that can result from a benign pathology and rarely presents with malignancy. Intracholecystic papillary-tubular neoplasm (ICPN) is a relatively new entity first described by V. Adsay in 2012 and included in the World Health Classification of Digestive System Tumours in 2019. Intracholecystic papillary-tubular neoplasm is a preinvasive lesion with an incidence of around 1% that may present as four histologic subtypes-biliary, gastric, intestinal, or oncocytic-of which the biliary subtype has the highest risk of associated invasive cancer. Although invasive carcinoma is present in about 50% of cases of ICPN, these patients have a significantly better prognosis than those with usual gallbladder cancer, suggesting that the entities may have distinct biological signatures.

Case report: A 77-year-old female presented to the hospital with progressive swelling in the right hemiabdomen, a loss of appetite, and weight loss. MRI highlighted a giant abdominal tumor located in the right hypochondrium and right abdominal flank with liver invasion (segment V). Preoperatively, a gallbladder 25 × 17 cm in size was noted, and the patient underwent radical cholecystectomy. It was surprising to find such a giant malignant gallbladder tumor, diagnosed as invasive poorly cohesive carcinoma associated with ICPN.

Discussion: A megacholecyst is a rare discovery. Although most often found in benign pathologies, giant gallbladder cancer can be considered. The neoplastic features and the loco-regional extension of the tumor must be evaluated by imaging scans. Few cases of giant benign gallbladder have been reported in the literature; however, this appeared to be the largest resectable gallbladder carcinoma reported to date according to the literature.

Conclusion: The stage of gallbladder neoplasia is not correlated with the size of the gallbladder. Regardless of tumor size, the prognosis seems to be directly related to the stage, morphology, and resectability.

Keywords: cholecystectomy; gallbladder cancer; giant gallbladder; intracholecystic papillary–tubular neoplasm.

Figure 1

MRI (left) and CT (right) images, sagittal section and cross-section. A large subhepatic tumor mass occupied the entire flank and right hypochondrium, with the blurring of the demarcation line from the colon, duodenum, and jejunum, which appeared invaded by the tumor mass.

Figure 2

Intraoperative images. Gross appearance of a giant gallbladder tumor that presented adhesions with the neighboring structures, and aspects of peritonitis.

Figure 3

(A) Gross description: Nodular tumor with a size of 25/17/5 cm, irregular external surface, greyish-white color. Next to it, we identified a liver fragment with a size of 4.5/3/0.5 cm. The greater omentum was 14/8/1 cm in size, and the digestive tract segment was 3/3/1 cm. On section—mass with polypoid growth that was brittle, greyish-white, necrotic, protruding, and filling the entire lumen of the gallbladder. The tumor invaded the serosa of the gallbladder. Numerous yellow gallbladder stones were found inside the tumor, with hard consistency. (B) Hematoxylin and eosin ×200 (poorly cohesive cell carcinoma of the gallbladder): The histological study of the samples taken from the tumor showed the proliferation of carcinomatous cells with poorly cohesive cells and cord-like patterns forming a diffuse infiltrative growth invading the fat tissue. Neoplastic cells were round or oval, irregular in shape, with moderate cytonuclear atypia. The nuclei were vesicular and the nucleoli were eosinophilic and visible. The microscopic description suggested poorly cohesive cell carcinoma of the gallbladder. (C) Hematoxylin and eosin ×100 (intracholecystic papillary–tubular neoplasm of the gallbladder): The histological study of the samples taken from the neoplasm showed back-to-back epithelial units with a tubulopapilary growth pattern and limited stroma. The papillae were lined with cuboidal cells with eosinophilic cytoplasms that were enlarged, pleomorphic, and had atypical nuclei with distinct nucleoli; architectural complexity and a loss of polarity were also observed. The microscopic description suggested intracholecystic papillary–tubular neoplasm of the biliary type with high-grade dysplasia/carcinoma in situ.