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  Table of Contents    
LETTER TO EDITOR  
Year : 2017  |  Volume : 60  |  Issue : 3  |  Page : 440-441
Metastasis as initial presentation of squamous cell carcinoma of gallbladder: A rare clinical entity


Department of Medical Oncology and Paediatric Oncology, GCRI, Ahmedabad, Gujarat, India

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Date of Web Publication22-Sep-2017
 

How to cite this article:
Kendre P, Kataria P, Patel A, Mittal LC, Mule T. Metastasis as initial presentation of squamous cell carcinoma of gallbladder: A rare clinical entity. Indian J Pathol Microbiol 2017;60:440-1

How to cite this URL:
Kendre P, Kataria P, Patel A, Mittal LC, Mule T. Metastasis as initial presentation of squamous cell carcinoma of gallbladder: A rare clinical entity. Indian J Pathol Microbiol [serial online] 2017 [cited 2019 Dec 10];60:440-1. Available from: http://www.ijpmonline.org/text.asp?2017/60/3/440/215362


Editor,

Carcinoma gallbladder is the fifth most common malignancy of gastrointestinal tract with reported incidence of 2%–4% of all gastrointestinal malignancies. Adenocarcinoma is the most common histopathological diagnosis of carcinoma involving the gallbladder; however, squamous cell carcinoma (SCC) is a rare histopathological diagnosis with reported incidence of 0%–12.7%.[1]

A 40-year-old female presented with the chief complaints of fever for 3 months and intermittent pain in abdomen for 2 months. On examination, the patient was middle-aged female with average built. Clinically, the patient had pallor, icterus, edema feet, and ascites. Pulse rate was 100/min and blood pressure was 110/80 mmHg. Chest and cardiovascular system examination was normal. Per abdomen examination was soft, tenderness was present in the right hypochondrium, and globular mass was palpable in the right hypochondrium. Per rectum examination was normal. Laboratory investigation was suggestive of low hemoglobin (8.4 g/dl), raised total (17.87 mg/dl) and direct bilirubin (14.9 mg/dl), raised alkaline phosphatase (896.3 IU/L), and decreased albumin (2.45 mg/dl). Ultrasound abdomen showed a mass in gallbladder fossa with liver metastasis with dilatation of intrahepatic biliary radicles (IHBR). In view of this presentation, percutaneous transhepatic biliary drainage (PTBD) was done for making a conduit for bile. Biopsy from gallbladder fossa mass was suggestive of SCC [Figure 1]. In view of locally advanced features and deranged bilirubin, after PTBD, single-agent gemcitabine was given to the patient. At present, the patient is still undergoing chemotherapy at our center and is doing well. At present, total bilirubin had come down to 2.6 mg/dl with direct fraction being 1.98 mg/dl. Furthermore, international normalized ratio had decreased to 1.5 mg/dl. Being inoperable, the patient was given single-agent gemcitabine. After receiving two cycles of chemotherapy, bilirubin had declined and the appetite and performance status had improved. After three cycles of chemotherapy, we planned to evaluate the patient to analyze the response to chemotherapy.
Figure 1: Keratin pearls and squamous cell carcinoma cells involving the gallbladder (H and E, ×40)

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Primary carcinoma of gallbladder includes various histologies from adenocarcinoma, adenosquamous carcinoma, SCC, and oat cell carcinoma in decreasing order of incidence. SCC of gallbladder is a rare malignant with incidence ranging from 0% to 12.7%. Source of this epithelium in SCC of gallbladder is questionable; however, multiple theories have been put forth to explain the origin with most plausible theory being squamous metaplasia or squamous differentiation of adenocarcinoma.

The explanation being given to hypothesize its origin is that the squamous cells originate from preexisting metaplastic squamous epithelium which is the most accepted theory with others being that the SCC of the gallbladder originates from squamous differentiation of the adenocarcinoma cells, through expression of mixed phenotypes within a single tumor.[2],[3],[4]

Major risk factor as for any type of gallbladder carcinoma is gallstone, with 90% of squamous cell variant having cholelithiasis. The most common symptom is pain, which occurs in 66% of patients, rest being the right hypochondrial mass or jaundice.

Radical resection forms the mainstay of treatment for patients with locally invasive SCC and offers the only chance for cure. In relapsed or metastatic setting, various chemotherapy regimens have been used such as GEMOX (gemcitabine + oxaliplatin), FOLFOX (5 fluorouracil + oxaliplatin), FOLFIRI (5 fluorouracil + irinotecan), and cisplatin + gemcitabine. Of these regimens, cisplatin + gemcitabine had shown efficacy in this setting.

In our case, the patient had metastatic disease at presentation with dilated IHBR which is rare [5] and the treatment strategy has been not still elucidated and is based on the isolated case reports being published, so this case has been presented as an attempt to throw some light over this uncommon histology which makes clinicians perplexed in devising the treatment plan.

Pure primary SCC of the gallbladder is rarely reported. Clinicians and pathologists must be aware of its florid presentation.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Roppongi T, Takeyoshi I, Ohwada S, Sato Y, Fujii T, Honma M, et al. Minute squamous cell carcinoma of the gallbladder: A case report. Jpn J Clin Oncol 2000;30:43-5.  Back to cited text no. 1
    
2.
Hanada M, Shimizu H, Takami M. Squamous cell carcinoma of the gallbladder associated with squamous metaplasia and adenocarcinoma in situ of the mucosal columnar epithelium. Acta Pathol Jpn 1986;36:1879-86.  Back to cited text no. 2
    
3.
Karasawa T, Itoh K, Komukai M, Ozawa U, Sakurai I, Shikata T. Squamous cell carcinoma of gallbladder – Report of two cases and review of literature. Acta Pathol Jpn 1981;31:299-308.  Back to cited text no. 3
    
4.
Khaira HS, Awad RW, Thompson AK. Squamous cell carcinoma of the gallbladder presenting with a biliary-colic fistula. Eur J Surg Oncol 1995;21:581-2.  Back to cited text no. 4
    
5.
Hosseinzadeh M, Shokripur M, Salahi H. Primary pure squamous cell carcinoma of gallbladder presenting as acute cholecystitis. Iran J Med Sci 2012;37:271-3.  Back to cited text no. 5
    

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Correspondence Address:
Apurva Patel
Department of Medical and Paediatric Oncology, GCRI, Ahmedabad, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJPM.IJPM_113_17

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