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PRIMARY SQUAMOUS CELL CARCINOMA OF GALLBLADDER PRESENTING AS EMPYEMA

Rima Kamat*, Js Pandya**, Kusum Jashnani***, Abhilash Antony A+
*Lecturer, Dept of Pathology, **Assoc Professor, Dept of Gen Surgery & GESS; ***Assoc. Professor; +Resident; BYL Nair Hospital and TN Medical College, Mumbai.

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A 71 year old woman was admitted with h/o fever, vomiting and abdominal pain of 5 days duration. She was clinically and radiologically diagnosed as empyema of the gallbladder, with necrotic areas detected in the liver. Histology revealed primary squamous cell carcinoma with liver metastasis. Her recovery post operative was uneventful and patient is symptom-free at the end of 6 months.

INTRODUCTION

Primary calculus squamous cell carcinoma of gallbladder is a rare tumour. It constitutes 3% of all gall bladder malignancies.1 Patients presenting with acute cholecystitis tend to have a less advanced disease, which was contrary to our findings. Squamous cell carcinoma of gall bladder is more common with calculus cholecystitis. We report a case of primary squamous cell carcinoma of gallbladder without gallstones.

CASE REPORT

A 71 year old woman presented with pain in right hypochondrium and fever of 5 days duration with non-bilious vomiting for 2 days. On examination her temperature was 39oC. She had tachycardia, right hypochondriac tenderness with palpable lump measuring 10 x 8 cm and moving with respiration. Her while cell count was 10,800/cumm with normal biochemical parameters and liver function tests.

Ultrasonography revealed a massively dilated gallbladder with wall thickness of 0.5 cm and no calculi, multiple hypo-echoic to anechoic areas with an irregular mass. A diagnosis of empyema of the gallbladder was made. Inspite of 8 to 12 hours of medical treatment, patient’s parameters did not improve.

At exploration omentum was oedematous, thickened and struck to the under surface of right lobe of liver. There were surrounding adhesions with stomach, transverse colon and duodenum. During adhesiolysis, pericholecystic collection of 25 to 33 ml was drained. On palpation of the liver, multiple small necrotic lesions measuring up to 1.5 cm were felt in the right lobe of the liver, left lobe was normal. Cholescystectomy was performed. Wedge biopsy of the necrotic area was taken. A 32F drain was placed in the Morison’s pouch and abdomen was closed.

Patient was stable post operatively. Drain persisted for 4 days and was serosanguinous in nature. The drainage gradually decreased and the drain was removed on 5th day.

Gross morphology of the resected specimen showed a 6 x 3 x 3 cms gallbladder with irregular walls and mucosa being haemorrhagic and shaggy. No stones were found in the gall bladder. No area of normal mucosa was seen. Multiple sections studied showed only tumour tissue with features of well differentiated squamous cell carcinoma infiltrating all layers reaching up to serosa. At 6 months post-operative, the patient is symptom free.

Fig 1.Photomicrograph showing complete replacement of gall bladder mucosa by Keratinising squamous epithelium with underlying nests of malignant squamous cells (HE 100x)

Fig 2. Photomicrograph showing malignant squamous epithelial cells with Keratin (HE 200x)

DISCUSSION

Primary squamous cell carcinoma of gall bladder is a rare tumour.[1] The most significant symptom is pain, which occurs in 66% of patients. Although it is mentioned that gall bladder malignancies presenting as acute cholecystitis have got less advanced disease, the presence of a palpable gall bladder with or without jaundice indicates advanced disease. Radiological investigation like fine needle aspiration cytodiagnosis is a very effective and useful non-invasive technique indiagnosis of gall bladder neoplasm in experienced hands.[2]

Squamous cell carcinoma behave like anaplastic carcinomas. Literature review shows that only 7% with serosal involvement are alive at 5 years.[3] Extension to subserosa with positive resection margin is associated with 43% 1 year survival at 3 years.

In our case USG did not reveal liver metastasis. We conclude that squamous cell carcinoma of gall bladder may present rarely as empyema or acute cholecystitis. In an elderly patient with a palpable gallbladder mass presenting as empyema, the possibility of malignancy should be kept in mind.

REFERENCES

1.Fromn David. Carcinoma of the gall bladder in : Sabiston DC, Levily HK, eds. Textbook of surgery : The biological basis of modern surgical practice. 15th ed. India : Thompson Press (I) Ltd. Noida. 1999; pg 1148-51.

2.Gupta RK, et al. Fine needle aspiration cytodiagnosis of primary squamous cell carcinoma of gall bladder - Report of 2 cases. Acta Cytologica 2000; 44 (3) 467-71.

3.Nenn JE, et al. Carcinoma of the gall bladder - staging treatment and prognosis. Cancer 1976; 37 : 141.

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