Unusual cause of abdominal pain in a young adult: The clinical pitfalls of adenocarcinoma of the gallbladder with liver invasion

Ren-Tzer Wang; Jheng-Yan Chen; Jyh-Cherng Yu; Teng-Wei Chen; Chung-Bao Hsieh; De-Chuan Chan; Kuo-Feng Hsu

doi:10.4103/jmedsci.jmedsci_243_20

CASE REPORT

Year : 2021 | Volume : 41 | Issue : 6 | Page : 309-311

Unusual cause of abdominal pain in a young adult: The clinical pitfalls of adenocarcinoma of the gallbladder with liver invasion

Ren-Tzer Wang, Jheng-Yan Chen, Jyh-Cherng Yu, Teng-Wei Chen, Chung-Bao Hsieh, De-Chuan Chan, Kuo-Feng Hsu
Division of General Surgery, Department of Surgery, National Defense Medical Center, Tri-Service General Hospital, Taipei, Taiwan

Date of Submission	07-Aug-2020
Date of Decision	21-Aug-2020
Date of Acceptance	11-Dec-2020
Date of Web Publication	01-Nov-2021

Correspondence Address:
Dr. Kuo-Feng Hsu
Division of General Surgery, Department of Surgery, Tri-Service General Hospital, No. 325, Sec. 2, Cheng-Kung Road, Neihu 114, Taipei
Taiwan

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jmedsci.jmedsci_243_20

Abstract

Gallbladder (GB) cancer is a rare cause of abdominal pain in young adults. It is difficult to confirm an immediate and correct diagnosis based on the presentation of an acute episode of abdominal pain. We report a 36-year-old man who was referred to our hospital because of right upper abdominal pain that had persisted for 1 month. The tentative diagnosis was gallstone-induced acute on chronic cholecystitis according to the clinical symptoms/signs and imaging studies. Laparoscopic cholecystectomy (LC) was performed after admission. Histological examination revealed adenocarcinoma of the GB that was moderately differentiated and invading the perimuscular connective tissue. Magnetic resonance imaging was performed after the surgery, showing negativity for the invasion to other organs. Laparoscopic bisegmentectomy of the liver (seg. 4b + 5) and lymph node dissection was performed following LC. Adjuvant chemotherapy was administered, and the patient is currently alive without recurrence for 6 months. The uncommon etiology of cholecystitis in young adults is discussed.

Keywords: Gallstone, Murphy's sign, adenocarcinoma, cholecystitis

How to cite this article:
Wang RT, Chen JY, Yu JC, Chen TW, Hsieh CB, Chan DC, Hsu KF. Unusual cause of abdominal pain in a young adult: The clinical pitfalls of adenocarcinoma of the gallbladder with liver invasion. J Med Sci 2021;41:309-11

How to cite this URL:
Wang RT, Chen JY, Yu JC, Chen TW, Hsieh CB, Chan DC, Hsu KF. Unusual cause of abdominal pain in a young adult: The clinical pitfalls of adenocarcinoma of the gallbladder with liver invasion. J Med Sci [serial online] 2021 [cited 2023 Dec 4];41:309-11. Available from: https://www.jmedscindmc.com/text.asp?2021/41/6/309/317114

Introduction

Gallstone-induced biliary colic or cholecystitis is common in young adults, but adenocarcinoma of the gallbladder (GB) is a rare etiology of episodes of abdominal pain. Herein, we report an incidentally discovered case of GB adenocarcinoma in a 36-year-old man presenting with right upper quadrant abdominal pain. The management of unexpected GB carcinoma in young adults is discussed, and relevant published literature is reviewed.^[1],[2]

Case Report

A 36-year-old Taiwanese man without any underlying disease presented with intermittent abdominal pain that had persisted for 1 month. In a local medical clinic, gallstones with biliary colic were detected. He was referred to our hospital for subsequent treatment. On admission, he developed a fever with a body temperature of 38°C accompanied by nausea and vomiting. Physical examination showed positivity for Murphy's sign. No specific findings were noted in the family history. Blood test and laboratory data showed no elevations in the white blood cell count or C-reactive protein, alkaline phosphate, total bilirubin, and alanine aminotransferase levels. Abdominal sonography showed several small gallstones in the GB and thickening of the GB wall [Figure 1]. The tentative diagnosis was gallstone-induced acute on chronic cholecystitis.

Figure 1: An abdominal sonography showed several small gallstones in the gallbladder and thickening of the gallbladder wall

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Laparoscopic cholecystectomy (LC) was performed after admission. During the surgery, abizarre appearance of the GB was noted [Figure 2]. The frozen section of the GB for pathology showed adenocarcinoma of the GB [Figure 3]. Considering the lack of information about the involvements of other intraabdominal tissues or organs and patient's family's decision, only LC without exploratory laparotomy was performed. Histopathological examination showed adenocarcinoma of the GB invading the perimuscular connective tissue. Serial examinations to assess the cancer status were performed, including magnetic resonance imaging (MRI), tumor marker, and other blood laboratory data. MRI showed negativity for cancer invasion of the liver, pancreas, spleen, kidneys, and paraaortic lymph nodes. The laboratory data revealed no elevations in carcinoembryonic antigen and alpha-fetoprotein levels, but a significant elevation in the carbohydrate antigen 19-9 level was noted (>150 U/mL; normal <37 U/mL). Subsequently, no distant metastasis was found, and laparoscopic bisegmentectomy of the liver (seg. 4b + 5) and lymph node dissection were performed 1 week following LC. Histological examination revealed adenocarcinoma of the GB with liver invasion [Figure 4]. No lymph node, large vessel, perineural, or lymphovascular space invasion was identified. The American Joint Committee on Cancer stage was adenocarcinoma of the GB with liver invasion, pT3N0M0, and Stage IIIA. Adjuvant chemotherapy containing gemcitabine plus cisplatin was prescribed for the patient. The carbohydrate antigen 19-9 level was normal after three courses of adjuvant chemotherapy. The patient is currently alive without recurrence for 6 months.

Figure 2: During laparoscopic cholecystectomy, the bizarre appearance of the gallbladder and surrounding liver was noted

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Figure 3: The frozen section for pathology during the operation showed pictures of moderately differentiated adenocarcinoma, characterized by glandular tumor nests with hyperchromatic nuclei invading to peri-gallbladder fat

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Figure 4: A histologic examination revealed moderately differentiated adenocarcinoma, invading the liver tissue, characterized by tumor cells with nuclear pleomorphism, and focal prominent nucleoli as well as increased mitotic figures arranged in fused-glandular and solid patterns

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Discussion

Adenocarcinomas of the GB usually occur in elderly individuals, but rarely occur in young patients (approximately 0.1%–1.0% of all cases of adenocarcinomas of the GB).^[3],[4] The presence of a gallstone has been proven to be a risk factor for GB cancer. It is difficult to confirm a diagnosis of adenocarcinoma of the GB before surgery because the inflammatory processes may conceal the behavior of the malignancy. Adenocarcinoma of the GB may be distinguished from cholecystitis using color Doppler ultrasonography, based on the arterial blood velocity signal. Patients with GB carcinoma concurrent with acute cholecystitis are reported to have a better survival rate than that of patients with GB carcinoma without acute cholecystitis. This may be because the symptoms and signs of acute cholecystitis may lead to earlier detection of the malignancy.^[5] However, some doctors have suggested that the survival rate should not only depend on the presence or absence of acute cholecystitis.^[6] We should consider that an acute inflammatory response may lead to an increase in the regional lymphatic flow, which may lead to an increase in the metastasis rate of the malignancy. In our case, the bizarre appearance of the GB and surrounding tissue may be a clue indicating adenocarcinoma of the GB. Meticulous histopathological examinations should be considered. The incidental findings of GB cancer, immediate conversion to exploratory laparotomy, and later re-surgical intervention are not associated with differences in survival.^[7] However, a higher unresectability rate has been noted in patients undergoing conversion to exploratory laparotomy than that in patients who undergo later re-surgical intervention.^[7] In addition, aggressive adjuvant chemotherapy and close follow-up protocols are advised for young patients with invasive patterns of adenocarcinomas of the GB. In summary, GB cancers in young adults presenting with symptoms are rare, and unusual operative findings during LC may indicate the possibility of malignancy of the GB. We learned the following from the present case: (1) the masking effects of the gallstones and inflammatory responses result in difficulties in the preoperative diagnosis of cancerous lesions in young patients with calculous cholecystitis; (2) laparoscopic ultrasonography may be helpful in determining the extent of GB cancer; (3) to achieve R0 resection, extended en bloc cholecystectomy with surrounding hepatic parenchyma resection may be necessary; (4) staging based on computed tomography or MRI is needed; and (5) rescue re-laparotomy may be necessary to achieve an adequate surgical margin. Finally, prompt diagnosis and effective treatment modalities may confer better prognosis.

Declaration of patient consent

The patient understood that his name and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	D'Angelica M, Dalal KM, DeMatteo RP, Fong Y, Blumgart LH, Jarnagin WR, et al. Analysis of the extent of resection for adenocarcinoma of the gallbladder. Ann Surg Oncol 2009;16:806-16.
2.	Pawlik TM, Gleisner AL, Vigano L, Kooby DA, Bauer TW, Frilling A, et al. Incidence of finding residual disease for incidental gallbladder carcinoma: Implications for re-resection. J Gastrointest Surg 2007;11:1478-86.
3.	Kiran RP, Pokala N, Dudrick SJ. Incidence pattern and survival for gallbladder cancer over three decades – an analysis of 10301 patients. Ann Surg Oncol 2007;14:827-32.
4.	Yang JD, Kim B, Sanderson SO, Sauver JS, Yawn BP, Larson JJ, et al. Biliary tract cancers in olmsted county, minnesota, 1976-2008. Am J Gastroenterol 2012;107:1256-62.
5.	Thorbjarnarson B. Carcinoma of the gallbladder and acute cholecystitis. Ann Surg 1960;151:241-4.
6.	Chao TC, Jeng LB, Jan YY, Hwang TL, Wang CS, Chen MF, et al. Concurrent primary carcinoma of the gallbladder and acute cholecystitis. Hepatogastroenterology 1998;45:921-6.
7.	Shih SP, Schulick RD, Cameron JL, Lillemoe KD, Pitt HA, Choti MA, et al. Gallbladder cancer: The role of laparoscopy and radical resection. Ann Surg 2007;245:893-901.