Excision Margins

Distances (mm) of tumour to the proximal limit of the cystic duct.

Mucosal dysplasia in adjacent gall bladder mucosa, the cystic duct and its limit. Histological detection of mucosal dysplasia in a routine

Epithelium Lamina propria

Muscularis propria

Perimuscular connective tissue

Serosa pTis pTI

a b pT2

Figure 8.1. Gall bladder carcinoma. |Hp[|

pT3 pT4

Serosa

A

É

Adjacent structures

And/or into liver and/or one other adjacent structure eg. stomach, luodenum,colon, pancreas,

Into main portal vein or hepatic artery, ortwoormore extrahepatic structures

omentum, extrahepatic bile ducts

Serosal perforation

Figure 8.2. Gall bladder carcinoma.

Tumour perforates serosa (visceral peritoneum) and/or directly invades the liver and/or one other adjacent organ or structure, e.g., stomach, duodenum, colon, pancreas, omentum, extrahepatic bile ducts

Serosal perforation

Figure 8.2. Gall bladder carcinoma.

Figure 8.3. Gall bladder carcinoma.

cholecystectomy block should prompt extra blocks to look for an occult invasive cancer

8. OTHER PATHOLOGY

Adenoma—rare (0.5% cholecystectomies)—exclude FAPC. As in colorec-tum, the risk of malignancy increases with size, villousity and degree of dysplasia. There are intestinal, pyloric gland and biliary histological subtypes. A true adenoma should not be confused with the commoner fundal cholecystitis glandularis proliferans—a reactive mucosal hyperplasia associated with smooth muscle proliferation.

Figure 8.4. Gall bladder: regional lymph nodes. |W

periportal, coeliac, and superior mesenteric nodes.

The regional lymph nodes are the cystic duct node and the peripancreatic (head only), periduodenal, pericholedochal, hilar,

Figure 8.4. Gall bladder: regional lymph nodes. |W

Immunophenotype

Gall bladder carcinoma is cytokeratin (CAM5.2, AE1/AE3, CK7, CK19-9), CA19-9 and CEA positive.

Prognosis

Calculi, and anomalous choledochopancreatic duct anatomy are risk factors, with calculi present in 80-90% of cases in female patients (F : M 3:1) particularly responsible. Most gall bladder carcinomas are clinically inapparent and found incidentally as diffuse thickening of the wall at cholecystectomy for gall stones. Prognosis is better if lesions are of papillary type, low histological grade and confined to the mucous membrane, when resection is potentially curative (90% 5-year survival). A significant number of carcinomas are grossly inapparent and a microscopic finding only. However, curative resection is unusual and up to 50% present with regional node metastases and involvement of the gall bladder bed liver. In these patients 5-year survival rates are 5-10%.

9. OTHER MALIGNANCY

Lymphoma/leukaemia

— MALToma or more usually secondary to systemic nodal disease. Sarcoma (rare)

— embryonal rhabdomyosarcoma (children: desmin/myo D1/myogenin positive), leiomyosarcoma, angiosarcoma.

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