A novel peroral cholangioscopy of gallbladder carcinosarcoma: a case report

Abstract

Figures

Computed tomography image and magnetic resonance cholangiopancreatography. a, b A mass from the gallbladder neck to the extrahepatic bile duct was identified (arrows). Enlarged Lymph node with contrast enhancement was observed between the extrahepatic bile duct and gallbladder (arrowheads). c, d Filling defect in the biliary system, from the gallbladder neck to the junction of the cystic duct (arrows). There was no dilation in the common hepatic duct.

Endoscopic ultrasonography. a, b There was an irregular hypoechoic lesion from the gallbladder neck to the extrahepatic bile duct (arrowheads). A gallbladder stone exists near the lesion (arrow).

Endoscopic retrograde cholangiopancreatography showing. A filling defect is observed in the common bile duct near the junction of the cystic duct (arrowheads).

Peroral cholangioscopy. a, b There was a subepithelial-like lesion with irregularly dilated vessels at the junction of the cystic duct.

Hematoxylin and eosin staining images of the forceps biopsy sample. a, b Chromatin-rich short spindle cells are proliferating diffusely within the stroma. The chondroid matrix was also observed in the stroma (yellow arrowheads). c Atypical cells with irregular nuclei and disrupted polarity were proliferating, forming glandular ducts (green arrowheads). The above findings suggested a mixture of adenocarcinoma, sarcomatous cells, and chondroid matrix, and it was diagnosed as carcinosarcoma. d Adenocarcinoma and sarcomatous components were positive with immunohistochemical staining for pan-cytokeratin (CK AE1/AE3). e The chondroid matrix was immunohistochemically positive for S100.

Full text

Gallbladder carcinosarcoma (GBCS) is extremely rare, accounting for less than 1 % of malignant primary gallbladder tumors with poor prognosis 1 2 3 4 . Due to its rarity, the literature on GBCS is limited, with only approximately 100 cases reported 5 . We herein present a case of GBCS in which the tumor was visualized directly using a novel peroral cholangioscope (eyeMax; Micro-Tech, Nanjing, China).

A 74-year-old female visited a medical institution due to loss of appetite, where a gallbladder mass was detected, and she was admitted to our hospital. Contrast-enhanced abdominal computed tomography showed a mass from the gallbladder neck to the common bile duct (CBD). An enlarged Lymph node with contrast enhancement was observed between the extrahepatic bile duct and gallbladder ( Fig. 1 a, b ). The patient also underwent magnetic resonance cholangiopancreatography, which demonstrated a filling defect in the CBD, near the junction of the cystic duct ( Fig. 1 c, d ). Endoscopic ultrasonography revealed a hypoechoic lesion in this region ( Fig. 2 a, b ). Endoscopic retrograde cholangiopancreatography was performed to confirm the diagnosis of the biliary lesion and revealed a filling defect at the junction of the cystic duct ( Fig. 3 ). Peroral cholangioscopy (POCS) revealed an irregular subepithelial-like lesion with irregularly dilated vessels at the junction of the cystic duct, which was suspected to be a malignant tumor ( Fig. 4 a, b and Video 1 ). The histopathological findings of the forceps biopsies from the lesion revealed the diagnosis of carcinosarcoma, which consists of adenocarcinoma, sarcomatous cells, and chondroid matrix ( Fig. 5 ). POCS-guided mapping biopsy also showed that atypical epithelial cells exist in the confluence of intrahepatic bile ducts. The patient preferred best supportive care over aggressive treatment. To the best of our knowledge, this is the first report of the visualization of GBCS using a novel POCS.

Computed tomography image and magnetic resonance cholangiopancreatography. a, b A mass from the gallbladder neck to the extrahepatic bile duct was identified (arrows). Enlarged Lymph node with contrast enhancement was observed between the extrahepatic bile duct and gallbladder (arrowheads). c, d Filling defect in the biliary system, from the gallbladder neck to the junction of the cystic duct (arrows). There was no dilation in the common hepatic duct.

Endoscopic ultrasonography. a, b There was an irregular hypoechoic lesion from the gallbladder neck to the extrahepatic bile duct (arrowheads). A gallbladder stone exists near the lesion (arrow).

Endoscopic retrograde cholangiopancreatography showing. A filling defect is observed in the common bile duct near the junction of the cystic duct (arrowheads).

Peroral cholangioscopy. a, b There was a subepithelial-like lesion with irregularly dilated vessels at the junction of the cystic duct.

The video shows a case of gallbladder carcinosarcoma in which the tumor was visualized directly using a peroral cholangioscope. It seemed a subepithelial-like lesion with irregularly dilated vessels.Video 1

Hematoxylin and eosin staining images of the forceps biopsy sample. a, b Chromatin-rich short spindle cells are proliferating diffusely within the stroma. The chondroid matrix was also observed in the stroma (yellow arrowheads). c Atypical cells with irregular nuclei and disrupted polarity were proliferating, forming glandular ducts (green arrowheads). The above findings suggested a mixture of adenocarcinoma, sarcomatous cells, and chondroid matrix, and it was diagnosed as carcinosarcoma. d Adenocarcinoma and sarcomatous components were positive with immunohistochemical staining for pan-cytokeratin (CK AE1/AE3). e The chondroid matrix was immunohistochemically positive for S100.

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