19 | P a g e International Standard Serial Number (ISSN): 2319-8141

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I nternational J ournal of Universal Pharmacy and Bio Sciences 3(3): May-J une 2014
INTERNATIONAL JOURNAL OF UNIVERSAL
PHARMACY AND BIO SCIENCES
IMPACT FACTOR 1.89***
ICV 5.13***
Bio Sciences CASE REPORT !!!

UNDIFFERENTIATED CARCINOMA OF GALLBLADDER,
SPINDLE CELL VARIANT-A RARE CASE REPORT
Dr. T. Subachitra
*
, Dr. Deepadevi,

Dr. R.Padmavathy,

Dr.Deepa
Govt.Stanley Medical College.

KEYWORDS:

Gall bladder,
Undifferentiated,
Epithelial and
Mesenchymal,
Sarcomatoid Carcinoma.
For Correspondence:
Dr. T. Subachitra
*

Address:
Govt.Stanley Medical
College.
Email:
mangairms@yahoo.com







ABSTRACT
Undifferentiated carcinoma or sarcomatoid carcinoma of
gallbladder malignancy, the diagnosis of which requires the
presence of both malignant epithelial and mesenchymal
components. The prognosis of this disease is extremely poor
because it normally presents at advanced stages. We are reporting
a case of undifferentiated carcinoma of the gallbladder, spindle cell
variant in a 56 year-old woman who was treated by radical
cholecystectomy for its rare occurrence.
20 | P a g e International Standard Serial Number (ISSN): 2319-8141
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INTRODUCTION:
Primary gallbladder carcinoma is a malignant neoplasm with an incidence of 1.2 cases per 100,000
people each year. Its occurrence increases with age, particularly in women
(1, 2)
. It is the fifth most
common cancer of the gastrointestinal tract, and the most common malignancy
in the biliary tract
(1,5)
. Adenocarcinoma is the most common type of gallbladder neoplasm whereas
sarcomatoid carcinoma is rare with an incidence of less than one percent of all malignant gall bladder
neoplasms
(1,2,4)
. Sarcomatoid carcinomas are composed of malignant epithelial and sarcomatous
components, sometimes with heterologous sarcomatous elements.
To our knowledge, only 79 cases with sarcomatoid carcinoma of the gallbladder have been reported in
the English-language literature
(1,7)
. Therapeutic methods of the tumor include surgery, chemotherapy,
radiotherapy, and medical treatment.
CASE REPORT:
A 56 year old postmenopausal female was admitted with complaints of intermittent, dull aching, right
upper abdominal pain of 2 years duration.
USG abdomen revealed distended gall bladder with wall thickening and a 4.2 x 2.4 cm echogenic
lesion in the fundus with no blood flow - ? Inspissated sludge/ ? neoplastic lesion. CECT abdomen
revealed broad based 2.9 x 2.3 cm polyp in GB. Laboratory investigations revealed CA 19-9: 97.37 U/
ml, GGT: 291 U/L, SAP: 412 U/L and TLC: 10900/cmm, other blood parameters were within normal
limits.
Laparoscopic intraoperative USG was done which revealed a 4-5cm polypoidal GB mass with
papillary excrescences and dense omental adhesions. Doppler showed flow within the mass and breach
of GB wall. Hence it was followed by open radical cholecystectomy.
Gross appearance:
We received specimen of GB(fig-1) measuring 6 x 5 x 3 cm with attached liver parenchyma measuring
8 x 6 x 5 cm was received. Cut surface of GB showed a friable irregular gray white mass measuring 3
x 2 x 1 cm in the fundus. Mucosa of rest of the GB was thickened. No nodes made out. The specimen
was routinely processed and stained with haematoxylin and eosin stains.
Microscopic appearance:
Sections from the growth in GB (fig-2,3)show a neoplasm composed of glands which are cystically
dilated with intraglandular papillae. Lining epithelium exhibits moderate nuclear atypia and
stratification. Stroma shows pleomorphic spindle to polyhedral tumor cells exhibiting bizarre nuclei,
interspersed with multinucleate tumor giant cells. Focal chondroid metaplasia is seen. Adjoining liver
is free from tumor infiltration.
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A diagnosis of undifferentiated sarcomatoid carcinoma of GB- grade IV, pT
2
N
0
M
x
was done.
Immuno Histochemistry was done in Chrom -alum coated slides(fig-4) using Horse radish peroxidise
method, revealed CK positive neoplastic glands and vimentin positivity in spindle cell areas.

Fig-1 Shows polpoidal growth fig-2 sheets of spindle cells with
in gall bladder wall occasional neoplastic glands

Fig-3 40x view of spindle cells with fig-4 vimentin positive spindle bizarre nuclei
cells
DISCUSSION:
Adenocarcinoma is the most common type of gallbladder neoplasm whereas undifferentiated
carcinoma is rare with an incidence of less than one percent of all malignant gall bladder neoplasms
(1,2,4)
. The cancer was first reported by Landsteiner in 1907, and until now, only 79 cases have been
reported in the English-language literature, with mean age range from 66.5-72 years
(1,7)
.
Similar to adenocarcinoma, gallbladder undifferentiated carcinoma usually present with abdominal
pain, jaundice, nausea, and poor oral intake, and some may present with a palpable abdominal mass
and weight loss. Liver function tests are normal, except in patients with obstructive jaundice caused by
tumor invasion of the biliary tract
(1,4)
.
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Sarcomatoid carcinoma of the gall bladder is not associated with specific radiological findings or
serum data, including tumor markers
(1)
. In our case CA 19-9, GGT and SAP were elevated.
It has been described that undifferentiated sarcomatoid carcinoma arises from totipotent stromal stem
cells and is composed of epithelial and mesenchymal components
(1)
.Four histological variants of
undifferentiated carcinoma has been described.
Undifferentiated carcinoma,spindle and giant cell type,which is the most common type resembles a
sarcoma. And refered to as pleomorphic, spindle and giant cell adenocarcinoma or sarcomatoid
carcinoma. They contain variable propotion of spindle and giant cells, foci of well differentiated
neoplastic glands restricted to <5% are usually found after extensive sampling.
The sarcoma like portion consists of undifferentiated stellate and spindle-shaped cells which are
variably admixed with foci which resemble an osteosarcoma, a chondrosarcoma or a
rhabdomyosarcoma
(2)
. In our case, there is focal area of chondroid metaplasia seen.
Other histological variants include undifferentiated carcinoma with osteoclast like giant cells which
has evenly distributed osteoclast like giant cells,undifferentiated carcinoma small cell type composed
of sheets of round cells with vesicular nuclei and prominent nucleoli with occasional intracytoplasmic
mucin, undifferentiated carcinoma nodular or lobular type which resembles breast carcinoma.
Surgery is suggested as the only recognized treatment for gallbladder sarcomatoid carcinoma. Previous
studies reported the use of chemo radiotherapy did not significantly improve patient prognosis.
Exploration of new radiation techniques and of chemotherapeutic regimens with new drugs is required
for the treatment of sarcomatoid carcinoma of the gall bladder because conventional chemotherapy and
radiotherapy do not increase patient survival
(1)
.
Zhang et al, in their study, reported that tumours which were smaller than 5 cm had a longer survival
and that therefore, the tumour size should be considered as a major component in the future staging
system for sarcomatoid carcinoma of GB
(2,7)
.
Thus we conclude that this histological variant of gallbladder carcinoma inspite of its rarity should be
kept in mind both by the pathologist and the clinicians.Since it is known for its poor prognosis and the
advanced stages of clinical presentation, its early diagnosis and treatment will hopefully improve
patient survival.
REFERENCES:
1. Kataria K, Yadav R, Seenu V. Sarcomatoid carcinoma of the gall bladder. JSCR 2012. 2:5
2. Menka Khanna, Ashish Khanna, Mridu Manjari, Carcinosarcoma of the Gallbladder: A Case
Report and Review of the Literature-DOI: 10.7860/JCDR/2013/4924.2825.
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3. Tanu Agarwal, Manoj Jain,Amit Goel, Paari visayaragavan, R.K.Gupta: Carcinosarcoma of the
gall bladder, IJPM 52(2), April-June 2009.
4. Sung Bae Park, Yang Hee Kim, Hye Lin Rho, Gi Bong Chae, Seong Kweon Hong, Primary
carcinosarcoma of the gallbladder case report J Korean Surg Soc 2012;82:54-58.
5. Keng-Hao Liu, Ta-Sen Yeh, Tsann-Long Hwang, Yi-Yin Jan, Miin-Fu Chen Surgical
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gall bladder: A review. World J Gastroenterol. 2009; 15(39): 4877-82.
7. Zhang L, Chen Z, Fukuma M, Lee LY, Wu M. Prognostic Significance of Race and Tumor
Size in Carcinosarcoma of Gallbladder: a Meta-Analysis of 68 Cases. Int J Clin Exp Pathol.
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8. Kim MJ, Yu E, Ro JY. Sarcomatoid Carcinoma of the Gallbladder with a rhabdoid tumor
component. Arch Pathol Lab Med. 2003;127:e406-8.