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Year : 2006  |  Volume : 16  |  Issue : 4  |  Page : 491-493
Carcinosarcoma of the gallbladder with chondroid differentiation: Mri findings


Consultant Radiologist, Ganesh Diagnostic & Imaging Centre, Sector-8, Rohini,New Delhi- 110085, India

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Date of Submission05-Apr-2006
Date of Acceptance10-Aug-2006
 

   Abstract 

Carcinosarcoma is a rare type of gallbladder malignancy, the diagnosis requires the presence of both malignant epithelial and mesenchymal components. The prognosis of this disease is extremely poor. We report a case of carcinosarcoma of the gallbladder with chondroid differentiation in a 68 years old man presented as an intraluminal growth of gallbladder. MR findings, histological findings and differential diagnosis of the case were discussed.

Keywords: Carcinosarcoma, Gallbladder, Magnetic Resonance Imaging

How to cite this article:
Oberoi R, Jena A, Tangri R, Saharia A. Carcinosarcoma of the gallbladder with chondroid differentiation: Mri findings. Indian J Radiol Imaging 2006;16:491-3

How to cite this URL:
Oberoi R, Jena A, Tangri R, Saharia A. Carcinosarcoma of the gallbladder with chondroid differentiation: Mri findings. Indian J Radiol Imaging [serial online] 2006 [cited 2019 Aug 24];16:491-3. Available from: http://www.ijri.org/text.asp?2006/16/4/491/32253

   Introduction Top


Carcinosarcomas are rare tumors that are characterized by malignant epithelial and mesenchymal elements. These tumors have been reported in may different origins including the uterus, lung, oesophagus, kidney and pancreas. Carcinosarcoma of the gallbladder are rare and only 41 cases were published in the world literature [1],[2]. To best of our knowledge MRI (Magnetic resonance imaging) finding of carcinosarcoma of the gallbladder is not reported in literature.


   Case report Top


A 68 - year old man was admitted to our institute with complaints of loss of appetite and distension of abdomen since last 3 months. He had no Jaundice or fever. Physical examination revealed gross ascites. The results of laboratory investigations revealed mild increase in serum bilirubin level (3.2 mg/100 ml) and serum enzymes (SGOT/SGPT 252/282 Iu/ml, Alkaline phosphatase 1780 Iu/ml). The levels of tumor markers were elevated: carcinoembryogenic antigen (CEA) 7.3 ng/ml and carbohydrated antigen (CA 19-9) 195 u/ml.

Ultrasonography revealed an ill defined intraluminal mass in the gallbladder with calculi and gross ascites. Magnetic resonance imaging (MRI) was performed to evaluate the gallbladder mass. The tumor appeared as isointense to hypointense in T1Weighted and hyperintense in T2Weighted images relative to the adjacent liver, filling the entire gallbladder lumen with focal involvement of gallbladder wall & minimal infiltration of adjacent segment V of the liver [Figure - 1]. Signal void areas suggesting calcifications are seen within the tumor [Figure - 2], in addition to signal void calculi in the gall bladder lumen. Enlarged portocaval node [Figure - 2], gross ascites & omental thickening were also noted.

CT guided FNAC from the mass revealed adenocarcinoma. At surgery the tumor was found filling the entire gallbladder lumen with multiple calculi & invasion of adjacent right lobe of the liver. Evidence of ascites, omental deposits and enlarged lymphnode were also noted. Cholecystectomy, omentectomy and saphenoperitoneal shunt was performed.

On gross examination [Figure - 3] a friable greyish white tumor mass seen filling the entire gallbladder lumen with areas of calcification within the tumor. Also multiple calculi are seen in the gall bladder lumen. The tumor appears predominantly limited to gallbladder lumen with infiltration of wall. Histologically [Figure - 4] the tumor contained two distinct components: a mixture of both well differentiated adenocarcinoma composed of malignant columnar cells filling the gallbladder cavity & infiltrating the full thickness of gallbladder wall with involvement of serosa and the other poorly differentiated sarcomatoid tissue with chondroid differentiation. Adjacent liver parenchyma is infiltrated by the tumor. Omental biopsy shows infiltration by the tumor showing mostly adenocarcinomatous component. On immunohistochemistry the epithelial component of tumor were positive for Cytokeratin (CK). The sarcomatous tumor cells were positive for Vimentin (VM) & Cytokeratin. Thus the tumor was histologically diagnosed as carcinosarcoma of the gallbladder with chondroid differentiation.


   Discussion Top


Carcinosarcoma of the gallbladder is a rare tumor characterized by malignant epithelial and mesenchymal components. The epithelial component is usually adenocarcinoma, the sarcomatous component is either fibrosarcoma, chondrosarcoma, osteosarcoma, spindle cell sarcoma or rhabdomyosaroma.

The first case of carcinosarcoma of the gall bladder reported by Landsteiner in 1907 in a museum specimen. These tumors are six times as common in females as in the males with a peak incidence in the eighth decade of life and 75% of patients had cholelithiasis simultaneously [3].

The four possible pathogenetic mechanisms of carcinosarcoma has been described [2]. The first theory hold that the malignant clone induces an atypical but benign connective tissue reaction. The second theory holds that the tumor represents a dual growth of carcinoma and sarcoma arising from two distinct but adjacent malignant clones (so-called collision tumor). The two malignant clones could arise simultaneously or metachronously. The third theory holds that a single malignant clone arises with the capability of divergent, yet simultaneous, mesenchymal and epithelial differentiation. The last theory holds that the sarcomatous component of the carcinosarcoma arises through a process of differentiation from conventional carcinoma.

The only recognised treatment for carcinosarcoma of gallbladder is surgery. However the preoperative diagnosis of the tumor was often gallbladder carcinoma, and in spite of aggressive surgical resection the prognosis of this tumor was very poor. The mean survival time after diagnosis in normally only a few months. Some reports indicated that carcinosarcoma of gallbladder may be curable with long-term survival if resected at any early stage when the tumor is located within the gallbladder lumen [4].

Carcinosarcoma of the gallbladder tends to grow, occupying the lumen of the gallbladder. However other radiological characteristics of this tumor are similar to those of carcinoma that are difficult to distinguish carcinosarcoma from intraluminal growth of the gallbladder carcinoma [5].

We described the MRI findings of carcinosarcoma of the gallbladder. On MRI the tumor was predominantly intraluminal filling the gallbladder lumen with focal involvement of gallbladder wall & minimal invasion of adjoining liver. The tumor appears isointense to hypointense in T1Weighted and hyperintense in T2Weighted images relative to liver with signal void areas embedded within the mass that corresponds to the areas of calcification revealed on histology and could not be differentiated from other signal void calculi in the gall bladder lumen. In addition gross ascites, lymphadenopathy & omental thickening were also noted. The differential diagnosis includes gall bladder carcinoma with calcification & Porcelain gall bladder with carcinoma.

In summary, we report an uncommon case of gallbladder carcinosarcoma, a rare type of gallbladder malignancy. The MR appearances were non specific, however in a predominantly intraluminal gallbladder tumor seen on MRI with calcific areas within the tumor, carcinosarcoma should be considered in differential diagnosis.

Acknowledgements: We acknowledge the contribution of Mr. Pradeep Negi (technologist) & Mrs. Vandana Pal for helping in the preparation of the manuscript.

 
   References Top

1.Tetsu Ajiki, Takeshi Nakamura, Yasuhiro Fujino, et al. Carcinosarcoma of the gallbladder with Chondroid differentiation. J. Gastroenterol 2002; 37:966-971.   Back to cited text no. 1    
2.Tsukasa Hotta, Hiroshi Tanimura, Shozo Yokoyoma, Kimiko Ura, and Hiroki Yamaue. So-called Carcinosaroma; Spindle cell carcinoma of the gallbladder: Report of a case. Surg Today 2002; 32:462-467.  Back to cited text no. 2    
3.Michael W. Born, William G. Ramey, Stephen F, Ryan, and Philip E. Gordon. Carcinosarcoma and carcinoma of the gallbladder. Cancer 1984; 2171-2177.  Back to cited text no. 3    
4.Von Kuster LC, Cohen C. Malignant mixed tumor of the gallbladder report of two cases and a review of the literature. Cancer 1982; 50:1166-1170.  Back to cited text no. 4  [PUBMED]  
5.Nakagawa T, Yamakado K, Takeda K. An Ossifying Carcinosarcoma of the gallbladder: Radiologic findings. Am J Roentgenol 1996, 166: 1233-1234.  Back to cited text no. 5    

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Correspondence Address:
R Oberoi
GG-1-64/C, Vikaspuri, New Delhi-110085
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-3026.32253

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    Figures

  [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]

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