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\begin{document}

\title{Carcinoma of gallbladder associated with pancreatic pseudocyst: A rare
case report}



\author[1]{Diwan Shrestha}%
\author[1]{Bibek  Shrestha}%
\author[1]{Prakash Gyawali}%
\author[1]{Prasan  Kansakar}%
\author[2]{Kaushal Pakhrin}%
\author[3]{Sumina Shrestha}%
\affil[1]{Tribhuvan University Institute of Medicine}%
\affil[2]{National Academy of Medical Sciences}%
\affil[3]{Dhulikhel Hospital, Nepal}%


\vspace{-1em}



  
  \date{May 20, 2024}


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\textbf{Introduction}

Gall bladder carcinoma is a rare neoplasm and is the fifth most common
gastrointestinal malignancy with an incidence of 1 to 2 per 100,000 in
the US and 22 per 100,000 in women in Delhi.(1) However, it is usually
diagnosed at an advanced stage with an overall median survival of less
than 6 months as the gall bladder has a thin wall, narrow lamina propia,
and single muscular layer. It usually presents in the 6th to 7th decade
of life with a female-to-male ratio of 3.4:1.(2) Only 0.3 to 3\% of
patients develop gall bladder carcinoma, although approximately
sixty-nine to eighty-six percent of patients have a gallstone disease
history. Other risk factors of carcinoma gallbladder include porcelain
gallbladder, Mirizzi syndrome, ethanol \& tobacco abuse, gallbladder
polyp size \textgreater{} 10mm, anomalous pancreaticobiliary duct
junction, and chronic infection with Salmonella typhi. Sixty percent of
the tumor arises from the fundus of the gallbladder.(3)The pathogenesis
of carcinoma gallbladder follows the progression from metaplasia to
dysplasia to carcinoma.

Most pancreatic pseudocysts occur as a consequence of acute
pancreatitis. But, they may also occur in the setting of chronic
pancreatitis, postoperatively, or after pancreatic trauma. (4) One
common mechanism for carcinoma of gallbladder and pancreatitis is
abnormal pancreaticobiliary duct junction.(5,6) Pancreatic pseudocyst
associated with gallbladder carcinoma occurs very rarely. We here
present an unusual case of carcinoma of the gallbladder with a
pancreatic pseudocyst.

\textbf{Case report}

A 35-year-old female presented at the Department of General Surgery,
Tribhuvan University Teaching Hospital in Kathmandu, Nepal, complaining
of pain in the upper middle and right upper abdomen for the past year.
The pain was intermittent, not radiating to other areas of the abdomen,
but had worsened over the past month. She also experienced episodes of
vomiting, significant weight loss of approximately 6 kg, and shortness
of breath while sitting or lying down. There was no history of fever,
jaundice, loss of appetite, itching, dark stools, or pale-colored stool.

During the abdominal examination, a firm, smooth, non-tender mass
measuring approximately 10x14 cm was detected in the upper middle and
right upper abdomen. Abdominal ultrasound revealed signs of acute
pancreatitis with the presence of a pseudocyst and a mass in the
gallbladder. The levels of CEA (Carcinoembryonic Antigen) were measured
at 1.5, and CA 19.9 (Cancer Antigen 19-9) was less than 1.4. Upper
gastrointestinal (UGI) endoscopy showed a bulge in the first part of the
duodenum (D1), possibly due to external compression (Figure 1).\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

\end{center}
\end{figure}

Fig 1: showing bulge in D1 during UGI endoscopy.

The contrast-enhanced computed tomography (CECT) of the abdomen revealed
findings consistent with acute interstitial pancreatitis, accompanied by
a pancreatic pseudocyst measuring 19x9.5x5.8 cm. The pseudocyst was
located in the lesser sac region and extended into the left anterior
pararenal area and the right mesentery. Additionally, there was a
heterogeneously enhancing asymmetric soft tissue thickening measuring
approximately 2.7x1.9 cm, originating from the posterior wall of the
body of the gallbladder (Figure 2 and 3).\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image2/image2}

\end{center}
\end{figure}\selectlanguage{english}
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\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image3/image3}

\end{center}
\end{figure}

Fig 2 and 3: showing acute interstitial pancreatitis with pancreatic
pseudocyst and

mass arising from posterior wall of body of gallbladder.

An extended cholecystectomy with cystogastrostomy was done (Figure 4).
Intraoperatively, the patient presented with frozen Calot's triangle, a
pancreatic pseudocyst in the lesser sac containing around 500 ml of
discolored fluid, and a 2.5 cm hard nodular mass on the body of the
gallbladder towards the peritoneal wall (Figure 5 and 6).\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image4/image4}

\end{center}
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Fig 4: showing intraoperative picture of extended cholecystectomy with
cystogastrostomy.\selectlanguage{english}
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\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image5/image5}

\end{center}
\end{figure}\selectlanguage{english}
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\includegraphics[width=0.70\columnwidth]{figures/image6/image6}

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Fig 5 and 6: showing hard nodular mass on the body of gallbladder.

Her histopathological examination (Figure 7 and 8) showed
adenocarcinoma, biliary type with tumor extending upto perimuscular
connective tissue and perineural invasion present, AJCC stage: pT2aN1.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image7/image7}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image8/image8}

\end{center}
\end{figure}

Fig 7 and 8: showing adenocarcinoma in HPE.

\textbf{Discussion}

Gallbladder cancer is a rare neoplasm of the gastrointestinal tract;
however, it is the most common malignancy of the biliary tract. In 2018,
GLOBOCAN reported high age-standardized incidence rate(ASIR) of gall
bladder carcinoma in South Asia. Cholelithiasis is the most common risk
factor for developing gallbladder cancer.(7) There is an approximately
10-fold higher risk of developing gallbladder cancer in patients with
gallstones larger than 3 cm.(8)

As a high proportion of tumors is already advanced at the time of
presentation, the prognosis of gall bladder carcinoma is generally
extremely poor. This is reflected by the 5-year survival for all stages
of gallbladder cancer which is about 5\%.(9,10) Resection remains the
only chance for a cure because chemotherapy and radiotherapy are
ineffective as primary treatments. Various surgical options for
treatment have evolved over the last 10 years such as procedures ranging
from a simple cholecystectomy to a radical or extended cholecystectomy.
They may include liver resections, from segmentectomies to right
hepatectomies and trisectionectomy.

Pancreatic pseudocysts form usually after 4 weeks of initial insult and
are commonly associated with acute pancreatitis or pancreatic
trauma.(11) They may also occur in approximately 20\%-40\% of patients
with chronic pancreatitis.(12)

Pancreatic pseudocyst may resolve spontaneously and thus can be managed
conservatively by watchful monitoring.(13) Indications for decompression
of pseudocyst are abdominal pain, nausea and vomiting, superimposed
infection, and gastric outlet or biliary tract obstruction.(14)
Association of gallbladder carcinoma with pancreatic pseudocyst is rare.
Only a few case studies have been reported of this association.

\textbf{Conflict of interest}

None to declare.

\textbf{Funding}

The authors received no financial support for the research, authorship,
and publication of this article.

\textbf{Consent to participate}

Written informed consent was obtained from the patient for the
publication of this case report and accompanying images.

\textbf{Ethical approval}

Not required.

\textbf{Registration of research studies}

Not applicable.

\textbf{Guarantor}

Diwan Shrestha

\textbf{Declaration of competing interest}

The authors declare no competing interests.

\textbf{References}

1. Randi G, Franceschi S, La Vecchia C. Gallbladder cancer worldwide:
Geographical distribution and risk factors. International Journal of
Cancer. 2006 Apr 1;118(7):1591--602.

2. Hsing AW, Gao YT, Han TQ, Rashid A, Sakoda LC, Wang BS, Shen MC et
al. Gallstones and the risk of biliary tract cancer: a population-based
study in China. Br J Cancer. 2007 Dec 3;97(11):1577-82.

3. Shaffer EA. Gallbladder Cancer: The Basics. Gastroenterol Hepatol .
2008 Oct;4(10):737.

4. Bradley EL. A Clinically Based Classification System for Acute
Pancreatitis: Summary of the International Symposium on Acute
Pancreatitis, Atlanta, Ga, September 11 Through 13, 1992. Arch Surg.
1993 May 1;128(5):586--90.

5. Yamauchi S, Koga A, Matsumoto S, Tanaka M, Nakayama F.
Anomalousjunction of pancreaticobiliary duct without congenital
choledochal cyst:a possible risk factor for gallbladder cancer. Am J
Gastroenterol1987;82:20--24.

6. Sameshima Y, Muto Y, Uchimura M, Waki S, Hayashi T.
Clinicopatho-logical study of the gallbladder in congenital dilatation
of the bile duct---with special reference to the association with cancer
{[}in Japanese{]}. NipponShokakibyo Gakkai Zasshi 1982;79:1129--1136.

7. Serra I, Calvo A, B\selectlanguage{ngerman}áez S, Yamamoto M, Endoh K, Aranda W. Risk factors
of gallbladder cancer: An international collaborative case-contol study.
Cancer. 1996 Oct 1;78(7):1515--6.

8. Diehl AK. Gallstone Size and the Risk of Gallbladder Cancer. JAMA.
1983 Nov 4;250(17):2323--6.

9. Chan CP, Chang HC, Chen YL, Yang LH, Chen ST, Kuo SJ, et al. A
10-year experience of unsuspected gallbladder cancer after laparoscopic
cholecystectomy. International surgery. 2003;88(3):175-9.

10. Bartlett DL, Fong Y, Fortner JG, Brennan MF, Blumgart LH. Long-term
results after resection for gallbladder cancer. Implications for staging
and management. Ann Surg. 1996 Nov;224(5):639.

11. Cannon JW, Callery MP, Vollmer CM Jr. Diagnosis and Management of
Pancreatic Pseudocysts: What is the Evidence? J Am Coll Surg. 2009
Sep;209(3):385.

12. Complications of Chronic Pancreatitis. Surg Clin North Am. 1989 Jun
1;69(3):481--97.

13. Brugge WR. Approaches to the drainage of pancreatic pseudocysts.
Curr Opin Gastroenterol. 2004 Sep;20(5):488.

14. Varadarajulu S, Bang JY, Sutton BS, Trevino JM, Christein JD, Wilcox
CM. Equal efficacy of endoscopic and surgical cystogastrostomy for
pancreatic pseudocyst drainage in a randomized trial. Gastroenterology.
2013 Sep;145(3):583-90.~

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