Comparison of clinicopathological characteristics and survival outcomes between gallbladder mucinous adenocarcinoma and gallbladder adenocarcinoma:A propensity score-matched study

BACKGROUND Gallbladder mucinous adenocarcinoma(GBMAC)is a rare subtype of gallbladder adenocarcinoma(GBAC),with limited knowledge of its survival outcomes from small case series and single-center retrospective analysis.AIM To compare the clinicopathological characteristics of GBMAC with typical GBAC and its prognostic factors to gain insights into this field.METHODS This study was conducted using data from the Surveillance,Epidemiology,and End Results database,including cases of GBMAC and typical GBAC diagnosed from 2010 to 2017.The Pearson chi-square test or Fisher exact test was used to examine the differences in clinicopathological features between these two cohorts.In addition,propensity score matching(PSM)analysis was performed to balance the selection biases.Univariate and multivariate Cox hazards regression analyses were performed to determine independent prognostic factors for cancer-speci
c survival(CSS)and overall survival(OS).The Kaplan–Meier curves and log-rank tests were used to assess the OS and CSS of GBMAC and typical GBAC patients.RESULTS The clinicopathological and demographic characteristics of GBMAC were different from typical GBAC.They included a larger proportion of patients with unmarried status,advanced American Joint Committee on Cancer(AJCC)stage,higher T stage,higher N1 stage rate and lower N0 and N2 stage rates(P<0.05).Multivariate analyses demonstrated that surgery[OS:Hazard ratio(HR)=2.27,P=0.0037;CSS:HR=2.05,P=0.0151],chemotherapy(OS:HR=6.41,P<0.001;CSS:HR=5.24,P<0.001)and advanced AJCC stage(OS:Stage IV:HR=28.99,P=0.0046;CSS:Stage III:HR=12.31,P=0.015;stage IV:HR=32.69,P=0.0015)were independent prognostic indicators for OS and CSS of GBMAC patients.Furthermore,after PSM analysis,there was no significant difference between GBMAC and matched typical GBAC patients regarding OS(P=0.82)and CSS(P=0.69).CONCLUSION The biological behaviors of GBMAC are aggressive and significantly different from that of typical GBAC.However,they show similar survival prognoses.Surgery,chemotherapy,and lower AJCC stage were associated with better survival outcomes.Further research is needed in the future to verify these results.

Spilled gallstone mimicking intra-abdominal seeding of gallbladder adenocarcinoma: A case report

BACKGROUND Gallbladder rupture is common in laparoscopic cholecystectomy because the gallbladder is usually in acute or chronic inflammation status.The gallstones may sometime be spilled into the peritoneal cavity,resulting in intra-abdominal ab-scess if the gallstones were not retrieved.The diagnosis of intra-abdominal ab-scess caused by unretrieved gallstone can usually be correctly identified in the routine imaging studies,such as abdominal ultrasonography or computed tomo-graphy(CT).Here we present a case of abscess formation from unretrieved gall-stone following laparoscopic cholecystectomy,which mimics the imaging findings of metastatic gallbladder ade-nocarcinoma.CASE SUMMARY This case described a 78-year-old man who received laparoscopic cholecystectomy and gallbladder adenocarcinoma was diagnosed after surgery.After adjuvant chemotherapy,the following up abdominal CT showed several small nodules at right upper abdomen and peritoneal carcinomatosis is considered.Repeated laparoscopic surgery for the excision of seeding tumor was conducted and the pathological diagnosis of the nodules and mass was inflammatory tissues and gallbladder stone.CONCLUSION Spilled gallstones are a common complication during laparoscopic cholecystectomy and some gallstones fail to be retrieved due to the size or the restricted view of laparoscopic surgery.For spilled gall bladder stones,surgeons may consider regular computerized tomography follow-up,and if necessary,laparoscopic examination can be used as a means of confirming the diagnostic and treatment.

Comparative study of ROR2 and WNT5a expression in squamous/adenosquamous carcinoma and adenocarcinoma of the gallbladder

AIM To investigate the expression and clinical pathological significance of ROR2 and WNT5a in gallbladder squamous/adenosquamous carcinoma (SC/ASC) and adenocarcinoma (AC). METHODS EnVision immunohistochemistry was used to stain for ROR2 and WNT5a in 46 SC/ASC patients and 80 AC patients. RESULTS Poorly differentiated AC among AC patients aged >45 years were significantly more frequent compared with SC/ASC patients, while tumors with a maximal diameter >3 cm in the SC/ASC group were significantly more frequent compared with the AC group. Positive ROR2 and WNT5a expression was significantly lower in SC/ASC or AC with a maximal mass diameter = 3 cm, a TNM stage of I + II, no lymph node metastasis, no surrounding invasion, and radical resection than in patients with a maximal mass diameter >3 cm, TNM stage., lymph node metastasis, surrounding invasion, and no resection. Positive ROR2 expression in patients with highly differentiated SC/ASC was significantly lower than in patients with poorly differentiated SC/ASC. Positive ROR2 and WNT5a expression levels in highly differentiated AC were significantly lower than in poorly differentiated AC. Kaplan-Meier survival analysis showed that differentiation degree, maximal mass diameter, TNM stage, lymph node metastasis, surrounding invasion, surgical procedure and the ROR2 and WNT5a expression levels were closely related to average survival of SC/ASC or AC. The survival of SC/ASC or AC patients with positive expression of ROR2 and WNT5a was significantly shorter than that of patients with negative expression results. Cox multivariate analysis revealed that poor differentiation, a maximal diameter of the mass >= 3 cm, TNM stage. or., lymph node metastasis, surrounding invasion, unresected surgery and positive ROR2 or WNT5a expression in the SC/ASC or AC patients were negatively correlated with the postoperative survival rate and positively correlated with mortality, which are risk factors and independent prognostic predictors. CONCLUSION SC/ASC or AC patients with positive ROR2 or WNT5a expression generally have a poor prognosis.

Hodgkin lymphoma masquerading as perforated gallbladder adenocarcinoma:A case report

BACKGROUND There are several case reports of acute cholecystitis as the initial presentation of lymphoma of the gallbladder;all reports describe non-Hodgkin lymphoma or its subtypes on histopathology of the gallbladder tissue itself.Interestingly,there is no description in the literature of Hodgkin lymphoma causing hilar lymphadenopathy,inevitably presenting as ruptured cholecystitis with imaging mimicking gallbladder adenocarcinoma.CASE SUMMARY A 48-year-old man with a past medical history of diabetes mellitus presented with progressive abdominal pain,jaundice,night sweats,weakness,and unintended weight loss for one month.Work-up revealed a mass in the region of the porta hepatis causing obstructions of the cystic and common hepatic ducts,gallbladder rupture,as well as retroperitoneal lymphadenopathy.The clinical picture and imaging findings were suspicious for locally advanced gallbladder adenocarcinoma causing ruptured cholecystitis and cholangitis,with metastases to retroperitoneal lymph nodes.Minimally invasive techniques,including endoscopic duct brushings and percutaneous lymph node biopsy,were inadequate for tissue diagnosis.Therefore,this case required exploratory laparo-tomy,open cholecystectomy,and periaortic lymph node dissection for histopathological assessment and definitive diagnosis.Hodgkin lymphoma was present in the lymph nodes while the gallbladder specimen had no evidence of malignancy.CONCLUSION This clinical scenario highlights the importance of histopathological assessment in diagnosing gallbladder malignancy in a patient with gallbladder perforation and a grossly positive positron emission tomography/computed tomography scan.For both gallbladder adenocarcinoma and Hodgkin lymphoma,medical and surgical therapies must be tailored to the specific disease entity in order to achieve optimal long-term survival rates.

Clinical outcomes of small cell neuroendocrine carcinoma and adenocarcinoma of the gallbladder

AIM: To compare the demographics and survival rates between gallbladder adenocarcinoma(GB-adenocarcinoma) and small cell neuroendocrine carcinoma of the gallbladder(GB-NEC-SCC).METHODS: From March 2007 to September 2012,patients who underwent resection of tumor stage T2/T3 GB cancer were enrolled for this study.Fortytwo patients were included in this study,including 38 diagnosed with GB-adenocarcinoma and four diagnosed with GB-NEC-SCC.In the GB-adenocarcinoma group,a radical operation was performed in 28 patients,and ten patients underwent simple cholecystectomy.In the GB-NEC-SCC group,a radical operation was performed in three patients,and one patient underwent simple cholecystectomy.Comparative analysis of the two groups was performed,including clinicopathologic features and survival rates.RESULTS: The median age of the patients was 68 y(range: 35-83 years) and females comprised 26/42 of the patients.GB-adenocarcinoma patients were significantly older than GB-NEC-SCC patients(67.89 ± 11.15 vs 55.75 ± 10.31 years; P = 0.029).The median tumor size in GB-adenocarcinoma patients was 2.56 ± 1.75 cm and 3.98 ± 3.74 cm in GB-NEC-SCC patients; however,there was no significant difference between the two groups.For tumors > 2 cm,T stage(T2 vs T3),lymphovascular invasion,perineural invasion,lymph node metastasis and lymph node ratio showed no significant differences between the two groups.The overall survival rate of the 42 patients at five years was 77.0%.In the GB-adenocarcinoma group,the overall five-year survival rate was 74.8%,and survival in the GB-NEC-SCC group was 100%,which was not significantly different between the two groups.CONCLUSION: The strategy for treating patients with GB-NEC-SCC should be similar to that used for treating GB-adenocarcinoma,including radical cholecystectomy and liver resection.

Correlation of S1P1 and ERp29 expression to progression, metastasis, and poor prognosis of gallbladder adenocarcinoma

BACKGROUND: Gallbladder cancer (GBC) is one of the most aggressive malignant neoplasms with an extremely poor prognosis. Early diagnosis significantly increases the survival rate. The present study was undertaken to evaluate the diagnostic and prognostic value of sphingosine-1-phosphate receptor 1 (S1P1) and endoplasmic reticulum protein 29 (ERp29) in benign and malignant gallbladder lesions and to develop a possible alternative treatment for GBC. METHODS: A total of 100 gallbladder adenocarcinoma, 46 peritumoral, 30 gallbladder adenomatous, 15 gallbladder polyp and 35 chronic cholecystitis tissues were included. S1P1 and ERp29 expressions were evaluated by immunohistochemistry The correlation between S1P1 and ERp29 expression and tumor pathological features and prognosis was analyzed. RESULTS: S1P1 positive rate was significantly higher in gallbladder adenocarcinomas than that in peritumoral adenomatous, polyp, and chronic cholecystitis tissues. On the contrary, ERp29 positive rate was significantly lower in adenocarcinomas than that in peritumoral, adenomatous polyp, and chronic cholecystitis tissues. Benign lesions with positive S1P1 or negative ERp29 expression showed moderate or severe atypical hyperplasia in the gallbladder epithelium The overexpression of S1P1 or non-expression of ERp29 was significantly associated with tumor differentiation, tumor mass, lymph node metastasis, and adenocarcinoma invasion Univariate Kaplan-Meier analysis showed that the elevated S1P1 (P=0.008) or absence of ERp29 (P=0.043) was closely associated with decreased survival rate. Multivariate Cox regression analysis showed that S1P1 positive (P=0.004) or ERp29 negative (P=0.029) was an independent predictor of poor prognosis in gallbladder adenocarcinoma.CONCLUSION: S1P1 overexpression or ERp29 absence is related to the carcinogenesis and progression, and may be potential biomarkers for early detection of gallbladder adenocarcinoma.

Gallbladder adenocarcinoma and paraneoplastic parathyroid hormone mediated hypercalcemia

Parathyroid hormone mediated hypercalcemia is not always exclusively primary hyperparathyroidism and rarely could be due to ectopic parathyroid hormone secretion from tumor cells.We present a case of 86-yearold female with metastatic gall bladder adenocarcinoma diagnosed eight months back who presented with generalized fatigue and poor oral intake and was found to be hypercalcemic with elevated parathyroid hormone levels.Imaging with technetium 99 m sestamibi scintigraphy with dual phase,subtraction thyroid scan(dual isotope scintigraphy),magnetic resonance imaging and ultrasonography did not demonstrate any parathyroid lesion in normal or ectopic sites.We believe that the tumor cells were the source of ectopic parathyroid hormone secretion as we had excluded all the other possibilities with extensive combined imaging thereby increasing the sensitivity of our testing.We report the first case of metastatic gall bladder adenocarcinoma with paraneoplastic ectopic parathyroid hormone secretion.

Synchronous primary duodenal papillary adenocarcinoma and gallbladder carcinoma:A case report and review of literature

BACKGROUND Synchronous primary cancers(SPCs) have become increasingly frequent over the past decade.However,the coexistence of duodenal papillary and gallbladder cancers is rare,and such cases have not been previously reported in the English literature.Here,we describe an SPC case with duodenal papilla and gallbladder cancers and its diagnosis and successful management.CASE SUMMARY A 68-year-old Chinese man was admitted to our hospital with the chief complaint of dyspepsia for the past month.Contrast-enhanced computed tomography of the abdomen performed at the local hospital revealed dilatation of the bile and pancreatic ducts and a space-occupying lesion in the duodenal papilla.Endoscopy revealed a tumor protruding from the duodenal papilla.Pathological findings for the biopsied tissue revealed tubular villous growth with moderate heterogeneous hyperplasia.Surgical treatment was selected.Macroscopic examination of this surgical specimen revealed a 2-cm papillary tumor and another tumor protruding by 0.5 cm in the gallbladder neck duct.Intraoperative rapid pathology identified adenocarcinoma in the gallbladder neck duct and tubular villous adenoma with high-grade intraepithelial neoplasia and local canceration in the duodenal papilla.After an uneventful postoperative recovery,the patient was discharged without complications.CONCLUSION It is essential for clinicians and pathologists to maintain a high degree of suspicion while evaluating such synchronous cancers.

Estimating survival benefit of adjuvant therapy based on a Bayesian network prediction model in curatively resected advanced gallbladder adenocarcinoma

BACKGROUND The factors affecting the prognosis and role of adjuvant therapy in advanced gallbladder carcinoma(GBC)after curative resection remain unclear.AIM To provide a survival prediction model to patients with GBC as well as to identify the role of adjuvant therapy.METHODS Patients with curatively resected advanced gallbladder adenocarcinoma(T3 and T4)were selected from the Surveillance,Epidemiology,and End Results database between 2004 and 2015.A survival prediction model based on Bayesian network(BN)was constructed using the tree-augmented na?ve Bayes algorithm,and composite importance measures were applied to rank the influence of factors on survival.The dataset was divided into a training dataset to establish the BN model and a testing dataset to test the model randomly at a ratio of 7:3.The confusion matrix and receiver operating characteristic curve were used to evaluate the model accuracy.RESULTS A total of 818 patients met the inclusion criteria.The median survival time was 9.0 mo.The accuracy of BN model was 69.67%,and the area under the curve value for the testing dataset was 77.72%.Adjuvant radiation,adjuvant chemotherapy(CTx),T stage,scope of regional lymph node surgery,and radiation sequence were ranked as the top five prognostic factors.A survival prediction table was established based on T stage,N stage,adjuvant radiotherapy(XRT),and CTx.The distribution of the survival time(>9.0 mo)was affected by different treatments with the order of adjuvant chemoradiotherapy(cXRT)>adjuvant radiation>adjuvant chemotherapy>surgery alone.For patients with node-positive disease,the larger benefit predicted by the model is adjuvant chemoradiotherapy.The survival analysis showed that there was a significant difference among the different adjuvant therapy groups(log rank,surgery alone vs CTx,P<0.001;surgery alone vs XRT,P=0.014;surgery alone vs cXRT,P<0.001).CONCLUSION The BN-based survival prediction model can be used as a decision-making support tool for advanced GBC patients.Adjuvant chemoradiotherapy is expected to improve the survival significantly for patients with node-positive disease.

Spontaneous necrosis of solid gallbladder adenocarcinoma accompanied with pancreaticobiliary maljunction

A 71-year-old Japanese man with acute cholecystitis and an incarcerated gallbladder （GB） stone was admitted. Plain ultrasonography （US） incidentally detected a mass-like lesion in the fundus. Doppler US revealed that this elevated lesion had no blood flow. Computed tomography showed a relatively low-density mass, measuring 5 cm x 4 cm in diameter, with no positive enhancement. Magnetic resonance imaging showed a mass in the fundus with a slightly low intensity on Tl-weighted images and a slightly high intensity on T2-weighted images. We were agonized in making the qualitative diagnosis of mass-like lesions of the fundus, such as a benign tumor, cancer, or debris. We performed laparoscopic cholecystectomy, because the incarcerated GB stone clearly caused acute cholecystitis. Intra-operative cholangiography clearly revealed pancreaticobiliary maljunction. Amylase levels in the common bile duct and gallbladder were quite high. The elevated lesion in the fundus dearly showed severe necrosis. Although this necrotic nodule included non-viable adenocarcinoma cells, viable cancer cell nests were located in the muscularis propria and subcutaneous layer. Histopathological examination confirmed a solid adenocarcinoma. Thus, we diagnosed it as a gallbladder cancer, based on histopathological analysis of the resected specimen. We therefore undertook radical surgery, including wedge resection of the liver, radical dissection of regional lymph nodes, and resection of the extrahepatic bile duct. Histopathological findings revealed no cancer, hyperplasia or dysplasia in the additionally resected specimens. The patient was finally staged as T2, N0, H0, P0, M（-）, stage Ⅱ. We present the first case of spontaneous necrosis of solid gallbladder adenocarcinoma, with a review of previous studies.

Natural history of asymptomatic gallbladder stones in clinic without beds:A long-term prognosis over 10 years

BACKGROUND Several studies have explored the long-term prognosis of patients with asymp-tomatic gallbladder stones.These reports were primarily conducted in facilities equipped with beds for addressing symptomatic cases.AIM To report the long-term prognosis of patients with asymptomatic gallbladder stones in clinics without bed facilities.METHODS We investigated the prognoses of 237 patients diagnosed with asymptomatic gallbladder stones in clinics without beds between March 2010 and October 2022.When symptoms developed,patients were transferred to hospitals where appropriate treatment was possible.We investigated the asymptomatic and survival periods during the follow-up.RESULTS Among the 237 patients,214(90.3%)remained asymptomatic,with a mean asymptomatic period of 3898.9279±46.871 d(50-4111 d,10.7 years on average).Biliary complications developed in 23 patients(9.7%),with a mean survival period of 4010.0285±31.2788 d(53-4112 d,10.9 years on average).No patient died of biliary complications.CONCLUSION The long-term prognosis of asymptomatic gallbladder stones in clinics without beds was favorable.When the condition became symptomatic,the patients were transferred to hospitals with beds that could address it;thus,no deaths related to biliary complications were reported.This finding suggests that follow-up care in clinics without beds is possible.

Adenocarcinomas of the gallbladder from United States patients demonstrate less frequent molecular change for several genetic markers than other intra-abdominal cancers

Context: The incidence of gallbladder cancer is quite low in the US, with an estimate (2013) for new cases of less than 10,000. The rarity suggests a possible shared molecular pathology that might facilitate a greater understanding of this tumor. Objective: We wished to assess the molecular genetic profile of this tumor, particularly KRAS gene mutations, which are frequent in tumors associated with chronic inflamemation elsewhere within the abdomen. Design: We ascertained 25 cases of gallbladder adenocarcinoma from our pathology department records for 2000-2012. PCR based techniques were used to evaluate the DNA for loss of heterozygosity of the APC and DCC genes;for point mutations in the KRAS gene, codons 12 and 13;for point mutation in the BRAF gene, codon 600;for point mutation in the GNAS gene, codon 201;and for microsatellite instability. Results: Patients included 5 males and 20 females. Approximately three-quarters of cases were associated with gallstones, inflammation and dysplasia. Microsatellite instability and GNAS mutation, both present in just 4% of cases, and BRAF mutation present in no cases, do not appear to be significant parts of carcinogenesis of gallbladder carcinoma. We detected a KRAS gene mutation in only 8% of the cases. Loss of heterozygosity for the APC was detected in 16.7% of informative cases;and for the DCC gene, in 34.8% of informative cases. Conclusions: Many molecular genetic changes frequently seen with tumors arising from other intra-abdominal organs are infrequent in this tumor type. In particular, KRAS mutations were uncommon, in contra-distinction to other malignant tumors developing in the setting of chronic inflammation/infection.

Use of endoscopic ultrasound-guided gallbladder drainage as a rescue approach in cases of unsuccessful biliary drainage

This narrative review provides an overview of the utilization of endoscopic ultrasound-guided gallbladder drainage(EUS-GBD)as a salvage approach in cases of unsuccessful conventional management.EUS-GBD is a minimally invasive and effective technique for drainage in patients with acute cholecystitis with high risk of surgery.The procedure has demonstrated impressive technical and clinical success rates with low rates of adverse events,making it a safe and effective option for appropriate candidates.Furthermore,EUS-GBD can also serve as a rescue option for patients who have failed endoscopic retrograde cholangiopancreatography or EUS biliary drainage for relief of jaundice in malignant biliary stricture.However,patient selection is critical for the success of EUS-GBD,and proper patient selection and risk assessment are important to ensure the safety and efficacy of the procedure.As the field continues to evolve and mature,ongoing research will further refine our understanding of the benefits and limitations of EUS-GBD,ultimately leading to improved outcomes for patients.

New trends in diagnosis and management of gallbladder carcinoma

Gallbladder(GB)carcinoma,although relatively rare,is the most common biliary tree cholangiocarcinoma with aggressiveness and poor prognosis.It is closely associated with cholelithiasis and long-standing large(>3 cm)gallstones in up to 90%of cases.The other main predisposing factors for GB carcinoma include molecular factors such as mutated genes,GB wall calcification(porcelain)or mainly mucosal microcalcifications,and GB polyps≥1 cm in size.Diagnosis is made by ultrasound,computed tomography(CT),and,more precisely,magnetic resonance imaging(MRI).Preoperative staging is of great importance in decisionmaking regarding therapeutic management.Preoperative staging is based on MRI findings,the leading technique for liver metastasis imaging,enhanced three-phase CT angiography,or magnetic resonance angiography for major vessel assessment.It is also necessary to use positron emission tomography(PET)-CT or ^(18)F-FDG PET-MRI to more accurately detect metastases and any other occult deposits with active metabolic uptake.Staging laparoscopy may detect dissemination not otherwise found in 20%-28.6%of cases.Multimodality treatment is needed,including surgical resection,targeted therapy by biological agents according to molecular testing gene mapping,chemotherapy,radiation therapy,and immunotherapy.It is of great importance to understand the updated guidelines and current treatment options.The extent of surgical intervention depends on the disease stage,ranging from simple cholecystectomy(T1a)to extended resections and including extended cholecystectomy(T1b),with wide lymph node resection in every case or IV-V segmentectomy(T2),hepatic trisegmentectomy or major hepatectomy accompanied by hepaticojejunostomy Roux-Y,and adjacent organ resection if necessary(T3).Laparoscopic or robotic surgery shows fewer postoperative complications and equivalent oncological outcomes when compared to open surgery,but much attention must be paid to avoiding injuries.In addition to surgery,novel targeted treatment along with immunotherapy and recent improvements in radiotherapy and chemotherapy(neoadjuvant-adjuvant capecitabine,cisplatin,gemcitabine)have yielded promising results even in inoperable cases calling for palliation(T4).Thus,individualized treatment must be applied.

Current considerations for the surgical management of gallbladder adenomas

Gallbladder adenomas are rare lesions(0.5%)associated with potential malignant transformation,particularly with gallbladder adenomas that are≥1 cm in size.Early detection and management are crucial for preventing lethal carcinoma de-velopment.These polyps can often be distinguished from the more often nonneo-plastic cholesterol pseudopolyps(5%-10%),which are benign.Ultrasonography is the first-line tool for initial diagnosis and follow-up when indicated.The question is whether cholecystectomy is always necessary for all adenomas.The manage-ment of gallbladder adenomas is determined according to the size of the tumor,the growth rate of the tumor,the patient’s symptoms and whether risk factors for malignancy are present.Adenomas≥1 cm in size,an age>50 years and a familial history of gallbladder carcinoma are indications for immediate laparoscopic chole-cystectomy.Otherwise,ultrasound follow-up is indicated.For adenomas 6-9 mm in size,the absence of≥2 mm growth at 6 months,one year,and two years,as well as an adenoma sized<5 mm without existing risk factors indicates that no further surveillance is required.However,it would be preferable to individualize the management in doubtful cases.Novel interventional modalities for preserving the gallbladder need further evaluation,especially to determine the long-term outcomes.

Hepatoid adenocarcinoma of the lung:A case report

BACKGROUND Hepatoid adenocarcinoma of the lung(HAL)is a rare type of non-small cell lung cancer(NSCLC),histologically similar to hepatocellular carcinoma.HAL has high malignancy and poor prognosis,and a better treatment plan needs further study.CASE SUMMARY In order to deeply understand the occurrence and development of HAL,here we report a case of HAL with extensive metastasis of alpha fetoprotein negative KRAS A146T mutation.The patient refused chemotherapy and received one course of treatment(immune checkpoint inhibitors),and died three months later due to progressive disease.CONCLUSION HAL is a special type of NSCLC.The surgical treatment of HAL in the limited stage can achieve long-term survival,but most of them were in the advanced stage when they were found,and the prognosis was poor,which requires multidisciplinary comprehensive treatment.

Practical approach to linear endoscopic ultrasound examination of the gallbladder

The gallbladder(GB)is a susceptible organ,prone to various pathologies that can be identified using different imaging techniques.Transabdominal ultrasound(TUS)is typically the initial diagnostic method due to its numerous well-established advantages.However,in cases of uncertainty or when a definitive diagnosis cannot be established,computed tomography(CT)or magnetic resonance imaging may be employed to provide more detailed information.Nevertheless,CT scans may sometimes offer inadequate spatial resolution,which can limit the differentiation of GB lesions,particularly when smaller yet clinically relevant abnormalities are involved.Conversely,endoscopic ultrasound(EUS)provides higher frequency compared to TUS,superior spatial resolution,and the option for contrast-enhanced harmonic imaging,enabling a more comprehensive examination.Thus,EUS can serve as a supplementary tool when conventional imaging methods are insufficient.This review will describe the standard EUS examination of the GB,focusing on its endosonographic characteristics in various GB path-ologies.

Stereotactic body radiotherapy in pancreatic adenocarcinoma

Background:Stereotactic body radiotherapy(SBRT)in pancreatic cancer allows high delivery of radiation doses on tumors without affecting surrounding tissue.This review aimed at the SBRT application in the treatment of pancreatic cancer.Data sources:We retrieved articles published in MEDLINE/PubMed from January 2017 to December 2022.Keywords used in the search included:“pancreatic adenocarcinoma”OR“pancreatic cancer”AND“stereotactic ablative radiotherapy(SABR)”OR“stereotactic body radiotherapy(SBRT)”OR“chemoradiotherapy(CRT)”.English language articles with information on technical characteristics,doses and fractionation,indications,recurrence patterns,local control and toxicities of SBRT in pancreatic tumors were included.All articles were assessed for validity and relevant content.Results:Optimal doses and fractionation have not yet been defined.However,SBRT could be the standard treatment in patients with pancreatic adenocarcinoma in addition to CRT.Furthermore,the combination of SBRT with chemotherapy may have additive or synergic effect on pancreatic adenocarcinoma.Conclusions:SBRT is an effective modality for patients with pancreatic cancer,supported by clinical practice guidelines as it has demonstrated good tolerance and good disease control.SBRT opens a possibility of improving outcomes for these patients,both in neoadjuvant treatment and with radical intent.

Diagnosis of poorly differentiated adenocarcinoma of the stomach by confocal laser endomicroscopy:A case report

BACKGROUND In recent years,confocal laser endomicroscopy(CLE)has become a new endoscopic imaging technology at the microscopic level,which is extensively performed for real-time in vivo histological examination.CLE can be performed to distinguish benign from malignant lesions.In this study,we diagnosed using CLE an asymptomatic patient with poorly differentiated gastric adenocarcinoma.CASE SUMMARY A 63-year-old woman was diagnosed with gastric mucosal lesions,which may be gastric cancer,in the small curvature of the stomach by gastroscopy.She consented to undergo CLE for morphological observation of the gastric mucosa.Through the combination of CLE diagnosis and postoperative pathology,the intraoperative CLE diagnosis was considered to be reliable.According to our experience,CLE can be performed as the first choice for the diagnosis of gastric cancer.CONCLUSION CLE has several advantages over pathological diagnosis.We believe that CLE has great potential in the diagnosis of benign and malignant gastric lesions.

Diagnostic challenges and individualized treatment of cervical adenocarcinoma metastases to the breast:A case report

BACKGROUND Cervical cancer is a rare primary tumor resulting in metastases to the breast with few cases reported in literature.Breast metastases are associated with poor prognosis.The following case highlights the diagnostic challenges associated with metastatic cervical cancer to the breast along with individualized treatment.CASE SUMMARY A 44-year-old G7P5025 with no significant past medical or surgical history presented with heavy vaginal to an outside emergency department where an exam and a pelvic magnetic resonance imaging showed a 4.5 cm heterogenous lobulated cervical mass involving upper two thirds of vagina,parametria and lymph node metastases.Cervical biopsies confirmed high grade adenocarcinoma with mucinous features.A positron emission tomography/computed tomography(PET/CT)did not show evidence of metastatic disease.She received concurrent cisplatin with external beam radiation therapy.Follow up PET/CT scan three months later showed no suspicious fluorodeoxyglucose uptake in the cervix and no evidence of metastatic disease.Patient was lost to follow up for six months.She was re-imaged on re-presentation and found to have widely metastatic disease including breast disease.Breast biopsy confirmed programmed death-ligand 1 positive metastatic cervical cancer.The patient received six cycles of carboplatin and paclitaxel with pembrolizumab.Restaging imaging demonstrated response.Patient continued on pembrolizumab with disease control.CONCLUSION Metastatic cervical cancer to the breast is uncommon with nonspecific clinical findings that can make diagnosis challenging.Clinical history and immunohistochemical evaluation of breast lesion,and comparison to primary tumor can support diagnosis of metastatic cervical cancer to the breast.Overall,the prognosis is poor,but immunotherapy can be considered in select patients and may result in good disease response.