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- 我科有争议的胆囊切片
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Well differentiated adenocarcinoma of gallbladder is always a very difficult diagnosis to make. Equally difficult is a well differentiated pancreatic adenocarcinoma or cholangiocarcinoma with direct extension to gallbladder wall. I have seen rare cases of both diagnoses that showed very subtle changes. Stromal desmoplasia is always a worrisome sign, but many cases of chronic cholecystitis have Aschoff-Rokitansky sinuses extending from mucosa to muscle wall. Some normal gallbladder contain ducts of Luschka on the adventitia and subserosal soft tissue that are surrounded by desmoplastic stroma. All of these makes detection of primary gallbladder adenocarcinoma very difficult. I have always looked for epithelial dysplasia in the overlying mucosa to support the possibility of a rare incidental case of gallbladder adenocarcinoma. In the photos uploaded from this case, I do not see definite epithelial dysplasia. Certainly an isolated cell budding off the nearby gland and embedded in the stroma is very suspicious, but I would like to see deeper levels of this focus to better appreciate its three-dimensional extent before making a final judgement. I believe more extensive histologic sampling of the remaining specimen would definitely help. An interesting and challenging case this is!
聞道有先後,術業有專攻
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| 以下是引用mjma在2009-6-16 5:03:00的发言： Well differentiated adenocarcinoma of gallbladder is always a very difficult diagnosis to make. Equally difficult is a well differentiated pancreatic adenocarcinoma or cholangiocarcinoma with direct extension to gallbladder wall. I have seen rare cases of both diagnoses that showed very subtle changes. Stromal desmoplasia is always a worrisome sign, but many cases of chronic cholecystitis have Aschoff-Rokitansky sinuses extending from mucosa to muscle wall. Some normal gallbladder contain ducts of Luschka on the adventitia and subserosal soft tissue that are surrounded by desmoplastic stroma. All of these makes detection of primary gallbladder adenocarcinoma very difficult. I have always looked for epithelial dysplasia in the overlying mucosa to support the possibility of a rare incidental case of gallbladder adenocarcinoma. In the photos uploaded from this case, I do not see definite epithelial dysplasia. Certainly an isolated cell budding off the nearby gland and embedded in the stroma is very suspicious, but I would like to see deeper levels of this focus to better appreciate its three-dimensional extent before making a final judgement. I believe more extensive histologic sampling of the remaining specimen would definitely help. An interesting and challenging case this is! |
试译马老师点评：
高分化胆囊腺癌通常很难作出正确诊断，同样困难的还有直接蔓延到胆囊壁的分化好的胰腺癌或胆管上皮癌，我曾经看过此类仅具有微细差别的罕见病例。促纤维增生的间质相当麻烦，因为不仅多数慢性胆囊炎（have Aschoff-Rokitansky不明）的黏膜腺体会从黏膜层长入胆囊壁肌层，而且部分正常胆囊也包含有位于浆膜和浆膜下软组织内的Luschka管，这些管腔周围间质同样具有促结缔组织增生的特点，所有这些都使得原发性胆囊腺癌的诊断非常困难。我通常会仔细寻找黏膜表面上皮发育不良来支持少见的胆囊腺癌的诊断，但从此例上传的图片中我并没有看到明确的上皮发育不良。当然腺体出芽和陷入间质值得怀疑，但在作出最终诊断前我希望看到这种改变的侵入深度以便更好地理解其三维立体感。相信其余样本的广泛组织学观察能提供更多帮助。总之，这是个有趣且富于挑战的病例。
