Gallbladder polyps: correlation and agreement between ultrasonographic and histopathological findings in a population with high incidence of gallbladder cancer / Pólipos da vesícula biliar: correlação e concordância entre achados ultrassonográficos e histopatológicos em uma população com alta incidência de câncer de vesícula biliar

ABSTRACT BACKGROUND: Gallbladder polyps are becoming a common finding in ultrasound. The management has to consider the potential risk of malignant lesions. AIMS: The aim of this study was to analyze the ultrasound findings in patients undergoing cholecystectomy due to gallbladder polyps and compare them for histopathological findings (HPs). METHODS: Patients with an ultrasonographic diagnosis of gallbladder polyp and who underwent cholecystectomy from 2007 to 2020 were included in the study. RESULTS: A total of 447 patients were included, of whom 58% were women. The mean age was 45±12 years. The mean size of polyps in US was 7.9±3.6 mm. Notably, 9% of polyps were greater than 10 mm, and single polyps were significantly larger than the multiple ones (p=0.003). Histopathological findings confirmed the presence of polyps in 88.4%, with a mean size of 4.8±3.4 mm. In all, 16 cases were neoplastic polyps (4.1%), 4 of them being malignancies, and all were single and larger than 10 mm. We found a significant correlation between ultrasound and histopathological findings polyp size determination (r=0.44; p<0.001). The Bland-Altman analysis obtained an overestimation of the US size of 3.26 mm. The receiver operating characteristic (ROC) curve analysis between both measures obtained an area under the receiver operating characteristic curve (AUC) of 0.77 (95%CI 0.74-0.81). Ultrasound polyps size larger than 10 mm had an odds ratio (OR) of 8.147 (95%CI 2.56-23.40) for the presence of adenoma and malignancy, with a likelihood ratio of 2.78. CONCLUSIONS: There is a positive correlation and appropriate diagnostic accuracy between ultrasound size of gallbladder polyps compared to histopathological records, with a trend to overestimate the size by about 3 mm. Neoplastic polyps are uncommon, and it correlates with size. Polyps larger than 10 mm were associated with adenoma and malignancy.

RESUMO RACIONAL: Os pólipos da vesícula biliar estão se tornando um achado comum na ultrassonografia (US). O manejo deve levar em consideração o risco de lesões malignas. OBJETIVOS: Analisar os achados da ultrassonografia em pacientes submetidos à colecistectomia por pólipos vesicais e compará-los com os achados histopatológicos. MÉTODOS: Foram revisados os prontuários médicos dos pacientes com diagnóstico ultrassonográfico de pólipo vesicular e submetidos à colecistectomia no período de 2007 a 2020. RESULTADOS: Foram incluídos no estudo 447 pacientes. A média de idade foi 45±12anos, sendo 58% mulheres. O tamanho médio dos pólipos na US foide 7,9±3,6mm. Nove por cento foram maiores que 10 mm, e os pólipos únicos encontrados foram maiores do que os múltiplos (p=0,003). A HP confirmou a presença de pólipos em 88,4%, tamanho médio 4,8±3,4mm. Dezesseis eram pólipos neoplásicos (4,1%) e quatro deles malignos, únicos e maiores que 10 mm. Foi encontrado correlação significativa entre a determinação do tamanho do pólipo ao ultrassonografia e histopatológicos (r=0,44; p<0,001). A análise de Bland-Altman obteve uma superestimação do tamanho do pólipo ao US em 3,26 mm. A análise da curva da característica de operação do receptor entre as duas medidas obteve uma área sob a curva curva da característica de operação do receptor (AUC) de 0,77 (IC95% 0,74-0,81). Pólipos ao ultrassonografia maiores que 10 mm apresentaram razão de chance (OR) de 8,147 (IC95% 2,56-23,40) para presença de adenoma e malignidade, com razão de verossimilhança de 2,78. CONCLUSÕES: Há uma correlação positiva e acurácia diagnóstica apropriada entre o tamanho dos pólipos da vesícula biliar por ultrassonografia em comparação com os achados histopatológicos, com uma tendência de superestimar o tamanho em cerca de 3 mm. Pólipos maiores que 10 mm foram associados a adenoma e malignidade.

Textbook outcome in gallbladder carcinoma after curative-intent resection: a 10-year retrospective single-center study / 中华医学杂志(英文版)

BACKGROUND@#Textbook outcome (TO) can guide decision-making among patients and clinicians during preoperative patient selection and postoperative quality improvement. We explored the factors associated with achieving a TO for gallbladder carcinoma (GBC) after curative-intent resection and analyzed the effect of adjuvant chemotherapy (ACT) on TO and non-TO patients.@*METHODS@#A total of 540 patients who underwent curative-intent resection for GBC at the Department of Hepatobiliary Surgery of the First Affiliated Hospital of Xi'an Jiaotong University from January 2011 to December 2020 were retrospectively analyzed. Multivariable logistic regression was used to investigate the factors associated with TO.@*RESULTS@#Among 540 patients with GBC who underwent curative-intent resection, 223 patients (41.3%) achieved a TO. The incidence of TO ranged from 19.0% to 51.0% across the study period, with a slightly increasing trend over the study period. The multivariate analysis showed that non-TO was an independent risk factor for prognosis among GBC patients after resection ( P = 0.003). Age ≤60 years ( P = 0.016), total bilirubin (TBIL) level ≤34.1 μmol/L ( P <0.001), well-differentiated tumor ( P = 0.008), no liver involvement ( P <0.001), and T1-2 stage disease ( P = 0.006) were independently associated with achieving a TO for GBC after resection. Before and after propensity score matching (PSM), the overall survival outcomes of non-TO GBC patients who received ACT and those who did not were statistically significant; ACT improved the prognosis of patients in the non-TO group ( P <0.05).@*CONCLUSION@#Achieving a TO is associated with a better long-term prognosis among GBC patients after curative-intent resection, and ACT can improve the prognosis of those with non-TO.

Mucosal Schwann cell hamartoma of the gallbladder

Mucosal Schwann cell hamartoma (MSCH) is a rare benign neurogenic tumor characterized by pure S100p positive spindle cell proliferation. Most cases occur in the distal colon. Involvement of the gall bladder is exceedingly rare. There have been no reports of recurrence or a syndromic association with MSCH. Herein, we describe a case of MSCH of the gallbladder in a 55-year-old female patient with prior history of gastrointestinal neurofibromas who presented with abdominal pain. MR imaging revealed choledocholithiasis, gallbladder thickening, and marked biliary and pancreatic ductal dilation. The patient subsequently underwent cholecystectomy with choledochoduodenostomy. Histologic evaluation of the gallbladder showed diffuse expansion of the mucosa with S100p positive cells with spindly nuclei and indistinct cytoplasmic borders and diagnosis of MSCH of the gallbladder was rendered.

Colecistectomía extendida mínimamente invasiva en pacientes con cáncer de vesícula biliar / Minimal invasive extended cholecystectomy in gallbladder cancer patients

Resumen Objetivo: Describir resultados en términos de morbilidad y mortalidad de la colecistectomía extendida laparoscópica (CELap) en pacientes con cáncer de vesícula biliar (CVB) incidental. Materiales y Método Serie de casos de pacientes con CVB incidental sometidos a CELap en el Hospital Regional de Temuco entre diciembre de 2017 y marzo de 2019. Resultados: Incluimos 10 pacientes, con edad promedio de 59,2 ± 11 años, 90% de género femenino. Respecto a la invasión de pared de la vesícula biliar (TNM), 1 presentó invasión hasta mucosa (T1a) con invasión de senos de Rokitansky Aschoff y 9 hasta subserosa (T2). Dos tuvieron ganglio cístico positivo en biopsia inicial. Respecto a la CELap, el tiempo operatorio promedio fue 333 ± 40 minutos. El promedio de ganglios resecados fue 4 ± 2,78, presentando lecho hepático positivo en 1 paciente. La clasificación TNM obtenida: un paciente T1aN0M0, siete T2N0M0 y dos T2N1M0. La estancia hospitalaria promedio fue 5 ± 2,3 días. Siete pacientes recibieron, posteriormente, quimioterapia con gemcitabina + cisplatino. Hubo morbilidad en 2 pacientes, tipo I de Dindo-Clavien. No reportamos mortalidad. El seguimiento promedio fue 7,1 ±5,1 meses, no reportamos recurrencia. Discusión: Esta serie presenta menor número de ganglios resecados que otros estudios (posiblemente por ser nuestra serie inicial) y mayor morbilidad, pero sólo tipo I de Dindo-Clavien. Presentamos una estancia hospitalaria similar a series internacionales y menor presencia de metástasis según reportan análisis retrospectivos. Conclusión: La CELap es una opción terapéutica aceptable y presenta cifras de morbilidad y mortalidad comparables con series nacionales e internacionales.

Aim: Describe results in terms of morbidity and mortality of minimally invasive treatment in patients with gallbladder cancer until subserosal layer. Materials and Method: Case series of patients with gallbladder cancer undergoing CELap at Hospital Regional of Temuco between December 2017 and March 2019. Results: Ten patients were included, the average age was 59,2 ±11 years. Ninety percent female. According to the invasion in gallbladder layers (TNM Classification), 1 patient was T1a (mucosa) with invasion of Rokytansky-Aschoff sinus and 9 patients T2 (subserosa). Two patients had a positive cystic node. The average operating time of CELap was 333 ± 40 minutes. The average number of resected nodes was 4 ± 2,78 and a positive liver bed was found in 1 patient. The TNM classification was 1 patient T1aN0M0, 7 patients T2N0M0 and 2 patients T2N1M0. Mean hospitalization was 5 ± 2,3 days. Seven patients subsequently received chemotherapy with gemcitabine + cisplatin. There was 2 patients with morbidity, type I of Dindo-Clavien scale. No mortality is reported. The average follow-up was 7,1 ±5,11 months and no recurrence was reported. Discussion: This series has a lower number of resected nodes than other studies (possibly because it is our initial series) and higer morbidity, but only Dindo-Clavien type I. Furthermore, we present a hospital stay similar to international series and a lower presence of metastases as reported in retrospective analysis. Conclusion: CELap is an acceptable therapeutic option and presents morbidity and mortality comparable with the national and international series.

Análisis epidemiológico de cáncer de vesícula / Epidemiologic analysis of gallbladder cancer

Antecedentes: El cáncer de vesícula biliar se caracteriza por ser un tumor de mal pronóstico y diagnóstico tardío. Objetivo: Describir variables epidemiológicas del cáncer de vesícula en nuestro centro y compararlos con la bibliografía internacional. Material y métodos: En pacientes sometidos a colecistectomía entre el 1º de enero de 2006 y el 31 de diciembre de 2015, se estudiaron las siguientes variables: sexo, edad, relación mujer/varón, causa de colecistectomía, clasificación en urgencias y programadas; en los casos de cáncer de vesícula: sexo, edad, histopatología, diferenciación celular, invasión (de pared vesicular, angiolinfática, del ganglio cístico, tejidos vecinos y del hígado), estadificación (clasificaciones de Nevin y de Unión Internacional Contra el Cáncer-UICC). Resultados: Se diagnosticaron 92 neoplasias vesiculares (1,26% de todas las colecistectomías). El promedio de edad para cáncer de vesícula fue 57,9 años (rango 22-88); sexo femenino 64 (69,5%, con relación mujer/varón 2:1. La histopatología mostró 86 (93,4%) adenocarcinomas, 4 (4,4%) carcinomas escamosos y 2 (2,2%) indiferenciados con elementos de origen mesenquimático y epitelial de vesícula. Las lesiones asociadas fueron adenocarcinoma con metaplasia escamosa, 2 casos; mucosecretante, 2 casos; papilar, 1 caso; metaplasia intestinal y antral, 1 caso. En 60 (65,4%) casos fueron moderadamente diferenciados; bien diferenciados, 12 (13%); pobremente diferenciados, 11 (11,9%) e indiferenciados, 4 (4,3%). En 5 casos (5,4%), no se especificaba la diferenciación celular. Conclusión: El cáncer de vesícula diagnosticado luego de una colecistectomía es más frecuente en mujeres, con tipo histológico adenocarcinoma, llamando la atención la cantidad de pacientes jóvenes diagnosticados.

Background: Gallbladder cancer is characterized by poor prognosis and late diagnosis. Objective: The aim of our study is to describe the epidemiological variables of gallbladder cancer at our centre and to compare them with data from the worldwide literature. Material and methods: Patients undergoing cholecystectomy between January 1, 2006, and December 31, 2015. The following variables were analyzed: sex, age, male to female ratio, reason for cholecystectomy, urgent or scheduled. In case of gallbladder cancer, sex, age, histopathology, cell differentiation, gallbladder layer invasion, lymphovascular, cystic lymph node, adjacent tissues and liver invasion; and cancer staging according to Nevin staging system and the Union for International Cancer Control (UICC). Results: Ninety-two gallbladder neoplasms were found, representing 1.26% of all cholecystectomies. Mean age of patients with gallbladder cancer was 57.9 years (range, 22-88 years) of whom 69.5% (n=64) were women, with the same female to men ratio of 2:1 described for cholecystectomy. The histopathology of the 92 gallbladder cancers corresponded to adenocarcinoma, 93.4% (n= 86); squamous cell carcinoma, 4.4% (n= 4); and undifferentiated malignancy with elements of epithelial and mesenchymal origin, 2.2% (n= 2). There were two cases of adenocarcinoma with squamous metaplasia, two mucinous carcinomas, one papillary adenocarcinoma and one case of antral-type and intestinal metaplasia. Sixty tumors (65.4%) were moderately differentiated; 12 (13%) well differentiated; 11 (11.9%) poorly differentiated; and 4 (4.3%) were undifferentiated. In 5 cases (5.4%) the type of differentiation was not described. Conclusion: In gallbladder cancer diagnosed after a cholecystectomy, it is more frequent in the female sex, with adenocarcinoma being the most common histological type. Interestingly, the number of young patients with gallbladder cancer is noteworthy.

Perfil de pacientes diagnosticados com câncer de vesícula biliar / Profile of patients diagnosed with gallbladder cancer

Objetivo: Descrever o perfil clínico-epidemiológico de pacientes diagnosticados com câncer de vesícula e identificar o estadiamento do tumor estabelecido no momento do diagnóstico, bem como o padrão histopatológico no momento da biópsia. Métodos: Trata-se de estudo transversal e descritivo realizado em um serviço de referência em oncologia clínica, baseado em análise secundária de dados correspondentes aos prontuários de indivíduos com diagnóstico de câncer de vesícula biliar atendidos entre janeiro de 2007 e janeiro de 2017. Resultados: A distribuição por sexo foi de cinco mulheres (62,5%) e três homens (37,5%). A idade variou de 47 a 74 anos, com média de 61,1 anos e desvio padrão de ±9,03. Nenhum indivíduo era assintomático ao diagnóstico; seis (75%) apresentaram dor em hipocôndrio direito, dois (25%) perda de peso e dois outros (25%) massa palpável. Dos oito indivíduos, seis (75%) apresentavam estadiamento clínico (EC) IV ao diagnóstico. O perfil histopatológico apresentou 100% de adenocarcinoma, sendo uma amostra com áreas papilíferas, três moderadamente diferenciadas, três metastáticas e uma bem diferenciada. Conclusão: O perfil clínico-epidemiológico estabelecido foi maior prevalência de câncer de vesícula biliar em mulheres, com média de idade na sétima década. Predominou a cólica biliar como sintoma. O padrão de adenocarcinoma foi identificado em todos os indivíduos. Três quartos dos indivíduos apresentavam estágio avançado de doença. (AU)

Objective: to describe the clinical-epidemiological profile of patients diagnosed with gallbladder cancer, and to identify tumor staging established at the time of diagnosis, as well as the histopathological pattern at the biopsy. Methods: This is a cross-sectional and descriptive study, carried out in a reference service of clinical oncology, based on secondary analysis of data corresponding to the medical records of patients diagnosed with Gallbladder cancer seen between January-2007 and January-2017. Results: Gender distribution was of five women (62.5%), and three men (37.5%). Patients' ages ranged from 47-74 years, mean age of 61.1 years and standard deviation of ±9.03). No patient was asymptomatic at diagnosis, six (75%) had right hypochondrium pain, two (25%) showed weight loss, and two others (25%), palpable mass. Of the eight patients, six (75%) had EC IV staging at diagnosis. The histopathological profile showed 100% of adenocarcinoma, with one sample having papilliferous areas, three being moderately differentiated, three metastatic, and one well differentiated. Conclusion: The clinical-epidemiological profile established in this study had a higher prevalence of gallbladder cancer in women, with a mean age of the individual around the 7th decade. The most frequent symptom was biliary colic. The adenocarcinoma pattern was identified in all individuals. Three-quarters of them had advanced disease. (AU)

Alterações histológicas da vesícula biliar de doentes submetidos à colecistectomia por colelitíase / Gallbladder histological alterations in patients undergoing cholecystectomy for cholelithiasis

RESUMO Objetivo: descrever os achados histológicos das vesículas biliares de pacientes submetidos à colecistectomia e avaliar a presença de fatores associados ao câncer incidental da vesícula. Métodos: estudo descritivo, transversal e observacional de 1.278 exames anatomopatológicos de vesículas biliares oriundas de colecistectomias por colelitíase e de seus respectivos laudos, realizadas no período de janeiro de 2008 a dezembro de 2017. Resultados: o achado anatomopatológico mais frequente foi a colecistite crônica, presente em 1.251 pacientes (97,8%), seguido pela colesterolose em 131 (10,2%). O câncer de vesícula foi identificado em seis pacientes, com prevalência de 0,5% nesta amostra. Houve associação significativa entre a presença de câncer e idade ≥60 anos e com a espessura da parede ≥0,3cm. Conclusão: houve baixa prevalência de câncer de vesícula na população avaliada, maior ocorrência na população idosa e associação de tumor com espessamento da parede vesicular.

ABSTRACT Objective: to describe the histological findings of the gallbladders of patients undergoing cholecystectomy and to evaluate the presence of factors associated with gallbladder incidental cancer. Methods: we conducted a descriptive, cross-sectional, observational study with 1,278 histopathological exams of gallbladders coming from cholecystectomy for cholelithiasis and of their reports, held from January 2008 to December 2017. Results: the most common pathological finding was chronic cholecystitis, present in 1,251 patients (97.8%), followed by gallbladder cholesterolosis, in 131 (10.2%). Gallbladder cancer was identified in six patients, with a prevalence of 0.5% in this sample. There was a significant association between the presence of cancer and age ≥60 years and wall thickness ≥0.3cm. Conclusion: there was low prevalence of gallbladder cancer in this population, higher occurrence in the elderly and association of the tumor with gallbladder wall thickness.

Incidência comparativa de câncer incidental de vesícula biliar em colecistectomias de urgência versus colecistectomias eletivas / Comparative incidence of incidental gallbladder cancer in emergency cholecystectomies versus in elective cholecystectomies

RESUMO Objetivo: analisar, comparativamente, a incidência de câncer incidental de vesícula biliar em colecistectomias de urgência versus colecistectomias eletivas realizadas em hospitais públicos de Teresina-PI. Métodos: estudo observacional descritivo, quantitativo, com delineamento transversal, cujo cenário foram dois hospitais públicos de Teresina-PI. Foram analisados 6.329 prontuários de pacientes submetidos à colecistectomia, entre janeiro de 2011 e dezembro de 2017. Os dados coletados foram divididos em dois grupos e confrontados estatisticamente através do teste Z para diferença entre proporções. Resultados: detectou-se câncer incidental da vesícula biliar em 6,53% das colecistectomias de urgência e em 0,38% das eletivas. Quanto ao sexo, observou-se que, na cirurgia de urgência, 69% eram mulheres e 31%, homens, enquanto no procedimento eletivo, 78% eram mulheres e 22%, homens. Quanto à idade, a maioria dos pacientes possuía mais de 60 anos e, entre estes, 69,3% submetidos à colecistectomias de urgência e 82,6%, à eletivas. O tipo histopatológico "adenocarcinoma" foi encontrado em 84,6% das cirurgias de urgência e 100% das eletivas. Conclusão: câncer incidental de vesícula biliar foi mais frequente em colecistectomias de urgência em comparação às eletivas. O perfil dos pacientes com essa doença maligna nos dois tipos de procedimento foi do sexo feminino, maiores de 60 anos de idade e com diagnóstico histopatológico de adenocarcinoma.

ABSTRACT Objective: to comparatively analyse the incidence of incidental gallbladder cancer in emergency cholecystectomies versus in elective cholecystectomies performed in public hospitals in Teresina city, Piaui state (PI). Methods: descriptive, quantitative, observational, cross-sectional study, whose scenarios were two public hospitals in Teresina-PI. We analysed 6,329 medical records of patients undergoing cholecystectomy between January 2011 and December 2017. The collected data were divided into two groups and statistically compared using Z-test for difference between proportions. Results: incidental gallbladder cancer was detected in 6.53% of emergency cholecystectomies and in 0.38% of elective ones. Regarding gender, it was observed that in emergency surgeries 69% of patients were women and 31% men, while in elective procedures 78% were women and 22% men. Regarding age, most patients were over 60 years old, and, among these, 69.3% underwent emergency cholecystectomies and 82.6% underwent elective cholecystectomies. The histopathological type "adenocarcinoma" was found in 84.6% of patients who underwent emergency surgeries and in 100% of patients who underwent elective surgeries. Conclusion: incidental gallbladder cancer was more frequent in urgent cholecystectomies compared to elective cholecystectomies. The profile of patients with this malignant disease in both types of procedure was female, older than 60 years, and with histopathological diagnosis of adenocarcinoma.

Neoplasia papilar intracolecística: reporte de un caso y revisión de la evidencia existente / Intracholecystic papillary neoplasia: report of a case and review of existing evidence

La neoplasia papilar intracolecística (NPIC), es un tumor compuesto por células neoplásicas preinvasivas, que forman masas de hasta 1,0 cm, clínicamente detectables. El objetivo de este estudio fue reportar un caso de NPIC y revisar la evidencia existente. Se trata de un paciente sexo masculino, de 33 años de edad, asintomático, que en el curso de un examen de salud, se realiza una ecotomografía abdominal, en la que se verifica una lesión polipoide vesicular de 32 x 19 mm de diámetro. Se programa para colecistectomía electiva, la que se realizó por vía laparoscópica, cirugía que se pudo realizar sin inconvenientes. Una vez extirpado el espécimen, se fue a estudio histopatológico en el que tras un mapeo vesicular se concluye NPIC, colecistitis crónica inespecífica, colesterolosis y pólipos colesterínicos. El paciente ha evolucionado sin inconvenientes. Presentamos un caso de NPIC en un paciente joven, cuyo diagnóstico fue confirmado por anatomía patológica tras una colecistectomía electiva, descartándose la presencia de carcinoma invasivo y displasia de alto grado, por lo que el pronóstico es favorable.

Intracholecystic papillary neoplasm (ICPN) is a tumor composed of pre-invasive neoplastic cells, with up to 1.0 cm clinically detectable masses. The objective of this study was to report a case of NPIC and review the evidence in the literature. A 33-year-old asymptomatic male patient had an abdominal ultrasonography during a health examination, in which a vesicular polyp lesion of 32 x 19 mm in diameter was verified. Thepatient was subsequently scheduled for elective cholecystectomy, which was performed laparoscopically and the surgery was uneventful. Once removed, the specimen was studied histopathologically and after performing vesicular mapping, we determined an ICPN, chronic non-specific cholecystitis, cholesteroliasis and cholesteric polyps. The patient has evolved without reported problems. We present a case of ICPN in a young patient, whose diagnosis was confirmed by pathological anatomy after an elective cholecystectomy, ruling out the presence of invasive carcinoma and high-grade dysplasia, with a favorable prognosis.

Tea polyphenols induce S phase arrest and apoptosis in gallbladder cancer cells

Gallbladder cancer (GBC) is the most common malignancy in the biliary tract. Without effective treatment, its prognosis is notoriously poor. Tea polyphenols (TPs) have many pharmacological and health benefits, including antioxidant, anti-inflammatory, anti-tumor, anti-thrombotic, antibacterial, and vasodilatory properties. However, the anti-cancer effect of TPs in human gallbladder cancer has not yet been determined. Cell viability and colony formation assay were used to investigate the cell growth. Cell cycle and apoptosis were evaluated by flow cytometry analysis. Western blot assay was used to detect the expression of proteins related to cell cycle and apoptosis. Human tumor xenografts were used to examine the effect of TPs on gallbladder cancer cells in vivo. TPs significantly inhibited cell growth of gallbladder cancer cell lines in a dose- and time-dependent manner. Cell cycle progression in GBC cells was blocked at the S phase by TPs. TPs also induced mitochondrial-related apoptosis in GBC cells by upregulating Bax, cleaved caspase-3, and cleaved PARP expressions and downregulating Bcl-2, cyclin A, and Cdk2 expressions. The effects of TPs on GBC were further proven in vivo in a mouse xenograft model. Our study is the first to report that TPs inhibit GBC cell growth and these compounds may have potential as novel therapeutic agents for treating gallbladder cancer.

Pathogenesis of gallbladder adenomyomatosis and its relationship with early-stage gallbladder carcinoma: an overview

The exact pathogenesis of gallbladder adenomyomatosis is still lacking and some controversies over its diagnosis and treatment exist. Originally recognized as a precancerous lesion, adenomyomatosis is currently recognized by recent studies as a benign alteration of the gallbladder that is often associated with cholecystitis and cholecystolithiasis. Gallbladder carcinoma is an extremely malignant disease with a 5-year survival rate of less than 5%. Therefore, it is important to diagnose, differentiate, and confirm the relationship between adenomyomatosis and early-stage gallbladder carcinoma. However, the early clinical symptoms of adenomyomatosis are extremely similar to those of gallbladder stones and cholecystitis, increasing the difficulty to identify and treat this disease. This article summarizes the research progress on gallbladder adenomyomatosis, aiming to improve the understanding of the pathogenesis of adenomyomatosis and further provide insight for its clinical diagnosis and treatment.

Frecuencia y características del cáncer de vesícula biliar en un hospital de referencia al sur del Perú, 2009-2014: estudio descriptivo / Frequency and characteristics of gallbladder cancer at a referral hospital in southern Peru, 2009-2014: a descriptive study

INTRODUCCIÓN: El cáncer de vesícula biliar es una neoplasia poco común, y su frecuencia es variable en las regiones de Perú. OBJETIVO: Determinar la frecuencia y describir las características clínicas del cáncer de vesícula biliar en un hospital de referencia al sur de Perú. MÉTODOS: Estudiamos los informes de todas las muestras de colecistectomías realizadas entre los años 2009 y 2014, en el servicio de anatomía patológica del Hospital Regional Honorio Delgado. Además, revisamos las historias clínicas de los pacientes que tuvieran algún resultado compatible con cáncer de vesícula biliar. RESULTADOS: De 2991 colecistectomías, 75 (2,5%) tuvieron cáncer de vesícula biliar. El síntoma más frecuente en ambos grupos fue el dolor (96,7%), seguido de náusea (87,5%) y vómitos (65,0%). La mayoría de pacientes fueron mujeres (83,3%) mayores de 60 años (65,0%). El tipo histológico más frecuente fue el adenocarcinoma (80,0%). CONCLUSIÓN: La frecuencia de cáncer de vesícula biliar en un hospital de referencia del sur de Perú, es de 2,5% mayor a la reportada en otros estudios en las regiones centro y norte del país.

INTRODUCTION: Gallbladder cancer is a rare neoplasm, its frequency is variable in the regions of Peru. OBJECTIVE: To determine the frequency and describe the clinical characteristics of gallbladder cancer in southern Peru. METHODS: The reports of the anatomopathological department of the Honorio Delgado Regional Hospital were selected from all samples of cholecystectomies performed between 2009 and 2014 and those that had some result compatible with gallbladder cancer were looked for. Subsequently, the clinical histories were searched to obtain the characteristics of these patients. RESULTS: Of 2991 cholecystectomies, 75 (2.5%) had gall bladder cancer. The most frequent symptom in both groups was pain (96.7%), followed by nausea (87.5%) and vomiting (65.0%). The majority of patients were women (83.3%) older than 60 years (65.0%). The most frequent histological type was the adenocarcinoma (80.0%). CONCLUSION: The frequency of gallbladder cancer in a reference hospital in southern Peru is 2.51%, higher than that reported in other studies in the central and northern regions of Peru.

Asociación de partición hepática y ligadura portal para hepatectomía por etapas (ALPPS) / Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS)

La disfunción hepática postoperatoria del remanente hepático que ocurre en pacientes sometidos a grandes resecciones hepáticas, es un problema complejo y temido, dado su pronóstico incierto. La asociación de partición hepática y ligadura portal para hepatectomía por etapas (ALPPS), es un enfoque novedoso para pacientes portadores de enfermedad hepática oncológica que anteriormente eran considerados "no resecables". El procedimiento se realiza en dos etapas. La primera, comprende la ligadura de la rama derecha de la vena porta. Luego, se realiza la transección del parénquima hepático; incluyendo o no, la sección y ligadura de la vena hepática media. A continuación se empaqueta el hígado tumoral en una bolsa de polietileno y el abdomen es cerrado. La segunda etapa, se realiza 7 a 15 días después. Una vez abierto el abdomen, se retira la bolsa de polietileno; se ligan y seccionan la arteria, el conducto biliar y la vena hepática derechos; y se elimina el hígado tumoral. Pueden instalarse drenes y se procede al cierre de la laparotomía. La técnica ALPPS puede permitir entonces, la resección curativa de hígados tumorales en pacientes con lesiones considerados previamente como no resecables. El objetivo de este artículo fue describir las indicaciones y aspectos técnicos del ALPPS a propósito del primer caso realizado en nuestra ciudad, en una paciente de 47 años con un cáncer de vesícula biliar avanzado y metástasis bilobares.

Postoperative hepatic malfunction subsequent to insufficiency of hepatic remnant is a complex and dire problem in patients subjected to large hepatic resections. The associating liver partition and portal vein ligation for staged hepatectomy (ALPPS), is a novel approach for oncology patients whose hepatic tumors were previously considered non-resectable. The technique is performed in two phases. The first one comprises the ligation of the right portal vein branch. Subsequently, a parenchymal transection is performed, including or not, the middle hepatic vein. A plastic bag is employed to cover the tumoral liver, and the abdomen is closed. The second one is performed at 7 to 15 days interval. After laparotomy, the plastic bag is removed. The right artery, bile duct and hepatic vein are sectioned and the tumoral liver is removed. Drain was placed at the resection surface, and the abdomen is closed. ALPPS can enable curative resection of hepatic metastasis in patients with tumors previously considered non-resectable. The aim of this manuscript was to describe the indications and technical aspects of ALPPS in relation to the first case carried out in our city, in a 47-year-old woman with advanced gallbladder cancer with bilobar metastases.

Carcinoma vesicular de células en anillo de sello: diseminación poco frecuente: reporte de un caso con tomografía computada por emisión de positrones con fluor 18-deoxiglucosa / Bone metastases of a gallbladder carcinoma detected by positron emission tomography/computed tomography: case report

Signet ring gallbladder carcinoma is a rare aggressive variant of mucinous adenocarcinoma with poor prognosis. Positron emission tomography/computed tomography (PET/CT) with Fluor18 deoxyglucose (F18-FDG) is a useful tool in the staging of gallbladder cancer. We report a 68 years old man with a surgically resected acute cholecystitis, whose biopsy was positive for signet ring cell gallbladder carcinoma. During surgery, locoregional lymph nodes, liver or peritoneal involvement were not detected. A PET/CT was performed for staging, finding multiple hypermetabolic lytic bone lesions. Percutaneous biopsy of a pelvis bone lesion, confirmed a metastasis of the tumor. In this case, the staging with PET/CT allowed the diagnosis of unsuspected bone metastases and was a useful tool for deciding the best site of biopsy for histologic confirmation.

¿Cuál es el rol de la cirugía en el tratamiento de un paciente con cáncer de la vesícula biliar estadio IIIb? / What is the role of surgery in the treatment of a patient with stage IIIb gallbladder cancer

El cáncer de la vesícula biliar (CaVB), es una neoplasias frecuente en nuestro país. La supervivencia (SV) global no supera el 40% a 5 años. La invasión de la túnica serosa y el estadio IIIB, se asocian a menor SV por considerarse una etapa avanzada de la enfermedad; por ello no hay consenso respecto del rol de la cirugía en estos casos. El objetivo de este artículo es analizar la evidencia existente respecto del rol de la cirugía en el tratamiento de un paciente con CaVB estadio IIIb. Se realizó una búsqueda sistemática de la evidencia disponible en la bases de datos Clinical Evidence, National Health Service, Health Technology Assessment, Tripdatabase, Cochrane Library y PubMed. Se buscaron a documentos de resumen de la evidencia (overviews, guías de práctica clínica (GPC, tablas GRADE), artículos secundarios (revisiones sistemáticas/RS) y artículos primarios (ensayos clínicos/EC y estudios observacionales/EO). Posteriormente, la evidencia se clasificó según la propuesta de la CEBM 2009. Se encontró un total de 420 documentos relacionados: 25 overviews, 15 tablas GRADE, 30 GPC, 37 RS, 99 EC y 214 EO. Al examinar en detalle todos los documentos; Se comprobó que sólo 17 estaban relacionados con los resultados del tratamiento quirúrgico de la CaVB en etapa III; y 5 se refieren a esta (3 EO, 1 GPC y una recomendación del NCI), pero ninguno al estadio IIIb. Existen pocos estudios relacionados, la mayor parte de ellos son de tipo retrospectivo, con un pequeño número de pacientes incluidos, de población y procedimientos quirúrgicos heterogéneos; por ende, es muy sacar conclusiones y realizar recomendaciones basadas en la evidencia existente.

Gallbladder cancer (GBC), is a common neoplasm in our country. The overall survival rate (OSR) does not exceed 40% at 5 years. The invasion of the serosa and IIIB stage, are associated with lower OSR seen it are an advanced stage of the disease, so there is no consensus on the role of surgery in this type ofpatients. The aim of this study is to analyze the existing evidence concerning the role of surgery in the treatment of a patient with stage IIIb GBC. A systematic search of available evidence in the databases Clinical Evidence, National Health Service, Health Technology Assessment, Tripdatabase, Cochrane Library and PubMed search was performed. Evidence summary documents (overviews, GRADE tables, Clinical Guidelines/CG), secondary articles (systematic reviews) and primary articles (Clinical trials/CT) and observational studies/OS) were searched. Subsequently, evidence was classified as proposed by EMBC 2009. A total of 420 related documents were found: 25 overviews, 15 GRADE tables, 30 CG, 37 SR, 99 CT and 214 OS. In reviewing at length all documents; It was verified that only 17 were related to results of surgical treatment of GC that stage III was mentioned and 5 refer to this (3 OS, 1 CG and a recommendation from NCI), but none of them to the IIIb stage. There are few related studies, most of them are retrospective, with a small number of patients included, heterogeneous population and surgical procedures; thereby, it is difficult to draw conclusions and make recommendations based on the evidence.

Fundal Variant of Adenomyomatosis of the Gall Bladder: An Uncommon Entity.

Adenomyomatosis of the gallbladder is a benign and degenerative condition of the gallbladder. It is an incidental finding in gall bladder specimens resected for chronic cholecystitis or cholelithiasis. It frequently occurs after 3rd or 4th decade of life and is often an incidental finding in cholecystectomy specimens resected for chronic cholecystitis or cholelithiasis. Patients with adenomyomatosis are usually asymptomatic it can be classified into three types: Segmental, fundal and diffuse types. The fundal variant is uncommon compared to the other two types. Here, in we present a case of a fundal variant of adenomyomatosis of the gall bladder in a 65-year-old male patient.

Fiocruz as an actor in Brazilian foreign relations in the context of the Community of Portuguese-Speaking Countries: an untold story / A Fiocruz como ator da política externa brasileira no contexto da Comunidade dos Países de Língua Portuguesa: uma história revelada

Brazilian foreign policy paradigms and changes in the global scenario since the Cold War created conditions for stronger ties between Brazil and Portuguese-speaking African countries. Recently, Brazil took the lead in regional integration processes and in South-South cooperation initiatives. These strategies and Fiocruz's acknowledged technical expertise resulted in its direct involvement in Brazilian foreign public health policy in the Community of Portuguese-Speaking Countries. Fiocruz developed cooperation projects in various areas, sharing its know-how and best practices in the most critical fields in partner countries, consolidating "public health framework cooperation" and contributing to diversifying Brazil's partners and promoting Brazil as a global actor.

Os paradigmas da política externa brasileira e as mudanças no cenário global desde a Guerra Fria criaram as condições para aproximação do Brasil com os países africanos de língua portuguesa. Recentemente, o Brasil tomou a liderança nos processos de integração regional e nas iniciativas de cooperação Sul-Sul. Essas estratégias e a reconhecida expertise técnica da Fiocruz abriram espaço para o envolvimento direto da instituição na política externa do Brasil com a Comunidade de Países de Língua Portuguesa na área da saúde. A Fiocruz desenvolveu projetos de cooperação em áreas diversas, compartilhando seu know-how e melhores práticas em áreas prioritárias dos países parceiros, consolidando a "cooperação estruturante em saúde" e contribuindo para a diversificação de parceiros do país e promovendo o Brasil como ator global.

Cáncer temprano de la vesícula biliar: tratamiento y sobrevida a largo plazo / Survival of patients with early gallbladder cancer

Background: Advanced gallbladder cancer has a high mortality. Therefore, this tumor should be diagnosed and treated in early stages. Aim: To analyze the survival rates of patients with an early gallbladder cancer. Material and Methods: Retrospective analysis of medical records of patients with early gallbladder cancer diagnosed until 2003. From that date, all patients with gastrointestinal cancer were registered in a prospective record. Patients with early gallbladder cancer defined as Tis (Carcinoma in situ), T1A (Tumor invades lamina propia) and T1B (Tumor invades muscular layer), were included in this analysis. Results: Eighty patients aged 31 to 87 years (74 percent women) were analyzed. The diagnosis was made during surgery in two patients and during the pathological study in the rest. All 24 patients with Tis tumors were alive after 96 months of follow up. Only one of 16 patients with T1A tumors died of unknown causes. Among the 40 patients with T1B tumors, 24 were re-operated and survival was over 90 percent. Conclusions: This group of patients with early gallbladder cancer had a five years survival over 90 percent. In patients with muscle involvement does not seem necessary to extend the surgery.

Introducción: Dada la elevada mortalidad del cáncer vesicular en etapas avanzadas, lo ideal es diagnosticarlo y tratarlo en una etapa temprana de la enfermedad. Objetivo: Analizar la sobrevida de pacientes con carcinoma temprano de la vesícula biliar y el impacto de una eventual re-operación. Material y Método: Se incluyen en el estudio 80 pacientes con cáncer temprano, siendo la mayoría (65 pacientes) parte de un estudio prospectivo desde mayo de 2004 hasta febrero de 2013. Fueron divididos en 3 grupos: a) carcinoma in situ T1s; b) carcinoma mucoso T1a; c) carcinoma muscular I1b. Seguimiento en el 100 por ciento de los casos. Resultados: El diagnóstico de carcinoma temprano se hizo en 2 pacientes durante la cirugía, en el resto fue un hallazgo del estudio histo-patológico. Los 24 pacientes con carcinoma in situ estaban vivos a los 96 meses de seguimiento. De los 16 pacientes con carcinoma mucoso, sólo 1 (6 por ciento) falleció sin conocerse la causa. Entre los 40 pacientes con cáncer muscular, hubo 24 que no se reoperaron y 16 reoperados. Los resultados anatomo patológicos fueron similares y la sobrevida de ambos grupos fue superior al 90 por ciento. Conclusión: En pacientes con carcinoma de la vesícula biliar in situ y hasta la mucosa, la colecistectomía logra sobrevida mayor del 95 por ciento a largo plazo. En pacientes con carcinoma muscular, ésta se acompaña de una sobrevida mayor a 90 por ciento a 5 años y no parece justificarse ampliar la cirugía.