Saudi Journal of Gastroenterology
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CASE REPORT Table of Contents   
Year : 1997  |  Volume : 3  |  Issue : 1  |  Page : 53-55
Primary keratinizing squamous cell carcinoma: An exceptional tumor of the gallbladder

1 Department of Pathology, Saudi German Hospital, Jeddah, Saudi Arabia
2 Department of Surgery, Al- Amin Hospital, Al Taif, Saudi Arabia

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Date of Submission09-Apr-1996
Date of Acceptance10-Sep-1996

How to cite this article:
Al-Hady SM, Al-Saed A. Primary keratinizing squamous cell carcinoma: An exceptional tumor of the gallbladder. Saudi J Gastroenterol 1997;3:53-5

How to cite this URL:
Al-Hady SM, Al-Saed A. Primary keratinizing squamous cell carcinoma: An exceptional tumor of the gallbladder. Saudi J Gastroenterol [serial online] 1997 [cited 2022 Dec 6];3:53-5. Available from:

Carcinoma of the gallbladder is a rare event to such an extent that it does not justify prophylactic cholecystectomy for asymptomatic gallstones. The diagnosis of this tumor is usually made at the time of operation for another indication, or postoperatively rather than preoperatively. Its overall incidence is around 1% among patients with gallstone disease [1] .

Microscopically, most carcinoma of the gallbladder are adenocarcinomas. We report here an exceptional entity, i.e. primary squamous cell carcinoma arising in the gallbladder of a 55-year-old lady.

The objective is to draw the attention of the clinicians and pathologists to this tumor entity especially in Saudi Arabia, where recent studies indicate high prevalence and incidence of gallstones [2] .

   Case Report Top

The patient first presented at Al-Amin Hospital, Al-Taif with jaundice, swelling in the right hypochondrium, and diabetes mellitus. Clinical examination revealed a gallbladder swelling. Ultrasonography and computerized tomography revealed a gallbladder mass infiltrating the liver by palpation and was found to compress the common bile duct and the head of the pancreas. The para-aortic lymph nodes were also enlarged and a few gallstones were detected. However, the portal vein was not infiltrated. Tumor thrombi or isolated liver nodules were not detected.

At operation, the gallbladder was found plastered in the region of the porta hepatic, and distended with a firm tumor in the fundus. Segmented wedge resection of the adjacent liver tissue was done, and the whole gallbladder with the excised adjacent liver tissue were removed en-block. A few yellowish brown stones 0.6 cm in average diameter came out from the bladder neck, and were given to the patient's relatives according to their request.

The surgically resected tissue was sent to the Pathology Department in Saudi German Hospital in Jeddah for pathological examination.

The received gallbladder and adjacent liver tissue were examined both grossly and microscopically. The gallbladder was received intact and measured 8.5X4.5X4 cm with the adjacent liver tissue 7X4X4 cm. The gallbladder was opened longitudinally and showed a polypoid firm whitish tumor 7.2X6X4 cm projecting from the fundis and filling the distal two thirds of the bladder cavity. Foci of hemorrhage and necrosis were present [Figure - 1]. The tumor appeared invading the whole thickness of the gallbladder wall down to the adjacent liver tissue. The uninvolved gallbladder wall was 0.2 cm thick with smooth mucosa.

Microscopic examination of the tumor tissue showed a keratinizing well differentiated squamous cell carcinoma formed of squamous cell nests and pearls with gradual central keratinization in many areas, and solid sheets of moderately differentiated squamous cells in others [Figure - 2]. The tumor cells showed well defined cell borders with intercellular bridges and abundant glassy or faintly eosinophilic cytoplasm in the better differentiated areas. A moderate number of typical and atypical mitotic figures were identified throughout the tumor. Foci of necrosis, hemorrhage and dystrophic calcification were present. There was vascular invasion by tumor cells but no perineural invasion was seen. The tumor appeared invading the whole thickness of the gallbladder wall down to the adjacent liver tissue. The gallbladder resection margins were also invaded with less differentiated tumor cells. However, the liver resection margins were free.

The adjacent covering gallbladder mucosa showed foci of squamous metaplasia and moderate to severe dysplasia of the squamous cells (carcinoma in situ) [Figure - 3].

The rest of gallbladder mucosa was intact and covered with papillary colunmar serous epithelium with minimal cytologic atypia.

   Discussion Top

Primary squamous cell carcinoma is well recognized as a separate entity of gallbladder cancer in the World Health Organization classification of the tumor of the gallbladder and extrahepatic bile ducts [3] .

Mixed adenosquamous carcinoma is another entity where both squamous and glandular elements exist in the same tumor, and is reported more frequently than the pure primary squamous cell carcinoma variety [4] . Both varities constitute about 5% of all the carcinomas of gallbladder [1] .

Secondary squamous cell carcinoma whether directly invading the gallbladder from neighboring structures or carried from distant organs is relatively more common than the primary tumor arising from the bladder [5] .

There are a few examples of primary squamous cell carcinoma reported in the literature with most cases presenting with large polypoid tumor filling the gallbladder cavity [5],[6],[7],[8] .

The men were more affected than women, with common age at 70 years or older at the time of presentation.

These findings differ from the present case in the age and sex of the patient, being a women at 55 years old, but coincide with the pathological findings.

A few gallstones were present in association with the present tumor, although not studied. The adjacent covering gallbladder mucosa showed squamous metaplasia with varying degrees of dysplastic changes which are closely related to chronic irritation by gallstones [Figure - 3]. This is similar to the pathogenetic events of squamous cell carcinoma arising elsewhere in the body. It also indicates the close relationship between gallstones and gallbladder cancer. About 90% of all bladder carcinomas show also the presence of gallstones. However, only 1% of the patients who contact gallstones develop gallbladder cancer [9],[10] .

The tumor stage was advanced at the time of operation. This was confirmed by histologic examination. The gallbladder was plastered in place so that the surgical resection was difficult to the extent that no local lymph node could be dissected. The para­aortic lymph nodes were also enlarged clinically. This is consistent with the poor prognosis of gallbladder carcinoma in general [11] . The mean five-year survival rate has been reported to be around 1 % despite surgical intervention [7],[8],[12],[13] .

Therefore, it would be wise to recommend routine histopathological examination of gallbladders in all symptomatic patients and to encourage the surgeons and the endoscopists to send all the material removed during surgical or laparoscopic or endoscopic procedures to the pathology departments for complete and final evaluation and study in order to help early detection of gallbladder cancer and preneoplastic conditions.

This is of particular importance in Saudi Arabia, in view of the high prevalence of gallstone disease among the populations [2] .

   References Top

1.Crawford JM. Carcinoma of the gallbladder. In: Cotran R, Kutnar V, and Robbin S. (eds.). Robbins Pathologic Basis of Disease. 5th edition, W.B. Saunders, Philadelphia 1994;891-6.  Back to cited text no. 1    
2.Al-Mofleh IA: Gallstones. Saudi J Gastroenterol 1995; 1; 173-9.  Back to cited text no. 2    
3.Albores-Saavedra J, Henson DE and Sobin LH: The WHO Histologic classification of tumors of the gallbladder and extrahepatic bile ducts. A commentary on the second edition. Cancer 1992:70:410-4.  Back to cited text no. 3    
4.Suster S, Huszar M, Herczeg E, and Bubis JJ: Adenosquarnous carcinoma of the gallbladder with spindle cell features. A light microscopic and imnmnocytochemical study of a case. Histopathology 1987;11:209-14.  Back to cited text no. 4    
5.Karasawa T, Itoh K, Komukai M, Ozawa U, Sakurai, and Shikata T: Squamous cell carcinoma of gallbladder. Report of two cases and review of literature. Acta pathol Jpn 1981;1:299-308.  Back to cited text no. 5    
6.Brandt-Rauf PW, Pincus M, and Adelson S. Cancer of the gallbladder: a review of 43 cases. Human Pathol 1982; 13:18-9.  Back to cited text no. 6    
7.Hamrick RE, Liner FJ, Hastings PR et al. Primary carcinoma of the gallbladder. Ann. Surg. 1982;195:270-3.  Back to cited text no. 7    
8.Miyazaki K, Tsutsurni N, Kitahara K, Mori M. Sasatomi E, Tokunaga O, and Hisatsuga T. Hepatopancreatoduodenectomy for squamous and adenosquamous carcinoma of the gallbladder. Hepato-gastroenterology 1995;42(1):47-50.  Back to cited text no. 8    
9.Russel PW, and Brown CH. Primary carcinoma of the gallbladder. Ann Surg 1950;132:121-8.  Back to cited text no. 9    
10.Malet PF. Complication of cholilithiasis. In Kaplowitz N (ed.). Liver and biliary disease. Baltimore, Williams and Wilkins 1992:610-27.  Back to cited text no. 10    
11.Collier NA, Carr D, Hemingway A et al. Preoperative diagnosis and its effect on the treatment of carcinoma of the gallbladder. Surg Gynecol Obstet 1984;159:465-7.  Back to cited text no. 11    
12.Anderson JB, et at. Adenocarcinoma of the extrahepatic biliary tree. Ann R Coll Surg 1985;67:139-40.  Back to cited text no. 12    
13.Fleischer GM, and Dittrich S. Therapy and prognosis of gallbladder cancer. Zentralblatt fur Chir u - gie 1992; 117:81-6 (English abstract).  Back to cited text no. 13    

Correspondence Address:
Samir M Al-Hady
Consultant Histopathologist Saudi German Hospital, P.O. Box 2550. Jeddah 21461
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

PMID: 19864815

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


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