In vivo appearances of gallbladder carcinoma under magnifying endoscopy and probe-based confocal laser endomicroscopy after endosonographic gallbladder drainage

An 87-year-old man with multiple medical co-morbidities was admitted for right upper quadrant pain and fever. Computed tomography showed a distended gallbladder with gallstones and pericholecystic fluid compatible with a diagnosis of acute cholecystitis. There was no gallbladder mass. Since the patient had sepsis and was unfit for surgery, endoscopic ultrasound (EUS) drainage of the gallbladder was performed with a lumen-apposing stent (10 × 15 mm, AXIOS; Xlumena, Mountain View, California, USA) as an alternative to percutaneous cholecystostomy ([Fig. 1 a, b]). The patient had an uneventful recovery.

Fig. 1 a, b Computed tomography showing the lumen-apposing stent drainage of the gallbladder to the first part of the duodenum.

Follow-up cholecystoscopy performed 3 months later showed clearance of all stones. However, a 2-cm polypoid lesion was noted at the fundus of the gallbladder. Magnifying narrow band imaging (NBI) showed enlarged and irregular mucosal glands with dilated and corkscrew-appearance microvasculature that was suspicious for malignancy ([Fig. 2]). Probe-based confocal laser endomicroscopy (CLE) (GastroFlex; Mauna Kea Technologies, France) showed darkened and irregular columnar cells with loss of villous architecture ([Fig. 3 a, b]). Miniprobe EUS examination (UM-DP12 – 25R; Olympus, Tokyo, Japan) showed suspicion of tumor involvement of the gallbladder muscularis propria ([Fig. 4]). Final histological findings confirmed the presence of a gallbladder adenocarcinoma ([Fig. 5]). The patient was then treated conservatively as he was too frail to undergo any major surgery.

Fig. 2 Gallbladder adenocarcinoma in an 87-year-old man, seen at follow-up endoscopy 3 months after endosonographic gallbladder drainage with a lumen-apposing stent: a white light endoscopic view; b magnified narrow band imaging (NBI) appearance.

Fig. 3 a Confocal laser endomicroscopy (CLE) image of the normal-looking gallbladder mucosa, showing villous architecture with columnar epithelium. b CLE image of the gallbladder adenocarcinoma, displaying marked darkened, variably sized glands.

Fig. 4 Miniprobe examination with endoscopic ultrasound (EUS) showed tumor involvement of the muscularis propria of the gallbladder.

Fig. 5 A complex cribriform malignant gland is present in the stroma supporting the diagnosis of adenocarcinoma (hematoxylin and eosin [H&E], original magnification × 400).

To our knowledge, this is the first description of a gallbladder adenocarcinoma discovered endoscopically. This was made possible through the use of endosonographic drainage that allowed endoscopic assessment of the gallbladder [1] [2]. Magnifying NBI endoscopy has revolutionized the diagnosis of early gastrointestinal neoplasms and is pivotal to performance of endoscopic mucosal resection or submucosal dissection [3]. CLE allows in vivo assessment of cellular architecture and has been shown to be associated with high sensitivity and specificity for diagnosis of Barrett’s metaplasia and biliary malignancy [4]. EUS-guided gallbladder drainage in this patient opened the way for application of the above instruments in aiding diagnosis that was not suspected on CT.

Endoscopy_UCTN_Code_CCL_1AZ_2AC

• References

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• 2 Itoi T, Binmoeller KF, Shah J et al. Clinical evaluation of a novel lumen-apposing metal stent for endosonography-guided pancreatic pseudocyst and gallbladder drainage (with videos). Gastrointest Endosc 2012; 75: 870-876
• 3 Endoscopic Classification Review Group. Update on the Paris Classification of superficial neoplastic lesions in the digestive tract. Endoscopy 2005; 37: 570–578
• 4 Nakai Y, Isayama H, Shinoura S et al. Confocal laser endomicroscopy in gastrointestinal and pancreatobiliary diseases. Dig Endosc 28.08.2013; doi: DOI: 10.1111/den.12152. [Epub ahead of print]