https://imcjms.com/public Ibrahim Medical College Journal of Medical Science https://imcjms.com/public/registration/journal_full_text/251 Mon, 10 Jul 2017 11:20:37 +0000 Squamous cell carcinoma of the gall bladder is rare.  It accounts for less than 12.7 % of all cases of gall bladder cancer. Pure squamous cell carcinoma is even less common with a reported incidence of 3.3%. We present a case of 70 years-old man with decreased appetite, vomiting and fever associated with right upper quadrant pain for two months. Ultrasonography of the abdomen revealed a distended gallbladder with multiple calculi along with large hyperechoic area of sludge. Provisional diagnosis was cholelithiasis with empyema of gall bladder. Cholecystectomy was done. Histopathological examination  revealed well to moderately differentiated squamous cell carcinoma of the gall bladder without evidence of metastasis.   Squamous cell carcinoma (SCC) of the gall bladder is rare and accounts for about 12.7% of all cases of gall bladder cancer.1-4  Pure squamous cell carcinoma is even less common with a reported incidence of 3.3%.1-4 SCC of the gall bladder usually runs an ill defined clinical course and is frequently detected at an advanced stage because of its tendency to infiltrate the adjacent organs and silent rapid growth pattern.1,2 Survival of the patients with squamous cell carcinomas/adenosquamous carcinomas has been reported to be significantly worse than that of adenocarcinomas of the gallbladder.3 We report a single case of squamous cell carcinoma of the gallbladder that was clinically diagnosed as calculus cholecystitis with sludge empyema of gallbladder. Case report Ultrasonography (USG) of abdomen revealed a distended gallbladder with the wall thickness of 6 mm and of a large hyperechoic mass measuring 4.5x3 cm within the gallbladder sludge. On this basis, a clinical diagnosis of calculus cholecystitis with sludge empyema of gallbladder was considered and the patient was admitted for surgery. Cholecystectomy was performed which revealed cholelithiasis of gall bladder with a friable mass, possibly carcinoma. No obvious involvement of hepatic flexure, common bile duct and extrahepatic biliary tree was observed. The gall bladder measured 7x5 cm with wall thickness of 8 mm. Lumen showed friable mass measuring 4x2 cm with multiple yellow colored cholesterol stones. Multiple tissue samples from representative areas were processed by hematoxylin and eosin stain (H&E). Microscopic examination demonstrated well to moderately differentiated large flat squamous cells with keratinized foci and tumor cells exhibiting intercellular bridges [Fig.1, 2, & 3]. Few mitotic cells and angiolymphatic invasion was present [Fig. 4]. The carcinoma perforated the gallbladder wall and extended up to the serosa. Surrounding gall bladder mucosa showed features of chronic cholecystitis. Histopathologic examination revealed a well to moderately differentiated squamous cell carcinoma of gall bladder confined to the serosa. Discussion Gallbladder cancers are asymptomatic at early stages. When symptomatic, the presentation is similar to biliary colic or chronic cholecystitis. If signs of biliary colic or chronic cholecystitis are present in an elderly patient in combination with decreased appetite and weight loss, carcinoma of the gall bladder should be considered as a differential diagnosis.5 Squamous cell cancer is characterized by rapid growth, early metastatic dissemination and diffuse local and regional infiltration. Despite local and regional infiltration, peritoneal seeding is rare. Hepatic metastases are more frequent in squamous cell carcinoma than adenocarcinoma of the gall bladder.4  Gallbladder stones appear to be a major risk factor in the carcinogenesis of carcinoma of any type but more so for squamous cell carcinoma. Approximately 90% of squamous cell carcinoma cases invariably have cholelithiasis.7 A previous study of seven patients with squamous cell carcinoma of gall bladder reported cholesterol stones in all the seven cases.8 Our case also revealed cholesterol stones. Other pathologies that have been associated with increased risk of gall bladder carcinomas include polypoidal lesions, adenomas, calcified porcelain gall bladder, cholecysto-enterior enteric fistulae, ulcerative colitis, adenomyosis, polyposis coli and anomalous connection between CBD and pancreatic duct. Mutations affecting decreased expression of c-erbb2 gene product have also been identified as a contributing factor.9 Radical resection is the mainstay of treatment for locally invasive squamous cell carcinoma and offers a chance for cure. References 2.    Soyama A, Tajmia Y, Kuroki T,  Tsneoka N,  Ohno S,  Adachi T, Eguchi S and  Kanematsu T. Radical surgery for Advanced Pure Squamous cell Carcinoma of the Gallbladder: Report of a case. Hepatogastroenterology 2011; 58(122): 2118-2120. 4.    Waisberg J, Bromberg SH, Franco MIF et al. Squamous Cell Carcinoma of the Gallbladder.  Sao Paulo Medical Journal 2001; 119(1): 43. 6.    Rai A, Ramakant, Kumar S, Pahwa SH, Kumar S. Squamous Cell Carcinoma of the Gallbladder: an unusual presentation. The Internet Journal of Surgery 2010;  22: 5. 8.    Cariati A, Francesco C. Squamous Cell Carcinoma and Non-squamous Cell Carcinoma: A case study.  J Diagn Med Sonography 2004; 20: 347-350. 2026 Ibrahim Medical College. All rights reserved.