European Journal of Cardiovascular Medicine

Carcinoma of the gall bladder is a malignant epithelial neoplasm arising from biliary epithelium. Gall bladder cancers are the most common biliary tract tumours. The incidence of GBC varies geographically and ethnically. The highest incidence has been reported in Mapuche people of Chile with an incidence among females of 27.3 cases per 100 000 person-years. High incidence has also been reported in parts of India, eastern Asia, and some central and European countries1. In India highest incidence has been seen in female population of Delhi (21.5/100 000), Jammu and Kashmir, Punja, Haryana, Himachal Pradesh, Uttar Pradesh, Assam, Uttarakhand, West Bengal, Manipur2. Gallbladder cancer occurs in adults and much more frequently in females than males3. Patients usually present with nonspecific clinical features that mimic the symptoms of chronic cholecystitis like nausea, pain right upper quadrant of abdomen, vomiting, features of obstructive jaundice, or sometimes with no symptoms, which ultimately leads to late diagnosis4,5. Chronic cholecystitis and cholelithiasis are frequent risk factors associated with the development of GBC. It has been observed that chronic inflammation poses a critical risk in the development of gall bladder carcinoma4,6.

Some patients may present with a mass, but in most cases, both imaging modalities and gross examination are unable to detect its presence6. These cases might show gallbladder wall thickening or mucosal ulceration thereby leading to late diagnosis and a poor outcome7,8. Owing to the aggressive nature of the gall bladder tumours’ and the complex anatomy of its adjoining structures, there is a rapid extension in the adjacent region, which in turn is responsible for a dismal 5% overall survival rate in gall bladder carcinoma with a median survival time of approximately six months9,10. However, a few cases in which incidental gallbladder carcinoma is observed at an early stage show a five-year survival rate of 80%11. This study was done owing to a lack of extensive studies on gallbladder neoplasms and its growing incidence, particularly GBCs in the our state.

Aims and Objectives

• To see the incidence of incidentally detected gall bladder tumours in Jammu and Kashmir.
• To study the clinic-demographic profile of the cases.
• To study histopathological spectrum of these cases.

This study was done at GMC Srinagar, a tertiary care centre in Kashmir province of Jammu and Kashmir. It was a cross-sectional study of two years conducted in the Department of Pathology of Govt. Medical College Srinagar from December 2022-2024. Over these two years 7632 cholecystectomies were performed which included 7611 simple and 23 radical cholecystectomies. Out of these 6128 were females and 1504 were performed in males. Our study sample comprised of 57 cases of gall bladder neoplasms. Out of these 34 underwent simple cholecystectomy and were incidentally found while the rest already had a pre- operative suspicion of tumour so they were treated by radical surgery. Inclusion and exclusion criteria All malignant as well as premalignant lesions (including intracystic papillary neoplasms as well as biliary intraepithelial neoplasms) were included in the study. Dysplastic lesions noted in the background of chronic cholecystitis were also included. However, cases diagnosed solely as chronic cholecystitis with no associated neoplasms were excluded. Also, cases which lacked relevant clinical data were not included in our study. Methodology All the gall bladder specimens received at our center were screened for gall bladder neoplasms. Data was manually archived from the registers of pathology department. Wax blocks available in the department were re-sectioned at 5um thickness and stained with haematoxylin and Eosin stain. Cases were examined microscopically and analysed along with their relevant clinical information. Additional attention was paid to the demographic profile as well as clinical and radiological details. Photomicrographic pictures of the slides were taken. Malignant lesions were staged according to the AJCC (American Joint Committee on Cancer) 8th edition. Gross Specimens were relooked wherever available and special focus was given to macroscopic details like wall thickness, mucosal appearance, site of tumour if present. Photographs of the gross specimens were also taken wherever available Statistical Analysis: After obtaining all the relevant gross, microscopic and clinical information (including history, demographic profile, radiological findings, and intraoperative notes) already mentioned on our requisition forms, data was entered into a Microsoft Excel Sheet and analyzed. The recorded data was compiled and entered in a spreadsheet and then exported to data editor of SPSS. Data was then tabulated using tables histograms and pie charts.

A total of 57 cases were studied in which 46 were reported in females while only 11 were reported in males. The male to female ratio for gall bladder neoplasms in our study was 1:4.18 (Figure 1). 22 cases were in the age group 41-64 years (Figure 2). 60% of the cases (34 Out of 57) were detected incidentally either during surgery or on gross examination while 40% (23 out of 57 cases) were suspected preoperatively for which radical cholecystectomies were performed (Figure 3).

For cases (23 of 57) that were suspicious on preoperative clinico-radiological assessment, radical (extended) cholecystectomies were performed with lymph node dissection while simple cholecystectomy was performed in 34 cases. 35% (20/57) of the gall bladder lesions were in fundus while 25% of the GB neoplasms showed unremarkable mucosa grossly (14 of the total cases). 14% were in the neck region while a small percentage (3%) showed patchy mucosal involvement (Figure 4). 30 cases were reported as Adenocarcinoma on histopathological examination. We reported 8 cases of Biliary Intraepithelial neoplasia with high grade dysplasia. 1 case showed foci of invasive adenocarcinoma as well. Squamous cell carcinomas were rare (only 1 case) in gall bladders. 3 cases were diagnosed as intramucosal adenocarcinomas. Other premalignant lesions like intracystic papillary neoplasms constituted a total of 3% cases. Other cases reported were Adenosquamous carcinoma, G1 neuroendocrine tumour, B cell Acute Lymphoblastic lymphoma, Mixed Neuroendocrine Non-Neuroendocrine neoplasia (MiNeN) and mucinous adenocarcinoma (1 case each) {Figure 5}. 43% of the patients presented with diffuse wall thickening followed by ulceroinfiltrative growth in malignant lesions (16%).24% of the patients had normal mucosal appearance of gall bladder.10% of the cases presented with polyp in the mucosa while 4% had papillary configuration (Figure 6). GB stones were a significant risk factor for gall bladder tumours with 56% showing a direct association with the latter (Figure 7). 35% cases showed infiltration into peri muscular connective tissue on the peritoneal side (pT2a) while only 3% showed infiltration on hepatic side pT2b. 5% of the cases were in situ. 14% of the lesions showed infiltration of muscularis propria (pT1b) while 11% showed direct extension into liver (pT3). None of the gall bladder carcinoma was detected at pT4 stage (Table 2). On observing the tumour stage, Node and Metastasis (TNM). 25/57 cases were at pT2 stage i.e. showed infiltration into the perimuscular connective tissue of which the most common was on peritoneal side i.e. pT2a.5/57 cases showed pT1b stage (infiltration into muscle). 6 cases showed pT3 stage while 3 were at pTis stage (Table 2).

Table 1 summarizes the distribution of surgical procedure types, gross tumor characteristics, and stone-related findings among the 57 patients included in the study. Simple cholecystectomy was the most commonly performed procedure, accounting for nearly two-thirds of cases (61.4%), followed by radical cholecystectomy in one-third of patients (33.3%), while extended cholecystectomy was performed in a small proportion (5.3%). With regard to the site of gross tumor involvement, the fundus was the most frequently affected location (36.8%), followed by the body of the gallbladder (28.1%) and the neck (15.8%). Patchy involvement was observed in a minority of cases (5.3%), whereas no grossly identifiable tumor was noted in 14.0% of specimens.

Analysis of gross morphological findings revealed that gallbladder wall thickening was the predominant appearance, seen in 40.4% of cases. Ulcero-infiltrative growth constituted 21.1% of specimens, while polypoidal lesions accounted for 14.0%. Unremarkable gross appearance was noted in 19.3% of cases, and less common findings such as papillary projections, mucosal granularity, firm areas, or solid grey-white lesions together comprised 5.3%. Cholelithiasis was present in 45.6% of patients, whereas 54.4% had no associated gallstones. Among those with stones, multiple calculi were more common (40.4%) compared to single stones (3.5%). Overall, more than half of the cases were detected incidentally (59.6%), while 40.4% were clinically suspected prior to surgery.

Overall, the table highlights that simple cholecystectomy for incidentally detected lesions with predominant fundal involvement and wall thickening constituted the most frequent presentation in this cohort.

The table shows that adenocarcinoma was the most common histopathological diagnosis, with moderately differentiated adenocarcinoma (31.6%) being the predominant subtype, followed by well differentiated adenocarcinoma (24.6%). Biliary intraepithelial neoplasia constituted a substantial proportion of cases, with high-grade (15.8%) and low-grade dysplasia (14.0%), indicating a significant burden of premalignant lesions. Poorly differentiated adenocarcinoma was less frequent (7.0%), while other tumor types were rare. Overall, the findings highlight a predominance of glandular malignancies with notable representation of precursor lesions.

The table indicates that pT2/pT2a was the most common tumor stage, observed in 45.6% of cases, suggesting that the majority of invasive tumors presented at an intermediate depth of invasion. Early-stage disease in the form of pTis and pT1b accounted for 17.5% of cases, reflecting a proportion of lesions detected at an early stage. Advanced local disease (pT3) was seen in 15.8% of patients. With respect to nodal status, 14.0% of cases showed lymph node positivity (N1), while 8.8% were node negative (N0); however, lymph node status was not assessed (Nx) in a substantial proportion (57.9%). Premalignant lesions, for which TNM staging is not applicable, constituted 29.8% of the study population. Overall, the findings demonstrate a predominance of pT2-stage tumors with limited nodal evaluation.

The table demonstrates that lymphovascular invasion and perineural invasion were confined to invasive malignant tumors and were absent in all premalignant lesions. Poorly differentiated adenocarcinoma showed the highest frequency of both LVI and PNI (75% each), indicating aggressive tumor behavior. Well and moderately differentiated adenocarcinomas exhibited intermediate rates of LVI and PNI, reflecting increasing invasiveness with decreasing differentiation. Squamous and adenosquamous carcinomas showed universal lymphovascular invasion, with perineural invasion present in half of the cases. In contrast, other invasive carcinomas demonstrated relatively low rates of both LVI and PNI. Overall, the findings indicate a strong association between poorer histological differentiation and the presence of LVI and PNI, underscoring their role as markers of tumor aggressiveness.

The table shows that there was a statistically significant association between lymphovascular invasion and histopathological diagnosis (p < 0.001), as well as between perineural invasion and histopathological diagnosis (p < 0.001). This indicates that the presence of LVI and PNI varies significantly across different histopathological tumor types and is more frequently associated with invasive and poorly differentiated malignancies, highlighting their importance as adverse pathological prognostic indicators.

Malignant gall bladder tumours are aggressive in nature and are diagnosed at advanced stages with a dismal overall survival rate10,12,13. The reason for late detection is non-specific symptoms which often masks the diagnosis4,5,11. In a study by Priya et al. Cureus 16 (6) found the incidence of gall bladder carcinomas to be 25/2536 (1.04%) in the last five years in their centre. In their study the male to female ratio was 1:4 which was the roughly the same as our study 1:4.18. Majority of the cases were reported in females (Figure 1). A diverse series of Indian studies have shown that the male-to-female ratio is from 3:1 to 4.514.

In recent years, there has been a rise in the incidence of gallbladder carcinoma among females. The average age-adjusted rate of gallbladder carcinoma in women has grown from 6.2/100,000 in 2001-2004 to 10.4/100,000 in 2012-201415. The average age at diagnosis of gallbladder carcinoma in India was 51±11 years, considerably younger in contrast to 71.2+12.5 years in the USA and Western European countries11,16,17. There have been several studies in which the mean age of Indian gallbladder carcinoma patients at the time of diagnosis was 50 to 55 years19. In our study, the mean age of patients was in the group 52.7 years comparable to the study of Priya et al. Most of the patients were in the age group 41-64 years (figure 2). 23 patients underwent radical cholecystectomy because of preoperative suspicion for malignancy while for the rest (34) simple cholecystectomy was performed .GB stones were a significant risk factor for gall bladder tumours with 56% showing a direct association with the latter {(25 cases) (figure 7)}. The chronic irritation of the gallbladder mucosa due to the development of gallbladder stones is one of the important steps in the transformation to carcinoma4,6. In 70-90% of patients with gallbladder carcinoma, gallstones were present, as reported by various studies in India14,18,19. Similar trend was observed in our study. There is a lack of understanding of the pathogenesis of gallbladder carcinoma in India, even today. Several external and host factors cause epigenetic and genetic mutations leading to tumorigenesis. Any impediment in emptying of the gallbladder adds to the anatomically weak muscular structure of the gallbladder and favours the growth of bacteria. It also leads to the release of toxic metabolites, which ultimately cause chronic inflammation. Moreover, the presence of gallbladder stones and chronic cholecystitis severely impact the emptying of the gallbladder, thus perpetuating the molecular insult20. Various studies from India have shown a mutation of the p53 pathway in about 70% of the cases21. 60% of the patients had incidentally discovered gall bladder lesions while for 40% they were preoperatively suspected (figure 3). This trend showed the silence nature with which these tumours present and how often these neoplasms are missed on radiological investigations.

Majority of the lesions were in fundus 35% (20/57) while 25% of the GB neoplasms showed unremarkable mucosa grossly (14 of the total cases). 14% were in the neck region while a small percentage (3%) showed patchy mucosal involvement (Table 1 and Figure 4). 43% of the patients had diffuse wall thickening of the gall bladder while 16% presented with ulceroproliferative growth. 24% of the cases did not show any gross mucosal abnormality of GB i.e. had unremarkable gall bladder mucosa with no tumour grossly (Figure 6). 10% of the cases presented with GB polyp and 4% had papillary configurations. 30 (52%) cases were reported as Adenocarcinoma on histopathological examination. Out of these 15 were moderately differentiated, 12 well differentiated and 3 poorly differentiated. We reported 8 cases of Biliary Intraepithelial neoplasia with high grade dysplasia (14%) while 12% of the BiLiN had foci of low grade dyspalsia. 1 case from the former showed foci of invasive adenocarcinoma as well. Squamous cell carcinomas were rare (only 1 case) in gall bladders.3 cases were diagnosed as intramucosal adenocarcinomas. Other premalignant lesions like intracystic papillary neoplasms constituted a total of 2 cases out of which one had foci of invasive carcinomas. We also reported one case each of Adenosquamous carcinoma, Neuroendocrine tumor-G1 (well differentiated), B cell Acute Lymphoblastic lymphoma, Mixed Neuroendocrine Non-Neuroendocrine neoplasia (MiNeN) and mucinous adenocarcinoma. These rare malignant tumours are not frequently encountered in the specimens (Figure 5).

Lymphovascular invasion and foci of perineural invasion was identified in 14 malignant lesions (Table 2). These histopathological parameters have been shown to be bad prognostic factors and directly predict the aggressiveness of gall bladder carcinomas. Birnbaum et al identified in a study of patients with advanced GBC, that PNI is an independent prognostic factor and a local recurrence was seen in patients who had PNI with a survival of 6% at 5 years22. Few studies are specifically conducted to assess the impact in terms of survival, and most of information comes from clinicopathological descriptions made by authors in retrospective studies on GBC23,24,25.

Most (35% cases) showed infiltration into perimuscular connective tissue on the peritoneal side (pT2a) while only 3% showed infiltration on hepatic side (pT2b). Shindoh et al.26 in their study of 437 patients analyzed whether there is a correlation between tumour location and long-term survival. They divided the tumours into liver-sided and peritoneal-sided tumours. Liver-sided tumours correlated strongly with a higher incidence of vascular invasion, lymph node invasion, and liver metastases; consequently, they reported poorer survival than cases with peritoneal-sided tumours, with the 5-year survival rate being 76% vs. less than 50%. In 32% of the cases staging was not possible as these were either benign or dysplastic lesions. 5% of the cases were in situ.14% of the lesions showed infiltration of muscularis propria (pT1b) while 11% showed direct extension into liver (pT3). None of the gall bladder carcinoma was detected at pT4 stage (Table 2). This shows the aggressive nature of gall bladder carcinomas. Patients do not make it till that stage and die before hand only.

Gall bladder neoplasms are notoriously known to be discovered incidentally often with no prior clinical suspicion. Gall bladder stones are a significant risk factor for GB malignancy. The clinical presentation of tumours is very nonspecific and these tumours are usually discovered at an advanced stage. Gross pathological findings can be absent or very subtle. Hence it is important to have a high index of suspicion during grossing of Gall bladder specimens and a thorough and meticulous histopathological examination should be done considering that our state is a high-risk zone for GB carcinomas

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