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Special Feature
Sep 2012

Image of the Month—Diagnosis

Arch Surg. 2012;147(9):888. doi:10.1001/archsurg.147.9.888

Answer: Primary Adenocarcinoma

Pathological examination of a frozen tissue section revealed superficial adenocarcinoma with no evidence of metastatic melanoma. The final microscopic report indicated well-differentiated adenocarcinoma (pTisN0M0) with mucinous metaplasia and high-grade dysplasia.

While the presumptive diagnosis for this patient was melanoma to the gallbladder owing to his history of previous metastatic melanoma to the brain and stomach, this case demonstrates that histological analysis is mandated despite clinical impression. Primary adenocarcinoma of the gallbladder is the sixth most common gastrointestinal malignant neoplasm and affects approximately 9000 patients in the United States each year.1 Patients often are asymptomatic and do not present until late in the course of illness, leading to the generally poor prognosis. On imaging, there are 3 common presentations for gallbladder adenocarcinoma. The most common appearance (55%) is that of the gallbladder replaced by a mass. The second most common appearance (25%) is one of focal or diffuse wall thickening. Finally, the third appearance is one with polypoidal masses.2

It has been demonstrated that the survival in these patients is heavily correlated with the American Joint Committee on Cancer TNM staging system. For patients with stage IA (T1N0M0) or stage IB (T2N0M0) disease, cholecystectomy is often curative, with a 70% to 90% 5-year survival rate. However, stage III disease and above (T4, any N, M0) is often not surgically curable and has a 1-year survival of less than 5%.3

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The Editor welcomes contributions to the Image of the Month. Manuscripts should be submitted via our online manuscript submission and review system (http://manuscripts.archsurg.com). Articles and photographs accepted will bear the contributor's name. Manuscript criteria and information are per the Instructions for Authors for Archives of Surgery (http://archsurg.ama-assn.org/misc/ifora.dtl). No abstract is needed, and the manuscript should be no more than 3 typewritten pages. There should be a brief introduction, 1 multiple-choice question with 4 possible answers, and the main text. No more than 2 photographs should be submitted. There is no charge for reproduction and printing of color illustrations.

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Article Information

Correspondence: Joshua L. Chan, MD, Department of Surgery, University of Southern California, 7415 Norris Cancer Research, NOR 7415, M/C 9180, Los Angeles, CA 90089 (joshua.l.chan@usc.edu).

Accepted for Publication: October 1, 2011.

Author Contributions:Study concept and design: Chan and Silberman. Acquisition of data: Chan and Silberman. Analysis and interpretation of data: Chan and Silberman. Drafting of the manuscript: Chan and Silberman. Critical revision of the manuscript for important intellectual content: Chan and Silberman. Administrative, technical, and material support: Chan. Study supervision: Chan and Silberman.

Financial Disclosure: None reported.

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Schottenfeld D, Fraumeni J. Cancer Epidemiology and Prevention. 3rd ed. Oxford, England: Oxford University Press; 2006:787-800