benign gallbladder tumor
Introduction
Introduction to benign gallbladder tumors Benign tumors of the gallbladder are rare in recent years. In recent years, due to the development and application of imaging diagnostic techniques, especially the general application of B-ultrasound in biliary surgery, the detection of benign gallbladder tumors has increased significantly. According to incomplete statistics in China, benign tumors of the gallbladder account for At the same time, 4.5% to 8.6% of cases of cholecystectomy. The name of benign tumors of the gallbladder wall is rather confusing. In previous literature, benign gallbladder tumors were generally referred to as papilloma or polyp. Japanese scholars refer to gallbladder-like lesions. In recent years, they are often used in China as polypoidlesion of gallbladder-like lesions (PLG). The above naming is not perfect. In fact, gallbladder-like lesions in Japan also include gallbladder cancer, and gallbladder benign tumors are not completely polypoid-like lesions. Therefore, the above naming is only a diagnostic term for morphology and imaging. basic knowledge The proportion of illness: 0.006%-0.008% Susceptible people: no special people Mode of infection: non-infectious Complications: jaundice
Cause
Causes of benign gallbladder tumors
(1) Causes of the disease
In a nutshell, the etiology of benign gallbladder tumors is still unclear. Gallbladder polyps are pathologically papillary adenomas, which can be divided into two types: cholesterol polyps and inflammatory polyps. The former is caused by excessive gallbladder pressure or abnormal cholesterol metabolism. Cholesterol particles are deposited in the basal layer of mucosal epithelial cells, and the tissue cells are over-expanded. Some scholars believe that the macrophages on the mucosa accumulate cholesterol crystals and accumulate; the latter cause glandular glandularity due to inflammation. Epithelial hyperplasia, and is formed by infiltration of a large number of inflammatory cells mainly composed of lymphocytes and monocytes.
Gallbladder adenoma belongs to one of the gallbladder proliferative lesions. It is due to hyperplasia of the gallbladder mucosa. The number of Luo-A sinus increases and expands into a sac, which penetrates deep into the muscular layer. The sinus and the gallbladder cavity communicate with each other to form a pseudo. Diverticulum.
(two) pathogenesis
The pathological features of different lesions are summarized as follows.
Benign tumor of the gallbladder
(1) adenoma: adenoma is a benign tumor from the gallbladder mucosa epithelium, accounting for about 23% of benign gallbladder lesions (Table 3), accounting for about 1% of cases of cholecystectomy in the same period, more common in women, occasionally reported in children Some cases are accompanied by gallstones. Most of the gallbladder adenomas are single, with a few multiple; can occur in any part of the gallbladder; brown to red; average diameter (5.5 ± 3.1) mm (1 ~ 25 mm), most The adenoma is less than 10mm.
Gallbladder adenomas are further divided into papillary adenomas and non-papillary adenomas, with similar rates.
1 papillary adenoma: can be subdivided into pedicle and no pedicle, the former is more common, the mirror shows a branch or branch structure, with a thin blood vessel connective tissue pedicle connected to the gallbladder wall, there is a single layer The cubic epithelium or columnar epithelium is covered, and it is better to migrate with the surrounding normal gallbladder mucosa.
2 non-papillary adenoma: also known as ductal adenoma, most of which have pedicles, the most visible hyperplasia of the gland is surrounded by a moderate amount of connective tissue interstitial, occasionally the gland shows cystic dilatation, covered single The columnar epithelium is continuous with the gallbladder mucosa epithelium. This type of adenoma is mainly caused by the tubular proliferation of glands. It is called adenoma, and sometimes the intestinal metaplasia of goblet cells or basal granule cells is changed.
A small number of adenomas can be between papillary adenomas and non-papillary adenomas, as well as gallstones, adenomas or adenomas.
Regarding the canceration tendency of adenomas, there is still controversy. Some scholars hold negative opinions and believe that there is no direct evidence of adenoma carcinogenesis. Vadheim (1944) first reported 4 cases of gallbladder adenoma cancer, and reported adenoma malignant transformation in the past 30 years. :A. Statistics Domestic reports in 1989, the cancer rate of adenoma is about 11.3%. In 1989, Ishikawa reported that anatomical adenoma (33%) was significantly higher than anatomical adenoma (13%). In 1982, Kozulka reported 7 cases of adenoma malignant, 6 cases of papillary adenoma, half of which contain tubular adenoma; B. adenoma size and malignant relationship: Kozuka reported that the average diameter of benign adenoma is (5.5 ± 3.1) mm The malignant adenoma has an average diameter of (17.6±4.4) mm, so it is determined that the good and bad abdomen is limited to a diameter of 12 mm. The possibility of malignant transformation is greater than 12 mm. Bai Jingliang (1986) believes that the maximum diameter exceeds 15mm gallbladder bulging lesions have a high possibility of malignancy. Chinese scholars believe that people over 10mm should be alert to malignant transformation and set this index as one of the important surgical indications. In 1988, Koga reported 94%. Benign lesions less than 10mm in diameter, 88% of the evil Sexual lesions are larger than 10mm. Therefore, when the tumor exceeds 10mm, it should be considered malignant. In fact, a small number of adenomas have already undergone canceration when the diameter is less than 10mm, so do not relax the adenoma of less than 10mm; C. In 1982, Xiao Xiongxiong observed that as the volume of adenoma increased, the interstitial became less, the glandular vessels approached each other, the nucleus of the epithelial cells gradually increased, and some pseudostratified epithelial cells appeared. The changes of the cancer's prognostic lesions gradually became obvious. In large adenomas, epithelial cells are often disordered, some of the nuclei are larger, and the pseudostratified arrangement of epithelial cells is more pronounced, suggesting that the adenomas have signs of malignant migration in histology; D.Kozuka observed 79 In 15 cases (19%) of gallbladder invasive carcinomas, there were residual adenoma tissues, suggesting that some gallbladder carcinogenesis originated from adenoma tissues already existing.
The above tips:
1 adenoma has a higher cancer rate;
2 as the adenoma increases, the malignant rate increases;
3 adenoma tissue has histological signs of malignant migration;
4 A considerable proportion of gallbladder invasive carcinomas have residual adenoma tissue. The above 4 points are sufficient to show that gallbladder adenoma is a precancerous lesion of gallbladder cancer.
Some people have also noticed that the age of cancerous cases of gallbladder adenoma is high, and there are many females. Some gallbladder cancer or adenoma cancer is accompanied by gallstones. Therefore, it is considered that the adenoma is cancerous and the presence of gallstones and its chronic mechanical stimulation of the gallbladder mucosa. Closely related, adenomas without gallstones rarely malignant.
(2) Benign gallbladder tumors derived from supporting tissues: such benign tumors are more rare, including hemangioma, lipoma, leiomyoma and granulosa cell tumors, and the microscopic structures of hemangioma, lipoma and leiomyoma The same type of tumor that occurs in other parts is identical.
Gallbladder granulosa cell tumor (GCT) is very rare, there are only 20 cases reported in the world, the disease is called granulosa cell myoblastoma, the disease is more common in the cystic duct, accounting for the extrahepatic biliary system GCT 37%, as seen by the naked eye, the cystic duct is a polypoid, brownish yellow, harder small lesion, causing cystic duct stenosis and obstruction, leading to mucinous cyst of the gallbladder, histology showing neurogenic, intracellular hobby Acidic particles are strongly positive for PAS. Clinically, gallbladder angiography shows that the gallbladder is not developed or has no function. So far, no reports of malignant tendency of gallbladder granulosa cell tumor have been reported.
2. pseudotumor of the gallbladder
Gallbladder pseudotumor is often referred to as non-neoplastic lesions, mainly including polyps, proliferative lesions and tissue ectopic diseases. Among them, gallbladder polyps are the most common, due to the widespread application of ultrasound imaging techniques, the detection of gallbladder polyps The rate has increased significantly.
(1) Gallbladder polyps: According to statistics in 1989, gallbladder polyps accounted for 67% of benign gallbladder tumors. Gallbladder polyps were classified into cholesterol polyps and inflammatory polyps, of which cholesterol polyps accounted for the majority (67%).
1Cholesterol polyp: is a local manifestation of cholesterol metabolism disorder, the incidence of no significant difference in gender, can occur in any part of the gallbladder, a small number of cases accompanied by gallstones, most of which are multiple, a small part of a single hair, the appearance of yellow It is lobulated or mulberry-like, soft and easy to fall off, and is connected with the gallbladder mucosa. Some stalks are slender, polyps can swing in the gallbladder; some are thick and short, polyps are small nodules, and polyps vary in size. Generally 3 to 5 mm, most of them are less than 10 mm, occasionally polyps with a diameter of 10 mm. Histology shows that the polyps are composed of accumulated foam tissue cells, the surface of which is covered by a single columnar epithelium, and occasionally the gallbladder is deposited as a strawberry by cholesterol. Change, cholesterol polyps have no tumor tendency, and no reports of malignant transformation.
2 inflammatory polyps: single or multiple, about 3 ~ 5mm size, thick or not obvious, color similar to the adjacent mucosa or slightly red, may be accompanied by gallstones, often accompanied by severe gallbladder chronic inflammation, histology Focal glandular epithelial hyperplasia with vascular connective tissue interstitial and obvious inflammatory cell infiltration, the epithelium is similar to the adjacent gallbladder mucosa epithelium, and no reports of malignant tendency of cholecystitis polyps have been reported.
(2) gallbladder proliferative lesions: including adenomyosis and adenomatous hyperplasia.
1 adenomyosis-like hyperplasia: is a kind of hypertrophic gallbladder wall hyperplasia due to gallbladder proliferation, gallbladder epithelial and smooth muscle hyperplasia, divided into three types, limited, segmental and diffuse, limited adenomyoma Hyperplasia, the vast majority occurs at the bottom of the gallbladder, often referred to as adenomyoma.
There are many names for adenomyosis, but the name of this disease is most appropriate. Christensen believes that the disease is not a tumor and does not have any malignant tendency; however, in 1987 Paraf reported two cases of adenoma-like hyperplasia, one case For adenocarcinoma with cholesterol deposition, the other is squamous cell carcinoma, and there are 4 similar reports in the literature, so the disease is considered to be a benign lesion, but cancer can occur.
The lesions seen by the naked eye are semilunar-shaped nodules with a diameter of 5 to 25 mm, with a central umbilical depression. The segmental and diffuse lesions are mainly affected by different extents. The lesions are grayish white and have a majority. Small cystic cavity.
Histological features are mainly hyperplasia of the gallbladder epithelium and smooth muscle. Epithelial hyperplasia is most prominent in the center of the lesion. The surrounding glands often have cystic dilatation and are filled with mucus. The expanded gland may have calcium deposition, in most cases. There is mild chronic inflammatory cell infiltration in the stroma.
Muto Ryo (1986) emphasized that the diagnostic criteria for this disease were: "In tissue specimens, more than 5 RASs per 1 cm proliferate, resulting in lesions of the gallbladder wall that are more than 3 mm thick."
2 adenoma-like hyperplasia: focal or diffuse mucosal thickening, divided into two types of villi and sponge, the villus is characterized by a high papillary mucosal bulge; the sponge is a branched gland Characteristics, sometimes accompanied by cystic dilatation, have not been reported for malignant cases associated with this disease.
3 tissue ectopic disease: this disease is rare, the reported ectopic tissue has gastric mucosa, small intestinal mucosa, pancreatic tissue, liver and thyroid, etc., all ectopic tissue nodules are located in the gallbladder wall, occurring in the gallbladder neck or cystic duct More common in the vicinity, the naked eye appears into the gallbladder cavity nodules, 10 ~ 25mm size, the section is grayish white, can be identified according to different tissue characteristics, for example, gastric mucosa ectopic disease can be seen under the wall cells and main cells; small intestinal mucosa Ectopic, visible Paneth cells and so on.
4 other benign pseudotumor: more rare, including granuloma formed by parasitic infections, traumatic neuroma and suture granuloma and fibrogranulomatous inflammation.
Prevention
Gallbladder benign tumor prevention
1. Maintain a happy state of mind, develop good eating habits, fast food, eat less thick food, do not drink hard alcohol.
2. For people over the age of 40, especially women, regular B-ultrasound examination, found cholecystitis, gallstones or polyps, etc., should be followed up and found that changes in the condition should be treated early.
Complication
Gallbladder benign tumor complications Complications
Patients with gallstones may have symptoms of gallstones, and occasionally some of the gallbladder papillary adenomas fall off and lead to obstructive jaundice. The surgical treatment of benign gallbladder tumors is satisfactory, with a satisfaction rate of about 85%. The therapeutic effect depends on whether the preoperative symptoms are obvious, whether other diseases are combined, and whether postoperative complications occur. Even if the early diagnosis of malignant transformation is timely, the prognosis is reasonable.
Symptom
Gallbladder benign tumor symptoms Common symptoms Appetite loss nausea dyspeps Abdominal tenderness Gallbladder wall thinning
Patients with benign gallbladder tumors have no special clinical manifestations. The most common symptoms are pain or discomfort in the right upper quadrant. The general symptoms are not heavy and can be tolerated. If the lesion is located in the neck of the gallbladder, it can affect the emptying of the gallbladder, often occurring after a meal. Pain or cramps in the right upper abdomen, especially after a fat meal, other symptoms including indigestion, occasional nausea, vomiting, etc., are lack of specificity, some patients can be asymptomatic, only found during health checkups or population screenings.
Examine
Examination of benign gallbladder tumors
Ultrasound examination
B-ultrasound is the first choice for the diagnosis of gallbladder polypoid lesions. It has the advantages of non-invasive, simple, economic and disease detection rate and easy to popularize. The common feature of gallbladder polypoid lesions is the echogenic light mass that bulges into the gallbladder cavity. The gallbladder wall is connected, without accompanying sound and shadow, does not move with the change of body position, cholesterol polyps are often multiple, polypoid, pedicle, often less than 10mm, pedicle can swing in the gallbladder, high-intensity uneven echo group , no sound shadow, does not shift with body position changes, inflammatory polyps are nodular or papillary, many without pedicle, diameter is often less than 10mm, up to 30mm, pedicle or no pedicle, low-intensity echo, no sound Adenoma-like hyperplasia can be seen in the small circular vesicles and scattered echoes in the gallbladder wall. The misdiagnosis rate or missed diagnosis rate of ultrasound examination is affected by stones in the gallbladder, often the stones are found. The lesion was missed, and the lesion was too small to be undetected.
Endoscopic ultrasonography (EUS) clearly shows the 3-layer structure of the gallbladder wall, showing from the inside out, the slightly higher mucosa and submucosa, the hypoechoic muscle fiber layer and the hyperechoic subserosal and serosal layer, It plays an important role in the differential diagnosis of cholesterol polyps, adenomas and gallbladder carcinomas. It is effective for EUS examination in cases where B-ultrasound is difficult to diagnose. Cholesterol polyps are aggregate images or multi-particulate structures composed of hyperechoic spots, gallbladder walls. The 3-layer structure is clear. Gallbladder carcinoma is a papillary-like hypoechoic mass. The level of the gallbladder wall is destroyed or disappeared, and the depth of tumor invasion can be understood. This method is superior to ordinary B-mode in the imaging of polypoid lesions in the gallbladder wall. Check, but the effect on the lesions at the bottom of the gallbladder is poor.
2. X-ray cholecystography
Including oral gallbladder angiography, venous cholangiography and endoscopic retrograde cholangiography, etc., is a useful diagnostic method, the image features mainly filling defects of different sizes, but most reports that the detection rate and diagnostic coincidence rate of gallbladder angiography Low, generally about 50% (27.3% ~ 53%), low detection rate is affected by gallbladder dysfunction, lesions are too small or stones in the gallbladder and other factors.
3. CT examination
The CT detection rate of gallbladder polypoid lesions is lower than B-ultrasound, higher than gallbladder angiography, the detection rate is 40%-80%, and its imaging features are similar to B-ultrasound imaging. If CT examination is performed under gallbladder angiography conditions The image is more clear.
4. Selective gallbladder angiography
According to the feather-like contrast image on the image, the stenosis or occlusion of the artery can distinguish tumor or non-tumor lesions, but early gallbladder cancer and gallbladder adenoma may not have stenosis and occlusion of the gallbladder artery or have tumor thick Dyeing, the identification between the two is more difficult.
Diagnosis
Diagnosis and differential diagnosis of benign gallbladder tumor
Diagnostic criteria
Most patients have no obvious signs. Some patients may have deep tenderness in the right upper abdomen. If there is obstruction of the cystic duct, the gallbladder can be swollen.
Because benign tumors of the gallbladder lack specific clinical signs and symptoms, it is difficult to make a correct diagnosis based on clinical manifestations. Imaging is the main diagnostic method.
Differential diagnosis
In the following aspects, the differential diagnosis of gallbladder polypoid lesions will be helpful.
The size of the lesions can be seen from Table 4. Most benign lesions <15 mm, >15 mm lesions are highly likely to be malignant. The 21st biliary tract disease study in Japan also defined gallbladder small lesions as lesions less than 15 mm.
Due to the lack of specificity of imaging features, to a large extent, the size of the lesion is the only or major difference. Therefore, the size of the lesion is a preliminary indicator to determine the degree of benign and malignant lesions, but the standards of each family are inconsistent. Most scholars have the same opinion as Koga. They think that the lesion of >10mm should be suspected to be malignant, and it is determined that this point is one of the indications for surgery. In fact, a small part of early cancer or adenoma is also less than 10mm. The size of the lesion to determine the benign and malignant lesions is still impractical and unsafe.
Number of lesions
Gallbladder polyps, especially cholesterol polyps, mostly multiple, gallbladder adenomas are mostly single, a small number of multiple, adenoma malignant although reported, but have not seen multiple adenomas in the same gallbladder report, Therefore, it is considered that the multiple onset becomes a benign possibility, and a single lesion larger than 10 mm should be suspected to be malignant.
2. Morphology of the lesion
A lot of data show that anatomical adenomas are more common, but there is no clear rule between anatomical or pedicled adenoma and its malignant transformation. It is still necessary to obtain a statistical analysis of large samples to obtain a positive conclusion.
3. The site of the lesion
Granulosa cell tumors often occur in the neck of the gallbladder. Localized adenomyosis is more common in the gallbladder. Other benign gallbladder lesions can occur in any part of the gallbladder.
In summary, the preoperative imaging findings lack specificity, and the size of the lesion is only a preliminary criterion for differential diagnosis. For patients with difficult B-diagnosis, EUS or selective gallbladder angiography can be further performed, which is beneficial for differential diagnosis. The final diagnosis still depends on histopathological examination.
In clinical work, it is also differentiated from other lesions in the upper abdomen, including duodenal ulcer, extrahepatic biliary calculi, chronic pancreatitis and hepatitis. Otherwise, symptoms will remain after surgery.
