27842605 Visualization

A 76 Age - year Age - old Age woman Sex presented Clinical_event to our hospital Nonbiological_location with complaints of epigastralgia Sign_symptom since a Date day Date prior Date to admission Clinical_event .
Laboratory Diagnostic_procedure data Diagnostic_procedure on admission revealed an elevation Lab_value of aminotransferase Diagnostic_procedure , alanine Diagnostic_procedure aminotransferase Diagnostic_procedure , ɤ Diagnostic_procedure - guanosine Diagnostic_procedure triphosphate Diagnostic_procedure , and alkaline Diagnostic_procedure phosphatase Diagnostic_procedure .
Serum Detailed_description total Diagnostic_procedure bilirubin Diagnostic_procedure and tumor Diagnostic_procedure markers Diagnostic_procedure , carcinoembryonic Diagnostic_procedure antigen Diagnostic_procedure ( CEA Diagnostic_procedure ), carbohydrate Diagnostic_procedure antigen Diagnostic_procedure 19 Diagnostic_procedure - 9 Diagnostic_procedure ( CA19 Diagnostic_procedure - 9 Diagnostic_procedure ), SPan-1, and neuron Diagnostic_procedure - specific Diagnostic_procedure enolase Diagnostic_procedure ( NSE Diagnostic_procedure ), were all within Lab_value normal Lab_value ranges Lab_value .
Abdominal computed Diagnostic_procedure tomography Diagnostic_procedure ( CT Diagnostic_procedure ) and magnetic Diagnostic_procedure resonance Diagnostic_procedure cholangiopancreatography Diagnostic_procedure ( MRCP Diagnostic_procedure ) showed a mass Sign_symptom in an enlarged Sign_symptom gallbladder Biological_structure and bulky Sign_symptom hepatic Biological_structure lymph Biological_structure nodes Biological_structure surrounding the hepatic Biological_structure hilum Biological_structure (Fig.1a, ​b).
There were also no apparent lesions Sign_symptom in upper Detailed_description and lower Detailed_description gastrointestinal Diagnostic_procedure endoscopy Diagnostic_procedure .
Endoscopic Diagnostic_procedure ultrasound Diagnostic_procedure - guided Diagnostic_procedure fine Diagnostic_procedure - needle Diagnostic_procedure aspiration Diagnostic_procedure ( EUS Diagnostic_procedure - FNA Diagnostic_procedure ) was performed to obtain tissue from the hilar Biological_structure lymph Biological_structure node Biological_structure .
Immunohistochemical Diagnostic_procedure staining Diagnostic_procedure of the specimen identified diffuse positivity Lab_value for keratin Diagnostic_procedure , CD56 Diagnostic_procedure , and synaptophysin Diagnostic_procedure in the tumor Detailed_description cells Detailed_description , which is consistent with NEC Disease_disorder .
An endoscopic Diagnostic_procedure naso Diagnostic_procedure - gallbladder Diagnostic_procedure drainage Diagnostic_procedure ( ENGBD Diagnostic_procedure ) catheter Detailed_description was placed, and the bile Diagnostic_procedure cytology Diagnostic_procedure revealed class Sign_symptom V Sign_symptom malignant Sign_symptom cells Sign_symptom .
Therefore, positron Diagnostic_procedure emission Diagnostic_procedure tomography Diagnostic_procedure / computed Diagnostic_procedure tomography Diagnostic_procedure ( PET Diagnostic_procedure / CT Diagnostic_procedure ) examination was performed to evaluate other primary Detailed_description or metastatic Detailed_description lesions Sign_symptom .
It revealed that no other accumulated lesions Sign_symptom were identified, and the accumulation Lab_value of 18F Diagnostic_procedure fluorodeoxyglucose Diagnostic_procedure ( FDG Diagnostic_procedure ) was in the gallbladder Biological_structure ( SUVmax Diagnostic_procedure 7.8 Lab_value ) and lymph Biological_structure nodes Biological_structure ( SUVmax Diagnostic_procedure 13.4 Lab_value ) (Fig.1c, d).
On the basis of these findings, the most likely diagnosis was a gallbladder Biological_structure NEC Disease_disorder that was confined to the regional hepatic Biological_structure hilar Biological_structure lymph Biological_structure nodes Biological_structure metastasis Disease_disorder .
Finally, we decided to perform surgical Therapeutic_procedure resection Therapeutic_procedure prior to chemotherapy Medication because of concerns about complications developing from mechanical Detailed_description obstruction Disease_disorder of the hepatic Biological_structure hilum Biological_structure by the enlarged Sign_symptom lymph Biological_structure node Biological_structure .
She underwent cholecystectomy Therapeutic_procedure , hepatic Biological_structure hilar Biological_structure lymphadenectomy Therapeutic_procedure , extrahepatic Biological_structure biliary Biological_structure duct Biological_structure resection Therapeutic_procedure , and hepaticojejunostomy Therapeutic_procedure .
The bulky Sign_symptom lymph Biological_structure nodes Biological_structure were totally resected Therapeutic_procedure as “ en Detailed_description bloc Detailed_description ”.
There were no apparent residual lesions Sign_symptom surgically.
The postoperative Diagnostic_procedure course Diagnostic_procedure was uneventful Lab_value and she was discharged Clinical_event on the tenth Date day Date after Date surgery Therapeutic_procedure .
Macroscopically Diagnostic_procedure , the tumor Sign_symptom was 58 Area   × Area   42 Area mm Area in size and was located in the fundus Biological_structure , which contained a yellowish Color gallstone Sign_symptom (Fig.2a).
A portion of the hepatic Biological_structure hilar Biological_structure lymph Biological_structure nodes Biological_structure ( 71 Area   × Area   37 Area mm Area ) was also excised Therapeutic_procedure separately (Fig.2b).
Microscopic Diagnostic_procedure examination Diagnostic_procedure of the gallbladder Biological_structure revealed a moderate Detailed_description to Detailed_description well Detailed_description differentiated Detailed_description tubular Detailed_description adenocarcinoma Disease_disorder infiltrating from the mucosa Biological_structure to the muscular Biological_structure layer Biological_structure , but not Biological_structure the Biological_structure serosal Biological_structure surface Biological_structure , without any NEC Disease_disorder components (Fig.2c, ​d).
The tumor Sign_symptom cells in the gallbladder Biological_structure are slightly Lab_value positive Lab_value for synaptophysin Diagnostic_procedure and CD56 Diagnostic_procedure , but negative Lab_value for chromogranin Diagnostic_procedure A Diagnostic_procedure (Fig.2e–g).
The resection Diagnostic_procedure margin Diagnostic_procedure from the liver Biological_structure bed Biological_structure was negative for tumor Sign_symptom cells.
The epithelium Biological_structure around the carcinoma Disease_disorder showed intestinal Biological_structure metaplasia Sign_symptom with the goblet Biological_structure cells Biological_structure (Fig.4a), which area was stained by alcian Diagnostic_procedure blue Diagnostic_procedure (Fig.4b).
On the other hand, the hepatic Biological_structure hilar Biological_structure lymph Biological_structure nodes Biological_structure were composed of small Detailed_description round Shape tumor Sign_symptom cells with hyperchromatic Lab_value nuclei Diagnostic_procedure and scant Lab_value cytoplasm Diagnostic_procedure (Fig.3a).
Some Detailed_description of the tumor Sign_symptom cells were large Qualitative_concept and had vesicular Texture nuclei Diagnostic_procedure .
The tumor Sign_symptom cells were arranged in sheets Detailed_description , cords Detailed_description , or in a trabecular Detailed_description or rosette Detailed_description fashion and were interspersed with focal Detailed_description necrosis Sign_symptom .
They were immunohistochemically Diagnostic_procedure positive Lab_value for CD56 Diagnostic_procedure , synaptophysin Diagnostic_procedure , and chromogranin Diagnostic_procedure A Diagnostic_procedure (Fig.3b–3d).
The mitotic Diagnostic_procedure count Diagnostic_procedure was 24 Lab_value per Lab_value 10 Lab_value high Lab_value - power Lab_value microscopic Lab_value fields Lab_value , and the Ki-67 proliferation Diagnostic_procedure index Diagnostic_procedure was 70–80%, consistent with NEC Disease_disorder .
The surgical Biological_structure dissection Biological_structure margin Biological_structure of the hepatic Biological_structure lymph Biological_structure nodes Biological_structure was microscopically Detailed_description cauterized Therapeutic_procedure within the tumor Sign_symptom cells.
There was no invasion Sign_symptom to the extrahepatic Biological_structure biliary Biological_structure duct Biological_structure .
As the result of thorough pathological Diagnostic_procedure re Diagnostic_procedure - evaluation Diagnostic_procedure by total Diagnostic_procedure segmentation Diagnostic_procedure , a negligible Severity area Severity of adenocarcinoma Disease_disorder was detected in the lymph Biological_structure nodes Biological_structure (Fig.3e, ​f).
The adenocarcinoma Disease_disorder component and the intestinal Biological_structure metaplastic Biological_structure epithelium Biological_structure in the gallbladder Biological_structure were both positive Lab_value for CDX2 Diagnostic_procedure (Fig.4a), but the neuroendocrine component in hilar Biological_structure lymph Biological_structure nodes Biological_structure was negative Lab_value for CDX2 Diagnostic_procedure (Fig.4b).
Postoperatively, the patient received three Dosage cycles Dosage of carboplatin Medication ( area Dosage under Dosage the Dosage curve Dosage of Dosage 5 Dosage on Dosage day Dosage 1 Dosage repeated Dosage every Dosage 21 Dosage days Dosage ) and etoposide Medication ( 80 Dosage mg/m2 Dosage on Dosage days Dosage 1 Dosage through Dosage 3 Dosage repeated Dosage every Dosage 21 Dosage days Dosage ).
During Date the Date first Date course Date , grade Severity 4 Severity neutropenia Sign_symptom occurred and it was managed with prophylactic Detailed_description fluoroquinolones Medication .
After Date 4 Date months Date , multiple Detailed_description recurrences Sign_symptom in the para Biological_structure - aortic Biological_structure lymph Biological_structure nodes Biological_structure were detected, which was pathologically demonstrated via EUS Diagnostic_procedure - FNA Diagnostic_procedure to be NEC Disease_disorder .
The patient underwent second Detailed_description - line Detailed_description chemotherapy Medication with amrubicin Medication ( 24 Dosage mg/m2 Dosage on Dosage days Dosage 1 Dosage through Dosage 3 Dosage repeated Dosage every Dosage 21 Dosage days Dosage ).
Grade Severity 4 Severity neutropenia Sign_symptom and anemia Sign_symptom developed during the courses, and she needed to receive pegylated Detailed_description granulocyte Medication colony Medication - stimulating Medication factor Medication and red Detailed_description blood Detailed_description cell Detailed_description transfusion Therapeutic_procedure .
However, she died Activity of progressive Disease_disorder disease Disease_disorder 8 Date months Date after Date surgery.