Gallbladder
Background
Normal appearance of gallbladder is a smooth, sac-like organ with sphincter at the neck and glistening serosa. It is filled with green-brown bile and lined with a folded mucosa.1-5
Gallbladders are mostly commonly removed as treatment of chronic cholecystitis with presence of gallstones (cholelithiasis) detected on imaging. Tumours occur infrequently but must be considered in reporting. Primary and secondary carcinomas need to be excluded in final diagnosis.
Biliary tract carcinomas are treated with a range of resections dependent on their location. Intrahepatic cholangiocarcinomas (within the liver) require a segmental resection liver. Perihilar cholangiocarcinoma (near the junction of right and left hepatic ducts) may require resection of the gallbladder, extrahepatic bile ducts and lymph nodes with or without a lobe of the liver. A Kausch-Whipple’s resection (pancreatoduodenectomy) may be required for tumours located close to the Ampulla of Vater. Segmental bile duct resections are possible but less common. Refer to cut-up instructions for liver and pancreas for further information.
Record the patient identifying information and any clinical information supplied together with the specimen description as designated on the container. See overview page for more detail on identification principles.
- No
- Non-routine fixation (not formalin), describe.
- Yes
- Special studies required, describe.
- Ensure samples are taken prior to fixation.
See general information for more detail on specimen handling procedures.
Inspect the specimen and dictate a macroscopic description.
External Inspection
Orientate and identify anatomical features of the specimen: cystic duct, body, fundus and gallbladder bed margin.
Photograph the intact specimen if required.
Describe the following features of the specimen:
Procedure
Record as stated by the clinician.
- Simple cholecystectomy
- Radical cholecystectomy
- Other, describe
Anatomical components included (more than one may apply) and dimensions (mm)
Describe and measure the anatomical components present.
- Gallbladder, in two dimensions
- Cystic duct
- Bile duct, length
- Liver with gallbladder bed (for tumour), in three dimensions -see liver protocols also
- Other organs/tissue present, describe and measure (refer to relevant specimen protocol for more detail)
Specimen integrity
- Intact
- Disrupted
- Number of pieces received
Outer surface
(more than one may apply)
- Unremarkable
- Congested
- Adhesions
- Fibrinopurulent exudate
- Fibrotic
- Nodular
- Perforation
- Tumour present
Dissection
On arrival in laboratory, open the gallbladder longitudinally along the serosal surface, preserving the cystic duct and gallbladder bed margins. This will allow to the specimen to fix adequately before processing.
Internal Inspection
Describe the internal appearance including the following items:
Gallbladder wall
Gall bladder contents (if not bile)
Gallstones (calculi)
- None present
- Present
- Number
- Range of sizes (mm)
Colour of gallstones
- Pigmented green-black
- Yellow cholesterol
- Mixed
Site of gallstones
- In bile
- Embedded in mucosa
- Impacted in neck/cystic duct
Note the presence or absence of gallstones, remove any that are present and wash. Stones may be fragmented during laparoscopic surgery and be gravel-like pieces in the bile. Look for stones embedded in the mucosa and note any impacted in the neck or cystic duct. A stone may be submitted for chemical analysis in some laboratories.
Mucosa
- Velvety
- Roughened
- Eroded/ulcerated
- Fibrotic/trabeculated
Number of tumours
- Number; if more than one tumour, designate and describe each tumour separately
Tumour size (mm)
- Maximum dimension
- Other dimensions
Tumour location
(more than one may apply)
- Cystic duct
- Neck
- Body
- Fundus
Surface involved
- Serosal aspect
- Gallbladder bed/hepatic aspect
- Not assessable
Tumour appearance
- Polyp
- Nodule
- Diffuse thickening
- Ulcer
Distance from margins (mm)
- Distance of tumour to closest margin, specify margin (gallbladder bed margin or cystic duct margin)
Retrieved from resection specimen
- Describe site(s)
- Number retrieved
Separately submitted
- For each container, record specimen number and designation
- Collective size of tissue in three dimensions (mm)
- Number of grossly identified lymph nodes submitted
- Maximum diameter of each (mm)
Serially section the specimen transversely at 3-4mm intervals
Photograph the lesion and the cut surface of the tumour if applicable.
Note photographs taken, diagrams recorded, ink or marks used for identification.
Processing
Dissect the specimen further and submit sections for processing according to the diagram provided.
Sections of cystic duct margin should be identified in a separate cassette or marked with ink. A small cystic duct lymph node is often present and should be submitted for processing if located.
Submit representative transverse sections, at least one section each of:
- Fundus
- Neck or body
- Cystic duct margin
Submit representative transverse sections including serosa of:
- Fundus
- Neck or body
- Cystic duct margin
- Any obvious lesions
Submit transverse sections of entire tumour demonstrating:
- Deepest extent of invasion
- Distance to gallbladder bed and/or cystic duct margin
Submit representative transverse sections from:
- Cystic duct margin
- Non-neoplastic areas of fundus and neck/body
Submit all lymph nodes for processing.
Record details of each cassette.
An illustrated block key similar to those provided below may be useful.
Block allocation keys
|
Cassette id
|
Site
|
No. of pieces
|
|
A
|
Cystic duct margin, neck/body, fundus
|
|
|
Cassette id
|
Site
|
No. of pieces
|
|
A
|
Cystic duct margin
|
|
|
B
|
Tumour, deepest point of invasion
|
|
|
C
|
Tumour with gallbladder bed margin (if applicable)
|
|
|
D
|
Tumour with cystic duct margin (if applicable)
|
|
|
E-F
|
Tumour, representative sections
|
|
|
G
|
Background mucosa
|
|
|
H
|
Lymph nodes
|
|
Acknowledgements
Dr Ian Brown for his contribution in reviewing and editing this protocol.
References
-
-
Lester SC. Manual of Surgical Pathology, Saunders Elsevier, Philadelphia, 2010.
-
Allen DC and Cameron RI (eds). Histopathology Specimens: Clinical, pathological and laboratory aspects. Springer-Verlag, London, 2012.
-
Odze RD. Surgical pathology of the GI tract, liver, biliary tract and pancreas. Goldblum J. Saunders Elsevier, Philadelphia, 2009.
-
Ishak KG, Goodman ZD and Stocker JT. Atlas of Tumour Pathology. Tumours of the Liver and Intrahepatic Bile Ducts. 3rd series, Fascicle 31. Armed Forces Institute of Pathology, Washington, 2001.