Published: 2019-10-24

Signet ring cell cholangiocarcinoma in a patient previously operated for cholecystectomy: is there any connecting link?

Priya Gupta, Veer Karuna, Preeti Singh, Nidhi Verma


Cholangiocarcinoma are malefic tumours of bile duct. Signet ring cell carcinoma (SRCC) is rare entity. Several risk factors have been attributed to its ethology, the main overriding link between two being chronic inflammation of the bile system. Cholecystectomy has also been a proposed risk factor. This study was undertaken in Department of Pathology at LLRM Medical College, Meerut. A 49 years old female, operated for cholecystectomy 1.5 year back in same hospital, now presented with chief complains of jaundice and abdominal discomfort. The blood chemistry revealed increased total bilirubin (13.7 mg/dl), Alkaline phosphatase (877.6 IU/L), Carbohydrate Antigen (CA) 199(184 U/ml) and Carcinoembryonic antigen (CEA) (14.5 ng/ml). Computed Tomography (CT) showed a stricture in mid Common bile duct (CBD). Excision of stricture was done using retrocholic hepatico-jejunostomy. Tissue was submitted for histopathology. Histopathological assessment showed SRCC. The patient failed to turn up for further management but returned back after a span of time presenting with gross ascites and pallor ultimately leading to death within 12 weeks of diagnosis. This was the first case of SRCC to arise in a patient who had a previous history of cholecystectomy. Whether there is some connecting link between the two is still not clear. Further studies are warranted in this direction to establish cholecystectomy as an etiological factor for cholangiocarcinoma.


Cholecystectomy, Connecting link, Malefic, Mid common bile duct, Signet ring cell cholangiocarcinoma, Stricture

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Gores GJ. Cholangiocarcinoma: Current concepts and insights. Hepatol. 2003;37:961-9.

Blechacz B. Cholangiocarcinoma: Current Knowledge and New Developments. Gut Liver. 2017;11:13-26.

Kita E, Tsujimoto A, Nakamura K, Sudoa K, Haraa T, Kainumab O, et al. Signet ring cell carcinoma of the extra hepatic bile duct diagnosed by preoperative biopsy: a case report. Case Rep Gastroenterol. 2014;8:353-7.

Lee EY, Kim C, Kim MJ, Park JY, Park SW, Song SY, et al. Signet ring cell carcinoma of the extra hepatic bile duct. Gut and Liver. 2010;4:402-6.

Welzel TM, Graubard BI, EI- Serang HB, Shaib YH, Hsing AW, Davila JA, et al. Risk factors for intrahepatic and extra hepatic cholangiocarcinoma in the United States: a population-based case-control study. Clin Gastroenterol Hepatol. 2007;5:1221-8.

Lee BS, Park EC, Park SW, Nam CM, Roh J. Hepatitis B virus infection, diabetes mellitus, and their synergism for cholangiocarcinoma development: a case-control study in Korea. World J Gastroenterol. 2015;21:502-10.

Xiong J, Wang Y, Huang H, Bian J, Wang A, Long J, et al. Systematic review and meta-analysis: cholecystectomy and the risk of cholangiocarcinoma. Oncotarget. 2017;8:59648-57.

Curley SA. Bile Duct Cancer. In: Kufe DW, Pollock RE, Weichselbaum RR, et al, eds. Holland-Frei Cancer Medicine. 6th ed. Hamilton (ON): BC Decker; 2003. Chapter 102 available at: Accessed 2003.

Kirstein MM, Vogel A. Epidemiology and risk factors of cholangiocarcinoma. Visc Med. 2016;32:395-400.

Razumilava N, Gores GJ. Cholangiocarcinoma. Lancet. 2014;383:2168-79.

Ogata S, Kimura A, Hatsuse K, Yamamoto J, Shimazaki H, et al. Poorly differentiated adenocarcinoma with signet-ring cell carcinoma of the extra hepatic bile duct in a 42-year-old Japanese female: a case report. Acta Med Okayama. 2010;64:63-5.

Rizvi S, Khan SA, Hallemeier CL, Kelley RK, Gores GJ. Cholangiocarcinoma - evolving concepts and therapeutic strategies. Nat Rev Clin Oncol. 2017;15:95-111.

Somer L, Andrejić B, Milošević P. Origin and pathological characteristics of Klatskin tumour: a case report and literature review. Pol J Pathol. 2012;63:65-70.

Kwon HJ, Yoon GS, Kwon YC, Kim SG, Jeong JY. Signet-Ring Cell Carcinoma of the Distal Common Bile Duct: Report of a Case. Kore J Pathol. 2014;48:315-18.

Mizukami Y, Ohta H, Arisato S, Nakano Y, Murakami M, Orii Y, et al. Case report: Mucinous cholangiocarcinoma featuring a multicystic appearance and periportal collar in imaging. J Gastroenterol Hepatol. 1999;14:1223-6.

Hiraki M, Yakushiji H, Hashiguchil K, Harada S, Okada K, Goto Y, et al. Signet ring cell carcinoma of the lower bile duct with rapid growth: report of a case. Hepatogastroenterol. 2007;54:1922-4.

Matsumoto T, Inoue S, Masuo K, Okamoto Y, Fukushima M, Wada M, et al. Signet ring cell carcinoma of the bile duct: a case report. Nihon Shokakib Gakkai Zasshi. 2011;108:2042-9.

Hua R, Zhang JF, Liu W, Huo YM, Sun YW. Signet-ring cell carcinoma coexisting with adenocarcinoma arising in a choledochal cyst: report of a case. Surg tod. 2015;45:1049-52.

Chedid MF, Lucas ET, Cerski CT, Lopes MF, Amaral OB, Chedid AD. Signet-ring cell hilar cholangiocarcinoma: case report. ABCD. Arquiv Brasileir de Cirurgia Digestiva. 2015;28:148-19.

Shechter Y, Dagan A, BenHaim M, Bar Z, Brazowski E, Shimon S, et al. An unusual case of signet ring cell cholangiocarcinoma - Case Report and a Review of Literature. Adv Res Gastroentero Hepatol. 2017;6(1):555676.

Welsh JL, Jaber O, Ivanovic M, Johlin FC, El Abiad RG, Clamon GH, et al. Rapidly Progressing Primary Extrahepatic Bile Duct Signet-Ring Cell Carcinoma in a Caucasian Woman. J Gastrointest Canc. 2018;49(1):63-6.

Mosconi S, Beretta GD, Labianca R, Zampino MG, Gatta G, Heinemann V. Cholangiocarcinoma. Critic Revie Oncology/Hematol. 2009;69(3):259-70.

Goldstein D, Lemech C, Valle J. New molecular and immunotherapeutic approaches in biliary Cancer. ESMO open. 2017;2(1):e000152.

Petrick JL, Yang B, Altekruse SF, Van Dyke AL, Koshiol J, Graubard BI, et al. Risk factors for intrahepatic and extrahepatic cholangiocarcinoma in the United States: A population-based study in SEER-Medicare. PloS One. 2017;12(10):e0186643.

Giovannucci E, Colditz GA, Stampfer MJ. A meta-analysis of cholecystectomy and risk of colorectal cancer. Gastroenterol. 1993;105:130-41.

Lin G, Zeng Z, Wang X, Wu Z, Wang J, Wang C, et al. Cholecystectomy and risk of pancreatic cancer: a meta-analysis of observational studies. Cancer Caus Contr. 2012;23:59-67.

Liu Y, He Y, Li T, Xie L, Wang J, Qin X, et al. Risk of primary liver cancer associated with gallstones and cholecystectomy: a meta-analysis. PLoS One. 2014;9:e109733.

Fan Y, Hu J, Feng B, Wang W, Yao G, Zhai J, et al. Increased Risk of Pancreatic Cancer Related to Gallstones and Cholecystectomy: A System Revi Meta-Analy. Pancreas. 2016;45:503-9.

Nogueira L, Freedman ND, Engels EA, Warren JL, Castro F, Koshiol J. Gallstones, cholecystectomy, and risk of digestive system cancers. Am J epidemiol. 2014;179(6):731-9.

Kang SH, Kim YH, Roh YH, Kim KW, Choi CJ, Kim MC, et al. Gallstone, cholecystectomy and risk of gastric cancer.Ann Hepatobiliary Pancreat Surgy. 2017;21:131-7.

Ekbom A, Yuen J, Adami HO, Hsieh CC, Trichopoulos D, Lon SJ, et al. Risk of extrahepatic bileduct cancer after cholecystectomy. The Lancet. 1993 Nov 20;342(8882):1262-5.

Tao LY, He XD, Qu Q, Cai L, Liu W, Zhou L, et al. Risk factors for intrahepatic and extrahepatic cholangiocarcinoma: a case control study in China. Liver Int. 2010;30:215-21.

Wikipedia contributors. Cholangiocarcinoma. Wikipedia, The Free Encyclopedia, 2019,12:56 UTC. Available at: Accessed 13 March 2019.