Gallbladder Polyp of 5 cm found to have Carcinoma In Situ on Frozen Section Managed by Open Cholecystectomy Alone: A Case report

Gallbladder Polyp of 5 cm found to have Carcinoma In Situ on Frozen Section Managed by Open Cholecystectomy Alone: A Case report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Gallbladder Polyp of 5 cm found to have Carcinoma In Situ on Frozen Section Managed by Open Cholecystectomy Alone: A Case report Anthony Kanaan, Hadi Farhat, Bassem Sawan, George Khalifeh This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8354258/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Gallbladder polyps larger than 1 cm are considered to carry malignant potential and are commonly managed surgically. Lesions exceeding 2 cm are often presumed to represent invasive carcinoma, frequently prompting consideration of extended hepatic resection. However, carcinoma in situ confined to the mucosa within large gallbladder polyps is rarely reported. This case highlights a rare presentation of a giant gallbladder polyp harboring carcinoma in situ and emphasizes the role of intraoperative pathological assessment in guiding appropriate surgical management. Case presentation: A 50-year-old woman presented with postprandial right upper quadrant discomfort of several weeks’ duration. Abdominal ultrasound revealed a large gallbladder polyp, and subsequent magnetic resonance imaging demonstrated a 5 cm sessile polypoid lesion arising from the gallbladder fundus, without evidence of hepatic invasion or lymphadenopathy. Given the size and morphology of the lesion, an open cholecystectomy with intraoperative frozen section analysis was performed. Frozen section examination demonstrated carcinoma in situ confined to the mucosa, with no evidence of stromal or muscular invasion. Based on these findings, no additional hepatic resection or lymphadenectomy was undertaken. Final histopathological analysis confirmed a 5 cm tubulovillous adenoma with focal high-grade dysplasia consistent with carcinoma in situ, limited to the mucosa, with negative surgical margins. The patient had an uneventful postoperative recovery and was discharged in good condition. Conclusions: This case demonstrates that even large gallbladder polyps may harbor pre-invasive disease confined to the mucosa. Intraoperative frozen section analysis plays a critical role in determining the extent of surgery and may prevent unnecessary radical resections. Simple cholecystectomy alone can be curative for gallbladder carcinoma in situ when accurately diagnosed intraoperatively, reinforcing the importance of tailored surgical decision-making in the management of large gallbladder polyps. Gallbladder polyp Carcinoma in situ Frozen section Cholecystectomy Gallbladder neoplasms High-grade dysplasia Tubulovillous adenoma Surgical management Case report Figures Figure 1 Figure 2 Background Gallbladder polyps are identified in approximately 4–7% of the general population and are most commonly benign, particularly when measuring less than 10 mm in diameter ( 1 – 3 ). Increasing polyp size, however, is strongly associated with malignant potential, and current recommendations generally advocate cholecystectomy for polyps measuring 10 mm or larger ( 4 , 5 ). Lesions exceeding 20 mm are frequently presumed to represent invasive gallbladder carcinoma, often prompting consideration of extended hepatic resection and lymphadenectomy ( 7 – 10 ). Carcinoma in situ of the gallbladder represents a pre-invasive epithelial neoplasm confined to the mucosal layer and is most often diagnosed incidentally on final histopathological examination following cholecystectomy ( 6 ). Reports of carcinoma in situ arising within large or giant gallbladder polyps are exceedingly rare, emphasizing the unusual nature of this presentation. Furthermore, the optimal intraoperative management of large gallbladder polyps remains challenging, particularly with regard to determining the appropriate extent of surgical resection. Intraoperative frozen section analysis may play a critical role in guiding surgical decision-making by providing immediate pathological assessment and helping avoid unnecessary radical resections in early-stage disease confined to the mucosa ( 11 – 13 ). According to current guidelines and contemporary surgical literature, gallbladder carcinoma in situ and mucosa-confined tumors can be effectively treated with simple cholecystectomy alone, as the risk of hepatic or lymphatic spread is negligible ( 11 , 14 , 15 ). The present case describes a patient with a giant (5 cm) gallbladder polyp found to harbor carcinoma in situ on intraoperative frozen section and aims to highlight the importance of tailored surgical management based on real-time pathological evaluation. Case Presentation A 50-year-old woman with no significant past medical or surgical history presented with postprandial right upper quadrant discomfort of several weeks’ duration. She denied fever, weight loss, jaundice, nausea, vomiting, or changes in bowel habits. There was no personal or family history of hepatobiliary malignancy. On physical examination, the patient was hemodynamically stable. Abdominal examination was unremarkable, with no palpable masses, tenderness, or signs of peritonitis. Routine laboratory investigations, including complete blood count, liver function tests, and tumor markers (carbohydrate antigen 19 − 9 and carcinoembryonic antigen), were within normal limits. Abdominal ultrasonography revealed a large echogenic lesion measuring approximately 5 cm arising from the gallbladder wall, without acoustic shadowing or posterior reverberation artifacts. No gallstones were initially identified. Subsequent magnetic resonance imaging of the abdomen demonstrated a 5.2 × 2.8 × 3.7 cm sessile, exophytic polypoid lesion originating from the gallbladder fundus, along with multiple gallbladder calculi measuring up to 1.2 cm. There was no radiological evidence of hepatic invasion, biliary obstruction, or regional lymphadenopathy. Given the large size and sessile morphology of the lesion, an open cholecystectomy with intraoperative frozen section analysis was performed. Careful dissection of the gallbladder from the liver bed was undertaken to ensure complete excision without rupture or intraperitoneal spillage, and the operative field was protected using an Alexis wound retractor (Fig. 1). The gallbladder was removed intact and immediately submitted for intraoperative pathological evaluation. Figure 1 Resected gallbladder showing tumor with surrounding cholelithiasis Frozen section analysis revealed carcinoma in situ, characterized by atypical epithelial proliferation confined to the mucosa, without evidence of stromal or muscular invasion. Based on these findings, no additional hepatic resection or lymphadenectomy was performed. Final histopathological examination confirmed a 5 cm tubulovillous adenoma with focal areas of high-grade dysplasia consistent with carcinoma in situ (pTis), confined to the mucosa. There was no evidence of stromal, muscular, lymphovascular, or perineural invasion, and all surgical margins were negative for malignancy (Fig. 2 ). a: Blue arrow: Tightly packed, bland looking pyloric type glands, with slight nuclear overlapping and increased N/C ratio, and areas of high grade dysplasia (complex architecture, prominent nucleoli and loss of nuclear polarity). There is minimal or no intervening stroma, Yellow arrow: Areas of cholesterolosis; b: Gallbladder Wall: Edge of lesion with cystically dilated glands The postoperative course was uneventful, and the patient was discharged on postoperative day 2 in good general condition. Follow-up was planned with clinical assessment, liver function tests, and abdominal ultrasonography at 6 months, with no evidence of recurrence at the time of last follow-up. Discussion This case describes a rare presentation of a giant (5 cm) gallbladder polyp harboring carcinoma in situ without evidence of invasion. Gallbladder polyps larger than 20 mm are generally considered to carry a high risk of malignancy and are frequently presumed to represent invasive carcinoma, often prompting recommendations for radical surgical approaches ( 7 – 10 ). However, reports of carcinoma in situ arising within such large polyps remain exceedingly uncommon, underscoring the unusual nature of this case. Carcinoma in situ of the gallbladder represents a pre-invasive epithelial neoplasm confined to the mucosal layer and is most often diagnosed incidentally on final histopathological examination following cholecystectomy ( 6 ). The intraoperative diagnosis of carcinoma in situ using frozen section, as demonstrated in this case, provides a unique opportunity to tailor the extent of surgical resection in real time. This approach allows surgeons to avoid unnecessary hepatic resection or lymphadenectomy when there is no evidence of stromal or muscular invasion. Several studies and contemporary guidelines support simple cholecystectomy as an adequate and curative treatment for gallbladder carcinoma in situ and mucosa-confined tumors, given the negligible risk of hepatic or lymphatic spread at this stage ( 11 – 15 ). More extensive surgical procedures are associated with increased morbidity and should be reserved for invasive disease. The present case reinforces these recommendations by demonstrating excellent outcomes following limited surgical intervention, despite the unusually large size of the lesion. Importantly, this report highlights the critical role of intraoperative frozen section analysis in the management of large gallbladder polyps. Reliance on polyp size alone may lead to overtreatment, whereas real-time pathological assessment enables individualized surgical decision-making. This is particularly relevant in cases where preoperative imaging cannot reliably distinguish between invasive carcinoma and high-grade dysplastic or pre-invasive lesions. Conclusion This case demonstrates that even giant gallbladder polyps may harbor carcinoma in situ confined to the mucosa and can be successfully treated with simple cholecystectomy alone. Intraoperative frozen section analysis plays a pivotal role in guiding the extent of surgery and preventing unnecessary radical resections. These findings reinforce current evidence that tailored surgical management based on real-time pathological assessment is both safe and effective for early-stage gallbladder neoplasia, regardless of lesion size. Abbreviations CIS Carcinoma in situ MRI Magnetic resonance imaging CA 19 − 9 Carbohydrate antigen 19 − 9 CEA Carcinoembryonic antigen pTis Pathological tumor in situ Declarations Ethics approval and consent to participate Ethical approval was obtained from the Batroun Hospital ethical committee. Written informed consent was obtained from the patient for participation in this case report. Consent for publication Written informed consent was obtained from the patient for publication of this case report and any accompanying images. Competing interests The authors declare that they have no competing interests. Funding The authors received no specific funding for this work. Author Contribution A.K. ,H.F. and G.K. were involved in patient management and surgical decision-making. H.F. drafted the initial manuscript. B.S. contributed to the histopathological analysis and interpretation of findings. G.K. contributed to manuscript revision and critical intellectual content. All authors read and approved the final manuscript. Acknowledgement The authors would like to thank the operating room and pathology department staff for their contributions to patient care and diagnostic evaluation. Data Availability All data generated or analyzed during this study are included in this published article. References van Dooren M, de Reuver PR. Gallbladder polyps and the challenge of distinguishing benign lesions from cancer. United Eur Gastroenterol J. 2022;10(7):625. Szpakowski JL, Tucker LY. Outcomes of gallbladder polyps and their association with gallbladder cancer in a 20-year cohort. JAMA Netw Open. 2020;3(5):e205143. Pavlidis ET, Galanis IN, Pavlidis TE. Contemporary diagnosis and management of gallbladder polyps. Gastroenterol Funct Med. 2023;1. Sun Y, Yang Z, Lan X, Tan H. Neoplastic polyps in gallbladder: a retrospective study to determine risk factors and treatment strategy for gallbladder polyps. Hepatobiliary Surg Nutr. 2019;8(3):219. eMedicine. Gallbladder tumors: practice essentials, anatomy, pathophysiology [Internet]. Updated 2023 Jun 15. Available from: https://emedicine.medscape.com/ Kasle D, Rahnemai-Azar AA, Bibi S, Gaduputi V, Gilchrist BF, Farkas DT. Carcinoma in situ in a 7 mm gallbladder polyp: Time to change current practice? World J Gastrointest Endoscopy. 2015;7(9):912. Abi-Rached B, Neugut AI. Diagnostic and management issues in gallbladder carcinoma. Oncol (Williston Park NY). 1995;9(1):19–24. Inui K, Yoshino J, Miyoshi H. Diagnosis of gallbladder tumors. Intern Med. 2011;50(11):1133–6. Wiles R, Thoeni RF, Barbu ST, Vashist YK, Rafaelsen SR, Dewhurst C, Arvanitakis M, Lahaye M, Soltes M, Perinel J, Roberts SA. Management and follow-up of gallbladder polyps: joint guidelines between the European Society of gastrointestinal and abdominal radiology (ESGAR), European association for endoscopic surgery and other interventional techniques (EAES), International society of digestive surgery–European Federation (EFISDS) and European society of gastrointestinal endoscopy (ESGE). Eur Radiol. 2017;27(9):3856–66. Choi J, Kim JS, Lee JS. Recent Trends in Surgical Strategies of Early-Stage Gallbladder Cancer: A Narrative Review. J Clin Med. 2025;14(15):5483. Newman N, Gasalberti DP, Brachytherapy. Gallbladder Cancer. InStatPearls [Internet] 2025 Feb 15. StatPearls Publishing. Shao J, Lu HC, Wu LQ, Lei J, Yuan RF, Shao JH. Simple cholecystectomy is an adequate treatment for grade I T1bN0M0 gallbladder carcinoma: Evidence from 528 patients. World J Gastroenterol. 2022;28(31):4431. Hundal R, Shaffer EA. Gallbladder cancer: epidemiology and outcome. Clin Epidemiol 2014 Mar 7:99–109. Lee SE, Kim KS, Kim WB, Kim IG, Nah YW, Ryu DH, Park JS, Yoon MH, Cho JY, Hong TH, Hwang DW. Practical guidelines for the surgical treatment of gallbladder cancer. J Korean Med Sci. 2014;29(10):1333–40. Board PA. Gallbladder Cancer Treatment (PDQ®). InPDQ Cancer Information Summaries [Internet] 2025 Feb 12. National Cancer Institute (US). Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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10:25:08","extension":"html","order_by":14,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":45130,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8354258/v1/80e77d7a4bfcf53387c1e166.html"},{"id":100036626,"identity":"141580e6-622d-4ef4-aa9f-eb83757f215e","added_by":"auto","created_at":"2026-01-12 10:25:09","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":224691,"visible":true,"origin":"","legend":"\u003cp\u003eResected gallbladder showing tumor with surrounding cholelithiasis\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8354258/v1/b8ceb03202c9bb7166b7f4b6.jpg"},{"id":100036637,"identity":"3ba7a2d6-d188-409e-b497-dc70e15dffe4","added_by":"auto","created_at":"2026-01-12 10:25:10","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":288134,"visible":true,"origin":"","legend":"\u003cp\u003eHistopathologic Findings.\u003c/p\u003e\n\u003cp\u003ea: Blue arrow: Tightly packed, bland looking pyloric type glands, with slight nuclear overlapping and increased N/C ratio, and areas of high grade dysplasia (complex architecture, prominent nucleoli and loss of nuclear polarity). There is minimal or no intervening stroma, Yellow arrow: Areas of cholesterolosis; b: Gallbladder Wall: Edge of lesion with cystically dilated glands\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8354258/v1/f43e29f2278fe4041687e85f.jpg"},{"id":104888037,"identity":"d28f26f3-a105-4cae-b6dc-b061aa6cb60b","added_by":"auto","created_at":"2026-03-18 10:13:12","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":881479,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8354258/v1/5e41b7d3-4036-41be-980c-5d7328c60f19.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Gallbladder Polyp of 5 cm found to have Carcinoma In Situ on Frozen Section Managed by Open Cholecystectomy Alone: A Case report","fulltext":[{"header":"Background","content":"\u003cp\u003eGallbladder polyps are identified in approximately 4\u0026ndash;7% of the general population and are most commonly benign, particularly when measuring less than 10 mm in diameter (\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Increasing polyp size, however, is strongly associated with malignant potential, and current recommendations generally advocate cholecystectomy for polyps measuring 10 mm or larger (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Lesions exceeding 20 mm are frequently presumed to represent invasive gallbladder carcinoma, often prompting consideration of extended hepatic resection and lymphadenectomy (\u003cspan additionalcitationids=\"CR8 CR9\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eCarcinoma in situ of the gallbladder represents a pre-invasive epithelial neoplasm confined to the mucosal layer and is most often diagnosed incidentally on final histopathological examination following cholecystectomy (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Reports of carcinoma in situ arising within large or giant gallbladder polyps are exceedingly rare, emphasizing the unusual nature of this presentation. Furthermore, the optimal intraoperative management of large gallbladder polyps remains challenging, particularly with regard to determining the appropriate extent of surgical resection.\u003c/p\u003e \u003cp\u003eIntraoperative frozen section analysis may play a critical role in guiding surgical decision-making by providing immediate pathological assessment and helping avoid unnecessary radical resections in early-stage disease confined to the mucosa (\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). According to current guidelines and contemporary surgical literature, gallbladder carcinoma in situ and mucosa-confined tumors can be effectively treated with simple cholecystectomy alone, as the risk of hepatic or lymphatic spread is negligible (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). The present case describes a patient with a giant (5 cm) gallbladder polyp found to harbor carcinoma in situ on intraoperative frozen section and aims to highlight the importance of tailored surgical management based on real-time pathological evaluation.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eA 50-year-old woman with no significant past medical or surgical history presented with postprandial right upper quadrant discomfort of several weeks\u0026rsquo; duration. She denied fever, weight loss, jaundice, nausea, vomiting, or changes in bowel habits. There was no personal or family history of hepatobiliary malignancy.\u003c/p\u003e \u003cp\u003eOn physical examination, the patient was hemodynamically stable. Abdominal examination was unremarkable, with no palpable masses, tenderness, or signs of peritonitis.\u003c/p\u003e \u003cp\u003eRoutine laboratory investigations, including complete blood count, liver function tests, and tumor markers (carbohydrate antigen 19\u0026thinsp;\u0026minus;\u0026thinsp;9 and carcinoembryonic antigen), were within normal limits.\u003c/p\u003e \u003cp\u003eAbdominal ultrasonography revealed a large echogenic lesion measuring approximately 5 cm arising from the gallbladder wall, without acoustic shadowing or posterior reverberation artifacts. No gallstones were initially identified. Subsequent magnetic resonance imaging of the abdomen demonstrated a 5.2 \u0026times; 2.8 \u0026times; 3.7 cm sessile, exophytic polypoid lesion originating from the gallbladder fundus, along with multiple gallbladder calculi measuring up to 1.2 cm. There was no radiological evidence of hepatic invasion, biliary obstruction, or regional lymphadenopathy.\u003c/p\u003e \u003cp\u003eGiven the large size and sessile morphology of the lesion, an open cholecystectomy with intraoperative frozen section analysis was performed. Careful dissection of the gallbladder from the liver bed was undertaken to ensure complete excision without rupture or intraperitoneal spillage, and the operative field was protected using an Alexis wound retractor (Fig.\u0026nbsp;1). The gallbladder was removed intact and immediately submitted for intraoperative pathological evaluation.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eFigure 1\u003c/strong\u003e \u003cp\u003eResected gallbladder showing tumor with surrounding cholelithiasis\u003c/p\u003e \u003c/p\u003e \u003cp\u003eFrozen section analysis revealed carcinoma in situ, characterized by atypical epithelial proliferation confined to the mucosa, without evidence of stromal or muscular invasion. Based on these findings, no additional hepatic resection or lymphadenectomy was performed.\u003c/p\u003e \u003cp\u003eFinal histopathological examination confirmed a 5 cm tubulovillous adenoma with focal areas of high-grade dysplasia consistent with carcinoma in situ (pTis), confined to the mucosa. There was no evidence of stromal, muscular, lymphovascular, or perineural invasion, and all surgical margins were negative for malignancy (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003ea: Blue arrow: Tightly packed, bland looking pyloric type glands, with slight nuclear overlapping and increased N/C ratio, and areas of high grade dysplasia (complex architecture, prominent nucleoli and loss of nuclear polarity). There is minimal or no intervening stroma, Yellow arrow: Areas of cholesterolosis; b: Gallbladder Wall: Edge of lesion with cystically dilated glands\u003c/p\u003e \u003cp\u003eThe postoperative course was uneventful, and the patient was discharged on postoperative day 2 in good general condition. Follow-up was planned with clinical assessment, liver function tests, and abdominal ultrasonography at 6 months, with no evidence of recurrence at the time of last follow-up.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis case describes a rare presentation of a giant (5 cm) gallbladder polyp harboring carcinoma in situ without evidence of invasion. Gallbladder polyps larger than 20 mm are generally considered to carry a high risk of malignancy and are frequently presumed to represent invasive carcinoma, often prompting recommendations for radical surgical approaches (\u003cspan additionalcitationids=\"CR8 CR9\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). However, reports of carcinoma in situ arising within such large polyps remain exceedingly uncommon, underscoring the unusual nature of this case.\u003c/p\u003e \u003cp\u003eCarcinoma in situ of the gallbladder represents a pre-invasive epithelial neoplasm confined to the mucosal layer and is most often diagnosed incidentally on final histopathological examination following cholecystectomy (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). The intraoperative diagnosis of carcinoma in situ using frozen section, as demonstrated in this case, provides a unique opportunity to tailor the extent of surgical resection in real time. This approach allows surgeons to avoid unnecessary hepatic resection or lymphadenectomy when there is no evidence of stromal or muscular invasion.\u003c/p\u003e \u003cp\u003eSeveral studies and contemporary guidelines support simple cholecystectomy as an adequate and curative treatment for gallbladder carcinoma in situ and mucosa-confined tumors, given the negligible risk of hepatic or lymphatic spread at this stage (\u003cspan additionalcitationids=\"CR12 CR13 CR14\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). More extensive surgical procedures are associated with increased morbidity and should be reserved for invasive disease. The present case reinforces these recommendations by demonstrating excellent outcomes following limited surgical intervention, despite the unusually large size of the lesion.\u003c/p\u003e \u003cp\u003eImportantly, this report highlights the critical role of intraoperative frozen section analysis in the management of large gallbladder polyps. Reliance on polyp size alone may lead to overtreatment, whereas real-time pathological assessment enables individualized surgical decision-making. This is particularly relevant in cases where preoperative imaging cannot reliably distinguish between invasive carcinoma and high-grade dysplastic or pre-invasive lesions.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis case demonstrates that even giant gallbladder polyps may harbor carcinoma in situ confined to the mucosa and can be successfully treated with simple cholecystectomy alone. Intraoperative frozen section analysis plays a pivotal role in guiding the extent of surgery and preventing unnecessary radical resections. These findings reinforce current evidence that tailored surgical management based on real-time pathological assessment is both safe and effective for early-stage gallbladder neoplasia, regardless of lesion size.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCIS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCarcinoma in situ\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMRI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMagnetic resonance imaging\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCA 19\u0026thinsp;\u0026minus;\u0026thinsp;9\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCarbohydrate antigen 19\u0026thinsp;\u0026minus;\u0026thinsp;9\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCEA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCarcinoembryonic antigen\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003epTis\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePathological tumor in situ\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e \u003cp\u003eEthical approval was obtained from the Batroun Hospital ethical committee. Written informed consent was obtained from the patient for participation in this case report.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication\u003c/strong\u003e \u003cp\u003eWritten informed consent was obtained from the patient for publication of this case report and any accompanying images.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eCompeting interests\u003c/h2\u003e \u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThe authors received no specific funding for this work.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eA.K. ,H.F. and G.K. were involved in patient management and surgical decision-making. H.F. drafted the initial manuscript. B.S. contributed to the histopathological analysis and interpretation of findings. G.K. contributed to manuscript revision and critical intellectual content. All authors read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThe authors would like to thank the operating room and pathology department staff for their contributions to patient care and diagnostic evaluation.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eAll data generated or analyzed during this study are included in this published article.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003evan Dooren M, de Reuver PR. Gallbladder polyps and the challenge of distinguishing benign lesions from cancer. United Eur Gastroenterol J. 2022;10(7):625.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSzpakowski JL, Tucker LY. Outcomes of gallbladder polyps and their association with gallbladder cancer in a 20-year cohort. JAMA Netw Open. 2020;3(5):e205143.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePavlidis ET, Galanis IN, Pavlidis TE. Contemporary diagnosis and management of gallbladder polyps. Gastroenterol Funct Med. 2023;1.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSun Y, Yang Z, Lan X, Tan H. Neoplastic polyps in gallbladder: a retrospective study to determine risk factors and treatment strategy for gallbladder polyps. Hepatobiliary Surg Nutr. 2019;8(3):219.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eeMedicine. Gallbladder tumors: practice essentials, anatomy, pathophysiology [Internet]. Updated 2023 Jun 15. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://emedicine.medscape.com/\u003c/span\u003e\u003cspan address=\"https://emedicine.medscape.com/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKasle D, Rahnemai-Azar AA, Bibi S, Gaduputi V, Gilchrist BF, Farkas DT. Carcinoma in situ in a 7 mm gallbladder polyp: Time to change current practice? World J Gastrointest Endoscopy. 2015;7(9):912.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAbi-Rached B, Neugut AI. Diagnostic and management issues in gallbladder carcinoma. Oncol (Williston Park NY). 1995;9(1):19\u0026ndash;24.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eInui K, Yoshino J, Miyoshi H. Diagnosis of gallbladder tumors. Intern Med. 2011;50(11):1133\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWiles R, Thoeni RF, Barbu ST, Vashist YK, Rafaelsen SR, Dewhurst C, Arvanitakis M, Lahaye M, Soltes M, Perinel J, Roberts SA. Management and follow-up of gallbladder polyps: joint guidelines between the European Society of gastrointestinal and abdominal radiology (ESGAR), European association for endoscopic surgery and other interventional techniques (EAES), International society of digestive surgery\u0026ndash;European Federation (EFISDS) and European society of gastrointestinal endoscopy (ESGE). Eur Radiol. 2017;27(9):3856\u0026ndash;66.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChoi J, Kim JS, Lee JS. Recent Trends in Surgical Strategies of Early-Stage Gallbladder Cancer: A Narrative Review. J Clin Med. 2025;14(15):5483.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNewman N, Gasalberti DP, Brachytherapy. Gallbladder Cancer. InStatPearls [Internet] 2025 Feb 15. StatPearls Publishing.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShao J, Lu HC, Wu LQ, Lei J, Yuan RF, Shao JH. Simple cholecystectomy is an adequate treatment for grade I T1bN0M0 gallbladder carcinoma: Evidence from 528 patients. World J Gastroenterol. 2022;28(31):4431.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHundal R, Shaffer EA. Gallbladder cancer: epidemiology and outcome. Clin Epidemiol 2014 Mar 7:99\u0026ndash;109.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLee SE, Kim KS, Kim WB, Kim IG, Nah YW, Ryu DH, Park JS, Yoon MH, Cho JY, Hong TH, Hwang DW. Practical guidelines for the surgical treatment of gallbladder cancer. J Korean Med Sci. 2014;29(10):1333\u0026ndash;40.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBoard PA. Gallbladder Cancer Treatment (PDQ\u0026reg;). InPDQ Cancer Information Summaries [Internet] 2025 Feb 12. National Cancer Institute (US).\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Gallbladder polyp, Carcinoma in situ, Frozen section, Cholecystectomy, Gallbladder neoplasms, High-grade dysplasia, Tubulovillous adenoma, Surgical management, Case report","lastPublishedDoi":"10.21203/rs.3.rs-8354258/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8354258/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e \u003cp\u003eGallbladder polyps larger than 1 cm are considered to carry malignant potential and are commonly managed surgically. Lesions exceeding 2 cm are often presumed to represent invasive carcinoma, frequently prompting consideration of extended hepatic resection. However, carcinoma in situ confined to the mucosa within large gallbladder polyps is rarely reported. This case highlights a rare presentation of a giant gallbladder polyp harboring carcinoma in situ and emphasizes the role of intraoperative pathological assessment in guiding appropriate surgical management.\u003c/p\u003e\u003ch2\u003eCase presentation:\u003c/h2\u003e \u003cp\u003eA 50-year-old woman presented with postprandial right upper quadrant discomfort of several weeks\u0026rsquo; duration. Abdominal ultrasound revealed a large gallbladder polyp, and subsequent magnetic resonance imaging demonstrated a 5 cm sessile polypoid lesion arising from the gallbladder fundus, without evidence of hepatic invasion or lymphadenopathy. Given the size and morphology of the lesion, an open cholecystectomy with intraoperative frozen section analysis was performed. Frozen section examination demonstrated carcinoma in situ confined to the mucosa, with no evidence of stromal or muscular invasion. Based on these findings, no additional hepatic resection or lymphadenectomy was undertaken. Final histopathological analysis confirmed a 5 cm tubulovillous adenoma with focal high-grade dysplasia consistent with carcinoma in situ, limited to the mucosa, with negative surgical margins. The patient had an uneventful postoperative recovery and was discharged in good condition.\u003c/p\u003e\u003ch2\u003eConclusions:\u003c/h2\u003e \u003cp\u003eThis case demonstrates that even large gallbladder polyps may harbor pre-invasive disease confined to the mucosa. Intraoperative frozen section analysis plays a critical role in determining the extent of surgery and may prevent unnecessary radical resections. Simple cholecystectomy alone can be curative for gallbladder carcinoma in situ when accurately diagnosed intraoperatively, reinforcing the importance of tailored surgical decision-making in the management of large gallbladder polyps.\u003c/p\u003e","manuscriptTitle":"Gallbladder Polyp of 5 cm found to have Carcinoma In Situ on Frozen Section Managed by Open Cholecystectomy Alone: A Case report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-12 10:24:57","doi":"10.21203/rs.3.rs-8354258/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"66023a11-019a-442a-b99a-03d7650b3cf9","owner":[],"postedDate":"January 12th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-03-18T10:12:10+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-12 10:24:57","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8354258","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8354258","identity":"rs-8354258","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}