Gallbladder Carcinoma

46 year old female with right upper quadrant pain and jaundice. Diagnosis? • Xray of the Week

Figure 1. What are the important findings?

Figure 2

A: Transverse ultrasound of RUQ. Hyperechoic shadowing gallstone within lumen of gallbladder (green arrow) with diffuse irregular wall thickening (red arrows).

B: T1 weighted axial MRI with contrast. Irregularly thickened enhancing gallbladder wall (red arrows).

C: CT Abdomen with contrast, coronal reconstruction. Irregular mass with heterogenous enhancement (red arrows). Gallstone within lumen of gallbladder (green arrow).

D: T1 weighted coronal MRI. Irregularly thickened enhancing gallbladder wall (red arrows). Gallstone in fundus of gallbladder (green arrow).

Discussion:

Gallbladder carcinoma is the most common malignancy of the biliary tract and is associated with a mean survival of 6 months from diagnosis (1). The poor prognosis is due to late diagnosis, often with advanced disease as a result of the nonspecific symptoms with which the cancer may present. Risk factors include, Native American and Southeast Asian descent, female gender, and history of inflammation of the gallbladder, from gallstones, parasitic illness or primary sclerosing cholangitis (1,2).

Figure 3. Porcelain gallbladder in a different patient. Plain radiograph

Endoscopic ultrasonography is the optimal modality for staging (1). However, symptomatic patients may get an initial abdominal radiograph, which can show gas production from invasion into bowel or fistula formation or a heterogenous pattern from tumor necrosis (3). Findings suggestive of malignancy can include porcelain gallbladder, characterized by calcium deposition in the gallbladder wall, which is associated with underlying carcinoma in 25% of patients (Fig. 3). Furthermore, wall thickness greater than 3 mm should raise an index of suspicion, although diffuse wall thickening can be associated with other inflammatory conditions such as cholecystitis and adenomyomatosis (4). Focal or diffuse asymmetric wall thickening greater than 3 mm can be concerning for underlying carcinoma, with increased likelihood of malignancy when there is marked enhancement of the wall during the arterial phase and isointensity in the venous phase on CT and MRI (5). Increased vascularity and the presence of polyps are most often benign and secondary to cholesterol or inflammation, but may have malignant potential (6,7). Resection is indicated for polyps greater than 1 cm (5).

CT can be utilized to depict lymphadenopathy, regional spread to liver or metastasis (1). CT can also serve in highlighting regions of the gallbladder that may be poorly visualized on ultrasound, when there are gallstones or mural calcification present (5). A CT demonstrating a weakly enhancing outer layer and thicker inner layer of gallbladder wall is highly suggestive of malignancy (4). On CT, gallbladder carcinoma can present as a polyploid mass within the lumen, focal or diffuse thickening or with a mass replacing the gallbladder (2,3). MRI/MRCP can show vascular or bile duct invasion (3).

References:

1. Hundal, R., & Shaffer, E. A. (2014). Gallbladder cancer: epidemiology and outcome. Clinical epidemiology, 6, 99–109. doi:10.2147/CLEP.S37357

2. Kanthan R, Senger JL, Ahmed S, Kanthan SC. Gallbladder Cancer in the 21st Century. J Oncol. 2015;2015:967472. doi:10.1155/2015/967472

3. Levy AD, Murakata LA, Rohrmann CA Jr. Gallbladder carcinoma: radiologic-pathologic correlation [published correction appears in Radiographics 2001 May-Jun;21(3):766]. Radiographics. 2001;21(2):295-555. doi:10.1148/radiographics.21.2.g01mr16295

4. Kim SJ, Lee JM, Lee JY, et al. Analysis of enhancement pattern of flat gallbladder wall thickening on MDCT to differentiate gallbladder cancer from cholecystitis. AJR Am J Roentgenol. 2008;191(3):765-771. doi:10.2214/AJR.07.3331

5. Andrén-Sandberg Å. Diagnosis and management of gallbladder cancer. North Am J Med Sci 2012;4:293-299. doi:10.4103/1947-2714.98586

6. Mitchell CH, Johnson PT, Fishman EK, Hruban RH, Raman SP. Features suggestive of gallbladder malignancy: analysis of T1, T2, and T3 tumors on cross-sectional imaging. J Comput Assist Tomogr. 2014;38(2):235-241. doi:10.1097/RCT.0b013e3182aafb6b

7. Rooholamini SA, Tehrani NS, Razavi MK, et al. Imaging of gallbladder carcinoma. Radiographics. 1994;14(2):291-306. doi:10.1148/radiographics.14.2.8190955

Usha Trivedi is a medical student at Rutgers New Jersey Medical School with aspirations to become a diagnostic radiologist. She completed her undergraduate education at The College of New Jersey with a major in Biology and a minor in Art History. She is drawn to radiology due its unique blend of technology, art and medicine that is rooted in patient care. Her first exposure to radiology was through clerkships in medical school, where she saw how crucial imaging can be for patient care. She is currently involved as a director for one of her medical school’s student-run clinics and with her medical school’s humanities-themed magazine. She aspires to become a radiologist with specific interests in mentorship, education and advocacy. In her spare time, she enjoys hiking, reading, art and board games.

Follow Usha Trivedi on Twitter @UshaTrivedi11.

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Kevin M. Rice, MD is the president of Global Radiology CME

Dr. Rice is a radiologist with Renaissance Imaging Medical Associates. He has held several leadership positions including Chair of Radiology, Board of Directors, and Chief of Staff at Valley Presbyterian Hospital in Los Angeles, California. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015, Dr. Rice and Natalie Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" Award for the Most Effective Radiology Educator.

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