Imaging of a gall bladder carcinoma: Presentation of a case

Clinical History

We present a case of an 82-year-old woman with upper quadrant pain and anorexia. On doing examination, she was found to have a palpable mass and a positive Murphy sign. It was clinically diagnosed that there was a possibility of cholecystitis.

Imaging Findings

We present a case of an 82-year-old woman with upper quadrant pain and anorexia. On doing an examination, she was found to have a palpable mass and a positive Murphy sign. It was clinically diagnosed that there was a possibility of cholecystitis. An emergency ultrasound scan taken revealed a distended GB, partially filled with an intraluminal mass with an irregular border along the nondependent wall, which was diffusely thickened. Cholelithiasis was also present, but no intrahepatic or extrahepatic duct dilatation was found. CT scans obtained before and after administration of the contrast material confirmed the presence of the diffused GB's wall thickening along with the rest of the sonographic findings. There were no signs of liver invasion or lymphadenopathy. Subsequently, the patient underwent surgery, and the macroscopic specimen showed a large polypoid mass that filled most of the lumen of the GB and caused focal penetration of the GB's wall. Microscopic features of the tumor were typical of early papillary adenocarcinoma.

Discussion

Carcinomas of the GB are thought to be extremely malignant tumors, with an often fatal prognosis owing to both their site and to the fact that they are diagnosed late, since the signs and symptoms of GB carcinoma are nonspecific, often resembling those of chronic cholecystitis. The majority of patients, in fact, undergo surgery at an advanced stage of the disease when surgery is only palliative. Patients with GB carcinoma have an overall mean survival period of 6 months, and the 5-year survival rate is only 5%. Well to moderately differentiated adenocarcinomas (90%) are the most commonly found malignant epithilial tumors of the GB, with only 10%–15% being of the squamous or adenosquamous variety. There are several histologic variants of adenocarcinomas recognized: papillary, intestinal, mucinous, signet-ring cell, and clear cell. Among these, the papillary type appears to occur more frequently. It shows little gender preponderance, appears to arise mainly from the native GB epithelium and has a low association with gallstones. Underlying chronic cholecystitis or epithelial metaplasia occurs infrequently. Most cases are in the early stage, defined as cancer cell invasion, limited to the mucosal or muscularis propria, with a favorable prognosis. Malignant mesenchymal and other malignant tumors such as carcinosarcomas, carcinoid tumors, lymphomas, and melanomas can also occupy the GB. GB tumors occur in the fundus in 60% of patients, in the body in 30% of patients, and in the neck in 10% of patients. Early lymphatic spread is of high prevalence in GB carcinoma and affects the retroperitoneal, right celiac, and pancreaticoduodenal nodes. A direct invasion of the liver, extrahepatic biliary ducts, duodenum and colon, as well as intraperitoneal seeding are common occurrences. With the development of diagnostic procedures, ultrasonography (US) is considered to be the most useful tool for the detection and diagnosis of carcinomas of the GB at an early stage because it is a readily available, noninvasive, and cost-effective technique. However, this technique has its limitations, since US cannot stage the tumor and the visualization of pathognomonic findings, lymph nodes, intraperitoneal disease, and distant metastases is difficult. Recent studies showed that only 37% of patients with advanced disease were identified using US. On the other hand, several authors have reported the successful use of endoscopic US for evaluating the depth of GB carcinoma invasion. Indirect signs that suggest the presence of GB carcinoma are (1) GB wall thickening, (2) the presence of a single or multiple intraluminal mass, or (3) the existence of an extraluminal mass extending to the liver. CT is more useful than US for detecting lymph node involvement, adjacent organ invasion, and distant metastasis. However, CT does not reliably demonstrate all regional lymph nodes, but, when abnormally sized nodes (>10 mm) are present, it does indicate that lymphatic spread has occurred. A recent study has showed that CT has a sensitivity of 100% in the detection of tumor extension greater than 2 cm into the liver; however, its sensitivity in the detection of less severe tumor extension into the liver (<2 cm or T3 stage) was only 65%. Direct cholangiography (endoscopic retrograde cholangiopancreatography [ERCP], percutaneous transhepatic cholangiography, or intraoperative cholangiography) may be performed in cases with biliary involvement when the diagnosis of GB carcinoma is unsuspected or when therapeutic management of biliary obstruction is necessary. MRI, which is a sensitive modality, is used for the detection and evaluation of the tumor and its extent, when invasion of the adjacent structures is not delineated with US or CT. Dynamic MRI has been promising in differentiating malignant from benign lesions and evaluating the depth of tumor invasion. GB carcinoma manifesting as diffuse GB wall thickening has a differential diagnosis that includes the more common inflammatory and noninflammatory causes of wall thickening . GB carcinoma should be suspected when there are features of a focal mass, lymphadenopathy, hepatic metastases, and biliary obstruction at the level of the porta hepatis. The differential diagnosis also includes adenomyomatosis and xanthogranulomatous cholecystitis. For those tumors that manifest as an intraluminal polypoid mass, the differential diagnosis includes adenomatous, hyperplastic, and cholesterol polyps; carcinoid tumor; metastatic melanoma and a hematoma within the GB. The differential diagnosis for a mass replacing the GB fossa includes hepatocellular carcinoma, cholangiocarcinoma, and metastatic disease to the GB fossa. We therefore conclude that knowledge of the varied appearances of GB carcinoma at cross-sectional imaging, particularly US and CT, is important so that the diagnosis can be considered preoperatively.

Differential Diagnosis List

Final Diagnosis

Papillary adenocarcinoma.

URL:	https://www.eurorad.org/case/2460
DOI:	10.1594/EURORAD/CASE.2460
ISSN:	1563-4086