Gallbladder adenocarcinoma: a clinical case

Clinical History

A 72-year-old man came to our attention because of increased level of direct bilirubin, GGT, transaminases and CA19-9. Jaundice was present at physical examination. The patient complained of weight loss and nausea during the past two months.

Imaging Findings

Ultrasounds examination showed a dilatation of both intrahepatic bile ducts emisystems and a "stop" at the biliary confluence, caused by irregular parenchymal tissue. The same tissue involved and filled gallbladder infundibulum (Fig. 1).
Computed tomography (CT) confirmed the presence of a lesion protruding into the infundibulum of gallbladder and into the biliary confluence (Fig. 2). The lesion size, best appreciable in coronal multiplanar reconstruction (MPR), was about 2.5 cm (Fig. 3).
Cholangiographic sequences of Magnetic resonance (MR) (Fig. 4) confirmed CT findings and highlighted the occlusion (no signal) of common hepatic duct and cystic duct while the main hepatic duct and the biliary confluence appear filiform (Fig. 5).
In order to resolve the obstructive jaundice, the patient had an external-internal biliary drainage as palliative treatment, before the beginning of chemotherapy. A CT examination was performed (Fig. 6).
A percutaneous cholangiography (PCT) confirmed the proper drainage function, as the iodinated contrast medium reached duodenum after external drainage administration (Fig. 7).

Discussion

Gallbladder carcinoma (GBC) is the most common malignant biliary neoplasm and the 7th most common gastrointestinal cancer [1].
More than 90% of GBCs have the histological pattern of adenocarcinoma, while anaplastic, squamous and adenosquamous carcinomas are the less common types [2].
The highest incidence of GBC occurs in women over 65 years.
The aetiology of this tumour is complex, but there is a strong association with gallstones. In fact, cholelithiasis is a well-recognized risk factor as it would be responsible of a chronic inflammation process causing dysplasia-adenocarcinoma. The geographical area of provenience is considered a risk factor because GBC has a high prevalence variance (major incidence in American Indians).
Signs and symptoms of GBC are not specific in early stage and, generally, arise late because of tumour infiltration of surrounding organs. Thus, the majority of cases are diagnosed in advanced stages, resulting in unfavourable prognosis [3, 4].
More frequently, the disease begins with abdominal pain or biliary colic.
If symptoms occur late, the jaundice may be the first sign due to the involvement of the biliary tree. Other accompanying symptoms of advanced stages may be fatigue, anorexia and weight loss [4].
In cases of locally advanced disease, abdominal ultrasound (US) has an accuracy of 80% in diagnosing GBC [2].
CT is the most important examination to show the tumour, the liver infiltration, metastases and enlarged lymph-nodes.
Endoscopic retrograde cholangiopancreatography (ERCP) may be useful for showing bile duct infiltration. Although ERCP is an invasive procedure, its advantages include the ability to obtain biopsies and to place stents or perform other interventions to relieve biliary obstruction.
Magnetic Resonance Cholangiopancreatography (MRCP) is a non-invasive alternative to ERCP for studying infiltration of biliary ducts.
Cholangiography during surgery can be performed to visualize the anatomy and the possible infiltration of the biliary tree.
Tumour resection with free margins remains a curative therapy. While simple cholecystectomy can be curative in early stages, large resections including hepatectomy need in advanced stages for obtaining free margins [1].
In advanced GBC, endoscopic drainage is a palliative method of increasing quality of life. Nevertheless drainage can be performed only by experienced staff because of potential procedural complications like cholangitis [5].
No definitive chemotherapeutic regimen has been established for advanced GBC, but Gemcitabine is an attractive option.

Differential Diagnosis List

Final Diagnosis

Gallbladder adenocarcinoma

URL:	https://www.eurorad.org/case/10468
DOI:	10.1594/EURORAD/CASE.10468
ISSN:	1563-4086