4.4 Malignant Tumors

#115 Gallbladder Carcinoma,

General

KEY FACTS: DISEASE

●Histology: variable (from well-differen- tiated to anaplastic)

●Incidence:

–Most common biliary cancer

–Found in 0.4%–0.6% of biliary tract operations

●Peak age: sixth to seventh decade

●Ratio of women to men: 3 : 1

●Location: usually body, fundus

●Predisposing factors/associated disease:

–Porcelain gallbladder (incidence of carcinoma up to 22%; see # 110)

–Gallstones (in 65%–98%; carcinoma occurs in only 1% of patients with stones, however)

–Chronic cholecystitis

–Anomalous pancreaticobiliary duct union (see # 123)

–Focal adenomyomatosis (see # 109)

●Symptoms: either signs of malignancy or signs of cholecystitis

●75% unresectable at the time of diagnosis

●88% mortality rate within 1 year

KEY FACTS: MRI

●Morphologic appearance:

–Mass replacing the gallbladder (40%–70%)

–Focal/diffuse asymmetric irregular wall thickening (15%–30%; Fig. 115)

–Polypoid intraluminal mass (15%–25%)

●Signal intensity:

–Like most other neoplasms: T1, hypointense; T2, moderately hyperintense

–Usually heterogeneous

●Contrast-enhanced images: typically illdefined enhancement in the early phase

●Gallstones commonly present

●Differential diagnosis:

–Xanthogranulomatous cholecystitis (see # 105; Chun et al. 1997)

–Adenomyomatosis

(see # 108; Gerard et al. 1990)

–Acute/chronic cholecystitis (see #96, 104)

–Metastases

(50% malignant melanoma)

–Leukemia, lymphoma

–Benign polyps

–Direct invasion of gallbladder by other tumors (e.g., hepatic, duodenal)

●Signs of extramural spread: see # 116–118

References

Chun KA, Ha HK,Yu ES et al. (1997) Xanthogranulomatous cholecystitis: CT features with emphasis on differentiation from gallbladder carcinoma. Radiology 203 : 93–97

Demachi H, Matsui O, Hoshiba K et al. (1997) Dynamic MRI using a surface coil in chronic cholecystitis and gallbladder carcinoma: radiologic and histopathologic correlation. J Comp Assist Tomogr 21 : 643–651

Franquet T, Montes M, Ruiz de Azua Y, Jimenez FJ, Cozcolluella R (1991) Primary gallbladder carcinoma: imaging findings in 50 patients with pathologic correlation. Gastrointest Radiol 16 : 143–148

Gerard PS, Berman D, Zafaranloo S (1990) CT and ultrasound of gallbladder adenomyomatosis mimicking carcinoma. J Comp Assist Tomogr 14 : 490–491

Schwartz LH, Black J, Fong Y et al. (2002) Gallbladder carcinoma: findings at MR imaging with MR cholangiopancreatography. J Comput Assist Tomogr 26 : 405–410

#116 Spread of Gallbladder

Carcinoma (1):

Direct Invasion

of Liver Parenchyma and/or Biliary Tree

Related topic: #89 (extrahepatic bile duct, involvement by gallbladder carcinoma)

KEY FACTS: DISEASE

●Local spread to the liver and/or biliary tree occurs in up to 80% of cases (Kumar and Aggarwal 1994)

●Mechanism: venous drainage of the gallbladder ends in adjacent liver substance

●Other routes of spread:

–Duodenum (12%) or colon (9%)

–Lymphatic (see # 117)

–Peritoneal (see # 118)

–Hematogenous (see # 118)

KEY FACTS: MRI (FIG. 116)

●MR features of liver invasion:

–Abnormal aspect of the gallbladder bed with absence of clear separation between the gallbladder and liver

–Soft tissue mass in hepatic parenchyma cranial to the gallbladder and/or in the liver hilum

–Narrowing of the common hepatic duct (see # 89) or intrahepatic ducts

●Differential diagnosis: e.g., cholangiocarcinoma, metastases, lymphoma, hepatocellular carcinoma

●Note: Coronal images should be obtained to evaluate intrahepatic spread

References

Kumar A, Aggarwal S (1994) Carcinoma of the gallbladder: CT findings in 50 cases.Abdom Imaging 19 : 304–308

Schwartz LH, Black J, Fong Y et al. (2002) Gallbladder carcinoma: findings at MR imaging with MR cholangiopancreatography. J Comput Assist Tomogr 26 : 405–410

Yamaguchi K,Enjoji M (1988) Carcinoma of the gallbladder. A clinicopathology of 103 patients and a newly proposed staging. Cancer 62 : 1425–1432

Fig. 116 a–c. a Coronal T2-weighted image showing a large mass in the right liver lobe (arrows), discrete thickening of the gallbladder wall (arrowhead), and absence of a fatty interface between the gallbladder and liver: gallbladder carcinoma with direct hepatic invasion. b Sagittal cross-sectional image obtained in a different patient showing similar abnormalities as in a (arrows). c Same patient as in b. Projective image showing amputation of bile

ducts in the right liver lobe (arrow). d–e Different patient. Coronal T2-weighted HASTE image (TE 60) (d) showing a slightly hyperintense mass in the gallbladder fossa (large arrow), with extension into the adjacent liver parenchyma (small arrow). e Axial post-gadolinium T1-weighted VIBE images obtained in the venous phase showing ring enhancement of the intrahepatic mass (large arrow) together with focal thickening of the gallbladder wall (small arrow)

#118 Spread of Gallbladder

Carcinoma (3):

Other Metastases

KEY FACTS: DISEASE

●Local spread to adjacent organs such as the stomach, duodenum, and hepatic colonic flexure is relatively common

●Hematogenous spread:

–Intrahepatic dissemination may occur secondary to spread into branches of the portal vein

–Distant metastases are rare

●Peritoneal metastases: found in ± 6% (Buhr et al. 1996)

●Ovarian metastases (rare)

●Note: A problem that has arisen recently is the risk of implantation metastases following laparoscopic cholecystectomy (seeding may occur along the trocar pathways)

KEY FACTS: MRI

●Liver metastases: see #60 (Fig. 118)

●Findings in peritoneal metastatic disease:

–Ascites

–Thickening of parietal peritoneum

–Marked enhancement of peritoneum (Low et al. 1997)

References

Buhr J, Hürten M, Heinrichs CM, Graf M, Padberg WM (1996) Implantation metastases following laparoscopic cholecystectomy in gallbladder carcinoma. Dtsch Med Wochenschr 121 : 57–61

Kriplani AK, Jayant S, Kapur BML (1992) Laparoscopy in primary carcinoma of the gallbladder. Gastrointest Endosc 38 : 326–329

Low RN, Barone RM, Lacey C, Sigeti JS, Alzate GD, Sebrechts CP (1997) Peritoneal tumor: MR imaging with dilute oral barium and intravenous gadolinium-containing contrast agents compared with unenhanced MR imaging and CT. Radiology 204 : 513–520

Fig. 118 a–d. Axial (a–c) and coronal (d) T2weighted HASTE image (TE 60) showing diffuse thickening of the gallbladder wall (small arrows)

with extension into the adjacent liver parenchyma (large arrow). Several hepatic metastases are seen

(arrowheads)