Adenocarcinoma of the Gallbladder

Bang Huu Huynh, MD - Case Coordinator
Amy Ho Huang, MD - Radiology Discussion
Jian Shen, MD, PhD - Pathology Discussion
Steven E Seltzer, MD - Attending Radiologist

May 12, 2003

Presentation

Imaging Findings

Ultrasound images demonstrate an asymmetrically thickened gallbladder wall involving the body and neck of the gallbladder. There are no stones, free fluid, or enlarged nodes; the visible liver seems normal.

On heavily T2 weighted MRI images, the gallbladder appears distended with fluid. The wall has a nodular appearance.

Differential Diagnosis

Diagnosis

Discussion

The patient underwent cholecystectomy. The gross specimen demonstrates diffuse thickening of the wall but no obvious focal lesion. Low-power microscopy shows diffuse papillary projections of epithelium, and a high-power view shows diffuse, adenomatous epithelial change. In some areas, dysplastic changes consistent with adenocarcinoma in situ are also visible. The tumor focally invades into muscularis propria only superficially. In summary, the tumor arises in association with adenomatous changes with mulitfocal high grade dysplasia and carcinoma in situ, covering the entire surface of the gallbladder. Pathology images courtesy of Mary R Kwaan, MD.

Radiology Discussion:

Gallbladder carcinoma, a highly lethal condition, is the sixth most common gastrointestinal malignancy (after colon, pancreas, stomach, liver, and esophagus). Because symptoms are often vague, this carcinoma is frequently detected late; in fact, detection is typically related to invasion of adjacent organs. Gallbladder carcinoma is three times more common among women and typically occurs in elderly patients (average age of diagnosis is 72 years.)

Risk factors include postmenopausal status, cigarette smoking, gallstones (seen in 85% of cases of gallbladder carcinoma), and porcelain gallbladder (10-25% later develop gallbladder carcinoma). The presence of a choledochal cyst, anomalous junction of the pancreaticobiliary ducts, and low insertion of the cystic duct are also associated with higher incidence. It is thought, in these cases, that gallbladder carcinoma may develop in response to chronic biliary reflux of pancreatic secretions.

There are three common imaging appearances for gallbladder carcinoma. The most common is that of a mass replacing the gallbladder (55%). The differential diagnosis for this appearance includes hepatocellular carcinoma, cholangiocarcinoma, and metastatic disease of the gallbladder fossa. The second most common appearance is that of focal or diffuse wall thickening (25%), for which the differential diagnosis includes congestive heart disease, hypoalbuminemia, cirrhosis, hepatitis, cholecystitis, and adenomyomatosis. The third presentation is that of a polypoid mass, with a differential diagnosis of polyps (adenomatous, hyperplastic, or cholesterol), carcinoid tumor, melanoma metastasis, and hematoma.

Gallbladder carcinoma can spread by direct invasion or by lymphatic or hematogenous routes. Ultrasound is useful for detecting the primary tumor as well as adjacent liver invasion. CT is more useful for evaluating the extent of the disease, such as direct extension to the liver, periportal and peripancreatic lymphadenopathy, extension to the biliary tree (resulting in biliary obstruction), and hematogenous metastases. The literature provides very little information about the accuracy of preoperative staging. Therapeutic options are limited; there is no standardized therapy. Surgical resection is the mainstay. The five-year survival is less than 5%; the median survival is six months.

References

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