Diagnostic Ultrasound - Abdomen and Pelvis

Gallbladder Carcinoma
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Diagnoses: Biliary System
Metastatic Disease to GB Fossa
• Variable appearance (polypoid, mural infiltration, GB fossa
mass)
• Metastases: Melanoma may directly metastasize to GB
mucosa
• Direct invasion: Primary hepatic tumors may spread to GB
via duct invasion
• Mimic: Porta hepatis lymphadenopathy
○ Lymphoma and GI tract carcinoma most common
• Require correlation with history of malignancy
PATHOLOGY
General Features
• Etiology
○ Pathogenesis
– Most with gallstones → mucosal abrasion/ulceration
→ regeneration → metaplasia/dysplasia
– Less commonly, malignant degeneration of
adenomatous polyps
• Usually arises in fundus or neck
• Thin muscularis layer and close approximation to liver,
lymphatics, and vasculature → early local, lymphatic, and
hematogenous spread
○ Penetration of serosa → peritoneal dissemination
(ascites, omental/peritoneal implants)
Staging, Grading, & Classification
• Stage I: Confined to mucosa
• Stage II: Involves mucosa and muscularis
• Stage III: Serosal extension
• Stage IV: Lymph node involvement
○ Nodal status most suggestive of overall prognosis
• Stage V: Direct extension to liver or distant metastases
Microscopic Features
• Adenocarcinoma (80-95%)
CLINICAL ISSUES
Presentation
• Most common signs/symptoms
○ Right upper quadrant (RUQ) pain, weight loss, anorexia,
fever
○ Jaundice: When tumor invades common or right hepatic
duct or CBD
Demographics
• Age
○ Mean: 65 years
• Gender
○ F:M 3:1; female gender is independent risk factor
• Epidemiology
○ Prevalence 3-7%
• Risk factors
○ Gallstones (GS)
○ Polyps
– Up to 88% of adenomatous polyps > 10 mm in
patients over 50, have been found to harbor
malignancy
○ Chronic infection
– Salmonella typhi and S. paratyphi, Helicobacter pylori
○ Anomalous union of the pancreaticobiliary ducts
(AUPBD)
○ Porcelain gallbladder: Controversial
– More likely, porcelain GB represents changes
associated with chronic inflammation, harbinger of
GBC
○ Genetics: Marked geographic variability with genetic
predisposition to GBC
– Family history is strong risk factor
○ Other chronic inflammatory states, including IBD
(primary sclerosing cholangitis) and familial
adenomatous polyposis, and toxic exposures (cigarette
smoking; workers exposed to petroleum, rubber, paper
mills)
Natural History & Prognosis
• Histologic type and stage at presentation are most
important prognostic factors
• Spreads by local invasion to liver, nodal spread to porta
hepatis and paraaortic nodes, hematogenous spread to
liver
Treatment
• Early stage (Tis or T1a): Simple cholecystectomy
• Beyond muscularis: Radical cholecystectomy, ± partial
hepatectomy, ± LN dissection
• Preventative treatment: Cholecystectomy recommended
for polyps > 10 mm in patients > 50 years
DIAGNOSTIC CHECKLIST
Consider
• Most often, diagnosed incidentally after elective
cholecystectomy for presumed benign disease
Image Interpretation Pearls
• Mass infiltrating GB fossa with liver invasion
• Large polypoid GB mucosal mass with flow
• Associated adjacent lymphadenopathy
SELECTED REFERENCES
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prognosis, and prevention. Eur J Gastroenterol Hepatol. 26(5):562-9, 2014
3. Pitt SC et al: Incidental gallbladder cancer at cholecystectomy: when should
the surgeon be suspicious? Ann Surg. 260(1):128-33, 2014
4. Runner GJ et al: Gallbladder wall thickening. AJR Am J Roentgenol.
202(1):W1-W12, 2014
5. Wernberg JA et al: Gallbladder cancer. Surg Clin North Am. 94(2):343-60,
2014
6. Xu JM et al: Differential diagnosis of gallbladder wall thickening: the
usefulness of contrast-enhanced ultrasound. Ultrasound Med Biol.
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7. Zemour J et al: Gallbladder tumor and pseudotumor: Diagnosis and
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8. Cairns V et al: Risk and Cost-effectiveness of Surveillance Followed by
Cholecystectomy for Gallbladder Polyps. Arch Surg. 147(12):1078-83, 2012
9. Kai K et al: Clinicopathologic features of advanced gallbladder cancer
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