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Analysis of Enhancement Pattern of Flat Gallbladder Wall Thickening on MDCT to Differentiate Gallbladder Cancer from Cholecystitis

Soo Jin Kim1, Jeong Min Lee1,2, Jae Young Lee1, Se Hyung Kim1, Joon Koo Han1,2, Byung Ihn Choi1,2 and Jin Young Choi3

1 Department of Radiology and Institute of Radiation Medicine, Seoul National University Hospital, 101 Daehangno, Jongno-gu, Seoul 110-744, Korea.
2 Department of Radiology, Seoul National University College of Medicine, Seoul, Korea.
3 Department of Diagnostic Radiology, Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, Korea.


Figure 1
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  		Fig. 1A —Diagrams show five enhancement patterns of gallbladder diseases. Type 1: Heterogeneously enhancing thick one-layer pattern.

 

Figure 2
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  		Fig. 1B —Diagrams show five enhancement patterns of gallbladder diseases. Type 2: Strongly enhancing thick inner layer (≥ 2.6 mm) with weakly enhancing or nonenhancing thin outer layer (≤ 3.4 mm).

 

Figure 3
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  		Fig. 1C —Diagrams show five enhancement patterns of gallbladder diseases. Type 3: Borderline pattern.

 

Figure 4
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  		Fig. 1D —Diagrams show five enhancement patterns of gallbladder diseases. Type 4: Weakly enhancing thin inner layer with nonenhancing thin outer layer.

 

Figure 5
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  		Fig. 1E —Diagrams show five enhancement patterns of gallbladder diseases. Type 5: Weakly enhancing thin inner layer with nonenhancing thick outer layer.

 

Figure 6
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  		Fig. 2A —Five enhancement patterns of gallbladder diseases showing flat gallbladder wall thickening on portal venous phase MDCT. 54-year-old man with gallbladder cancer. Axial contrast-enhanced CT image shows heterogeneously enhancing thick one-layer pattern (arrowheads, type 1). This pattern of gallbladder wall thickening includes gallbladder cancer and special forms of chronic cholecystitis, such as xanthogranulomatous cholecystitis.

 

Figure 7
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  		Fig. 2B —Five enhancement patterns of gallbladder diseases showing flat gallbladder wall thickening on portal venous phase MDCT. 68-year-old woman with gallbladder cancer. Intense enhancement of inner layer (white arrow) and weakly enhanced or unenhanced outer layer (black arrow) were noted on portal phase of axial CT scan (type 2). Enhancement degree of inner layer is stronger than that of hepatic parenchyma, similar to that of vessels. This enhancing inner wall thickness is ≥ 2.6 mm.

 

Figure 8
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  		Fig. 2C —Five enhancement patterns of gallbladder diseases showing flat gallbladder wall thickening on portal venous phase MDCT. 38-year-old man with adenomyomatosis. Axial CT scan shows diffuse, segmental gallbladder wall thickening with two layers. Enhancement degree and thickness of inner (white arrow) and outer (black arrow) layers were not strictly categorized (type 3). However, enhancement degree is same or less than that of liver parenchyma. We can observe subtle low-attenuated foci (arrowheads) within inner enhancing layer, thereby suggesting dilated Rokitansky-Aschoff sinuses.

 

Figure 9
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  		Fig. 2D —Five enhancement patterns of gallbladder diseases showing flat gallbladder wall thickening on portal venous phase MDCT. 63-year-old man with calculus chronic cholecystitis. In this pattern, differential point with type 3 is thin inner enhancing layer (white arrow) showing weak enhancement, fuzzy margin, and luminal collapse (type 4). Thin outer layer (black arrow) does not show enhancement.

 

Figure 10
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  		Fig. 2E —Five enhancement patterns of gallbladder diseases showing flat gallbladder wall thickening on portal venous phase MDCT. 70-year-old woman with acute cholecystitis. In this pattern, weakly enhancing thin inner layer (white arrow), suggesting mucosal inflammation, with nonenhancing, thick outer layer (black arrow), suggesting subserosal edema and pericholecystic fluid with luminal distention of gallbladder (type 5), is seen. Weakly enhancing layer shows rather fuzzy margin.

 

Figure 11
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  		Fig. 3A —False-positive case of gallbladder cancer in 51-year-old woman diagnosed as having chronic cholecystitis with phlegmon. Axial contrast-enhanced CT image shows segmental area of thick single-layer enhancement with focal low-attenuating lesion (arrowheads) in fundus of gallbladder, which corresponds to type 1 pattern of enhancement.

 

Figure 12
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  		Fig. 3B —False-positive case of gallbladder cancer in 51-year-old woman diagnosed as having chronic cholecystitis with phlegmon. Other area shows weakly enhancing thin inner layer (white arrow) and nonenhancing thick outer layer (black arrow), which is compatible with type 5 pattern suggesting acute cholecystitis. In this case, enhancement degree was similar to that of hepatic parenchyma, suggesting chronic inflammation rather than gallbladder cancer. This fact could be helpful in making correct diagnosis.

 

Figure 13
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  		Fig. 4A —False-negative case of gallbladder cancer in 76-year-old man with gallbladder cancer. Axial (A) and oblique coronal (B) contrast-enhanced CT images show strong enhancement of inner layer (white arrow, A) and weakly enhancing or nonenhancing outer layer (black arrow, A), which is similar to type 2 pattern of enhancement. However, thickness of inner layer is 2.3 mm, whereas that of outer layer is 3.4 mm, and multiple stones (asterisk) exist in gallbladder lumen. Observer 1 interpreted this case as type 5 pattern and observer 2, as type 4 pattern. Patient underwent laparoscopic cholecystectomy and was diagnosed with early gallbladder cancer (pT1a), which shows flat type of growth and concomitant chronic active cholecystitis. When we reviewed this case, enhancement degree of inner layer was intense, but enhancement degree of hepatic parenchyma was also strong, which could be pitfall in differentiating type 2 from types 4 and 5 enhancement patterns even if thickness of inner and outer layers is equivocal.

 

Figure 14
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  		Fig. 4B —False-negative case of gallbladder cancer in 76-year-old man with gallbladder cancer. Axial (A) and oblique coronal (B) contrast-enhanced CT images show strong enhancement of inner layer (white arrow, A) and weakly enhancing or nonenhancing outer layer (black arrow, A), which is similar to type 2 pattern of enhancement. However, thickness of inner layer is 2.3 mm, whereas that of outer layer is 3.4 mm, and multiple stones (asterisk) exist in gallbladder lumen. Observer 1 interpreted this case as type 5 pattern and observer 2, as type 4 pattern. Patient underwent laparoscopic cholecystectomy and was diagnosed with early gallbladder cancer (pT1a), which shows flat type of growth and concomitant chronic active cholecystitis. When we reviewed this case, enhancement degree of inner layer was intense, but enhancement degree of hepatic parenchyma was also strong, which could be pitfall in differentiating type 2 from types 4 and 5 enhancement patterns even if thickness of inner and outer layers is equivocal.

 

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