AJR 2005; 184:S86-S87
© American Roentgen Ray Society
Primary Non-Hodgkin's Lymphoma of the Gallbladder
Toru Yamamoto1,
Masaru Kawanishi2,
Hidemaro Yoshiba2,
Eiji Kanehira2 and
Harumi Itoh3
1 Department of Radiology, Yawata Medical Center, 12-7 Yawata, Komatsu 923-8511,
Japan.
2 Department of Surgery, Yawata Medical Center, Komatsu 923-8511, Japan.
3 Department of Radiology, Faculty of Medical Sciences, University of Fukui,
Matsuoka-cho, Yoshida-gun, Fukui 910-1193, Japan.
Received March 16, 2004;
accepted after revision April 30, 2004.
Address correspondence to T. Yamamoto
(toruy{at}po.incl.ne.jp).
Introduction
Primary non-Hodgkin's lymphoma of the gallbladder represents an
extremely rare location of extranodal non-Hodgkin's lymphoma. We report an
exceptional case of primary non-Hodgkin's lymphoma of the gallbladder with a
unique radiologic description.
Case Report
A 40-year-old woman presented with back pain that was associated with
pyelonephritis. It was resolved within a week using oral antibiotics, but
abdominal sonography revealed gallbladder thickening and low-echoic masses
near the gallbladder neck (Fig.
1A). Neither gallbladder stones nor bile duct dilatation was
observed. Physical examination showed normal findings, and serum chemistry
levels were within normal limits.
CT showed gallbladder thickening and a soft-tissue density mass in the
liver bed (Fig. 1B). Focal
liver pathology and lymphadenopathy in the hepatoduodenal ligament were not
observed. The gallbladder lesion showed low intensity on fat-suppressed
T1-weighted MR images and high intensity on fat-suppressed T2-weighted images
compared with those of the liver parenchyma (Figs.
1C and
1D). The intensity of the mass
in the liver bed resembled that of the wall lesion. MR
cholangio-pancreatography (MRCP) showed no high-intensity foci, which are
usually seen on intramural diverticula in adenomyomatosis.
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Fig. 1C. —40-year-old woman with pyelonephritis. Gallbladder lesions
are low intensity on fat-suppressed T1-weighted images (C) and high
intensity on fat-suppressed T2-weighted images (D) compared with those
of liver parenchyma (arrows). Intensity of mass in liver bed
resembles that of wall lesion (arrowheads).
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Fig. 1D. —40-year-old woman with pyelonephritis. Gallbladder lesions
are low intensity on fat-suppressed T1-weighted images (C) and high
intensity on fat-suppressed T2-weighted images (D) compared with those
of liver parenchyma (arrows). Intensity of mass in liver bed
resembles that of wall lesion (arrowheads).
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Pathologic examination revealed a diffuse large B-cell lymphoma of the
gallbladder with involvement of noncontiguous lymph nodes on the liver bed
(Fig. 1E). Intraoperatively,
lymphadenopathy was not identified in other sites. Biopsy at the iliac bone
showed neither normocellular bone marrow nor tumor cells. Abnormal findings
were not detected on PET with FDG or whole-body CT. After that operation, the
patient was treated with chemotherapy (cyclophosphamide, doxorubicin,
vincristine, and prednisone) for 6 months. She has remained free of disease
for 7 months.
Discussion
More common than primary lymphoma of the gallbladder is secondary
involvement along with adjacent lymph nodes in patients with known malignant
lymphoma. However, primary lymphomas of the gallbladder are exceedingly rare
[1]: to date, only
approximately 20 cases (including one case of Hodgkin's lymphoma) have been
reported in the English-language literature
[2-6].
The origin of gallbladder lymphoma is controversial. Lymphoid tissue in
normal gallbladder mucosa is sparse. Lymphoid follicles are not evident, but
some intraepithelial lymphocytes are present among surface columnar cells
[1]. It is also noteworthy that
lymphoid hyperplasia of the gallbladder after chronic cholecystitis has been
reported [2].
A method for preoperative diagnosis has not been established. All cases in
previous reports were diagnosed after surgery by pathologic examination.
Fine-needle aspiration may constitute an option for preoperative diagnosis of
gallbladder lymphoma. Nevertheless, surgical resection of the gallbladder is
usually performed without pathologic examination.
Differential diagnosis includes various diseases. However, adenocarcinoma
and adenomyomatosis are common diseases that can have various appearances.
Adenomyomatosis can have focal wall thickening and often has foci within the
lesions. Various appearances of diverticula (Rokitansky-Aschoff sinus) on
sonography have been noted because of their myriad size and content. They
appear anechoic or low-echoic with or without comet-tail artifact on
sonography, and small cystic structures are usually found around them on MRCP
images [7,
8].
In our patient, the mass lesion in the liver bed may resemble the
Rokitansky-Aschoff sinus of adenomyomatosis. However, the MRCP images were not
consistent with adenomyomatosis. Gallbladder carcinoma is frequently
associated with portal adenopathy. However, metastasis of the mass to the
liver bed was exceptional. One conjecture is that malignant transformation of
the original clone could occur outside the gallbladder and that homing to this
organ occurs via an adhesion molecule mechanism
[2]. In our case, the liver bed
mass may have existed before the intramural mass of the gallbladder.
We infer that mass lesions in the liver bed associated with gallbladder
lesions may characterize gallbladder lymphoma. In conclusion, lymphoma of the
gallbladder may be added to differential diagnosis of gallbladder lesions,
especially when a mass in the liver bed is found.
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AJR 1999;172:1535
-1540[Abstract/Free Full Text]
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