DOI:10.2214/AJR.04.1560
AJR 2005; 185:1571-1572
© American Roentgen Ray Society
Biliary Cystadenoma of the Gallbladder
Timothy B. Rooney1,
Joel M. Schofer2,
Mark D. Stanley1 and
Steven L. Banks2
1 Department of Radiology, Naval Medical Center, Bob Wilson Drive, San Diego, CA
92134.
2 Department of Emergency Medicine, Naval Medical Center, San Diego, CA
92134.
Received October 5, 2004;
accepted after revision December 6, 2004.
Address correspondence to T. B. Rooney
(tbrooney{at}NMCSD.med.navy.mil).
Introduction
Biliary cystadenoma of the gallbladder is a rare disease with few
reports in the literature [1,
2]. We present a case that
includes the clinical course, radiologic findings on sonography and CT scan,
and pathologic correlation of this unusual entity.
Case Report
A 38-year-old woman presented to the emergency department with a 1-day
history of sharp, episodic abdominal pain, nausea, and vomiting. She had
experienced prior episodes of similar pain the last 2 years previously, and
all were self-limited. Examination showed a nondistended abdomen with normal
bowel sounds and tenderness to palpation in both upper quadrants with no
organomegaly, rebound, or guarding. No masses were noted and Murphy's sign was
absent.
A complete blood count revealed a mildly elevated WBC and mild anemia
(hemoglobin, 8.4 g/dL) with normal platelets and differential. She had normal
liver function tests, a mildly elevated amylase of 139 U/L (normal range,
36-128 U/L), and normal lipase.
Initial imaging was an acute abdominal series, which was normal. Right
upper quadrant sonography was performed that showed a thick, hyperechoic
septation in the midportion of the gallbladder with apparent separation of the
gallbladder into two compartments. The distal compartment contained diffuse
low-level echoes while the proximal compartment was anechoic and contained
multiple gallstones. The central septation itself was complex with multiple
thin echogenic septa separating small hypoechoic cystic regions for
approximately half of its length and a thick septation for the remainder
(Figs. 1A and
1B). The gallbladder wall was
otherwise not thickened, bile ducts were normal, and a small amount of
pericholecystic fluid was present. The patient had no Murphy's sign on
sonography.
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Fig. 1A —38-year-old woman with biliary cystadenoma of gallbladder.
Transverse sonogram through gallbladder. Biliary cystadenoma is seen as
rounded region of peripheral cystic spaces surrounding hyperechoic focus
(arrow).
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Fig. 1B —38-year-old woman with biliary cystadenoma of gallbladder.
Longitudinal sonogram of gallbladder. Thick septation is present, dividing
gallbladder into two compartments. Biliary cystadenoma is within septation
near arrow.
|
|
The patient was admitted and had an abdominal CT scan that showed the
complex septation within the gallbladder and cholelithiasis as seen on
comparison sonography (Fig.
1C). The remainder of the abdominal CT was unremarkable.
Specifically, no evidence of additional intrahepatic or biliary ductal lesions
was seen. The presumptive diagnosis was focal adenomyomatosis and
cholecystitis. The patient later had a laparoscopic cholecystectomy without
complications. Surgical pathology showed a firm, circumferential submucosal
mass measuring 1.2 x 0.8 x 0.8 cm, closing off the gallbladder
lumen and segregating the distal and the proximal compartments. The total
gallbladder measurements were 5.0 x 3.5 x 0.5 cm. The local and
Armed Forces Institute of Pathology diagnosis described smooth-muscle
hypertrophy, marked hypertrophy of nerves, and multiple cysts lined by benign
cuboidal epithelium with cilia consistent with biliary cystadenoma of the
gallbladder.
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Fig. 1C —38-year-old woman with biliary cystadenoma of gallbladder.
Axial contrast-enhanced CT image through gallbladder. Biliary cystadenoma is
seen as faint septa enclosing cystic spaces (arrow).
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Discussion
Biliary cystadenoma of the gallbladder is rarely reported in the
literature. Simmons et al. [1]
described a case in 1989 in which a 65-year-old white woman was admitted with
acute-on-chronic abdominal pain, increasing girth focused in the right upper
quadrant, jaundice, and fever. A clinically palpable right upper quadrant mass
was found on CT and sonography to be a large cystic lesion with multiple septa
emanating from the gallbladder fossa and causing biliary ductal compression.
Her cystic mass was removed by open laparotomy. The imaging findings were
similar to those described for intrahepatic biliary cystadenoma but
originating from the gallbladder
[1].
In the 2003 pathology literature, Terada et al.
[2] reported a biliary
cystadenocarcinoma within the gallbladder with cystadenoma elements. An
88-year-old man was admitted for right-sided abdominal pain and jaundice.
Imaging at the time of admission, sonography, and CT showed a cystic tumor of
the gallbladder fundus. Pathologic diagnosis was consistent with biliary
cystadenocarcinoma with elements of cystadenoma, suggesting malignant
transformation of cystadenoma
[2].
These two previously reported cases and our case have in common right upper
quadrant abdominal pain as a presenting complaint. Sonography and CT show the
cystic nature of these tumors. The cystic regions in our case were smaller
than in the previously reported lesions. The differential diagnosis based on
the imaging findings in our case included adenomyomatosis of the gallbladder,
which can present with a thick septation and cystic structures within the
gallbladder wall, representing Rokitansky-Aschoff sinuses.
Although biliary cystadenoma and cystadenocarcinoma of the gallbladder have
been rarely reported in the literature, both intra- and extrahepatic biliary
cystadenoma and cystadenocarcinoma have been discussed more comprehensively
[3-6].
The clinical symptoms are similar to those that our patient described and
include intermittent abdominal pain and epigastric discomfort in middle-aged
women. Sonography shows cystic masses with multiple septations and papillary
projections [5,
6]. Low-density lesions (less
than 30 H) with internal septa and nodules are seen on CT
[6]. Although CT findings are
more specific in defining the size and extent of these lesions, sonography is
better able to describe the internal structure
[6].
We present a rare biliary cystadenoma of the gallbladder that mimicked
adenomyomatosis. Sonography and CT were complementary in determining the
extent and character of the disease and can help guide the surgeon in managing
this unusual entity.
References
- Simmons TC, Miller C, Pesigan AM, et al. Cystadenoma of the
gallbladder. Am J Gastroenterol 1989;84
: 1427-1430[Medline]
- Terada T, Takeuchi T, Taniguchi M. Hepatobiliary cystadenocarcinoma
with cystadenoma elements of the gall bladder in an old man. Pathol
Int 2003; 53:790
-795[CrossRef][Medline]
- Ishak KG, Willis GW, Cummins SD, et al. Biliary cystadenoma and
cystadenocarcinoma: report of 14 cases and review of the literature.
Cancer 1977; 39:322
-338[CrossRef][Medline]
- Albores-Saavedra J, Vardaman CJ, Vuitch F. Non-neoplastic polypoid
lesions and adenomas of the gallbladder. Pathol Annu1993; 28:145
-177
- Forrest ME, Cho KJ, Shields JJ, et al. Biliary cystadenomas:
sonographic-angiographic-pathologic correlations. AJR1980; 135:723
-727[Abstract]
- Choi BI, Lim JH, Han MC, et al. Biliary cystadenoma and
cystadenocarcinoma: CT and sonographic findings.
Radiology 1989;171
: 57-61[Abstract/Free Full Text]
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Introduction
Case Report
