DOI:10.2214/AJR.05.0524
AJR 2006; 187:473-480
© American Roentgen Ray Society
Unusual Malignant Tumors of the Gallbladder
Min-Jeong Kim1,
Kyoung Won Kim2,
Hyo-Cheol Kim3,
So Yeon Kim2,
Seong Ho Park2,
Ah Young Kim2,
Hyun Kwon Ha2,
Jae Ho Byun2,
Hyung Jin Won2,
Yong Moon Shin2,
Pyo Nyun Kim2 and
Moon-Gyu Lee2
1 Department of Radiology, Hallym University Sacred Heart Hospital, Anyang,
Korea.
2 Department of Radiology, Asan Medical Center, University of Ulsan College of
Medicine, 388-1, Pungnap-2 dong, Songpa-ku, Seoul, Korea 138-736.
3 Department of Radiology, Seoul National University Hospital, Seoul National
University College of Medicine, Seoul, Korea.
Received March 24, 2005;
accepted after revision May 6, 2005.
Address correspondence to K. W. Kim
(kimkw{at}amc.seoul.kr).
Abstract
OBJECTIVE. The purpose of this pictorial essay is to review the
spectrum of unusual malignant tumors of the gallbladder and to illustrate
their radiologic features.
CONCLUSION. Radiologic findings of unusual malignant gallbladder
tumors are varied and overlap with those of ordinary gallbladder carcinoma.
Despite their rarity, being familiar with the wide spectrum of radiologic
findings of these unusual tumors is helpful to improve diagnostic
accuracy.
Keywords: gallbladder • oncologic imaging
Introduction
Most malignant gallbladder tumors are adenocarcinomas, but the several
unusual histologic variants include papillary, mucinous, and signet ring
cell-type tumors. Also, although rare, a variety of unusual epithelial and
nonepithelial malignancies, such as squamous cell carcinoma, carcinosarcoma,
small cell carcinoma, lymphoma, and metastasis, may occur in the gallbladder
as well [1,
2].
The radiologic findings of adenocarcinoma of the gallbladder have been
described as three basic patterns including a mass replacing the gallbladder,
diffuse or focal thickening of the gallbladder wall, and a polypoid mass
within the gallbladder lumen. Only a few articles, however, have reported the
radiologic findings of unusual malignant gallbladder neoplasms. Being familiar
with radiologic findings of unusual malignant gallbladder tumors is worthwhile
because they may show a different clinical behavior and prognosis than the
usual adenocarcinoma.
Unusual Histologic Variants of Adenocarcinoma
Papillary Adenocarcinoma
Papillary adenocarcinoma consists of predominantly fibrovascular stalks
lined by malignant epithelial cells, and it often produces mucin in the
gallbladder. The tumor has a tendency toward intraluminal papillary growth and
fills the lumen before invading the wall of the gallbladder. Metastatic
lesions in the liver and regional lymph nodes are rarely encountered with this
tumor. Therefore, papillary adenocarcinoma has a better prognosis than other
variants [1,
2]. At cross-sectional imaging,
solitary or multiple polypoid lesions may be clearly visualized as papillary
protrusion [2] (Figs.
1A,
1B, and
1C).
View larger version (133K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1B —71-year-old woman with papillary adenocarcinoma of
gallbladder. Contrast-enhanced CT scan clearly depicts polypoid masses
(arrows) with mild enhancement filling neck and body of
gallbladder.
|
|
Mucinous Adenocarcinoma
Mucinous adenocarcinoma is a type of mucin-producing carcinoma and consists
of a massive mucous pool within the neoplastic tissues
[1]. The tumor has a poor
prognosis because of its tendency toward invasive growth. Although mucinous
adenocarcinoma is uncommon, it shows characteristic radiologic findings
because of the abundant mucin within the tumor. At sonography, the tumor may
show a localized thickened wall or intraluminal polypoid mass with
hyperechogenicity. Spotty and hyperechoic contents suggesting mucin may also
fill the enlarged gallbladder and dilated bile duct
[3]. Unenhanced CT scan may
reveal a near-water-density lesion with punctate calcification
(Fig. 2A). After contrast
medium injection, the localized thickened wall is visualized as a multilocular
lesion by peripheral rim enhancement (Fig.
2B). These sonographic and CT findings are correlated
pathologically with the tumor containing a large amount of mucin pool with
fibrous septa [3].
View larger version (123K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 2A —64-year-old woman with mucinous adenocarcinoma of
gallbladder. Unenhanced CT scan reveals several punctate calcifications
(arrows) and suspicious localized wall thickening in body of
gallbladder.
|
|
View larger version (132K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 2B —64-year-old woman with mucinous adenocarcinoma of
gallbladder. On contrast-enhanced CT, mass is clearly visualized as localized
wall thickening with enhancement and some multilocular lesion with rimlike
enhancement (arrow). There also is direct invasion into segment IV of
liver (arrowhead) and metastatic lymphadenopathy (curved
arrow) along bilateral paraaortic area.
|
|
Signet Ring Cell Carcinoma
This rare malignant tumor contains cells with intracytoplasmic mucin, which
displaces the nuclei toward the periphery. The characteristic feature of the
tumor is spreading laterally through the lamina propria. Infiltrative
submucosal growth pattern resembling linitis plastica of the stomach is a
prominent feature of signet ring cell carcinoma
[1,
2]. In our case, sonography
shows an echogenic polypoid mass and targetlike wall thickening of the
gallbladder. Contrast-enhanced CT scans reveal circumferential wall thickening
with target appearance and massive conglomerated lymphadenopathy (Figs.
3A and
3B).
View larger version (108K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 3B —43-year-old woman with signet ring cell carcinoma of
gallbladder. CT scan reveals targetlike wall thickening with enhancement
(arrow) of fundus of gallbladder. There also is noted massive
necrotic lymphadenopathy (arrowheads) along porta hepatis,
hepatoduodenal ligament, and porta cava space.
|
|
Squamous/Adenosquamous Cell Carcinoma
Squamous and adenosquamous cell carcinomas of the gallbladder are rare, and
the incidence ranges from 1.4% to 12.7%
[4]. Their clinical behavior
and clinicopathologic characteristics are very different from those of
adenocarcinoma. The tumors characteristically tend to arise from the
gallbladder fossa and present rapid and invasive growth, which results in
direct invasion into the liver and adjacent organs. In contrast to their
aggressive tendency and advanced stage, they usually do not present lymph node
metastasis or peritoneal seeding. Liver metastases are more frequently seen,
however, than with the adenocarcinoma
[4,
5]. CT scans may reveal a
heterogeneously enhancing mass in the gallbladder fossa with direct invasion
of the liver and/or other neighboring organs (Figs.
4A,
4B,
4C,
4D and
5). CT can also show biliary
obstruction, bowel obstruction, or perforation because of tumor invasion or
hepatic metastasis.
View larger version (122K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 4A —51-year-old woman with adenosquamous cell carcinoma. On
contrast-enhanced CT scan, huge heterogeneous enhancing mass replaces
gallbladder fossa and directly invades adjacent liver. Mass is composed of
endoluminal (arrow) and exophytic (E) mass with interrupted mucosal
lining.
|
|
View larger version (117K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 4B —51-year-old woman with adenosquamous cell carcinoma. On axial
T2-weighted MR image (TR/TE, 4/134), endoluminal mass (arrow) shows
low signal intensity, and exophytic mass (E) shows slightly high signal
intensity.
|
|
View larger version (109K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 4C —51-year-old woman with adenosquamous cell carcinoma. Axial
T1-weighted image (TR/TE, 149/4) shows two components, which are endoluminal
polypoid mass with high signal intensity (arrow) and huge exophytic
mass with low signal intensity (E).
|
|
View larger version (134K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 4D —51-year-old woman with adenosquamous cell carcinoma. On
gadolinium-enhanced coronal MR image, huge mass with peripheral rim
enhancement (arrows) replaces gallbladder fossa and invades adjacent
liver.
|
|
View larger version (139K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 5 —64-year-old man with squamous cell carcinoma.
Contrast-enhanced CT scan shows huge mass replacing gallbladder fossa (G) and
direct invasion of adjacent liver (L). No lymphadenopathy is noted.
|
|
Undifferentiated Carcinoma
Undifferentiated carcinoma has four histologic variants, including spindle
and giant cell type, osteoclast-like giant cell type, small cell type, and
nodular or lobular type. The most common and most anaplastic variant is
spindle and giant cell type, which has been referred to as sarcomatoid
carcinoma [1]. Undifferentiated
carcinoma of the gallbladder tends to form a large mass with central necrosis
and exhibits rapid growth with direct invasion into an adjacent organ. The
tumor is highly aggressive and shows progression to lymph node metastasis and
peritoneal dissemination. The prognosis is very poor
[6]. However, in our case, the
tumor was localized to the fundus of the gallbladder and no tumor recurrence
was evident at the 6-month follow-up (Figs.
6A,
6B, and
6C).
View larger version (92K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 6C —77-year-old woman with sarcomatoid carcinoma. Photograph of
gross pathologic specimen shows endoluminal mass in gallbladder with extensive
necrosis (N) and peripheral viable tumor (arrow).
|
|
Small Cell Carcinoma
Extrapulmonary small cell carcinoma has been found in various sites
including the gallbladder. Small cell carcinoma of the gallbladder is a
distinct but very rare tumor. It is more common in women and usually
associated with cholelithiasis
[1,
7]. The characteristic
morphologic features of small cell carcinoma of the gallbladder include a
large mass at presentation, extensive necrosis, and a propensity for
submucosal growth. It tends to metastasize in the early stage, which results
in death shortly after diagnosis. Sonographic imaging may reveal an echogenic
polypoid mass into the lumen or a contracted gallbladder with multiple
gallstones. CT may show a heterogeneous mass occupying the gallbladder fossa
(Fig. 7A) and metastases to
the lymph nodes, liver, pancreas, omentum, and peritoneum
[7] (Figs.
7B and
7C).
View larger version (119K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 7A —48-year-old woman with small cell carcinoma of gallbladder.
Contrast-enhanced CT scan shows heterogeneous enhancing mass (M) in
gallbladder fossa and adjacent gallbladder wall thickening with enhancement
(arrowhead). There are also noted multiple enlarged lymph nodes at
porta hepatis and along common hepatic artery.
|
|
Sarcoma
Malignant mesenchymal tumors include Kaposi's sarcoma, leiomyosarcoma,
malignant fibrous histiocytoma, angiosarcoma, and embryonal rhabdomyosarcoma.
Although the radiologic appearance of these tumors is rarely reported, MRI of
malignant fibrous histiocytoma in our series showed a large ill-defined mass
with extensive central necrosis (Figs.
8A and
8B).
View larger version (112K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 8A —70-year-old woman with malignant fibrous histiocytoma. Axial
T2-weighted MR image (TR/TE, 4/134) shows huge mass (arrows) in
gallbladder fossa with peripheral high signal intensity and central bright
signal intensity.
|
|
Lymphoma
Primary lymphoma of the gallbladder is defined as an extranodal lymphoma
localized to the gallbladder with or without contiguous lymph node
involvement. It is extremely rare with only approximately 13 cases reported
[1]. Sonography and CT show the
primary mass presenting as an intraluminal mass (Figs.
9A and
9B), a large mass replacing
the gallbladder, or diffuse wall thickening
(Fig. 10), along with
additional findings such as cholelithiasis or sludge
[8].
Metastases
Malignant melanoma is the most common cause of metastatic tumors of the
gallbladder, accounting for more than 50% of all cases of metastases found
there [9]. At sonography,
metastatic melanoma of the gallbladder may appear as single or multiple
hyperechoic masses greater than 1 cm in diameter, attached to the gallbladder
wall [9]. At CT, metastatic
melanoma may appear as a polypoid enhancing mass
(Fig. 11) or focal, irregular
wall thickening. Although most metastatic lesions are located on the serosal
surface because of peritoneal implantation, some metastatic masses present as
an intraluminal polypoid mass
[9]. Other primary tumors are
renal cell carcinoma and hepatocellular carcinoma
(Fig. 12).
View larger version (117K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 12 —62-year-old man with metastatic hepatocellular carcinoma of
gallbladder. Contrast-enhanced CT scan shows polypoid enhancing mass
(arrow) with adjacent wall thickening of gallbladder. There is also
noted hepatocellular carcinoma (arrowhead) containing iodized oil in
liver.
|
|
Conclusion
In conclusion, radiologic findings of unusual malignant gallbladder tumors
are varied and overlap with those of ordinary gallbladder carcinoma. Despite
their rarity, a familiarity with the wide spectrum of radiologic findings of
these unusual tumors and an understanding of their pathologic background may
lead to improved diagnostic accuracy.
References
- Albores-Saavedra J, Scoazec JC, Wittekind C, et al. Tumours of the
gallbladder and extrahepatic bile ducts. In: Hamilton SR, Aaltonen LA, eds.
World Health Organization classification of tumors: pathology and
genetics of tumours of the digestive system. Lyon, France: IARC,2000
: 204-217
- Levy AD, Murakata LA, Rohrmann CA Jr. Gallbladder carcinoma:
radiologic-pathologic correlation. RadioGraphics2001; 21:295
-314[Abstract/Free Full Text]
- Tian H, Matsumoto S, Takaki H, et al. Mucin-producing carcinoma of
the gallbladder: imaging demonstration in four cases. J Comput
Assist Tomogr 2003; 27:150
-154[CrossRef][Medline]
- Waisberg J, Bromberg SH, Franco MI, Yamagushi N, dos Santos PA,
Castro MA. Squamous cell carcinoma of the gallbladder. Sao Paulo
Med J 2001; 119:43[Medline]
- Miyazaki K, Tsutsumi N, Kitahara K, et al.
Hepatopancreatoduodenectomy for squamous and adenosquamous carcinoma of the
gallbladder. Hepatogastroenterology 1995;42
: 47-50[Medline]
- Kubota H, Kageoka M, Iwasaki H, et al. A patient with
undifferentiated carcinoma of gallbladder presenting with hemobilia.
J Gastroenterol 2000;35
: 63-68[CrossRef][Medline]
- Muraina OI, Tank R, Dhingra C, et al. Small cell carcinoma of
gallbladder: report of two cases. Am J Gastroenterol1996; 91:792
-794[Medline]
- Mitropoulos FA, Angelopoulou MK, Siakantaris MP, et al. Primary
non-Hodgkin's lymphoma of the gallbladder. Leuk
Lymphoma 2000; 40:123
-131[Medline]
- Guida M, Cramarossa A, Gentile A, et al. Metastatic malignant
melanoma of the gallbladder: a case report and review of the literature.
Melanoma Res 2002;12
: 619-625[CrossRef][Medline]
CiteULike 
Complore 
Connotea 
Del.icio.us 
Digg 
Reddit 
Technorati What's this?
This article has been cited by other articles:
|
|
|
|
 
D. M. Biko, S. A. Anupindi, A. Hernandez, L. Kersun, and R. Bellah
Childhood Burkitt Lymphoma: Abdominal and Pelvic Imaging Findings
Am. J. Roentgenol.,
May 1, 2009;
192(5):
1304 - 1315.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
J.-P. A. Martel, C. A. McLean, and R. N. Rankin
Best Cases from the AFIP: Melanoma of the Gallbladder1
RadioGraphics,
January 1, 2009;
29(1):
291 - 296.
[Full Text]
[PDF]
|
|
|
|
|
|
|
W.-K. Lee, E. W. F. Lau, V. A. Duddalwar, A. J. Stanley, and Y. Y. Ho
Abdominal Manifestations of Extranodal Lymphoma: Spectrum of Imaging Findings
Am. J. Roentgenol.,
July 1, 2008;
191(1):
198 - 206.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
O. A. Catalano, D. V. Sahani, S. P. Kalva, M. S. Cushing, P. F. Hahn, J. J. Brown, and R. R. Edelman
MR Imaging of the Gallbladder: A Pictorial Essay
RadioGraphics,
January 1, 2008;
28(1):
135 - 155.
[Abstract]
[Full Text]
[PDF]
|
|
|
Top
Abstract
Introduction
