DOI:10.2214/AJR.07.3599
AJR 2008; 191:1440-1447
© American Roentgen Ray Society
Gallbladder Carcinoma Update: Multimodality Imaging Evaluation, Staging, and Treatment Options
Alessandro Furlan1,2,
James V. Ferris1,
Keyanoosh Hosseinzadeh1 and
Amir A. Borhani1
1 Department of Radiology, University of Pittsburgh Medical Center (Presbyterian
Campus), 200 Lothrop St., Rm. 3950 CHP MT, Pittsburgh, PA 15213.
2 Present address: Istituto di Radiologia, Azienda Ospedaliero-Universitaria
"Santa Maria della Misericordia"di Udine, 33100 Udine (UD),
Italy.
Received December 28, 2007;
accepted after revision May 30, 2008.
Address correspondence to J. V. Ferris
(ferrisjv{at}upmc.edu).
CME
This article is available for CME credit. See
www.arrs.org
for more information.
Abstract
OBJECTIVE. The purpose of this article is to review the
epidemiology, multimodality imaging findings, differential diagnosis,
pathologic staging, and current treatment options of gallbladder
carcinoma.
CONCLUSION. Understanding the characteristic appearances of primary
gallbladder carcinoma at multiple imaging modalities can facilitate diagnosis
and enable more accurate staging for triage to extended resection or an
alternate therapy.
Keywords: CT • gallbladder neoplasm • MRI • PET • sonography
Introduction
Gallbladder carcinoma is the fifth most common gastrointestinal malignancy
and the most common biliary tract malignancy worldwide. Imaging detection at
early stages of gallbladder carcinoma remains elusive. Clinical presentation
of the disease is often vague or delayed relative to pathologic progression,
contributing to advanced staging and dismal prognosis at the time of diagnosis
[1]. Preoperative imaging for
tumor recognition and noninvasive staging is essential to triage patients to
appropriate care and has become more reliable as advances in CT, MRI, and PET
have occurred [2]. This article
reviews the epidemiology, multimodality imaging findings, differential
diagnosis, pathologic staging, and current treatment options of gallbladder
carcinoma.
Epidemiology, Pathogenesis, and Clinical Presentation
Gallbladder carcinoma occurs in three per 100,000 people in the United
States and is more common in the elderly and in women. Well- to moderately
differentiated adenocarcinoma accounts for the most common form of gallbladder
carcinoma. Predisposing risk factors include cholelithiasis, chronic biliary
infections (Opisthorchis viverrini, Salmonella typhi), primary
sclerosing cholangitis, and porcelain gallbladder
[3]. The exact pathogenesis
remains unclear, although pooling of carcinogens in conditions causing biliary
stasis or malignant degeneration of metaplastic changes after chronic
inflammation are suggested mechanisms
[1]. The clinical presentation
of gallbladder carcinoma is nonspecific and may include abdominal pain, weight
loss, fever, and jaundice, any of which can be seen in cholecystitis and other
benign gallbladder conditions as well as in other abdominal malignancies
[1,
2]. Approximately 2% of
patients with gallbladder carcinoma are diagnosed incidentally at
histopathology after cholecystectomy is performed for cholelithiasis,
cholecystitis, or biliary dyskinesia
[4].
Imaging Findings
In cases of suspected gallbladder disease, sonography is often the first
imaging technique because of its relatively low cost and widespread
availability [2,
5]. Although sonography has a
relatively high sensitivity for the detection of tumor at advanced stages, it
is limited in the diagnosis of early lesions and is unreliable for staging.
Therefore, CT and, increasingly, MRI are more widely used for further
characterization of potentially malignant gallbladder lesions and metastatic
survey
[6–8].
Gallbladder carcinoma may appear at any of these imaging techniques as a mass
completely occupying or replacing the gallbladder lumen, focal or diffuse
asymmetric gallbladder wall thickening, or an intraluminal polypoid lesion
[9].
Mass Occupying or Replacing the Gallbladder Lumen
This pattern may be present in 40–65% of patients with gallbladder
carcinoma at initial detection
[9]. On sonography, CT, or MRI,
the presence of a large gallbladder mass that nearly fills or replaces the
lumen, often directly invading the surrounding liver parenchyma, is highly
suggestive of gallbladder carcinoma
[2]. On sonography,
heterogeneous, predominantly hypoechoic tumor fills much or all of the
gallbladder lumen (Fig. 1A).
Anechoic foci of trapped bile or necrotic tumor may be present, as well as
echogenic shadowing foci from gallstones, porcelain gallbladder, or tumor
calcifications [5].
View larger version (158K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1A —70-year-old woman with abdominal pain and weight loss.
Sonogram shows large heterogeneous mass (arrowheads) replacing
gallbladder lumen that is consistent with biopsy-proven gallbladder
carcinoma.
|
|
Primary gallbladder carcinoma is usually hypodense on unenhanced CT, with
up to 40% of lesions showing hypervascular foci of enhancement equal to or
greater than that of liver after IV contrast administration
[6,
7] (Figs.
1B and
1C). On MRI, gallbladder
carcinoma usually shows hypo- to isointense signal characteristics on
T1-weighted and moderately hyperintense signal characteristics on T2-weighted
sequences
[9](Fig.
2). On CT or MRI, intense irregular enhancement may occur at the
periphery of large primary gallbladder carcinoma lesions during the early
arterial phase. Contrast enhancement may be retained in fibrous stromal
components of gallbladder carcinoma during the portal venous and delayed
phases (Fig. 3A,
3B), aiding differentiation
from large central hepatocellular carcinomas, which have a greater tendency to
washout contrast material
[10]. Intermixed fluid and
calcific components, if present on CT or MRI, have similar implications as
when seen on sonography. At PET, an intense accumulation of 18F-FDG
in the region of the gallbladder suggests malignancy, although it lacks
specificity in distinguishing primary gallbladder carcinoma from other
malignant lesions [11,
12] (Fig.
4A,
4B).
View larger version (152K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1B —70-year-old woman with abdominal pain and weight loss.
Contrast-enhanced CT scan during hepatic arterial phase shows primary
gallbladder carcinoma as large necrotic mass (asterisk) replacing
gallbladder lumen and extending into adjacent liver parenchyma
(arrowhead). Note hypervascularity in tumor periphery
(arrow).
|
|
View larger version (157K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1C —70-year-old woman with abdominal pain and weight loss.
Contrast-enhanced CT scan during portal venous phase at same anatomic level
asB shows some contrast retention in periphery of primary tumor
(arrow) and liver metastasis (arrowhead).
|
|
View larger version (147K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 2 —68-year-old woman with cirrhosis undergoing MRI for tumor
screening. Axial fast spin-echo T2-weighted MR image shows hyperintense mass
(arrow) occupying gallbladder lumen and extending into adjacent liver
parenchyma (arrowheads) with similar signal intensity. Biopsy proved
this to be gallbladder carcinoma.
|
|
View larger version (183K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 3A —59-year-old man with fever and anorexia. Contrast-enhanced CT
scan during hepatic arterial phase shows large carcinoma replacing gallbladder
lumen (asterisk) and intense enhancement in viable periphery
(arrow) and adjacent liver metastasis (arrowhead).
|
|
View larger version (153K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 3B —59-year-old man with fever and anorexia. Contrast-enhanced CT
scan during portal venous phase shows hypodense necrotic component
(asterisk) and contrast retention in viable portions of primary tumor
(arrow) and adjacent liver metastasis (arrowhead).
|
|
View larger version (173K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 4A —63-year-old woman with elevated liver function test results
and remote history of breast carcinoma. Contrast-enhanced CT image shows large
gallbladder mass (arrows) and adjacent liver lesions
(arrowhead) that are more suggestive of advanced gallbladder
carcinoma than suspected breast metastases.
|
|
View larger version (135K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 4B —63-year-old woman with elevated liver function test results
and remote history of breast carcinoma. PET/CT image at same anatomic level as
A shows intense 18F-FDG uptake in gallbladder
(arrows) and hepatic extension (arrowhead) of tumor.
Percutaneous biopsy with sonography confirmed gallbladder carcinoma.
|
|
The differential diagnosis of a mass nearly filling or replacing the
gallbladder lumen includes malignancies located centrally in the liver that
have invaded the gallbladder fossa, such as hepatocellular carcinoma
(Fig. 5), cholangiocarcinoma,
and metastatic disease.
View larger version (176K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 5 —45-year-old man with alcoholic cirrhosis and biopsy-proven
hepatocellular carcinoma. Contrast-enhanced CT scan during portal venous phase
shows large right hepatic lobe mass (white arrow) directly invading
gallbladder (asterisk) and portal vein (black arrow), which
may mimic gallbladder carcinoma.
|
|
Focal or Diffuse Asymmetric Wall Thickening
Gallbladder carcinoma may present as focal or diffuse asymmetric wall
thickening in 20–30% of cases
[6] (Figs.
6A,
6B,
6C,
6D and
7). Gallbladder wall
thickening can have an expansive differential diagnosis, including acute and
chronic cholecystitis (Fig.
8A), xanthogranulomatous cholecystitis (Figs.
8B and
8C), and adenomyomatosis
(Fig. 8D), as well as diffuse
hepatic or systemic diseases such as acute hepatitis, portal hypertension, and
congestive heart failure [13].
Conventional cross-sectional imaging may be limited in differentiating
gallbladder carcinoma from chronic cholecystitis; however, at
contrast-enhanced CT and MRI, diffuse symmetric wall thickening suggests a
nonneoplastic process, whereas asymmetric, irregular, or extensive thickening
which may have marked enhancement during the arterial phase that persists or
becomes isodense or isointense to the liver during the portal venous phase
should heighten suspicion of gallbladder carcinoma
[7,
10]. Gallbladder carcinoma may
arise as a nidus in preexisting background chronic cholecystitis, which can
obscure or delay the diagnosis of cancer
(Fig. 9). FDG PET may be
limited in this setting because benign inflammatory lesions can accumulate FDG
and result in false-positive interpretations
[11].
View larger version (111K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 6A —57-year-old woman with abdominal pain and jaundice. Sonogram
shows heterogeneously hypoechoic, asymmetric thickening of gallbladder wall
(straight arrows) and intraluminal gallstones (arrowhead).
Hypoechoic hepatic lesion (curved arrow) further supports presumptive
diagnosis of gallbladder carcinoma.
|
|
View larger version (171K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 6B —57-year-old woman with abdominal pain and jaundice.
Contrast-enhanced CT scan shows corresponding appearance of asymmetric
gallbladder wall thickening (arrows) and liver metastasis
(arrowhead), although gallstones were not apparent.
|
|
View larger version (174K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 6C —57-year-old woman with abdominal pain and jaundice.
Contrast-enhanced CT scan more cephalad than B shows adenopathy
(arrowhead) and bilateral adrenal metastases (arrows),
denoting stage IV or unresectable disease.
|
|
View larger version (131K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 6D —57-year-old woman with abdominal pain and jaundice.
Sonographically guided percutaneous 18-gauge core biopsy (arrow) of
gallbladder wall (asterisk) confirmed gallbladder carcinoma. Note
layering gallstones in gallbladder lumen (arrowhead).
|
|
View larger version (153K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 7 —78-year-old man undergoing further evaluation of gallbladder
lesion reported on sonography performed at outside institution.
Gadolinium-enhanced coronal T1-weighted MR image during equilibrium phase
shows gallbladder partially filled with sludge (arrowhead),
asymmetric irregular wall thickening, and delayed enhancement
(arrow).
|
|
View larger version (127K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 8A —Common benign causes of gallbladder wall thickening.
40-year-old woman with chronic cholecystitis that was histologically proven
after surgical resection. Axial T2-weighted MR image shows hyperintense and
symmetric gallbladder wall thickening (arrow).
|
|
View larger version (113K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 8B —Common benign causes of gallbladder wall thickening.
49-year-old man with xanthogranulomatous cholecystitis proven at
cholecystectomy. Color Doppler sonogram (B) shows gallbladder lumen
with diffuse wall thickening (arrowheads, B) and intramural
hyperechoic nodule (arrow, B) with acoustic shadowing
corresponded at pathology to xanthogranuloma. Coronal T2-weighted MR image
(C) shows xanthogranulomas as multiple intramural nodules
(arrows, C). Note presence of sludge in gallbladder lumen
(asterisk).
|
|
View larger version (175K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 8C —Common benign causes of gallbladder wall thickening.
49-year-old man with xanthogranulomatous cholecystitis proven at
cholecystectomy. Color Doppler sonogram (B) shows gallbladder lumen
with diffuse wall thickening (arrowheads, B) and intramural
hyperechoic nodule (arrow, B) with acoustic shadowing
corresponded at pathology to xanthogranuloma. Coronal T2-weighted MR image
(C) shows xanthogranulomas as multiple intramural nodules
(arrows, C). Note presence of sludge in gallbladder lumen
(asterisk).
|
|
View larger version (159K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 8D —Common benign causes of gallbladder wall thickening.
49-year-old woman with right upper quadrant pain. Contrast-enhanced CT scan
shows focal gallbladder wall thickening with intramural diverticulum
(arrow). Subsequent cholecystectomy for cholelithiasis confirmed
adenomyoma.
|
|
View larger version (153K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 9 —51-year-old woman with primary sclerosing cholangitis
undergoing evaluation for liver transplantation. Contrast-enhanced CT scan
during portal venous phase shows focal nodular thickening (arrow) and
diffuse gallbladder wall thickening, proven at cholecystectomy to be T2
carcinoma and background chronic cholecystitis, respectively. Note cirrhosis
and varices (asterisk).
|
|
Intraluminal Polyp
The initial detection of gallbladder carcinoma as a polypoid lesion occurs
in 15–25% of cases [1,
2]. Malignant lesions are
usually larger than 1 cm in diameter and may have a thickened implantation
base [2] (Figs.
10A,
10B and
11). The differential
diagnosis of a polypoid gallbladder lesion includes adenomatous or
hyperplastic cholesterol polyps as well as uncommon tumors such as carcinoid
or metastases such as melanoma (Fig.
12A,
12B). At sonography, if
movement of a polypoid mass occurs with a change of the patient's position,
then a pseudotumor of biliary sludge or clot can be diagnosed
[5].
View larger version (116K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 10A —81-year-old woman with weight loss. Sonogram shows
hyperechoic shadowing portions of gallbladder wall (arrowheads)
consistent with porcelain gallbladder and hypoechoic, polypoid, nondependent
mass (arrow) suggestive of malignant degeneration into gallbladder
carcinoma.
|
|
View larger version (138K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 11 —70-year-old man undergoing CT for suspected abdominal aortic
aneurysm. Contrast-enhanced CT scan during portal venous phase shows enhancing
3-cm polypoid gallbladder mass (arrow) that was proven at
cholecystectomy to be gallbladder carcinoma.
|
|
View larger version (133K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 12B —42-year-old man with malignant melanoma. PET/CT image
corresponding to A shows intense 18F-FDG uptake in proven
melanoma metastases to gallbladder (arrow) and lymph nodes
(asterisk), which mimic primary gallbladder carcinoma with nodal
metastasis.
|
|
Preoperative Evaluation and Staging
MDCT is now widely available and has a reported accuracy of up to 84% in
determining local extent or the T stage of primary gallbladder carcinoma
[14] and 85% in predicting
resectability through its ability to delineate hepatic and vascular invasion,
lymphadenopathy, and distant metastases
[15]. MDCT is commonly
performed as unenhanced and iodinated contrast-enhanced studies during the
hepatic arterial and portal venous phases, from which multiplanar and 3D
volume-rendered reconstruction images may be generated to provide a vascular
road map, as well as coronal oblique images that are useful for surgical
planning [15]. Kim et al.
[16] suggest that an
all-in-one protocol supplementing MRI with cholangiographic (MR
cholangiopancreatography) and contrast-enhanced arterial and portal phase 3D
angiographic (MR angiography) images may be up to 100% sensitive for bile duct
and vascular invasion, yet sensitivity falls to 67% for hepatic invasion and
56% for lymph node metastases. PET/CT has a promising role in the detection of
unsuspected metastases, which may alter staging and therapy
[2,
11,
12]. To date, prospective
studies that directly compare CT, MRI, and PET/CT in their ability to diagnose
and stage gallbladder carcinoma have not been performed.
The spread of gallbladder carcinoma to the liver and adjacent organs is
facilitated by the lack of a muscularis mucosa and submucosa in the
gallbladder wall and its direct venous drainage through the liver parenchyma
to the hepatic veins. According to the sixth edition of American Joint
Committee on Cancer staging manual for gallbladder carcinoma
[17], primary gallbladder
carcinoma can be classified as T1, confined to the lamina propria or the
muscle layer of the gallbladder (T1A and T1B, respectively); T2, extending to
the serosa; T3, perforating the serosa or directly invading the liver or one
other adjacent structure (stomach, duodenum, colon, pancreas, omentum,
extrahepatic bile ducts); or T4, invading the main portal vein, the hepatic
artery, or multiple extrahepatic organs
(Fig. 13). Lymphatic spread is
present in more than 50% of patients at initial diagnosis and first reaches
cystic, pericholedochal, hilar, periduodenal, peripancreatic, and superior
mesenteric nodes, which are considered regional or N1 nodes
(Fig. 14). Portacaval,
interaortocaval, and more distant nodes are considered distant or M1
disease.
View larger version (175K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 13 —80-year-old woman referred for surgical consideration after
sonography performed at outside institution suggested gallbladder carcinoma
(not shown). Contrast-enhanced CT scan shows large gallbladder mass
(asterisk) directly invading liver (arrow), duodenum (D),
omentum (O), and colon (C), denoting stage IV (unresectable) disease.
|
|
View larger version (181K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 14 —76-year-old man with suspected gallbladder carcinoma
undergoing staging CT. Contrast-enhanced CT scan shows hypodense polypoid
gallbladder mass (black arrow) extending to surrounding liver (T3)
(arrowhead) and adenopathy (white arrows).
|
|
Gallbladder carcinoma can also disseminate via intraductal spread along the
cystic duct (Fig. 15A),
hematogenous and neural pathways, and intraperitoneal "drop"
metastases [1]
(Fig. 15B). T1 or T2 primary
lesions without nodal metastasis are classified as stage IA or IB disease,
respectively. T3 lesions without nodal spread are stage IIA. T1, T2, or T3
lesions with N1 lymph node involvement are defined as stage IIB. A T4 lesion
without distant metastasis is considered stage III. Any patient with distant
disease automatically becomes stage IV.
View larger version (169K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 15A —61-year-old woman with primary sclerosing cholangitis,
abdominal pain, and weight loss. Contrast-enhanced CT image shows superior
aspect of primary gallbladder carcinoma (arrowheads) with intraductal
growth via cystic duct to common duct (arrow).
|
|
View larger version (182K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 15B —61-year-old woman with primary sclerosing cholangitis,
abdominal pain, and weight loss. Contrast-enhanced CT image shows enhancing
mixed cystic and solid bilateral ovarian masses (arrows) that were
confirmed at biopsy via transvaginal sonography to be metastases from
gallbladder carcinoma.
|
|
Treatment and Prognosis
Because small hepatic, peritoneal, and omental tumor implants can be missed
at preoperative imaging, thorough laparoscopic or open exploration should
precede aggressive surgery, either at the same or at an earlier operation
[18]. Most surgeons and
oncologists agree that patients with stage I gallbladder carcinoma who are
surgical candidates may benefit from extended resection after cholecystectomy,
which includes resection of hepatic margins bordering the gallbladder fossa
and en bloc nodal dissection
[1,
18]. At major hepatobiliary
centers, patients with stage IIA or IIB disease may still undergo exploration
and subsequent resection if metastasis is confined to minimal adjacent liver
or choledochal nodes, although the role of radical dissection for T3 and T4
lesions is controversial [1,
18].
External beam radiation therapy and systemic chemotherapy have improved
survival in patients with negative resection margins, whereas patients with
positive microscopic margins or residual disease show no added benefit from
chemotherapy and are offered adjuvant radiation therapy only
[19]. Although up to 60% of
patients with gallbladder carcinoma who undergo extended resection may survive
5 years, the overall prognosis is only 13%
[20]. In patients with
disseminated disease or medical contraindications to surgery, imaging-guided
percutaneous biopsy for tissue confirmation can be performed before palliative
therapy, experimental trials, or hospice referral. Further investigation is
needed to determine whether chemotherapy or radiation therapy can improve
survival of patients with locally advanced gallbladder carcinoma or be used
preoperatively to reliably downstage certain cases
[18,
19].
Summary
The clinical and radiologic detection of gallbladder carcinoma at a
curative stage remains problematic. It is imperative for radiologists to
closely scrutinize the gallbladder, particularly in patients who are at
increased risk of developing gallbladder carcinoma, for subtle morphologic
abnormalities that may indicate cancer. Recognition of the characteristic
imaging appearances of primary gallbladder carcinoma and understanding its
pathways of spread and staging criteria help optimize patient triage to
appropriate treatment regimens.
References
- Reid KM, Ramos-De la Medina A, Donohue JH. Diagnosis and surgical
management of gallbladder cancer: a review. J Gastrointest
Surg 2007; 11:671
–681[CrossRef][Medline]
- Rodríguez-Fernádez A, Gómez-Río M,
Medina-Benitez A, et al. Application of modern imaging methods in diagnosis of
gallbladder cancer. J Surg Oncol 2006;93
: 650–664[CrossRef][Medline]
- Strom BL, Soloway RD, Rios-Dalenz JL, et al. Risk factors for
gallbladder cancer: an international collaborative case-control study.
Cancer 1995; 76:1747
–1756[CrossRef][Medline]
- Matsusaka S, Yamasaki H, Kitayama Y, et al. Occult gallbladder
carcinoma diagnosed by a laparoscopic cholecystectomy. Surg
Today 2003; 33:740
–742[CrossRef][Medline]
- Tsuchiya Y. Early carcinoma of the gallbladder: macroscopic
features and sonography findings. Radiology1991; 179:171
–175[Abstract/Free Full Text]
- Franquet T, Montes M, Ruiz de Azua Y, Jimenez FJ, Cozcolluela R.
Primary gallbladder carcinoma: imaging findings in 50 patients with pathologic
correlation. Gastrointest Radiol 1991;16
: 143–148[CrossRef][Medline]
- Yun EJ, Cho SG, Park S, et al. Gallbladder cancer and chronic
cholecystitis: differentiation with two-phase spiral CT. Abdom
Imaging 2004; 29:102
–108[Medline]
- Demachi H, Matsui O, Hoshiba K, Kimura M, Miyata S, Kuroda Y.
Dynamic MRI using a surface coil in chronic cholecystitis and gallbladder
carcinoma: radiologic and histopathologic correlation. J Comput
Assist Tomogr 1997; 21:643
–651[CrossRef][Medline]
- Levy AD, Murakata LA, Rohrmann CA. Gallbladder carcinoma:
radiologic–pathologic correlation. RadioGraphics2001; 21:295
–314[Abstract/Free Full Text]
- Yoshimitsu K, Honda H, Kaneko K, et al. Dynamic MRI of the
gallbladder lesions: differentiation of benign from malignant. J
Magn Reson Imaging 1997; 7:696
–701[Medline]
- Koh T, Taniguchi H, Yamaguchi A, Kunishima S, Yamagishi H.
Differential diagnosis of gallbladder cancer using positron emission
tomography with fluorine-18-labeled fluoro-deoxyglucose (FDG-PET).
J Surg Oncol 2003;84
: 74–81[CrossRef][Medline]
- Corvera CU, Blumgart LH, Akhurst T, et al.
18F-fluorodeoxyglucose positron emission tomography influences
management decision in patients with biliary cancer. J Am Coll
Surg 2008; 206:57
–65[CrossRef][Medline]
- van Breda Vriesman AC, Engelbrecht MR, Smithuis RH, Puylaert JB.
Diffuse gallbladder wall thickening: differential diagnosis.
AJR 2007; 188:495
–501[Abstract/Free Full Text]
- Kim SJ, Lee JM, Lee JY, et al. Accuracy of preoperative T-staging
of gallbladder carcinoma using MDCT. AJR2008; 190:74
–80[Abstract/Free Full Text]
- Kalra N, Suri S, Gupta R, et al. MDCT in the staging of gallbladder
carcinoma. AJR 2006;186
: 758–762[Abstract/Free Full Text]
- Kim JH, Kim TK, Kim BS, et al. Preoperative evaluation of
gallbladder carcinoma: efficacy of combined use of MR imaging, MR
cholangiography, and contrast-enhanced dual-phase three-dimensional MR
angiography. J Magn Reson Imaging 2002;16
: 676–684[CrossRef][Medline]
- Greene FL, Fleming ID, Fritz A, et al. AJCC cancer
staging manual, 6th ed. New York, NY: Springer,2002
: 139–142
- Mekeel KL, Hemming AW. Surgical management of gallbladder
carcinoma: a review. J Gastrointest Surg2007; 11:1188
–1193[CrossRef][Medline]
- Kresl JJ, Schild SE, Henning GT, et al. Adjuvant external beam
radiation therapy with concurrent chemotherapy in the management of
gallbladder carcinoma. Int J Radiat Oncol Biol Phys2002; 52:167
–175[CrossRef][Medline]
- Ito H, Matros E, Brooks DC, et al. Treatment outcomes associated
with surgery for gallbladder cancer: a 20-year experience. J
Gastrointest Surg 2004; 8:183
–190[CrossRef][Medline]
CiteULike 
Complore 
Connotea 
Del.icio.us 
Digg 
Reddit 
Technorati What's this?
Top
Abstract
Introduction
