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Gallbladder: Tumors Imaging Pearls - Educational Tools | CT Scanning | CT Imaging | CT Scan Protocols - CTisus
Imaging Pearls ❯ Gallbladder ❯ Tumors

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  • “Gallbladder disease is very common and presents in a variety of ways due to a wide range of pathologies.Most common forms of disease can be broadly classified into several categories: calculousdisease, infection, inflammation, neoplasia,miatrogenic complications, and trauma. Calculous disease encompasses gallstones and their complications. Gallbladder infection results in suppurative cholecystitis, emphysematous cholecystitis, and gangrenous cholecystitis, while additional forms of cholecystitis and porcelaingallbladder are related to inflammatory causes. Gallbladder neoplasia includes a myriad of benignand malignant lesions. Finally, iatrogenic and traumaticprocesses can result in complications suchas abscess formation, fistulas, hematomas, bile leaks, perforation, and torsion.”
    Gallbladder Imaging Interpretation Pearls and Pitfalls Ultrasound, Computed Tomography, and Magnetic Resonance Imaging
    Sergio P. Klimkowski et al.
    Radiol Clin N Am - (2022) (in press)
  • • Clinical history, physical examination, and laboratory values are important in the accurate imaging assessment of the right upper quadrant due to significant overlap in imaging features of both benign and malignant etiologies.  
    • Ultrasound is commonly the first-line modality of choice for the imaging evaluation of right upper quadrant pain.  
    • Cross-sectional imaging provides a more global view of the right upper quadrant with the benefit of evaluating the entire abdomen.
    Gallbladder Imaging Interpretation Pearls and Pitfalls Ultrasound, Computed Tomography, and Magnetic Resonance Imaging
    Sergio P. Klimkowski et al.
    Radiol Clin N Am - (2022) (in press)
  • • Gallbladder wall thickening is nonspecific and  hould be considered with other clinical information including presence of positive Murphy’s sign, focality, hemodynamic status,presence or absence of heart failure andhypoproteinemia.  
    • Small bowel should be carefully examined oncross sectional imaging for obstructing stonesin cases of suspected gallstone ileus or in casesof suspected biliary-enteric fistulas (though may be difficult to identify if stones are relatively radiolucent).  
    • Distinguishing gallbladder neoplasia fromchronic inflammatory changes can be difficult.Signs such as high ADC values, irregular margins and invasive appearance tend tofavor malignancy.Inflammatory changes can mask underlying malignancy
    Gallbladder Imaging Interpretation Pearls and Pitfalls Ultrasound, Computed Tomography, and Magnetic Resonance Imaging
    Sergio P. Klimkowski et al.
    Radiol Clin N Am - (2022) (in press)
  • “Gallbladder cancer can present as focal wall thickening, a mass, or a polyp, and distinguishing benign gallbladder disease from gallbladder cancer is sometimes challenging. This presents a significantdiagnostic dilemma with an impact on patient management, specifically because resectable gallbladder cancer requires resection of hepatic segments 4 and 5 at the time of cholecystectomy to offer the best surgical outcome.Common risk factors for gallbladder cancer include gallstone disease, polyps greater than 1.5 cm, chronic gallbladder inflammatory changes, chronic cholecystitis, obesity, and porcelain gallbladder.44 Clinical presentations are nonspecific and overlap with benign gallbladder disease.”
    Gallbladder Imaging Interpretation Pearls and Pitfalls Ultrasound, Computed Tomography, and Magnetic Resonance Imaging
    Sergio P. Klimkowski et al.
    Radiol Clin N Am - (2022) (in press)
  • Gallbladder Pathology: Neoplastic
    - Gallbladder adenoma
    - Gallbladder cancer
    - Metastasis to gallbladder
  • Pattern Based Approach
    - Intraluminal mass
    - Focal wall thickening
    - Diffuse wall thickening
    - Mass replacing the gallbladder
  • Intraluminal Mass
    - Polyp
    - Adenoma
    - Adenomyoma
    - Xanthogranulomatous Cholecystitis
    - Gallbladder Cancer
    - Metastasis
  • Gallbladder Adenoma
    - Rare benign tumor
    - pyloric gland, intestinal, biliary
    - pyloric gland type can be dysplastic
    - intestinal and biliary have higher rates of malignant degeneration
  • Gallbladder Cancer
    - Most are aggressive, advanced adenocarcinoma
    - Surgical resection yields 50% survival at 5 years
    - Nonsurgical patients have 5% survival at 5 years
  • Gallbladder Cancer
    1. Morphologies at CT and US:
    - Polypoid intraluminal mass
    - Tumor filling gallbladder lumen
    - Wall thickening (focal or diffuse)
    - Mass replacing gallbladder
    2. MDCT 84% accurate for staging
    3. MPRs increase accuracy
  • Metastases to Gallbladder
    - Melanoma
    - Renal cell carcinoma
    - Breast cancer
    - Gastrointestinal (stomach, colon)
    - Lung
  • Focal Wall Thickening
    - Adenomyomatosis
    - Xanthogranulomatous cholecystitis
    - Gallbladder cancer
    - Metastatic melanoma
  • Diffuse Wall Thickening
    - Acute Cholecystitis
    - Chronic Cholecystitis
    - Xanthogranulomatous cholecystitis
    - Cancer
  • Diffuse Wall Thickening
    - pancreatitis
    - hepatitis
    - perforated duodenal ulcer
    - right-sided diverticulitis
    - right-sided pylenonephritis
    - congestive heart failure
    - cirrhosis
    - renal failure
    - hypoalbuminemia
  • Porcelain Gallbladder
    1. 0.06-0.8% of resected GB
    2. Cause unknown
    - Associated with cholelithiasis
    3. 6th decade, M:F = 5:1
    4. Cancer incidence 12-62%
    - Data from 1950-1960’s
    5. Large cholecystectomy series show cancer in 7% of porcelain GB
    6. Resection still recommended
  • Mass Replacing Gallbladder
    - Gallbladder cancer
    - Hepatocellular cancer
    - Cholangiocarcinoma
    - Metastatic disease
  • Gallbladder Cancer
    1. >50% local invasion of liver
    2. 15-20% infiltrate bowel (colon, duodenum)
    3. 52% biliary dilatation
    4. ~1/3 adenopathy
    - cystic, choledochal, peripancreatic
    5. 16% ascites
  • Extension of GB Cancer: Which of the following is resectable??
    - Right or left portal vein 
    - Right or left hepatic artery 
    - Concomitant ipsilateral hepatic artery and portal vein
    - 2 contiguous segments in both lobes
    - All of the above
  • Extension of GB Cancer: Which of the following is resectable??
    - Right or left portal vein 
    - Right or left hepatic artery 
    - Concomitant ipsilateral hepatic artery and portal vein
    - 2 contiguous segments in both lobes
    - All of the above
  • Periampullary Mass
    - ~ within 2 cm of the major duodenal papilla
    - Pancreatic cancer
    - Ampullary cancer
    - Extrahepatic cholangiocarcinoma
    - Duodenal cancer
    - Adenopathy
  • Periampullary Mass: 5 yr prognosis
    - Pancreatic adenocarcinoma        6-26%
    - Ampullary adenocarcinoma        33-48%
    - Bile duct cholangiocarcinoma        13-43%
    - Duodenal adenocarcinoma        32-60%
  • Ampullary Adenocarcinoma
    1. Primary ampullary adenocarcinoma is rare
    2. Traditionally assigned better prognosis than other pancreatic cancer and cholangiocarcinoma
    3. New research: different histologic subtypes
    - intestinal vs pancreaticobiliary impacts survival
    - intestinal behaves like duodenal counterparts
    - pancreaticobiliary more aggressive
  • Periampullary Cancer
    1. Patterns of growth differ
    2. Ampullary cancer
    - 40% intraluminal growth 
    - 60% invade the extraductal region
    3. Pancreatic cancer grow
    - 2% extend intraluminally into the duct
    - 98% invades the extraductal region 
  • CBD Cholangiocarcinoma: Risk Factors
    1. Cystic diseases (Caroli’s disease, polycystic liver disease)
    2. Primary sclerosing cholangitis
    3. Ulcerative colitis
    4. Exposure to chemicals (i.e. thorotrast)
    5. Medication 
    - oral contraceptives
    - methyldopa
  • CBD Cholangiocarcinoma
    - T1    Tumor confined to bile duct histologically   
    - T2    Tumor beyond the wall of bile duct   
    - T3    Tumor invades liver, GB, pancreas, but no involvement of celiac axis, or the superior mesenteric artery   
    - T4    Tumor involves the celiac axis or the superior mesenteric artery    
  • CBD Cholangiocarcinoma: CT
    - Thickened, enhancing bile duct wall
    - Papillary or nodular mass
    - Intrahepatic bile duct dilatation









  • Gallbladder Cancer: Facts

    - 6500 new cases per year in the USA
    - 4:1 female to male ratio
    - Peak incidence is in the 6th and 7th decades of life
    - On CT a mass filling in the gallbladder lumen is most common and a polypoid mass is the 2nd most common appearance

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