Gallbladder carcinoma
- Philips Australia, Paid speaker at Philips Spectral CT events (ongoing)
Updates to Article Attributes
Gallbladder carcinoma is a type of gallbladder cancer and specifically refers to primary epithelial malignancies arising from the gallbladder, in which the great majority (90%) are adenocarcinomas and the remainder are squamous cell carcinomas. They are more prevalent in elderly women and, in most cases, are only symptomatic when in advanced stages.
On imaging, they can present as a focal intraluminal mass, focal or diffuse gallbladder wall irregular thickening, or large mass lesion replacing the entire gallbladder. It is not uncommon to depict those tumours with some degree of invasion of adjacent structures or metastatic disease.
Epidemiology
Although overall uncommon, gallbladder adenocarcinoma is the most common primary biliary carcinoma and the 5th most common malignancy of the gastrointestinal tract 1.
Predominantly affects older persons with long-standing cholecystolithiasis, and as such is most common in elderly women (>60 years of age, F:M ratio = 4:1)1,3.
Risk factors
Risk factors include 1:
gallstones
areare seen in 70-90% of cases 3,4gallbladder polyps>1 cm that are sessile and solitary
certain ethnicities and geographical groups (e.g. Native Americans and Chileans)16
chronic infections including the typhoid carrier state 16
obesity, diabetes mellitus, and dietary factors 17
family history of gallbladder carcinoma 18
Clinical presentation
Early in the course of the disease, patients are invariably asymptomatic, and as such a therapeutic window is usually missed. Eventually, symptoms develop, at which time the mass is usually not resectable.
Clinical presentation depends on the direction in which the mass extends. In cases where the biliary obstruction is created then jaundice is often the first presentation. If the malignancy is located in the gallbladder's body or fundus, extending into the liver or adjacent colon or small bowel can lead to local pain or bowel obstruction, respectively.
Other symptoms include right upper quadrant pain, weight loss and anorexia.
Pathology
Over 90% of cases of gallbladder cancer are adenocarcinomas, with the majority related to chronic inflammatory metaplasia and dysplasia 15. Squamous cell carcinomas figure as the second most common histologic type of gallbladder carcinoma (representing up to 3% of all gallbladder primary malignancies) 19.
Radiographic features
Gallbladder adenocarcinomas present in one of three morphologies 19:
intraluminal mass
diffuse mural thickening
-
mass replacing the gallbladder
presumably the end result of progression from either 1 or 2
most common presentation
Gallstones are commonly present (60%–90%)14.
Ultrasound
Ultrasound can depict a focal intraluminal, wall involvement, or large mass-like lesion replacing the gallbladder. The tumour usually has irregular and sometimes ill-defined margins, with with heterogeneous echotexture and predominantly low echogenicity. Hyperechoic Hyperechoic foci with posterior acoustic shadowing may be seen within the mass, possibly reflecting gallstones or gallbladder wall calcifications (porcelain gallbladder) 19.
CT
In cases with strong suspicion of gallbladder cancer or biliary tract disease, arterial phase (at 20 to 30 seconds) and venous phase (50 to 60 seconds) can be acquired. When there is an incidental finding of gall bladdergallbladder cancer and no suspicion of biliary tract cancer, only venous phase is required 21.
In plain CT scan, gallbladder cancer is typically hypodense. It shows irregular, peripheral enhancement on arterial phase 21.
Typically gallbladder adenocarcinomas appear as large heterogeneous masses 21, which may have engulfed gallstones or areas of necrosis. Patchy moderate contrast enhancement is usually seen.
Features of advanced disease include 22:
intrahepatic biliary dilatation
invasion of adjacent structures
lymphadenopathy
hepatic and other distant metastases
MRI
Dynamic MRI is considered useful and reliable in staging advanced gallbladder carcinoma. MRI combined with MRCP is sensitive in detecting obstructive jaundice, liver invasion, and hepatic and lymph nodal metastasis. It may be more difficult to delineate any invasion into the duodenum or to detect omental metastasis by MRI 6. Reported sensitivity rates for direct hepatic invasion and lymph node invasion on MRI can be as high as 100% and 92% respectively 7.
Staging
See article:gallbladder cancer (staging).
Treatment and prognosis
Unfortunately, due to the mostly asymptomatic nature of these tumours, the presentation is typically late with the majority of tumours being large, unresectable, with direct extension into adjacent structures or distant metastases present at diagnosis.
Curative resection is only possible for localised early disease, which is usually found incidentally. This is reflected in the dismal prognosis 4:
1-year survival: 80%
5-year survival: 1-5%
Differential diagnosis
The differential will depend on the growth pattern of the tumour
-
intraluminal masses
gallbladder polyp: see differentiating benign vs malignant gallbladder polyps
-
melanoma is the most frequent 9
other described primaries include: lung, oesophagus, pancreas, colon, and kidney carcinomas 9
-
mural thickening has a limited differential but is difficult to distinguish on imaging alone,
possibilitiespossibilities include:gallbladder wall thickening due to portal hypertension
-
large tumours differentials include a number of nearby primaries with extension to the gallbladder
tumours from adjacent organs (pancreas, duodenum) invading gallbladder fossa 10
-<p><strong>Gallbladder carcinoma </strong>is a type of <a href="/articles/gallbladder-cancer-2">gallbladder cancer</a> and specifically refers to primary epithelial malignancies arising from the <a href="/articles/gallbladder">gallbladder</a>, in which the great majority (90%) are adenocarcinomas and the remainder are squamous cell carcinomas. They are more prevalent in elderly women and, in most cases, are only symptomatic when in advanced stages. </p><p>On imaging, they can present as a focal intraluminal mass, focal or diffuse gallbladder wall irregular thickening, or large mass lesion replacing the entire gallbladder. It is not uncommon to depict those tumours with some degree of invasion of adjacent structures or metastatic disease. </p><h4>Epidemiology</h4><p>Although overall uncommon, gallbladder adenocarcinoma is the most common primary biliary carcinoma and the 5<sup>th</sup> most common malignancy of the gastrointestinal tract <sup>1</sup>.</p><p>Predominantly affects older persons with long-standing cholecystolithiasis, and as such is most common in elderly women (>60 years of age, F:M ratio = 4:1) <sup>1,3</sup>.</p><h6>Risk factors</h6><p>Risk factors include <sup>1</sup>:</p><ul>- +<p><strong>Gallbladder carcinoma </strong>is a type of <a href="/articles/gallbladder-cancer-2">gallbladder cancer</a> and specifically refers to primary epithelial malignancies arising from the <a href="/articles/gallbladder">gallbladder</a>, in which the great majority (90%) are adenocarcinomas and the remainder are squamous cell carcinomas. They are more prevalent in elderly women and, in most cases, are only symptomatic when in advanced stages. </p><p>On imaging, they can present as a focal intraluminal mass, focal or diffuse gallbladder wall irregular thickening, or large mass lesion replacing the entire gallbladder. It is not uncommon to depict those tumours with some degree of invasion of adjacent structures or metastatic disease. </p><h4>Epidemiology</h4><p>Although overall uncommon, gallbladder adenocarcinoma is the most common primary biliary carcinoma and the 5<sup>th</sup> most common malignancy of the gastrointestinal tract <sup>1</sup>.</p><p>Predominantly affects older persons with long-standing cholecystolithiasis, and as such is most common in elderly women (>60 years of age, F:M ratio = 4:1) <sup>1,3</sup>.</p><h6>Risk factors</h6><p>Risk factors include <sup>1</sup>:</p><ul>
-<li><p><a href="/articles/gallstones-1">gallstones</a> are seen in 70-90% of cases <sup>3,4</sup></p></li>- +<li><p><a href="/articles/gallstones-1">gallstones</a> are seen in 70-90% of cases <sup>3,4</sup></p></li>
-<li><p><a href="/articles/gallbladder-polyp">gallbladder polyps</a> >1 cm that are sessile and solitary</p></li>-<li><p><a href="/articles/primary-sclerosing-cholangitis">primary sclerosing cholangitis</a> <sup>13</sup></p></li>-<li><p><a href="/articles/anomalous-junction-of-pancreaticobiliary-ducts-1">anomalous junction of pancreaticobiliary ducts</a> <sup>16</sup></p></li>-<li><p>certain ethnicities and geographical groups (e.g. Native Americans and Chileans) <sup>16</sup></p></li>- +<li><p><a href="/articles/gallbladder-polyp">gallbladder polyps</a> >1 cm that are sessile and solitary</p></li>
- +<li><p><a href="/articles/primary-sclerosing-cholangitis">primary sclerosing cholangitis</a> <sup>13</sup></p></li>
- +<li><p><a href="/articles/anomalous-junction-of-pancreaticobiliary-ducts-1">anomalous junction of pancreaticobiliary ducts</a> <sup>16</sup></p></li>
- +<li><p>certain ethnicities and geographical groups (e.g. Native Americans and Chileans) <sup>16</sup></p></li>
-<li><p>exposure to carcinogens (e.g. <a href="/articles/lead">lead</a>, cadmium, <a href="/articles/chromium">chromium</a>) <sup>16</sup></p></li>- +<li><p>exposure to carcinogens (e.g. <a href="/articles/lead">lead</a>, cadmium, <a href="/articles/chromium">chromium</a>) <sup>16</sup></p></li>
-</ul><h4>Clinical presentation</h4><p>Early in the course of the disease, patients are invariably asymptomatic, and as such a therapeutic window is usually missed. Eventually, symptoms develop, at which time the mass is usually not resectable.</p><p>Clinical presentation depends on the direction in which the mass extends. In cases where the biliary obstruction is created then <a href="/articles/jaundice">jaundice</a> is often the first presentation. If the malignancy is located in the gallbladder's body or fundus, extending into the liver or adjacent colon or small bowel can lead to local pain or bowel obstruction, respectively.</p><p>Other symptoms include right upper quadrant pain, weight loss and anorexia.</p><h4>Pathology</h4><p>Over 90% of cases of gallbladder cancer are adenocarcinomas, with the majority related to chronic inflammatory metaplasia and dysplasia <sup>15</sup>. Squamous cell carcinomas figure as the second most common histologic type of gallbladder carcinoma (representing up to 3% of all gallbladder primary malignancies) <sup>19</sup>. </p><h4>Radiographic features</h4><p>Gallbladder adenocarcinomas present in one of three morphologies <sup>19</sup>:</p><ol>- +</ul><h4>Clinical presentation</h4><p>Early in the course of the disease, patients are invariably asymptomatic, and as such a therapeutic window is usually missed. Eventually, symptoms develop, at which time the mass is usually not resectable.</p><p>Clinical presentation depends on the direction in which the mass extends. In cases where the biliary obstruction is created then <a href="/articles/jaundice">jaundice</a> is often the first presentation. If the malignancy is located in the gallbladder's body or fundus, extending into the liver or adjacent colon or small bowel can lead to local pain or bowel obstruction, respectively.</p><p>Other symptoms include right upper quadrant pain, weight loss and anorexia.</p><h4>Pathology</h4><p>Over 90% of cases of gallbladder cancer are adenocarcinomas, with the majority related to chronic inflammatory metaplasia and dysplasia <sup>15</sup>. Squamous cell carcinomas figure as the second most common histologic type of gallbladder carcinoma (representing up to 3% of all gallbladder primary malignancies) <sup>19</sup>. </p><h4>Radiographic features</h4><p>Gallbladder adenocarcinomas present in one of three morphologies <sup>19</sup>:</p><ol>
-</ol><p>Gallstones are commonly present (60%–90%) <sup>14</sup>.</p><h5>Ultrasound</h5><p>Ultrasound can depict a focal intraluminal, wall involvement, or large mass-like lesion replacing the gallbladder. The tumour usually has irregular and sometimes ill-defined margins, with heterogeneous echotexture and predominantly low echogenicity. Hyperechoic foci with <a href="/articles/acoustic-shadowing">posterior acoustic shadowing</a> may be seen within the mass, possibly reflecting gallstones or gallbladder wall calcifications (<a href="/articles/porcelain-gallbladder">porcelain gallbladder</a>) <sup>19</sup>. </p><h5>CT</h5><p>In cases with strong suspicion of gallbladder cancer or biliary tract disease, arterial phase (at 20 to 30 seconds) and venous phase (50 to 60 seconds) can be acquired. When there is an incidental finding of gall bladder cancer and no suspicion of biliary tract cancer, only venous phase is required <sup>21</sup>.</p><p>In plain CT scan, gallbladder cancer is typically hypodense. It shows irregular, peripheral enhancement on arterial phase <sup>21</sup>.</p><p>Typically gallbladder adenocarcinomas appear as large heterogeneous masses <sup>21</sup>, which may have engulfed gallstones or areas of necrosis. Patchy moderate contrast enhancement is usually seen.</p><p>Features of advanced disease include <sup>22</sup>:</p><ul>- +</ol><p>Gallstones are commonly present (60%–90%) <sup>14</sup>.</p><h5>Ultrasound</h5><p>Ultrasound can depict a focal intraluminal, wall involvement, or large mass-like lesion replacing the gallbladder. The tumour usually has irregular and sometimes ill-defined margins, with heterogeneous echotexture and predominantly low echogenicity. Hyperechoic foci with <a href="/articles/acoustic-shadowing">posterior acoustic shadowing</a> may be seen within the mass, possibly reflecting gallstones or gallbladder wall calcifications (<a href="/articles/porcelain-gallbladder">porcelain gallbladder</a>) <sup>19</sup>. </p><h5>CT</h5><p>In cases with strong suspicion of gallbladder cancer or biliary tract disease, arterial phase (at 20 to 30 seconds) and venous phase (50 to 60 seconds) can be acquired. When there is an incidental finding of gallbladder cancer and no suspicion of biliary tract cancer, only venous phase is required <sup>21</sup>.</p><p>In plain CT scan, gallbladder cancer is typically hypodense. It shows irregular, peripheral enhancement on arterial phase <sup>21</sup>.</p><p>Typically gallbladder adenocarcinomas appear as large heterogeneous masses <sup>21</sup>, which may have engulfed gallstones or areas of necrosis. Patchy moderate contrast enhancement is usually seen.</p><p>Features of advanced disease include <sup>22</sup>:</p><ul>
-</ul><h5>MRI</h5><p>Dynamic MRI is considered useful and reliable in staging advanced gallbladder carcinoma. MRI combined with MRCP is sensitive in detecting obstructive jaundice, liver invasion, and hepatic and lymph nodal metastasis. It may be more difficult to delineate any invasion into the duodenum or to detect omental metastasis by MRI <sup>6</sup>. Reported sensitivity rates for direct hepatic invasion and lymph node invasion on MRI can be as high as 100% and 92% respectively <sup>7</sup>.</p><h4>Staging </h4><p>See article: <a href="/articles/gallbladder-cancer-staging-ajcc-8th-edition">gallbladder cancer (staging)</a>.</p><h4>Treatment and prognosis</h4><p>Unfortunately, due to the mostly asymptomatic nature of these tumours, the presentation is typically late with the majority of tumours being large, unresectable, with direct extension into adjacent structures or distant metastases present at diagnosis.</p><p>Curative resection is only possible for localised early disease, which is usually found incidentally. This is reflected in the dismal prognosis <sup>4</sup>:</p><ul>- +</ul><h5>MRI</h5><p>Dynamic MRI is considered useful and reliable in staging advanced gallbladder carcinoma. MRI combined with MRCP is sensitive in detecting obstructive jaundice, liver invasion, and hepatic and lymph nodal metastasis. It may be more difficult to delineate any invasion into the duodenum or to detect omental metastasis by MRI <sup>6</sup>. Reported sensitivity rates for direct hepatic invasion and lymph node invasion on MRI can be as high as 100% and 92% respectively <sup>7</sup>.</p><h4>Staging </h4><p>See article: <a href="/articles/gallbladder-cancer-staging-ajcc-8th-edition">gallbladder cancer (staging)</a>.</p><h4>Treatment and prognosis</h4><p>Unfortunately, due to the mostly asymptomatic nature of these tumours, the presentation is typically late with the majority of tumours being large, unresectable, with direct extension into adjacent structures or distant metastases present at diagnosis.</p><p>Curative resection is only possible for localised early disease, which is usually found incidentally. This is reflected in the dismal prognosis <sup>4</sup>:</p><ul>
-<p>mural thickening has a limited differential but is difficult to distinguish on imaging alone, possibilities include:</p>- +<p>mural thickening has a limited differential but is difficult to distinguish on imaging alone, possibilities include:</p>
-<li><p><a href="/articles/tumefactive-sludge">tumefactive sludge</a> <sup>20</sup></p></li>- +<li><p><a href="/articles/tumefactive-sludge">tumefactive sludge</a> <sup>20</sup></p></li>
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