Gall bladder carcinoma: Aggressive malignancy with protean loco-regional and distant spread

Abstract

The most common malignancy of biliary tract is gallbladder cancer (GBC) which is the third most common cancer in gastrointestinal tract. It is a lethal disease for most patients in spite of growing awareness and improved diagnostic techniques. GBC has a very poor prognosis and the 5 year survival rate is < 10%. Although etiology of the carcinoma of the gallbladder is still obscure, various factors have been implicated, cholelithiasis being the most frequent. The incidence of GBC worldwide is based on the gender, geography and ethnicity which suggest that both genetic and environmental factors can cause GBC. The major route of spread of gallbladder cancer (GC) is loco-regional rather than distant. It spreads by lymphatic, vascular, neural, intraperitoneal, and intraductal routes. Sonography is usually the most common imaging test to evaluate symptoms of biliary tract disease including suspected GC. With recent advances in imaging modalities like multi-detector computed tomography (CT) scanners, magnetic resonance imaging-positron emission tomography/CT diagnosis of gallbladder cancer has improved. Studies have also targeted molecular and genetic pathways. Treatment options have included extended and radical surgeries and adjuvant chemotherapy. This review article deals in detail with important aspects of carcinoma gallbladder and its manifestations and challenges. Role of various imaging modalities in characterization and accurate staging has been discussed. The loco-regional spread of this aggressive malignancy is dealt explicitly.

Keywords: Adenocarcinoma; Cholelithiasis; Gallbladder cancer; Imaging; Loco-regional and distant spread.

Figure 1

Carcinoma gallbladder: Nodal and hepatic metastasis. A: Coronal contrast-enhanced computed tomography (CECT) abdominal section shows relatively defined heterogenous mass involving fundus of gall bladder (arrow) with loss of fat plane with adjacent hepatic segment; B: Axial CECT abdominal section shows multiple hepatic metastasis (arrow) along with interaortocaval lymph nodal metastasis (dashed arrow).

Figure 2

Aggressive gallbladder cancer and entero-biliary fistula. A: Axial contrast-enhanced computed tomography (CECT) abdominal section shows predominantly hypodense mass lesion replacing gall bladder fossa with presence of air (arrow) raising suspicion of fistula formation. Adjacent hepatic segments are also infiltrated by the mass; B and C: Axial and Coronal CECT abdominal sections clearly reveal the fistulous communication with D2 segment of duodenum (arrow); D: Coronal CECT abdominal section also show coexisting cholecysto-colonic fistula with hepatic flexure of colon (arrow).

Figure 3

Axial contrast-enhanced computed tomography abdominal section shows ill-defined heterogenous mass replacing gall bladder fossa with loss of fat plane with adjacent hepatic segments. Cholecystoduodenal and cholecysto-gastric fistulas are seen with D1 segment of duodenum and antropyloric region of stomach (arrow).

Figure 4

Axial contrast-enhanced computed tomography abdominal section shows ill-defined mass replacing gall bladder fossa with direct infiltration of hepatic segment V. Cholecystoduodenal fistula (arrow) is noted along with retroperitoneal lymph nodal metastasis (dashed arrow).

Figure 5

Axial contrast-enhanced computed tomography abdominal section shows ill-defined heterogenous mass replacing gall bladder fossa with direct infiltration of hepatic segments. Cholecystoduodenal fistula (arrow) is noted along with multiple hepatic metastasis (dashed arrow).

Figure 6

Axial contrast-enhanced computed tomography abdominal section shows diffuse irregular nodular enhancing wall thickening of gall bladder (arrow) along with circumferential wall thickening of distal stomach and proximal duodenum. Associated right adrenal metastasis is also seen (dashed arrow).

Figure 7

Axial contrast-enhanced computed tomography abdominal section shows ill-defined heterogenous mass replacing gall bladder fossa with direct infiltration of adjacent hepatic segments. Associated left adrenal lesion is also seen (dashed arrow) raising suspicion of adrenal metastasis.

Figure 8

Gallbladder carcinoma: regional and distant metastasis. A: Axial contrast-enhanced computed tomography abdominal section shows heterogenous mass lesion involving fundus of gall bladder fossa (arrow) with associated circumferential enhancing wall thickening of CBD (dashed arrow) indicating cholangitis or intraductal spread of malignancy; B: Axial CECT abdominal section shows hypodense filling defect in left branch of portal vein indicating thrombus formation (arrow). Hepatic infiltration is seen in segment VII (yellow arrow) with retroperitoneal lymph nodal metastasis (dashed arrow); C: MIP axial CT imaging shows soft tissue nodule in anterior segment of right lung indicating pulmonary metastasis (arrow); D and E: Sagittal and coronal CECT abdominal sections (bone window) show multiple osteoblastic skeletal metastatic lesions. CBD: Corticobasal degeneration; CECT: Contrast-enhanced computed tomography.

Figure 9

Axial contrast-enhanced computed tomography abdominal section shows heterogenous mass involving gall bladder fossa and leading to obstruction of biliary system due to intraductal spread (arrow).