Imaging patterns of wall thickening type of gallbladder cancer

Abstract

Gallbladder cancer (GBC) has a high incidence in certain geographical regions. Morphologically, GBC presents as a mass replacing the gallbladder, a polypoidal lesion, or wall thickening. The incidence of preoperative diagnosis of wall thickening type of GBC is less well studied. The patterns of mural involvement and extramural spread are not well described in the literature. Additionally, wall thickening in the gallbladder does not always indicate malignancy and can be secondary to inflammatory or benign gallbladder diseases and extracholecystic causes and systemic pathologies. Objective reporting of gallbladder wall thickening will help us appreciate GBC's early features. In this review, we illustrate the imaging patterns of wall thickening type of GBC.

Keywords: gallbladder; malignancy; wall thickening.

Fig. 1

Pattern of thickening in gallbladder cancer (GBC). A) Symmetrical circumferential thickening involving the GB which is infiltrating into the adjacent liver parenchyma (arrow). B) Asymmetrical mural thickening involving the GB with multiple calculi which is infiltrating the liver parenchyma (arrow). C) Asymmetrical mural thickening involving the fundus of the GB with maintained interface with adjacent liver surface (arrow). Ascites was also seen in this case (blue arrow)

Fig. 2

Different locations of gallbladder cancer (GBC) thickening type of GBC. A) Homogeneous thickening at GB fundus showing ill-defined fat planes with liver (arrow). B) Asymmetrical mural thickening at the neck region of the GB which is infiltrating into the adjacent liver parenchyma (arrow). C) Axial upper abdomen section shows diffuse circumferential thickening of the entire GB wall (arrow)

Fig. 3

Patterns of enhancement in wall-thickening type of gallbladder cancer (GBC). A) Heterogeneous enhancement (arrow). B) Bilayered appearance with thick enhancing inner layer (arrow)

Fig. 4

Enhancement characteristics of wall-thickening type of gallbladder cancer (GBC) in contrast enhanced ultrasound (CEUS). A) Gray-scale US image showing asymmetrical circumferential mural thickening involving the fundus and body of the gallbladder (arrow) with loss of interface with the adjacent liver parenchyma (thick arrow). B) Arterial phase image of the CEUS shows heterogeneous enhancement (arrow). C) There is early washout at 25 seconds (arrow)

Fig. 5

Dual energy CT in wall-thickening type of gallbladder cancer (GBC). A) Axial contrast enhanced CT (CECT) image in arterial phase shows circumferential thickening of the body and fundus of the GB (arrow). B) Axial iodine overlay dual-energy CT image shows iodine uptake in the thickened areas favoring the diagnosis of malignancy (arrow)

Fig. 6

Patterns of diffusion restriction in wall-thickening type of gallbladder cancer (GBC). A) The thickening involving the GB shows homogeneous intense diffuse restriction (arrow). B) Patchy diffusion restriction is present in the GB wall thickening (arrow). C) The retroperitoneal lymph node metastasis in a case of GBC was better seen on a diffusion weighted image showing intense diffusion restriction (arrow). D) The lesion in the liver shows more intense diffusion restriction in the periphery than the center, which helps to differentiate it from cholangitic abscesses (arrow)

Fig. 7

Infiltration into liver parenchyma in wall-thickening type of gallbladder cancer GBC. A) Axial CECT image shows GBC showing focal thickening at fundus infiltrating into the liver. B) Axial CECT abdomen showing diffuse heterogeneous circumferential thickening in GB infiltrating into the liver

Fig. 8

Different patterns of extramural extension of wall-thickening type of gallbladder cancer (GBC). A) Coronal reformatted image showing diffuse circumferential thickening of GB with ill-defined fat planes with liver (arrow) and showing maintained fat planes with adjacent bowel loop (blue arrow). B) Asymmetrical thickening at the neck with infiltration into the duodenum and pancreas (arrow). C) Axial CECT abdomen showing extensive circumferential thickening involving the GB which is fistulizing into the 2^nd part of the duodenum (arrow). D) The asymmetrical mural thickening involving the GB is extending into the antropyloric region, causing gastric outlet obstruction (arrow). Perihepatic fluid was also seen in this case (blue arrow). E) Asymmetrical mural thickening involving the GB which is infiltrating the hepatic flexure and transverse colon (arrows). F) Asymmetrical mural thickening involving the GB which is extending into the omentum (arrow). Perihepatic fluid was also seen in this case (blue arrow)

Fig. 9

Different pattern of biliary involvement in wall-thickening type of gallbladder cancer (GBC). A) There is extension of the thickening involving the GB neck in the cystic duct (arrow) along with the presence of a few enlarged periportal lymph nodes (blue arrow). B) The GB is overdistended with asymmetrical thickening in the neck region which is extending to involve the right secondary confluence (arrow). C) Asymmetrical mural thickening involving the GB which is infiltrating the bilateral secondary confluence, causing ductal isolation (arrows). D) Coronal reformatted images show asymmetrical mural thickening involving the neck of the GB extending into the suprapancreatic CBD beyond which the CBD is dilated (arrow). E) Axial CECT abdomen showing asymmetrical thickening at the neck which extends into the cystic duct (arrow). F) Coronal reformatted magnetic resonance cholangiopancreatographic (MRCP) image showing the block at the level of the primary confluence in a case of GBC (arrow). G) Coronal T2 weighted image showing an enlarged periportal lymph node causing compression of the CHD (arrow). H) Periductal infiltration involving the primary confluence (arrow) and left secondary confluence (blue arrow) in a case of GBC. Perihepatic fluid was also seen in this case (orange arrow)

Fig. 10

Different pattern of vascular involvement in wall-thickening type of gallbladder cancer (GBC). A) There is encasement of the main portal vein (arrow) and common hepatic artery (blue arrow) by the asymmetrical mural thickening present in the neck region of the GB. B) Multiple enlarged lymph nodes in the periportal location which are seen compressing the main portal vein (arrow). C) The main hepatic artery is compressed by multiple necrotic lymph nodes seen in periportal location (arrow). D) There is encasement of the right hepatic artery with asymmetrical thickening at the GB neck region (arrow). E) There is attenuation of the main portal vein by the asymmetrical mural thickening in the neck region of the GB (arrow). F) There is extension of thickening involving the GB along the left branch of the portal vein, causing its attenuation (arrow)

Fig. 11

Liver metastases in wall-thickening type of gallbladder cancer (GBC). A-D) Axial T2 weighted image shows a T2 hyperintense lesion (arrow, A) in segment IVb of the liver which is showing diffusion restriction predominantly in the periphery (arrows, B and C) and is showing solid enhancement (arrow, D) suggestive of metastasis. E-H) Axial T2 weighted image shows a T2 hyperintense lesion (arrow, E) in segment IV b of the liver without diffusion restriction (arrows, F and G) and is showing a peripheral rim of enhancement (arrow, H) likely suggestive of cholangitic abscess

Fig. 12

Different pattern of lymph nodal involvement in wall-thickening type of gallbladder cancer (GBC). A) Axial CECT section shows multiple enlarged necrotic regional lymph nodes in the periportal and peripancreatic region (arrow). B) Axial CECT section shows enlarged lymph nodes around the superior mesenteric artery (arrow). C, D) Axial CECT abdomen showing multiple enlarged lymph nodes in the retroperitoneum (arrow)

Fig. 13

Omental metastases in wall-thickening type of gallbladder cancer (GBC). A) Axial CECT abdomen shows a well-defined nodule in the omentum (arrow). B, C) Well-defined nodules of varying sizes are seen in the right paracolic gutter (arrows)

Fig. 14

Lung and adrenal metastases in wall-thickening type of gallbladder cancer (GBC). A) Multiple nodules of varying sizes are seen in the bilateral lung field along with a few atelectatic bands suggestive of metastatic nodules (arrows). B) Coronal reformatted image shows hypodense nodules in bilateral adrenal glands in a case of GBC suggestive of metastasis (arrows)