|Year : 2022 | Volume
| Issue : 3 | Page : 661-667
Panorama of multidetector-row computed tomography findings of carcinoma gall bladder - A retrospective observational study
Sudipta Mohakud, Simran Sidhu, Nerbadyswari Deep, Suprava Naik
Department of Radiodiagnosis, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
|Date of Submission||08-Feb-2021|
|Date of Acceptance||09-Jul-2021|
|Date of Web Publication||14-Jan-2022|
Department of Radiodiagnosis, All India Institute of Medical Sciences, Bhubaneswar, Odisha
Source of Support: None, Conflict of Interest: None
Background: Carcinoma of the gall bladder (Ca GB) has marked ethnic and geographical variations with a broad spectrum of imaging findings on multidetector-row computed tomography (MDCT). We aim to study the spectrum of the imaging findings of Ca GB on MDCT in an Eastern Indian hospital as these imaging findings help in accurate diagnosis and staging of this lethal disease.
Materials and Methods: The MDCT images of 100 biopsy-proven cases of adenocarcinoma of GB performed from January 1, 2017, to December 31, 2018, in our hospital were retrospectively reviewed by two experienced radiologists blinded to the diagnosis. The CT protocol was a plain scan followed by triple-phase contrast-enhanced CT. Reconstructed images in the form of maximum intensity projection, volume-rendered technology, and minimum intensity projection images were also assessed. Descriptive statistics were used for data analysis.
Results: Ca GB showed a female predominance (female:male –1.9:1). The mean age of presentation was 54.7 years (females) and 58 years (males). The morphological patterns were a mass replacing the GB (46%), focal or diffuse wall thickening (26%), and an intraluminal polypoidal mass (28%). Direct extension was to liver (76%), duodenum (32%), colon (19%), pancreas (9%), and abdominal wall (1%). Biliary dilatation (53%), vascular invasion (14%), omental involvement (23%), ascites (22%), N1 (40%), and retroperitoneal lymphadenopathy (33%) were common. Distant metastasis comprised of hepatic (42%), pulmonary (7%), Krukenberg's tumor (6%), and osseous (1%) lesions. The stages at diagnosis were I or II (3%), IIIA (4%), IIIB (16%), IVA (10%), and IVB (67%).
Conclusions: Ca GB has a broad spectrum of findings on MDCT and it mostly presents at an advanced stage. MDCT with reconstructions is beneficial in the assessment of locoregional and distant spread and cancer staging which has a direct implication on patient management, survival, and mortality.
Keywords: Carcinoma, gall bladder, multidetector computed tomography
|How to cite this article:|
Mohakud S, Sidhu S, Deep N, Naik S. Panorama of multidetector-row computed tomography findings of carcinoma gall bladder - A retrospective observational study. J Can Res Ther 2022;18:661-7
|How to cite this URL:|
Mohakud S, Sidhu S, Deep N, Naik S. Panorama of multidetector-row computed tomography findings of carcinoma gall bladder - A retrospective observational study. J Can Res Ther [serial online] 2022 [cited 2022 Aug 10];18:661-7. Available from: https://www.cancerjournal.net/text.asp?2022/18/3/661/335487
| > Introduction|| |
Carcinoma of the gall bladder (Ca GB) is the most prevalent biliary tract malignancy comprising 80%–90% of the cases. It ranks fifth among all the gastrointestinal (GI) cancers., The incidence of Ca GB in India is reported to be 1.01 per 1 lakh in males, and it is ten times more in females. Western Bihar and eastern Uttar Pradesh are considered as endemic zones for Ca GB. In these regions, Ca GB is the third most common GI malignancy., Nandakumar et al. have described that Ca GB has the highest prevalence in India's northern and north-eastern states comprising of Uttar Pradesh, Bihar, West Bengal, Odisha, and Assam.
We present our experience of the spectrum of imaging findings on multidetector-row computed tomography (MDCT) in 100 cases of adenocarcinoma of the GB done in our institute catering to patients of India's two eastern states, namely Odisha and West Bengal.
| > Materials And Methods|| |
In this observational study, the MDCT scan images of 100 consecutive biopsy-proven cases of adenocarcinoma of the GB done over 2 years from January 1, 2017, to December 31, 2018, were retrospectively reviewed by two experienced radiologists. These 100 cases were obtained as follows. One person listed down all the CT scan cases of proven or suspected Ca GB from the register, collected the histopathology reports, and finally selected the histopathologically proven cases of adenocarcinoma from the list. The sample for histopathological analysis was obtained either by percutaneous fine-needle aspiration cytology or biopsy mostly in cases of advanced inoperable Ca GB cases or the surgical specimen in operable cases. Then, the CT scans were given to two experienced radiologists blinded to the diagnosis for interpretation. In case of discrepancy between the radiologists, a consensus was achieved by mutual discussion.
A mass replacing GB fossa was defined as a lesion with total or near-total obscuration of the GB. Focal or diffuse wall thickening was defined as ≤50% or >50% of wall thickening, respectively, with maintained GB, and a polypoidal mass was defined as a lesion bulging into the GB lumen. Vascular invasion was defined as more than 90° encasement of the vessels by tumor or metastatic nodes, vascular wall irregularity, or intravascular tumor extension.
The lymph nodes of size ≥10 mm in their short-axis diameter were considered pathological or metastatic. Adjacent organ invasion was considered when there was irregular contiguity of the tumor with the adjacent organ, or there was a loss of fat plane for more than a distance of 10 mm. The distant metastasis was considered either when the both the radiologists independently admitted that the radiological appearance is classical of metastasis or by corroborating with histopathology, positron emission tomography scan, magnetic resonance imaging or bone scan reports, whichever was available in the records, especially in cases of discrepancy.
Inclusion criteria were biopsy-proven cases in which triple-phase imaging of the abdomen was done, and corroborative reports were available, and cases not meeting any of the criteria were excluded from the study.
All the scans were obtained in a 256 slice MDCT scanner Somatom Definition Flash (Siemens, Germany). Images of thickness 3 mm were acquired in the axial plane at a table speed of 5 mm/s (pitch 1.0) with 120 KVP and 280 MAs. The CT scan technique included a plain scan followed by scanning during dynamic intravenous injection of nonionic iodinated contrast medium (300 mg Iodine/ml) covering the abdomen from the dome of the diaphragm to the iliac crest. The iodinated contrast media was administered at a dose of 1.5 ml/kg at the rate of 3 ml/s, followed by normal saline flush at the 3 ml/s rate using a pressure injector. The contrast-enhanced CT (CECT) acquisitions were made during the arterial, portal, and hepatic venous phases using automatic bolus tracking technology. The arterial phase was obtained after 20 s of contrast injection, portal venous phase after 60 s, and hepatic venous phase after 80 s.
The arterial phase images were studied to look for arterial invasion and differentiate hepatic metastasis from hemangiomas. The portal venous phase images were used to evaluate the GB mass, hepatic parenchyma, portal venous invasion, and the rest of the abdomen. The delayed images were required to differentiate the GB mass from hepatocellular carcinoma.
The image reconstructions like maximum intensity projection images were useful for vascular invasion, volume-rendered technology images helped assess arterial invasion, and the minimum intensity projection (MinIP) images were useful for assessment of intra-and extrahepatic ductal dilatation.
The CT images were assessed for tumor morphology, enhancement, adjacent organ invasion, vascular invasion, abdominal lymphadenopathy, distant metastasis, and staging of the disease. The staging was done as per the 8th edition of the American Joint Committee on Cancer (AJCC) criteria.
Data analysis was done using frequency distribution and descriptive statistics.
| > Results|| |
Ca GB showed a female preponderance with a female:male ratio of 1.9:1, and the mean age of presentation was 54.7 years for females and 58 years for males. The frequency of cases in various age ranges is shown in [Table 1]. The majority (60%) of the cases occurred in the 41–60-year age group.
|Table 1: The frequency distribution of carcinoma of the gall bladder in various age ranges|
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The frequency distribution of the three morphological patterns of Ca GB is depicted in the pie chart [Figure 1]. In our study, mass replacing the gall bladder [Figure 2]a and [Figure 2]b was found in 46% of cases, focal or diffuse gall bladder wall thickening [Figure 2]c in 26%, and an intraluminal polypoid mass [Figure 2]d in 28% of cases.
|Figure 1: Pie chart showing the frequency distribution of morphological patterns of Carcinoma of the gall bladder|
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|Figure 2: (a) Axial computed tomography image showing heterogeneous mass with peripheral enhancement and central hypodensity replacing the gall bladder with the invasion of adjacent hepatic segments 4 and 5. (b) Coronal computed tomography image showing heterogeneous mass with peripheral enhancement and central hypodensity in the gall bladder fossa replacing the gall bladder. (c) Axial computed tomography showing gross diffuse wall thickening of the gall bladder. (d) Axial computed tomography showing an irregular enhancing polypoidal mass arising from the lateral wall of the gall bladder|
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The frequency of organ involvement by contiguous spread and distant metastases of Ca GB is depicted in the bar diagrams [Figure 3] and [Figure 4]. The liver [Figure 2]a and [Figure 2]b was the most frequently involved organ due to contiguous spread (76% of the cases), followed by the duodenum [Figure 5]a in 32% of cases, colon [Figure 5]b in 19%, pancreas in 9%, and anterior abdominal wall [Figure 5]c in 1% of the cases. Vascular invasion [Figure 6]a and [Figure 6]b involving the main portal vein, coeliac axis, hepatic artery, and the superior mesenteric artery was seen in 14% of cases. Intrahepatic biliary radicals were dilated [Figure 7]a and [Figure 7]b in 53% of cases. Omental involvement in the form of caking and nodularity was seen in 23% and ascites in 22% of cases. Distant metastasis comprised of hepatic [Figure 5]c in 42% of the cases, pulmonary in 7%, bilateral ovarian/Krukenberg's tumor [Figure 8]a in 6%, and osseous lesions [Figure 8]b in 1% of the cases.
|Figure 3: Bar diagram showing the frequency of invasion of adjacent structures by Carcinoma of the gall bladder|
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|Figure 4: Bar diagram showing the frequency of distant metastases by Carcinoma of the gall bladder|
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|Figure 5: (a) Axial computed tomography showing irregular peripherally enhancing hypodense mass in the gall bladder fossa with duodenal infiltration. (b) Coronal contrast-enhanced computed tomography showing gall bladder mass invading the hepatic flexure of the colon (arrow) and ascites (asterisk). (c) Axial computed tomography showing mass arising from gall bladder fundus invading segment 4 (large arrow), a metastatic lesion in segment 5 (arrowhead), enlarged necrotic retroperitoneal lymph nodes in the para-aortic and aortocaval regions (small arrows) and anterior abdominal wall invasion|
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|Figure 6: (a) Coronal maximum intensity projection image showing irregularity and narrowing of the portal confluence and main portal vein in a case of Carcinoma of the gall bladder suggestive of vascular invasion. (b) Three dimensional volume-rendered technology image of the coeliac trunk and its branches in a case of Carcinoma of the gall bladder. The RHA is irregular (yellow arrow) and narrowed suggestive of invasion. LHA = Left hepatic artery. RHA = Right hepatic artery, CHA = Common hepatic artery, GDA = Gastroduodenal artery, HA PROPER = Hepatic artery proper|
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|Figure 7: (a) Coronal MinIP image shows a necrotic lymph nodal mass (arrow) in the peripancreatic region compressing the CBD with dilated CBD (arrowhead) and bilobar dilated intrahepatic biliary radicals in a case of Carcinoma of the gall bladder. (b) 7b-Axial section contrast-enhanced computed tomography image of a case of Carcinoma of the gall bladder showing a necrotic lymph nodal mass (arrow) in the peripancreatic region compressing the CBD|
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|Figure 8: (a) Axial section computed tomography scan image at the level of the pelvis showing enlarged heterogeneously enhancing bilateral ovaries with solid and cystic areas suggestive of metastasis in a case of a Carcinoma of the gall bladder. (b) The bone window of the sagittal section computed tomography scan image showing heterogeneous mixed lytic and sclerotic D12 vertebra with mild central wedging suggestive of metastasis in a case of Carcinoma of the gall bladder|
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73% of patients had lymphadenopathy at initial diagnosis, and 27% were N0. Enlarged lymph nodes around the porta hepatis or peripancreatic region [Figure 7]b, considered as N1 stage, were involved in 39% of patients, whereas retroperitoneal lymphadenopathy [Figure 5]c regarded as M1 stage was seen in 34% of cases of patients. CT could not accurately differentiate between T1 and T2 lesions, and combinedly, they accounted for 7% of the cases. T3 lesions comprised 55% of the cases, whereas 38% of the lesions were T4.
The frequency distribution of various Ca GB stages is represented in the pie chart [Figure 9]. Majority of the cases (67%) presented at Stage IVB, followed by Stage IIIB (16%), Stage IVA (10%), and Stage IIIA (4%). STAGE I or II disease was seen in only 3% of the cases.
|Figure 9: Pie chart showing the frequency distribution of various stages of Carcinoma of the gall bladder|
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| > Discussion|| |
Ca GB has a female preponderance, and incidence in females is four to five times more than that in men. It predominantly occurs in the sixties and seventies., The mean age of presentation in our study of the eastern Indian population is similar to that of the northern Indian region reported by Kumar et al. and is almost a decade less than that of the western population. This change in the statistics may be attributed to variable geographical disease patterns or as a result of improved detection due to advances in imaging.
Ca GB is highly prevalent in northern India. A study by Khan et al. reveals high prevalence of GB carcinoma in eastern India. Some of the predisposing factors for the development of Ca GB are gall stones, chronic GB infections, and GB polyps of size >10 mm. The presenting symptoms may be an abdominal lump in the right hypochondrium, pain abdomen, pallor, weight loss, jaundice or nausea, and vomiting.
Ca GB has a high mortality rate with an overall 5-year survival rate of 5% and a mean survival period of 6 months. The anatomical location of GB favors rapid contiguous invasion of the liver by the carcinoma and early metastatic progression. Thus, most of the patients present with the advanced disease despite advances in cross-sectional imaging.
MDCT allows a faster and accurate examination in a single breath-hold. It allows postprocessing of the images with volumetric reconstructions and provides detailed information regarding the tumor, invasion into the adjacent organs, vascular involvement, obstructive biliopathy, and distant metastasis.
Ca GB has three morphologic patterns, namely a mass replacing the GB occupying the GB fossa, focal or diffuse wall thickening, and intraluminal polypoid mass with the frequency ranges of 40%–60%, 20%–30%, and 5%–25%, respectively., In our study, the frequency of morphological patterns of Ca Gb was also within the range reported in the literature.
In the case of a mass replacing the GB, CECT demonstrates a heterogeneously enhancing hypoattenuating mass in the gall bladder fossa invading hepatic segments IVb and V. The hypodense nonenhancing areas represent necrosis, and the enhancing component is the viable tumor.
The tendency of Ca GB to invade adjacent hepatic segments is due to a thin lamina propria and a single muscle layer of the GB. We observed that the GB fossa lesion invasion of the hepatic segments IVb and V was a reliable indicator of malignancy. The GB mass often invades the hepatic hilum leading to biliary obstruction. Lymph node metastasis is also a frequently associated finding.
Ca GB with wall thickening is the most difficult to diagnose as it mimics common benign conditions such as acute or chronic cholecystitis. Minimal areas of wall thickening may reflect early Cas. Irregular, asymmetric, moderate to gross wall thickening (10 mm or more) is suspicious of malignancy or complicated cholecystitis., CECT is beneficial in distinguishing complicated cholecystitis from Ca., The inner wall layer is mostly thick and brightly enhancing in Ca GB, whereas it is thin and less enhancing with an isodense appearance in chronic cholecystitis. The presence of a hypodense halo sign representing edema of the thickened GB wall favors cholecystitis diagnosis. Other associated findings such as the hepatic invasion, lymphadenopathy, and presence of distant metastases indicate gall bladder Ca.
The intraluminal polypoid lesion appears as a moderately homogeneously enhancing mass of size >10 mm in diameter on CECT. Internal necrosis or calcification is rare in the polypoid lesion. In our study, the polypoid lesions measured 1.5–4 cm in size and showed moderate homogeneous enhancement on CECT.
The most common mode of spread of gall bladder Ca is direct extension into adjacent organs, followed by lymphatic and hematogenous spread. The Ca also spreads through intraperitoneal, intraductal, and neural routes. The most common organ involved by direct extension of Ca GB is the liver seen in as high as 65% of the cases. The other organs in the list are the duodenum, colon, and pancreas accounting for 15%, 15%, and 6% of the cases, respectively, reported in the literature. We observed that the liver was the most frequently involved organ by contiguous spread, followed by the duodenum, colon, and pancreas.
Lymphatic spread is very rampant in Ca GB and is seen in more than half of the patients at the time of diagnosis. One study reported that nodal metastasis was present in 26%–75% of the Ca GB cases.
The route of lymphatic spread is GB fossa to peripancreatic lymph nodes through the hepatoduodenal ligament to the nodes along the coeliac axis, superior mesenteric vessels, and para-aortic stations. Peripancreatic and para-aortic lymph nodes are well seen on the CT scan. Lymph nodes measuring >10 mm in short-axis diameter are generally considered as malignant on CECT, and they show a ring-like or heterogeneous enhancement. Lymph nodal metastases were very high at the time of initial diagnosis and encountered in 73% of the cases in our study.
Biliary obstruction leading to dilatation and obstructive jaundice is frequently associated with Ca GB and mostly demonstrates an advanced stage of the Ca. In one study, the researchers have observed biliary dilatation in 38% of the cases. More than half of the patients presented with biliary obstruction in our study. Tumor infiltration of the cystic duct and the extrahepatic bile ducts, infiltration or compression of the bile ducts by the malignant lymph nodal mass, and intraductal tumor spread result in biliary obstruction.
MDCT is a very reliable modality to detect vascular invasion. Vascular invasion is a criterion of irresectability. 3D volume-rendered techniques aid in diagnosing vascular invasion as well as guide the surgeon about the normal and variant vascular anatomy.
The most frequent organ involved by hematogenous metastasis from Ca GB is the liver, which can be easily seen in the CT scan. The other organs where distant metastasis has been less frequently observed are lungs, bones, pancreas, kidney, adrenal, heart, and brain., Other rare sites of distant metastases such as uterus, thyroid, spleen, and breast have also been reported in the literature. In our study, the most common site of distant metastasis was the liver, followed by lungs, ovaries, and bone.
Ovarian metastases from GB Ca are rare. The neoplastic involvement of ovaries secondary to GI malignancies is known as Krukenberg's tumor. The mode of ovarian metastases from GI malignancies is surface implantation or abdominal cavity seeding. Lymphatic and rarely hematogenous spread to ovaries can also occur., Metastatic ovarian lesions tend to be bilateral and appear predominantly solid or a combination of solid and cystic components on imaging.
Jindal et al., in their study of 100 cases of Ca GB, found portal vein invasion in 11% cases, liver metastases in 33%, peritoneal involvement with ascites in 30%, and Krukenberg's deposits in bilateral ovaries in 6% of cases.
In our study, vascular invasion was seen in 14% of the cases. We found omental deposits in 23% of cases and ascites in 22% of cases. Distant metastasis was found most commonly in the liver (42% of cases), followed by lungs in 7%, bilateral ovaries in 6%, and bones in 1% of the patients.
According to the AJCC staging system (8th edition), the primary tumor (T) is classified as T1 limited to the lamina propria (T1A) or the muscularis layer (T1B), T2 involvement of the perimuscular connective tissue without hepatic extension (T2a when the invasion is on the peritoneal side and T2b if the hepatic side is invaded), T3 extending beyond the serosa invading the liver and/or another adjacent organ (stomach, duodenum, colon, pancreas, omentum, extrahepatic bile ducts), and T4 vascular invasion involving the main portal vein, the hepatic artery, or multiple extrahepatic organs.
The lymph nodal (N) spread is classified as N0, where there is no nodal metastasis, N1 comprising of spread to 1–3 regional lymph nodes, and N2 is the involvement of 4 or more regional lymph nodes. The celiac, superior mesenteric, peripancreatic, and the retroperitoneal nodes such as portocaval, aortocaval, para-aortic, and beyond fall in the distant metastatic or M1 disease. The AJCC staging of Ca GB is done as Stage I (T1, N0, M0), Stage IIA (T2a, N0, M0), Stage IIB (T2b N0, M0), Stage IIIA (T3 N0 M0), Stage IIIB (T1-3 N1, M0), Stage IVA (T4, N0-1, M0), and Stage IVB (any T N2 M0 or any T any N M1); M0 corresponds to an absence of distant metastasis.
Stages I and II are potentially resectable, and radical surgery may be planned. Stage III represents unresectable disease due to extensive contiguous invasion of multiple adjacent organs and vessels. Stage IV is nonresectable due to distant metastases.
Singh et al., observed that the percentage distribution of Stages I, II, IIIA, IIIB, and IV of Ca GB were 0%, 4%, 10%, 8%, 17%, and 61%, respectively, as per the Tumor Node Metastasis staging system which corresponds to AJCC Stage I – 4%, Stage IIA – 10%, Stage IIb – 8%, Stage III – 17%, and Stage IV – 67%. The stages of Ca GB in our study in the descending order of frequency were IVB (67%), IIIB (16%), IVA (10%), IIIA (4%), and I or II (3%).
Our study's limitations were mainly its retrospective nature, a single-center study, and a relatively small study group. Only proven cases were retrospectively analyzed; we might have excluded many Ca GB cases in that period because of the lack of histopathological reports. As ours is a tertiary center, the patients might be coming here at an advanced malignancy stage. To know the exact stage of initial presentation and the actual frequency of various findings in the population, we need larger study groups and multicentric studies.
| > Conclusions|| |
In our observational study, we found a varied spectrum of imaging findings of Ca GB in MDCT in the subset of the eastern Indian population. Ca GB mostly presents at an advanced stage. MDCT with reconstructions is very accurate in diagnosing the Ca GB, differentiating it from other benign and malignant conditions, and assessing the tumor operability by staging.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]