Diagnostic ultrasound ( PDFDrive )

CHAPTER 6 The Biliary Tree and Gallbladder 207
adenocarcinomas, with squamous cell carcinoma and metastases
accounting for the rest. he following three patterns of disease
have been described:
• Mass arising in the gallbladder fossa, obliterating the gallbladder
and invading the adjacent liver (most common pattern)
• Focal or difuse, irregular wall thickening
• Intraluminal polypoid mass
Patterns of Tumor Spread
Because the gallbladder wall is quite thin, without a muscularis
mucosa and little connective tissue to separate it from the liver
parenchyma, contiguous hepatic invasion is the most common
pattern of spread. Gallbladder tumors also extend along the cystic
duct into the porta hepatis, where they mimic hilar cholangiocarcinomas.
Tumor extension into bile ducts or encasement of
the portal vein or hepatic artery may ensue. Direct invasion into
adjacent loops of bowel, especially the duodenum or colon, may
also occur. A resultant cholecystenteric istula and inlammation
may be mistaken for a benign abscess collection. Metastases to
the peritoneum are a common inding.
Lymphatic spread is also a common feature of gallbladder
carcinoma and may occur in the absence of invasion of adjacent
organs. 116 he irst nodes to be afected are in the hilar region.
Adenopathy may then extend either down the hepatoduodenal
ligament, to afect peripancreatic and mesenteric nodes, or across
the gastrohepatic ligament to celiac nodal stations.
Surgical resection is the only chance of cure; however, reported
resection rates range from 10% to 30%. 116 If the tumor is not
conined to the mucosa, an extended cholecystectomy, involving
resection of 3- to 5-cm rim of liver adjacent to the gallbladder
fossa, or a formal right hepatectomy is required. Regional lymph
nodes of the cystic bile ducts and CBDs are also removed.
Noncontiguous hepatic or peritoneal metastases, celiac or
peripancreatic nodal disease, or encasement of the main portal
vein or hepatic artery should be carefully sought because they
render the patient unresectable.
Sonographic Appearance
he appearance on sonography varies depending on the pattern
of carcinoma (Fig. 6.49). When masses replacing the normal
gallbladder fossa are small, it may be diicult to appreciate them
because they may blend into the liver. he absence of a normalappearing
gallbladder with no history of cholecystectomy should
raise suspicion. A clue to the diagnosis is the common presence
of an immobile stone that is engrossed by the tumor, the “trapped
stone.” On Doppler interrogation the mass may demonstrate
internal arterial and venous low. Difuse, malignant thickening
of the wall difers from other causes in that the wall is irregular
with loss of the normal mural layers. Polypoid intraluminal masses
are diferentiated from nonneoplastic abnormalities by immobility
of the mass, larger size (>1 cm), and prominent internal vascularity.
Gallbladder carcinomas may produce large quantities of mucin,
which distends the gallbladder.
Contrast-enhanced ultrasound has been reported to be a useful
tool in diferentiating benign from malignant gallbladder disease.
In one study, the disruption of the wall of the gallbladder as
detected by contrast-enhanced ultrasound was reported as a
having a sensitivity of 85% and speciicity of 100% in diagnosing
gallbladder cancer. 117
Sonography performs very well in locally staging gallbladder
carcinoma. Bach et al. 118 reported 94% sensitivity and 63%
accuracy for prediction of resectability compared with surgical
indings. More recently, high-resolution ultrasound of gallbladder
cancer using higher frequency probes (5-12 MHz) has shown
excellent performance in diferentiating T1 from higher tumor
stages. 106 However, sonography is oten diicult in patients with
unresectable disease because of limited detection of noncontiguous
hepatic, lymph node, and especially peritoneal metastases. A
CT scan is recommended to improve detection of metastatic
gallbladder disease.
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