Tumorous Conditions of the Gallbladder CI. Leland

Melson,

M.D.,

Federico

Reiter,

T

UMOROUS conditions of the gallbladder encompass a broad spectrum of pathologic entities, including benign and malignant neoplasms, reactive processes, inflammatory lesions, and hyperplastic states. This topic has been of interest to radiologists since Kirklin first reported in 1931 that such lesions could be demonstrated by oral cholecystography.” The lack of a uniform nomenclature and classification and the widely differing opinions regarding their etiology, clinical significance, and therapeutic implications complicate discussion of these entities. BENIGN

TUMORS

Classification

In the early literature, most benign tumors of the gallbladder were termed “papillomas.“14~20’21 ,24 As more clearly defined histologic criteria evolved, several classifications have been presented.7’15*27Y40 We employ a modification of the comprehensive scheme proposed by Christensen and Ishak,’ based on their review of 180 cases from the Armed Forces Institute of Pathology, which, to our knowledge, is the largest series reported (Table 1). Incidence The incidence of tumorous conditions of the gallbladder is difficult to determine accurately because of inconsistent classification, and differences in the nature of the material reviewed. In 1915, Charles Mayo reported 107 cases of papilloma of the gallbladder among 2538 cholecystectomies over an g-year period, an incidence of 4.2%.22 Sixteen years later. Kirklin, from the same instituG. Leland Melson, M.D.: Associate Professor of Radiology. Mallinckroa’t institute of Radiology, Washington University School of Medicine, St. Louis, MO. Federico Reitcr, M.D.: Assistant Professor of Radiology, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO. Ronald G. Evens, M.D.: Elizabeth Mallinckrodt Professor and Head of Radiology, Mallinckrodt Institute of Radiology, Washingtorz University School of Medicine, St. Louis, MO. Reprint requests should be addressed to G. Leland M&on, M.D., Mallinckrodt Institute of Radiology, Washingtori University School of Medicine, 510 South KingshighhJax,

St.

Louis,

MO.

63110.

1’119 76 hv Grunt, & Stratton, Inc. Seminars

in Roentgenology,

Vol.

Xl,

No.

4 (October),

1976

M.D.,

and

Ronald

G. Evens,

M.D.

tion, stated that the incidence of papilloma was 8.5%~~~Shepard and co-workers reviewed cholecystectomy specimensfrom the Mayo Clinic between 1906 and 1938, and classifiedas “polypi” 45 lesionshaving histologic characteristics that by current criteria would have been designated as adenomas.36Without stating the total nutnber of gallbladders examined. they estimated the incidence of polyps to be I’%. They also reported 103 adenomyomasand 2 fibromas in the same material. which would make the overall incidence of these three lesionsabout 3.5%. It seemslikely that the disparity in the incidence of gallbladder tumors reported by Kirklin*’ and by Shepard et al.36 from the sameinstitution durmg a similar time period results from the fact that most of the lesionsin Kirklin’s serieswere probably cholesterol polyps, while these tumors were specifically excluded by Shepard. Ochsner3’ found 70 benign lesions in 1523 cholecystectomy specimens,an incidence of 4.6%. Eelkema and co-workers’ observed 226 cases01 polypoid filling defects among 54.755 oral cholecystograms. or an incidence of 1 lesion in every 242 patients examined. Thus, benign tumors occur in approximately 4%-S%ofcholecystectomy specimens and in less than 0.5’-%of the population examined by oral cholecystography. The three most common benign tumorous conditions of the gallbladder arc adenoma,cholesterol polyp, and adenomyoma (Table 2). Cholesterol polyp is usually considered to be the most common of these.17,25926 but in somereviews adenomyoma9y36 or adenoma4T30have been the most numerous. Radiologic

and

Pathologic

Features

The roentgenologic criteria for the cholecystographic diagnosis of benign gallbladder tumor remains essentially as originally described by Kirklin.20121 They are as follows: (1 ) rounded radiolucent filling defect, often multiple; (2) usually lessthan 1 cm in diameter: (3) often situated peripherally; (4) fixed, i.e., they maintain the same location in the gallbladder with changesin patient position and on repeated examination; (5) usually found in a well-opacified gallbladder; 269

270

NIELSON,

Table

1. Classification

of Benign

Pseudotumors True neoplasms Epithelial Adenoma,

papillary

Adenoma, Supporting

nonpapilary structures

of the

Tumors

and

Gallbladder*

Hemangioma Leiomyoma Lipoma Neuroma Fibroma Myxoma Granular Hyperplastic

cell tumor lesions

Adenomyomatosis cystoses”

and

Adenomatous

other

“hypertrophic

chole-

hyperplasia

Cystic lesions Mucocele Epithelial

cyst

Heterotopic Gastric

lesions mucosa

Intestinal Pancreas

mucosa

Liver Polyps Inflammatory Cholesterol

polyp polyp

Miscellaneous Fibroxanthomatous

inflammation

Parasitic infection Postoperative defect Congenital

fold

or septum

*Modified

from

Christensen

and

REITER,

AND

EVENS

Adenoma The designation adenoma is preferable to papilZoma for true neoplasms arising from gallbladder epithelium. Adenomas may be either papillary or nonpapillary. The papillary type has a branching tree-like configuration, with a single layer of columnar or cuboidal epithelium covering a thin, vascular connective tissue stalk. The nonpapillary forms consist of proliferating glands surrounding connective tissue stroma. There may be cystic glandular dilatation. Mixed forms occur, containing both papillary and nonpapillary elements, in which case the lesions are classified according to the predominant component. The diameter of an adenoma ranges from 0.1 to 2.5 cm; most are less than 1 cm in diameter. The majority are pedunculated, the others are sessile. Approximately two-thirds are multiple. They have no predilection for any site in the gallbladder.7730 On oral cholecystography, a sessile lesion will show a notch in the contour of the gallbladder on tangential view (Fig. IA) and a rounded radiolucent filling defect on en face projection (Fig. IB). The very thin stalk of a pedunculated adenoma (Fig. 1) may be obscured by opacified bile, making distinction between the sessile and pedunculated types difficult. Demonstration of fixation on appropriate projections is, of course, essential to exclude a calculus.

Ishaka7

(6) best seen on the postfatty meal film; and (7) frequently multiple. With the exception of adenomyoma, the radiographic findings in benign tumors are nonspecific. A stone fixed to or partially embedded within the gallbladder wall may be indistinguishable from a tumor. In the Ochsners’ series3’ 39% of the tumors were originally diagnosed as calculi on the oral cholecystogram. Stones fixed to the gallbladder wall were more common than true ade nomas in one series.26 Radiographs of high technical quality are essential for optimal demonstration of these lesions. The gallbladder should be well opacified, and compression spot films in varying degrees of obliquity, as well as standard films with an overhead tube, should be obtained. The abnormality may be visible only after a fatty meal.17

Tumors of Supporting Tissues These lesions are quite rare, and only a few have been demonstrated radiographically. Neither of the two fibrsmas in the series of Shepard et a1.36 was diagnosed preoperatively; one was an incidental finding at exploratory laparotomy and the other occurred in a nonfunctioning, inflamed gallbladder containing calculi. The single fibroadenoma reported by Ochsner and Ochsne? was a typical polypoid lesion. An oral cholecystogram on a patient with a hemangioma described by Sewell and Miron3’ showed a sessile lesion 2 cm in diameter in the body of the gallbladder. Two patients with a granular cell tumor associated with a mucocele in a gallbladder that did not opacify on oral cholecystography have been reported.7 A traumatic neuroma arose in the cystic duct stump a year after cholecystectomy.7

TUMOROUS

CONDITIONS

Table

2.

Benign

OF

THE

Tumors

and

371

GALLBLADDER

Pseudotumors

of the

Gallbladder:

Number

of Cases

in Reported

Series

Authors Lesion

Benign

Christensen

et al.7

Ochsner

et ak30

Nugent

et

al.26

Arbab

et aL4

Shepard

et al.36

neoplasms

Epithelial Supporting

(adenoma)” tissue

51

35

3

12t

45 1.

Fibroma

2

Fibroadenoma Hemangioma Lipoma

1

Granular Traumatic

cell tumor neuroma

Pseudotumor Hyperplasia Adenomyomatous Adenomatous Heterotopia Polyps

73

9

8

103

18 7

(gastric)

Inflammatory Cholesterol

3

4

4

21

21

26

Miscellaneous Fibroxanthomalous inflammation Parasitic *Both tTermed :!:Termed

7

infection papillary

2 and

nonpapillary.

“papilloma” “polypus”

Hyperplastic

histologic

features

described

consistent

Lesions

Adenomyomatous hyperplasia has been described under a variety of terms, including adenomyoma, adenomyomatosis, cystadenoma, fibromyoadenoma, myoepithelial anomaly, intramural diverticulosis, cholecystitis glandularis proliferans, cholecystitis cystica, and adenoma.16 Its etiology and clinical significance are controversial; the arguments are reviewed and well summarized by Jutras et al.‘67’7 ;and Fotopoulos and Cramptom.” That this entity represents a hyperplastic state is now widely accepted, although Ackerman and Rosai still consider it, along with cholesterosis apd diverticulosis, to be part of the spectrum of chronic cholecystitis. Jutras et al-l7 believe that adenomyomatous hyperplasia, together with cholesterolosis (cholesterol polyps), neuromatosis, and other rare conditions, belong to a group that they term the “hyperplastic cholecystoses.” This designation is chosen to emphasize their degenerative and proliferative nature; the relative or total absence of an inflammatory component; the tendency of more than one of these conditions to occur simulta-

with

criteria

of Christensen

and

Ishak7

for

adenoma

neously or consecutively in the same gallbladder; and the evidence that they possess a common etiology. Utilizing meticulous radiographic technique, including postfatty meal films, it is found ilt about 5% of oral cholecystograms.12Y16 There is a moderate predominance among women. The essential pathologic feature of this condition is hyperplasia of the gallbladder wall. There are three gross forms: localized, confined almost exclusively in the gallbladder fundus and comprising the vast majority of cases; segmental: and generalized (Fig. 2). Histologically, there is thickening of the muscularis to as much as five times normal, and mucosal proliferation. An increase in the number and height of mucosal folds causes a velvety surface and projection of mucosa into or through the trabecular meshwork of the muscular layer as tubules, crypts, saccules, or a branching gland-like network. The mucosal protrusions form intramural diverticula. Rokitansky, and later Aschoff, described these outpouchings that now bear their names.16 Studying 135 cholecystectomy specimens, Elf-

272

MELSON,

Fig. 1. Adenoma of gallbladder. (Al Recumbent tangential view. ent patient. Erect spot film from oral cholecystogram showing infundibulum of the gallbladder. Oral cholecystograms.

ving” reported the presence of RokitanskyAschoff sinuses in 86% with extension to the muscle in 10% penetration into the muscularis in 46%, and expansion outside the muscularis in 30%. Unlike a benign tumor, the area of involvement lacks a capsule separating it from adjacent normal tissue. The radiographic appearance of the localized form varies with the exact site of the adenomyoma along the inferior margin of the gallbladder, the degree of gallbladder distension, and such technical factors as the angle of projection on the film, patient positioning, and the degree of vector of compression. r’ The essential cholecystographic features are: (1) a sessile fnling defect, usually 0.4-2.0 cm in diameter; (2) a central opaque speck or indentation; and (3) opaque dots representing diverticula or Rokitansky-Aschoff sinuses

Note the notch a pedunculated,

REITER,

in the gallbladder smooth, round

AND

contour. (B) filling defect

EVENS

Differin the

at the periphery of the nodule (Figs. 3 and 4). See also page 231. Regardless of the form or position of the lesion, the key element in the cholecystographic diagnosis is the visualization of intramural diverticula, which appear as opaque dots ranging in diameter from pinpoint to 10 mm. In the localized or generalized forms, they may be the only manifestation. At times, they are seen only on films taken after a fatty meal (Fig. 5). When multiple and viewed tangentially, they appear reminiscent of a string of pearls closely applied to the circumferences of the opaque gallbladder lumen (Fig. 6). Occasionally, opaque filaments connecting the diverticula with the lumen of the gallbladder may be seen. They pass through the muscularis, represented by a radiolucent line whose thickness varies with the

TUMOROUS

CONDITIONS

OF

THE

GALLBLADDER

273

Fig. 2. Diagrams of the three types of adenomyomatosis: (A) generalized, (B) segmental, and (C) localized (adenomyoma). (Reproduced by permission of the American Journal of RoentgenolOgY. ‘7)

state of gallbladder filling, increasing with contraction and decreasing with luminal distension. The size and shape of the diverticula also varies with the degree of gallbladder distension; usually they are largest and best filled with maximal gallbladder contraction. In en face projections, the diverticula appear as opaque spots within the lucent halo of the tumor mass (Fig. 3B). Rokitansky-Aschoff sinuses may occasionally contain

opaque calculi, but due to their low calcium content and small size they may be invisible. Jutras et al. emphasize how often neuromatosis (hyperplasia of autonomic neural fibers) in the lamina propria is associated with adenomyomatosis.17 Because special fixation and staining techniques are required to demonstrate it, they suggest that the presence of neuromatosis in the specimen is usually overlooked. The concomitant hyperplasia

Fig. 3. Diagrams of cholecystographic images of adenomyoma. IA) Frontal view: left, intraluminal; middle, transmarginal; right, extraluminal. (B) Profile view: left, invagination; middle, intermediate state; r&h, evagination. (Reproduced by permission of the American Journal of Roentgenology. 17)

274

MELSON,

REITER,

AND

EVENS

Cystic Lesions These lesions are extremely rare. A mucocele is not visible on oral cholecystography. Ochsner encountered two examples of intramural epithelial CySt,2sJ9 each presenting as a large smooth intramural defect on oral cholecystography and could find reports of only two other similar tumors. Polyps

Fig. 4. Evaginated Rokitansky-Aschoff nodule (arrows).

localized sinuses

at

adenomyoma. the periphery

Note of

the the

of the mucosal, muscular, and neural tissues is felt to be responsible for the hyperconcentration, hyperexcitability, and hyperexcretion so commonly seen radiographically. The etiology of adenomyoma is unclear. It is practically never found in children” so it is probably not congenital. Increased intraluminal pressure secondary to partial obstruction from a kink or web is supported by several authors,s’12y’6 who suggest that adenomyomatosis should be suspected in any septated gallbladder, and that films after a fatty meal be taken to bring out its features. Adenomatous hyperplasia, described by Christensen and Ishak,’ to our knowledge has not been reported by others. We will not speculate about its significance. Grossly, the gallbladder exhibited mucosal thickening, either focal or diffuse. Microscopically, the mucosa was papillary or formed a sponge-like glandular network. Oral cholecystography was “noncontributory.”

A polyp is a tumor or tumor-like projection arising from a mucosal surface. In that sense, most tumors of the gallbladder are polyps. However, the designation is particularly applied to two specific lesions. IrQammatory polyps result from chronic cholecystitis and consist of glandular epithelial proliferation within a vascular connective tissue stroma having a marked chronic inflammatory cell infiltrate. Thickening of the wall, Rokitansky-Aschoff sinuses, and intramural and intraluminal calculi may be present. They may be single or multiple and shown by oral cholecystography. Cholesterol polyps are part of the spectrum of cholesterolosis, in which focal accumulations of cholesterol-laden histiocytes (foam cells) occur in the lamina propria. As the collections enlarge, the epithelium is progressively elevated, forming excrescences ranging from yellowish flecks to sessile or pedunculated polyps, usually 0.1-0.5 cm in diameter. They may be solitary but generally are multiple. Multiplicity, irregularity in size, and uneven distribution throughout the gallbladder suggest the diagnosis (Fig. 7). The very delicate pedicle of the pedunculated form may be obscured by opaque bile on the roentgenogram and easily ruptured during gallbladder palpation at the time of surgery. It is accepted that a spontaneously detached lesion may serve as a nidus for stone formation.*’ Other Benign Lesions The radiographic features of fibroxanthomatous inflammation are not discussed by the only authors classifying it as a distinct entity.7 Other miscellaneous conditions that may cause gallbladder tumors, such as parastic infections and congenital variations are considered elsewhere in this Seminar. Clinical

Implications

Far from the least controversial aspect of these conditions is their clinical implications. Nugent

TUMOROUS

CONDITIONS

OF

THE

GALLBLADDER

Fig. 5. Generalized with adenomyomatosis cholelithiasis. (A) The markedly thickened and irregular gallbladder wall is outlined by pericholecystic fat (arrows). Tiny radiolucent calculi are present in the fundus in this erect spot film. (6) Portfatty meal film shows irregular contraction and filling of Rokitansky-Aschoff sinuses (arrows).

275

276

MELSON,

REITER,

AND

Fig. 6. Segmental adenomyomatosis. Postfatty meal film. The infundibulum mal. The sinuses were inconspicuous initial fasting films. The gallbladder very dense. (6) Another example.

EVENS

(A) is noron the shade bw is

TUMOROUS

CONDITIONS

OF

THE

GALLBLADDER

277

Fig. 7. Cholesterol polyps. The oral cholecystogram demonstrates multiple, slightly irregular, rounded, radiolucent filling defects of varying size. Most are marginal, several are en face (arrow).

et al? have pointed out three important considerations: Do these lesions cause symptoms? What is the pathologic nature of the polyp? Is the lesion ever precancerous or cancer? It is generally recognized that any of the tumors we have discussed may be associated with a symptom complex indistinguishable from that of cholelithiasis or chronic cholecystitis. However, in many patients the symptoms are vague and nonspecific and often there are none at all. Reported series vary in the frequency of concomitant calculi or inflammation. Gallstones have been found in 33% to 47% of patients with benign gallbladder tumor,7>30 while the reported incidence of cholecystitis ranges from 34% to 1OO%.3o136Thus, many patients shown to have tumors on oral cholecystography will also have associated conditions for which cholecystectomy is indicated, a point that is strongly emphasized in the surgical literature. However, many clinicians believe that the tumor per se, especially adenomyomatosis, may cause symptoms.17

Another reason frequently given for removing the gallbladder containing a known tumor is the rare occurrence of noninvasive carcinoma in situ in an adenoma.7918J30*36P38 It is impossible in many reported cases to determine whether the adcnoma was visualized by oral cholecystography and if cholelithiasis was also present. Both cases of in situ carcinoma reported by the Ochsnersa” and two of the three in Tabah and McNeer’s series3” occurred in a nonfunctioning gallbladder containing calculi. However, Tabah and McNeer’s third case had a fixed filling defect and no stones on the oral cholecystogram. The defect proved to be an adenoma with carcinoma in situ. Adenomyoma and cholesterol polyps are not regarded as premalignant conditions. In the only study of its type of which we are aware, Eelkema and co-workers’ reported on a follow-up of 226 patients in whom the diagnosis of adenoma or papilloma had been made by oral cholecystography. At the time of initial evaluation, only 23 (10%) were considered to have

278

MELSON,

REITER,

AND

EVENS

Fig. 8. Carcinoma of the gallbladder. (A) Intravenous cholangiogram. The irregular defect in the gallbladder was attributed to adenomyomatosis. (6) One-and-one-half years later. Peritoneoscopic injection of contrast material into the gallbladder. Cholecystectomy. Papillary adenocarcinoma filled the gallbladder lumen and penetrated to the muscular layer. The patient was well 2 years later. (Courtesy of Dr. Benjamin Fe1son.j

TUMOROUS

CONDITIONS

OF

Fig. 9. T-tube cholangiogram ocarcinoma of the gallbladder intrahepatic spread. There are areas of irregularity and stenosis intrahepatic bile ducts.

THE

279

GALLBLADDER

in adenwith multiple in the

symptoms that warranted cholecystectomy. Polyps were found at operation in 20, calculi in 2; the pathologic report was not available in 1. Of 113 patients followed for 15 years, 10 had subsequently undergone removal of the gallbladder; 8 of these were found to contain stones, and 1 a benign tumor. In one, the pathologic findings were not stated. Repeat oral cholecystography had been performed in 59 of the 113 patients. The gallbladder was normal in 34, contained a polyp in 16 and stones in 6, and was nonfunctioning in 3. Only 6% of the 103 unoperated patients followed for 15 years had symptoms suggesting cholecystic disease. None developed carcinoma of the gallbladder. Considering all of this conflicting data, it seems to us that the following general conclusions are warranted: (1) In an asymptomatic patient, if a tumorous condition of the gallbladder is unaccompanied by gallstones, cholecystectomy is not indicated. (2) If the patient has convincing clinical indica-

tions of gallbladder disease, cholecystectomy should be performed. (3) The risk of developing carcinoma in a patient having a gallbladder tumor but no calculi is extremely small, and cholecystectomy for this reason alone is unwarranted. MALIGNANT

TUMORS

Primary

Carcinoma Carcinoma of the gallbladder is the fifth most common malignant tumor of the accessoryorgans of digestion’ and accounts for 3% of all deaths due to cancer. It occurs in about 1.8% of all cholecystectomies and is found in 0.3%-0.8% of autopsies.“3g Affecting primarily the elderly, about 86% of casesoccurring between the agesof 50 and 80 years, the neoplasm has a reported female-to-male ratio of 3.5 : 1 to 8 : 1,39 which is similar to that of cholelithiasis. Adenocarcinoma is the most common cell type; about 55% of these are scirrhous, 25% are papil-

280

lary, and 15% are mutinous. Squamous cell carcinoma is the least frequent (5%). l >4o Cholelithiasis is present in 80%-90% of patients with carcinoma and is widely considered to be an important predisposing condition.’ The incidence of carcinoma in calcified (porcelain) gallbladder is so striking-up to 61%-as to warrant prophylactic cholecystectomy. 32 Grossly, the early carcinoma is usually a thickened plaque or sessile polyp; pedunculated polyps comprise only about 10% of the carcinomas. Multicentric origin is common. A small carcinoma arising in the infundibulum may obstruct the gallbladder, causing hydrops. The modes of spread of gallbladder carcinoma have been analyzed in detail.3Y” Regional lymph nodes and the liver are involved by the time of operation in about 75%-90% of cases. The tumor may directly invade the stomach, duodenum, colon, omentum, pancreas, diaphragm, or anterior abdominal wall. Vascular dissemination results most often in metastases to the lungs, spine, and heart. Involvement of the adrenals, ovaries, kidneys, and spleen has also been described.” A significant problem in the diagnosis of gallbladder carcinoma is that its symptoms are indistinguishable from those of cholecystitis, cholelithiasis, or other biliary tract disease.3 Right upper quadrant pain, nausea, and weight loss are usually present. The patient is commonly referred with a diagnosis of obstructive jaundice or a suspected tumor of the liver, pancreas, or stomach. The correct diagnosis is rarely made preoperatively. In fact, even at operation the carcinomatous gallbladder may be misinterpreted as chronic cholecystitis13 and the diagnosis made only after opening the gallbladder. Radiologic diagnosis. The findings on abdominal plain films are directly related to the tumor size and are not useful in early cases. A right upper quadrant mass, with or without calculi or mural calcification, may be present. Oral cholecystography generally reveals a nonfunctioning or poorly opacified gallbladder. 3’ Rarely, the tumor is seen as a polyp or an irregular mural defect (Fig. 8).31T33 Barium studies of the upper gastrointestinal tract may demonstrate abnormalities secondary to a mass effect or regional invasion by the tumor. Deformity and infiltration of the stomach or duodenum are common findings. The barium enema may show a mass effect on the hepatic flexure of the colon.‘gT31 The diagnosis has been made by percutaneous transhepatic cholangiography and by peritoneos-

MELSON,

REITER,

AND

EVENS

copy (Fig. 8B). 23 lntraoperative cholangiography may reveal deformity or obliteration of biliary ducts (with or without dilatation), secondary to tumoral infiltration of the liver (Fig. 9). Angiography has been used in the diagnosis of gallbladder carcinoma and in evaluating its regional spread.31 p34,37 Excellent technique with supraselective injections are necessary if small tumors, which are usually hypovascular, are to be demonstrated. The main angiographic abnormalities are arterial encasement, neovascularity, and tumoral blush. Special attention should be directed to the cystic arteries, which tend to be enlarged and may exhibit abrupt angulation (Fig. 10). Thickening and unevenness of the gallbladder wall may be shown during the venous phase. The prognosis in gallbladder carcinoma is very poor. Patients are asymptomatic in the early potentially curable stages, and when symptoms finally appear they are initially nonspecific and suggest benign biliary tract disease. By the time surgery is performed, three-fourths of the patients have unresectable tumor.3 Death will occur within a year after diagnosis in 80% of the patients. The 5-year survival rate is a dismal 1%-5%.3g Even when an early lesion is discovered incidentally on pathologic examination of a removed gallbladder, the prognosis is only slightly better.i3 Long-term survivors have been reported; virtually all of them had a well-differentiated papillary lesion.* The value of radical surgery seems to be doubtful.3 Other Primary Malignant Tumors Carcinoid tumor and primary sarcoma of the gallbladder occur rarely. Good recent reviews of the literature are available.5Y42 Spindle cell, pleomorphic cell, and leiomyosarcoma are the most frequent sarcomas, and have no distinctive clinical or radiographic features.42 Secondary

Malignant

Tumors

Secondary malignant involvement of the gallbladder occurs most commonly by direct extension from contiguous structures. Blood-borne metastases from melanoma and carcinoma of the lung, kidney, and esophagus are well documented,6*41 but the diagnosis is rarely made radiographically. ACKNOWLEDGMENT Figure 1 was provided through the Francisco J. Medina, Catholic University ago, Chile.

courtesy Hospital,

of Dr. Santi-

TUMOROUS

CONDITIONS

Fig. 10. Selective hepatic arteriogram in adenocarcinoma of the gallbladder with intrahepatic metastases. (A) Early arterial phase, showing slight enlargement and angulation of the cystic arteries (arrows) and encasement of the right hepatic artery (arrowhead). (6) Late arterial phase, showing naovascularity and tumor blush in the gallbladder and the liver metastases.

OF

THE

GALLBLADDER

281

282

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REFERENCES 1. Ackerman LV, de1 Regato JA: Cancer: Diagnosis, lomas of the gallbladder. Am J Roentgen01 25:46-50, Treatment and Prognosis (ed 4). St. Louis, Mosby, 1970, 1931 pp 586-593 21. Klrklin BR: Cholecystographic diagnosis of neo2. Ackerman LV, Rosai J: Surgical Pathology (ed 5). plasms of the gallbladder. Am J Roentgen01 29:8-16, St. Louis, Mosby, 1974, pp 555-563 1933 22. Mayo CH: Papillomas of the gallbladder. Ann Surg 3. Adson MA: Carcinoma of the gallbladder. Surg Clin North Am 53:1203-1216, 1973 62:193-196, 1915 23. McNulty JG: Preoperative diagnosis of carcinoma 4. Arbab AA, Brasfield R: Benign tumors of the gallbladder. Surgery 61:535-540, 1967 of the gallbladder by percutaneous transhepatic chol5. Botha JBC, Kahn LB: Primary lymphoma of the angiography. Am J Roentgen01 101:605-607, 1967 24. Moore C: Cholecystographic diagnosis of papilgallbladder. Case report and review of the literature. S Afr lomas and tumors of the gallbladder. 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