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Indian Journal of Cancer
Medknow Publications on behalf of Indian Cancer Society
ISSN: 0019-509X EISSN: 1998-4774
Vol. 39, Num. 4, 2002, pp. 143-148

Indian Journal of Cancer, Vol. 39, No. 4, (October - December 2002) , pp. 143-148

Sonographic and Colour Doppler Morphology in Carcinoma Gallbladder

S. Pradhan,* V. K. Shukla, S. Agrawal,** V. K. Dixit,*** O. P. Sharma**

Department of Surgery; *Radiotherapy; **Radiodiagnosis & ***Gastroenterology, Institute of Medical Sciences, Banaras Hindu University, Varanasi 221 005, India.

ABSTRACT

Conventional radiography has limitations in accurate diagnosis of gallbladder cancer (GBC). Ultrasonography (USG) allows correct diagnosis in 70-80% advanced and 23% early GBC. Present study was initiated to identify morphology and flow characteristics in GBC using conventional USG and Colour Doppler USG (CD-USG).

In 100 patients, USG assessed morphology of mass lesion/wall thickening together with associated features. Of these, 60 cases were studied using CD-USG for intralesional/perilesional vascularity, peak systolic flow velocity (V max), resistive index (RI) and pulsatility index (PI).

USG identified GB with mass lesion in 44% cases (Group-I) and only mass in GB fossa in 56% cases (Group-II). Findings identified calculi (73%), Liver infiltration (74%), lntrahepatic ductal dilatation (IHDD) (52%), lymphadenopathy (19%) and ascites (5%). CD-USG revealed vascularity, mainly pulsatile flow, in 78.3% cases (in 91.3% Group-I cases). Mean Vmax was 0.3037 m/sec (0.109 - 0.646 m/sec.), mean RI was 0.6621 (0.526 - 1.000) and PI was 1.282 (0.772 -2.140), Mean Vmax and PI were higher in Group-I compared to Group-II.

Presence of calculus in 73% cases suggests a high association between calculus and malignancy. As flow signals were seen in 78% of all cases and 91.3% Group-I cases undergoing CD-USG, USG and CD-USG together can improve pickup rate of GBC.

Key Words: Gallbladder, Carcinoma, Gallbladder Neoplasm, Ultrasonography, Colour Doppler, Doppler Ultrasonography, Vascularity.

INTRODUCTION

Incidence of primary GBC shows global variation and in India this exhibits regional variation. In the west, while reported incidence of GBC is 1-3% of all malignancies,1,2 in India an incidence of 4.4% amongst all malignancies is seen.3 This is the third commonest cancer of gastrointestinal tract. 4 GBC is the most common malignancy of biliary tract, is the second commonest malignancy in the female population and first amongst digestive tract malignancy in Eastern Uttar Pradesh in India.5 Preoperative diagnosis of early stage carcinoma of the gallbladder is often not possible as symptoms usually simulate benign gallbladder disease and physical findings are equivocal. Delay in diagnosis obviously is the main reason for poor survival rate.6 The diagnosis is commonly made only on laparotomy with a reported frequency of 1.17% among all cholecystectomies. Conventional radiographic methods do not provide an accurate diagnosis of GBC as a result of nonspecific radiologic findings. USG allows correct preoperative diagnosis in 70-82% of the cases with advanced GBC.7-10 However, early carcinoma has been detected in only 23% of patients.11 Li et al12 reported high velocity arterial blood flow signal in the wall of gallbladder on Colour Doppler USG in cases of GBC not observed in either benign lesions or metastatic lesions of the gallbladder. Similar high flow has been reported by others.13-15 The present study was undertaken with intent to assess the USG morphology and Colour Doppler signals in patients with GBC.

PATIENTS AND METHODS

This study was carried out in the Departments of Surgery, Radiotherapy and Radiodiagnosis, University Hospital, Varanasi, India. One hundred histologically proven patients of GBC, which included 37 males and 63 females in the age group of 28-67 years, were the subjects of the study. The mean age for males and females were 55.22+7.1 and 42.7+9.12 years respectively. The patients were evaluated using a Siemens Sonoline Si-250 USG machine. A 3.5-5 MHz sector transducer was used to study altered ultrasonographic features in the morphology of gallbladder and liver. Patients were examined in fasting state to obtain physiological dilatation of the gall bladder and scanning was done in the sagittal and transverse planes using both subcostal and intercostal approach. Conventional USG was used for the study of the size and architecture of the liver. The gall bladder and biliary tract was scanned for the size and shape, abnormality such as mass lesion/ wall irregularity, evidence of obstructive jaundice, lymphadenopathy and ascites. Based on their morphology, the masses were classified into groups and subtypes as has been done by Kumar et al.3

Group-I - Gallbladder lumen identified along with a mass lesion. This was further classified as­

Type-1- mass almost obliterating the lumen
Type-2- Polypoidail mass
Type-3- Infiltrating mass (wall thickening)
Group-II - A large mass in the gallbladder fossa with no identifiable Gallbladder.

Of hundred cases, 60 patients agreed for and were also evaluated with Colour Doppler USG using a Wipro GE Logiq 500 equipment and 3.5 MHz convex transducer. Initially the patients were scanned real time in B mode to isolate the lesion and once the lesion was isolated colour flow imaging mode was employed. Once the colour signals were isolated in or around a lesion, pulsed Doppler mode was employed and spectral tracings were obtained. Depending on whether continuous or pulsatile flow was seen, following measurements were recorded:

  1. Peak systolic flow velocity (Vmax) in m/sec
  2. Resistive Index (Rl)- an index defined over the cardiac cycle as the difference between the maximum and minimum Doppler frequency shifts divided by the maximum shift.
    RI= (Peak systolic frequency shift - End diastolic frequency shift) X 100%
    Peak systolic frequency shift
  3. Pulsatility Index (PI)- the pulsatility index of a wave form is the difference between the maximum and minimum frequency shift value divided by the mean value of the wave form over the cardiac cycle.
    PI= (Peak systolic frequency shift- End diastolic frequency shift) X 100%
    Mean frequency shift

Hard copy record was prepared using multi format camera.

RESULTS

USG identified gallbladder with a mass lesion in 44 cases (Group-I) and in 56 cases gallbladder was not identified separately and was replaced by a mass lesion (Group-II), (Figure 1). In Group-I, polypoidal lesion was seen in 10 cases (22%), an infiltrating mass with wall thickening was seen in 24 cases (56%) and the mass was obliterating the lumen in 10 cases (22%). Calculus was seen in 35 (79.5%) Group-I and 38 (67.8%) Group-II cases suggesting a high association between calculus and malignancy. Hepatic scan revealed infiltration of hepatic parenchyma in 25 cases (56.8%) from Group-I and 49 cases (87.5%) from Group-II. IHDD was seen in 52 cases (16 or 36.4% Group-I and 36 or 64.3% Group-II) and secondary deposit in 29 cases (13 or 29.5% Group-I and 16 or 28.6% Group-II). Lymphadenopathy at porta hepatis was visualized in 6 (13.6%) Group-I and 13 (23.2%) Group-II cases. Although retroperitoneal lymph node was detected in only 3 cases (5.3%) of Group-II, peripancreatic lymph node involvement was found in 3(6.8%) and 5(8.9%) cases in Group-I and II respectively. Evidence of ascites was observed in five cases, (Table 1). Mixed echogenic mass ranging up to 14.1 x 14.2cm2 in maximum diameter and obliterating gallbladder lumen was visualized in 57% cases. Infiltrating mass with focal wall thickening up to 20mm was seen in 23% of the cases.

Sixty cases of GBC (23 Group-I and 37 Group-II) were evaluated with colour Doppler USG for assessment of flow pattern and flow velocity in the lesion. In lesions with colour signal, pulsed Doppler spectral tracing was recorded. Flow, both away from and towards the transducer, was noted. On spectral tracing pulsatile flow was seen in 44 (73.3%) cases and 3 (5%) cases showed continuous flow (Figure 2). Whereas, Group-I showed only pulsatile flow in 21/23 cases (91.3%), Group-II revealed pulsatile flow in 23/37 (62.16%) cases and continuous flow pattern in 3/37 (8.1%), (Table 2). Mean peak systolic flow velocity (Vmax) was 0.3037 m/sec (0.109-0.646 m/sec), mean RI was 0.6621 (0.526-1.0) and mean PI was 1.282 (0.772­2.149). The mean Vmax in Group-I was higher than that in Group-II (0.3535 m/sec compared to 0.2891 m/sec). Similarly, the mean PI was higher in Group-I and the difference was statistically significant (1.3024 compared to 1.1446; t=2.16 & p<0.05), (Table 3). In the subtypes of Group­ I, Type-2 lesions had higher mean Vmax, mean RI and mean PI compared to both Type-1 and Type-3 lesions, (Table 4).

DISCUSSION

Although ultrasonographic appearance of GBC is well known, it is often difficult to reliably distinguish carcinoma from benign disease. Reported sensitivity of sonographic diagnosis of GBC, in prospective series, ranges from 44% to 88.8%.9,16 As USG findings in early carcinoma are nonspecific, early detection is difficult on cholecystosonography.9 Many conditions, including wall thickening from cholecystitis, benign gallbladder tumors and extra-cholecystic lesions can be difficult to differentiate from GBC.2 Probably, the most frequently encountered and most difficult problem in these patients is distinguishing sludge or debris from a mass caused by GBC. Empyema and haematoma can produce echoes within the gallbladder that may be difficult to distinguish from a mass.8,10

The two reported signs for early disease in the literature are the presence of polyps and thickening of gallbladder wall. The presence of polyps is extremely rare in our population and gallbladder wall thickening is a common non-specific finding. In a study from our center, only 23 of 173 (13.3%) consecutive patients of GBC showed wall-thickening.17 In the preoperative setting, this wall thickening could be confused with chronic cholecystitis and if neglected could progress to advanced GBC. USG allows correct preoperative diagnosis in 70-82% of the cases with advanced GBC7-10 but detects early GBC in 23%.11 The need is felt for a methodology that will supplement the finding of USG and help in better preoperative diagnosis of the disease.

Hence, in the present study, colour Doppler USG was used to demonstrate vascularity within the gallbladder mass, allowing the preoperative diagnosis of carcinoma to be made with greater confidence. Out of 60 cases scanned, colour flow signals from gallbladder mass lesion were seen in 78% cases. Flow both away from and towards the transducer was noted. On spectral tracing, pulsatile flow was seen in 73.3% cases while 5% cases showed continuous flow pattern.

Li et al12 observed that all primary GBC (10 masses and 4 thickening of wall) in their study showed high velocity arterial blood flow signal in wall of gallbladder and nine of ten cases of primary gallbladder malignancy showed such flow in the tumour masses. In contrast, the 3 cases of metastatic GBC had no blood flow signal neither in the wall of the gallbladder nor in the mass. In 30 benign cases, they could find low velocity blood flow signal in only 12 cases. Hence, they concluded that an abnormal high velocity arterial blood flow signal observed within masses of the gallbladder or in gallbladder wall is a significant feature of primary GBC and thus helps to differentiate primary GBC from metastatic and benign lesions of the gallbladder. Komatsuda et al13 conducted a study based on colour Doppler and Pulsed Doppler sonography in a group of patients comprising of 13 cases with gallbladder carcinoma, 8 cases of adenomyomatosis and 8 cases of tumefactive biliary sludge. It was seen that the presence or absence of blood flow signal helps in the differentiation between GBC and tumefactive biliary sludge (81.6% sensitivity & 80.0% specificity). With colour Doppler ultrasound, Wilbur et al14 detected vascularity within the gallbladder lumen. Thereby, they differentiated the intraluminal tumour from isoechoic sludge and pus that on gray scale USG had shown heterogeneous echoes. Subsequent CT showed an enhancing intraluminal mass with small enhancing vessels that corresponded to those seen with colour Doppler. Similarly, in a case diagnosed with conventional USG as chronic cholecystitis, Ueno et al15 found the gallbladder lumen to be filled with debris like components and the gallbladder wall mildly thickened. Colour Doppler USG revealed colour signals in both the lesion and the gallbladder wall and these signals showed a high speed pulsatile wave. One of the visualized signals revealed a high RI (1.0). The findings were suggestive of malignancy and this was later confirmed by histological examination following surgery. Recently, Sato et al18 in their study involving 7 patients in whom colour Doppler was done and 3 patients in whom contrast Doppler study was done, showed that the presence or absence of blood flow signals distinguishes GBC in stage Tlb (muscular involvement) from tumefactive biliary sludge and that injection of contrast medium markedly increased diagnostic confidence. The investigators have suggested that when color Doppler sonography is ambiguous, contrast-enhanced Doppler sonography is the next line of investigation. However, greater Doppler sensitivity is mandatory for diagnosis of GBC in stage Tla (mucosal involvement).18

The presence of calculus in 73% cases of our study suggests a high association between calculus and malignancy. In the present study, colour flow signal from GBC mass lesions was seen in 78.3% cases. On spectral tracing, only pulsatile flow was seen in 91.3% cases with gallbladder showing a mass lesion. In cases where the gallbladder was replaced by a mass lesion, flow both pulsatile and continuous was seen only in 70.3 % cases. This may be because of the increased necrotic areas seen in the gallbladder replaced by mass lesions. Although the difference of mean Vmax, mean RI and mean PI of Type 2 lesions of Group-I compared to that of Types 1 and 2 is visible, it was not statistically significant, may be because of the small sample size among the three types. The higher Vmax, RI and PI in Type-2 lesions of Group-I compared to the two other subsets could be because of the fact that polypoidal tumours are usually proliferative lesions and such type of masses are usually more vascular than either ulcerative or infiltrative masses. In the present study, the mean RI of intralesional flow was 0.6621 (range 0.526 - 1.0), mean PI was 1.282 (range 0.772 - 2.140) and mean peak systolic flow velocity was 0.3037 m/sec. (range 0.109 - 0.646 m/sec). Ueno et al15 have detected signals with a high RI (1.0) in GBC. In view of our present study and the reports of other studies on colour Doppler USG in GBC, conventional USG in association with Doppler USG could be useful in the preoperative diagnosis of GBC and may turn out to be a valuable tool in the diagnosis of GBC.

REFERENCES

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Copyright 2002 - Indian Journal of Cancer.


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