Indian Journal of Cancer Medknow Publications on behalf of Indian Cancer Society ISSN: 0019-509X EISSN: 1998-4774 Vol. 48, Num. 1, 2011, pp. 132-134

Indian Journal of Cancer, Vol. 48, No. 1, January-March, 2011, pp. 132-134

Letter to Editor

Cancer in porcelain gallbladder - Rare imaging trait

KK Sen¹, A Upadhyaya¹, Y Pimpalwar², J D'Souza³

¹ Department of Radiology and Imaging, PSG IMSR, Coimbatore-641004, India
² Military Hospital, Barelly, U.P., India
³ Department of Radiology and Imaging, AFMC, Pune - 411 040, India

Correspondence Address:
K K Sen
Department of Radiology and Imaging, PSG IMSR, Coimbatore-641004
India
neeta28apr@yahoo.com

Code Number: cn11033

Sir,

Ultrasonography (US) in a 70-year-old lady, with features of resistant obstructive jaundice and postintervention status, revealed intrahepatic biliary radicular dilatation, a stent in the common bile duct, and calculus in the gallbladder [Figure - 1]. The gallbladder wall, though appeared hyperechoic, was devoid of any posterior acoustic shadowing. Two echo-poor oblong hepatic lesions in the left lobe were thought to be part of the dilated biliary channels. Abdominal lymph adenopathy (periportal, celiac, and peripancreatic groups) was also detected.

Subsequent computerized tomography (CT) demonstrated a gallbladder with mural plaque, discretely calcified irregularly thickened wall ^[1] and a dense stone of higher X-ray attenuation value of Hounsfield Unit (HU) 1108-1251 within [Figure - 2] and [Figure - 3]. A bowel loop was adherent to the wall of the gallbladder. Contrast-enhanced CT (CECT) of the abdomen revealed features of hepatic infiltration with intrahepatic biliary radicular dilatation ^[2] likely due to metastatic deposits. However, CECT of thorax did not demonstrate any evidence of metastasis. Cytological confirmation was obtained following ultrasound-guided fine needle aspiration of tissue from the abdominal lymph nodal mass, which on histopathology revealed adenocarcinoma. Palliative surgery and cytology confirmed the preoperative imaging and FNAC results.

• Cross-sectional imaging, particularly US and CT, was of extreme importance for an immediate preoperative diagnosis and staging with high level of accuracy. It will be worthwhile to undertake CECT studies of the thorax and abdomen as a protocol in such cases. Its main advantage lies in showing tumor infiltration into the adjacent viscera [Figure - 4] or vessels, lymph node, and distant metastasis. When gallbladder carcinoma is suggested by US findings, positron emission tomography can be considered complementary to establish the benign/malignant nature of the lesion and to obtain a primary staging study ^[3] with an improved specificity. Review of literature indicated that US features of a porcelain gallbladder can have four distinct patternsa hyperechoic semilunar structure with posterior acoustic shadowing that simulates a stone-filled gallbladder devoid of bile
• A biconvex curvilinear echogenic structure with variable acoustic shadowing
• An irregular clump of echoes with posterior acoustic shadowing
• An echogenic gallbladder wall without acoustic shadowing

Diagnosis of porcelain gallbladder with unusual imaging manifestation and artifacts in this patient was possible, since the variant features on ultrasound were taken into account and correctly interpreted by the vigilant sonologist.

References

Copyright 2011 - Indian Journal of Cancer

The following images related to this document are available:

Photo images