AFIP ARCHIVES 295

Gallbladder Carcinoma:
Radiologic-Pathologic
Correlation1
Angela D. Levy, LTC, USA, MC ● Linda A. Murakata, CDR, USN, MC
CME FEATURE
Charles A. Rohrmann, Jr, MD
See accompanying
test at http://
www.rsna.org
/education Primary carcinoma of the gallbladder is an uncommon, aggressive ma-
/rg_cme.html lignancy that affects women more frequently than men. Older age
groups are most often affected, and coexisting gallstones are present in
LEARNING the vast majority of cases. The symptoms at presentation are vague and
OBJECTIVES are most often related to adjacent organ invasion. Therefore, despite
FOR TEST 1 advances in cross-sectional imaging, early-stage tumors are not often
After reading this
article and taking
encountered. Imaging studies may reveal a mass replacing the normal
the test, the reader gallbladder, diffuse or focal thickening of the gallbladder wall, or a pol-
will be able to:
ypoid mass within the gallbladder lumen. Adjacent organ invasion,
䡲 Define the clinical
features and risk fac- most commonly involving the liver, is typically present at diagnosis, as
tors associated with is biliary obstruction. Periportal and peripancreatic lymphadenopathy,
gallbladder carci-
noma. hematogenous metastases, and peritoneal metastases may also be seen.
䡲 Enumerate the var- The vast majority of gallbladder carcinomas are adenocarcinomas. Be-
ied radiologic fea-
tures of carcinoma of
cause most patients present with advanced disease, the prognosis is
the gallbladder. poor, with a reported 5-year survival rate of less than 5% in most large
䡲 Describe the pat- series. The radiologic differential diagnosis includes the more fre-
terns of spread of
carcinoma of the gall-
quently encountered inflammatory conditions of the gallbladder, xan-
bladder. thogranulomatous cholecystitis, adenomyomatosis, other hepatobiliary
malignancies, and metastatic disease.

Abbreviation: ERCP ⫽ endoscopic retrograde cholangiopancreatography

Index term: Gallbladder, neoplasms, 762.321

RadioGraphics 2001; 21:295–314

1From the Departments of Radiologic Pathology (A.D.L., C.A.R.), and Hepatic and Gastrointestinal Pathology (L.A.M.), Armed Forces Institute of
Pathology, 6825 16th St NW, Bldg 54, Rm M-121, Washington, DC 20306-6000; the Department of Radiology and Nuclear Medicine, Uniformed
Services University of the Health Sciences, Bethesda, Md (A.D.L.); and the Department of Radiology, University of Washington, Seattle (C.A.R.).
Received; revision requested; revision received; accepted. Address correspondence to A.D.L. (e-mail: levya@afip.osd.mil ).

The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as representing the views of
the Departments of the Army, Navy, or Defense.
©
RSNA, 2001

See also the drawing by Cooper (p 322) in this issue.

296 March-April 2001
Introduction
Primary carcinoma of the gallbladder is an un-
common malignancy with a distinctive demo-
graphic and geographic distribution. In the
United States, it is the sixth most common gas-
trointestinal malignancy, following cancer of the
colon, pancreas, stomach, liver, and esophagus. It
is estimated that 7,000 new cases of extrahepatic
biliary cancers—most of them carcinomas of the
gallbladder—are diagnosed annually (1).
Gallbladder carcinoma is highly lethal, as ana-
tomic factors promote early local spread. The
ease by which this tumor invades the liver and
surrounding structures including the biliary tree
contributes to its high mortality. The median sur-
vival is 6 months, indicating that the majority of
patients present with advanced disease.
Despite the widespread use of modern imaging
techniques, early diagnosis is rare because there
are no specific signs and symptoms, and many
gallbladder carcinomas are not diagnosed preop-
eratively. This article reviews and illustrates the
pathologic and radiologic spectrum of gallbladder
carcinoma and its differential diagnosis.
Clinical Features
Epidemiology
Gallbladder carcinoma is three times more com-
mon in women than men. Higher prevalences
have been reported from New Mexico, Bolivia,
Chile, Israel, and northern Japan (2). It has also
been reported that ethnic groups with an in-
creased prevalence of cholelithiasis (eg, Native
Americans and Hispanic Americans) have a
greater risk of developing gallbladder carcinoma
(3,4). In addition, a recent review of the National
Cancer Database revealed that white women were
affected more frequently in the cases reported in
the United States from 1989 to 1995 (5). The
frequency of diagnosis increases with age; the av-
erage age at presentation is 72 years, and the me-
dian age is 73 years (6).
Risk Factors
Epidemiologic studies have shown that female
sex, age, postmenopausal status, and cigarette
smoking are risk factors (7). Ethnic origin, in-
creased body mass, and physician-diagnosed ty-
phoid are risk factors in the high-incidence popu-
lations of La Paz, Bolivia, and Mexico City,
Mexico (8). It is postulated that chronic Salmo-
nella typhi infection is associated with bile car-
cinogens and contributes to an increased risk of
hepatobiliary carcinoma (9) and gallbladder car-
cinoma (10). Exposure to chemicals used in the
RG f Volume 21 ● Number 2
Figure 1. Normal gallbladder. Photomicrograph
(original magnification, ⫻2; hematoxylin-eosin stain)
shows the mucosa as a single layer of columnar epithe-
lium with underlying lamina propria (solid arrows),
irregular muscle layer (open arrows), and connective
tissue (ⴱ).
rubber, automobile, wood finishing, and metal
fabricating industries has been associated with an
increased risk of gallbladder carcinoma (11,12).
Cholelithiasis is a well-established risk factor
for the development of gallbladder carcinoma
(13), and gallstones are present in 74%–92% of
affected patients (14). Gallstones cause chronic
irritation and inflammation of the gallbladder,
which leads to mucosal dysplasia and subsequent
carcinoma (15). Porcelain gallbladder is an un-
common condition in which there is diffuse calci-
fication of the gallbladder wall, and 10%–25% of
patients with this condition have gallbladder car-
cinoma (16).
Several pathologic and congenital anatomic
anomalies are associated with a higher prevalence
of gallbladder carcinoma, compared with that in
the general population. These conditions include
congenital cystic dilatation of the biliary tree, cho-
ledochal cyst (17,18), anomalous junction of the
pancreaticobiliary ducts (with or without a coexis-
tent choledochal cyst) (19 –22), and low insertion
of the cystic duct (23). Mucosal metaplasia and
consequent carcinoma are postulated to occur in
response to chronic biliary reflux of pancreatic
secretions (14).
Gallbladder abnormalities are frequently seen
in patients with primary sclerosing cholangitis,
and in one study of these patients, 41% had in-
trinsic gallbladder abnormalities, with 4% of
them having benign or malignant neoplasms (24).
Bile duct dysplasia can be found histologically in
patients with primary sclerosing cholangitis, and
it is thought to be a precursor to cholangiocarci-
noma (25) and gallbladder carcinoma (26). Ap-
proximately 5%–10% patients with primary scle-
rosing cholangitis develop cholangiocarcinoma
RG f Volume 21 ● Number 2 Levy et al 297

Figure 2. (a) Well-differentiated adenocarcinoma. Photomicrograph (original magnification, ⫻100; hematoxylin-

eosin stain) shows this well-differentiated adenocarcinoma is composed of variable-sized glands (arrows) that infil-
trate the wall of the gallbladder. The glands are surrounded by a desmoplastic stroma. (b) Moderately well-differenti-
ated adenocarcinoma. Photomicrograph (original magnification, ⫻200; hematoxylin-eosin stain) shows mucosa lined
by highly atypical epithelium consistent with high-grade dysplasia. Below the surface are malignant glands (arrows)
and small clusters of tumor cells infiltrating the lamina propria. The stroma is scant, and there is a mild infiltrate of
acute and chronic inflammatory cells.

(27). Although the risk of gallbladder carcinoma
in these patients is unknown, the association is
mentioned throughout the medical literature
(24,26,28,29).
Clinical Diagnosis
The diagnosis of gallbladder carcinoma is usually
unsuspected. Early-stage carcinoma is typically
diagnosed incidentally because of inflammatory
symptoms related to coexistent cholelithiasis or
cholecystitis. One percent of patients undergoing
cholecystectomy for cholelithiasis has an inciden-
tal gallbladder carcinoma (30).
The majority of patients with gallbladder carci-
noma present with advanced disease. Symptoms
are typically indolent. Chronic abdominal pain,
anorexia, or weight loss are common initial com-
plaints (31,32). Physical examination may dem-
onstrate a palpable mass, hepatomegaly, and
jaundice. Jaundice occurs more frequently as a
result of malignant obstruction of the biliary tree
rather than hepatic metastasis or coexistent cho-
ledocholithiasis (14). Elevated serum levels of
␣-fetoprotein and carcinoembryonic antigen have
been reported in association with gallbladder car-
cinoma (33–35).
Pathologic Features
Histologic Features
The normal gallbladder wall is composed of four
layers: mucosa, lamina propria, an irregular
muscle layer, and connective tissue (Fig 1). The
surface epithelium is composed of a single layer of
columnar epithelium with basal nuclei and eosin-
ophilic cytoplasm. There is no muscularis mucosa
or submucosa. Along the hepatic surface, the con-
nective tissue is continuous with the interlobular
connective tissue of the liver.
Gallbladder carcinomas are epithelial in origin
and account for 98% of all gallbladder malignan-
cies. The remainder are sarcomas, lymphomas,
carcinoid, metastases, and other unusual malig-
nancies. Adenocarcinomas account for 90% of
gallbladder carcinomas and are characterized by
glands lined by cuboidal or columnar cells, which
may contain mucin. They may be well, moder-
ately, or poorly differentiated, depending on the
degree of gland formation (Fig 2). There are sev-
eral histologic variants of adenocarcinoma recog-
nized: papillary, intestinal, mucinous, signet-ring
cell, and clear cell (36). Many tumors contain
more than one histologic variant. The frequency
of the most common histologic variants of gall-
bladder carcinoma reported to the Surveillance,
Epidemiology, and End Results program from
1977 to 1986 is listed in Table 1 (6).
The papillary adenocarcinoma consists of
branching fibrovascular stalks lined by atypical
cuboidal or columnar cells (Fig 3). Papillary car-
cinomas tend to fill the lumen of the gallbladder
before invading the gallbladder wall; therefore,
they are associated with a better prognosis than
other variants (Table 1) (6). The invading portion
of the tumor typically forms tubular structures
298 March-April 2001 RG f Volume 21 ● Number 2

Figure 3. Invasive papillary adenocarcinoma. Pho-

tomicrograph (original magnification, ⫻20; hematoxy-
lin-eosin stain) shows tumor invasion through the
muscle layer and into the subserosal adipose tissue (ar-
rowhead). The tumor is adjacent to large vessels (ar-
row) and nerves in the perimuscular connective tissue.
The gallbladder wall is thickened and fibrotic.
Figure 4. Intestinal variant of well-differentiated ad-
enocarcinoma of the gallbladder. Photomicrograph
(original magnification, ⫻10; hematoxylin-eosin stain)
shows a predominance of goblet cells (arrows) lining
the neoplastic glands that infiltrate the muscle layer.
There is necrotic debris in the lumen of the glands.

Table 1
Most Common Histologic Types of Gallbladder Carcinoma

Number of Percentage of 2-year Median Survival

Tumor Type* Patients Total (%) Survival Rate (months)
Adenocarcinoma, NOS 1,970 75.8 0.14 4
Carcinoma, NOS 200 7.6 0.06 2
Papillary adenocarcinoma 151 5.8 0.47 20
Mucinous adenocarcinoma 125 4.8 0.12 4
Adenosquamous carci-
noma 95 3.6 0.08 3
Squamous cell carcinoma 45 1.7 0.09 4
Oat cell carcinoma 13 0.5 0 2
Note.—Data from Surveillance, Epidemiology, and End Results Program, 1977–1986. Adapted, with permission,
from reference 6. Adenocarcinoma variants that are infrequent are not shown in this table.
*NOS ⫽ not otherwise specified.

rather than papillae. Both patterns may be seen in
metastatic deposits.
The intestinal type adenocarcinoma resembles
intestinal epithelium and is believed to be a vari-
ant of well-differentiated adenocarcinoma. This
category has two subtypes, which are character-
ized by the appearance of the intestinal glands:
(a) those lined chiefly by goblet cells (Fig 4) and
(b) those resembling the glands of colonic adeno-
carcinoma (34). Often, these subtypes are mixed
within the same tumor and may also contain foci
of ordinary well-differentiated adenocarcinoma.
Mucinous adenocarcinomas are those tumors
that consist of more than 50% extracellular mucin
(36). There are two histologic variants: one con-
tains large pools of extracellular mucin with small
clusters of malignant epithelial cells (Fig 5), and
the other is characterized by mucin-filled glands
with cystic dilatation. Foci of both variants may
be found admixed with conventional, well-differ-
entiated adenocarcinoma.
Signet-ring cell carcinoma contains cells with
abundant intracytoplasmic mucin, which dis-
places the nuclei to the periphery. When the tu-
mor is confined to the surface epithelium or in-
vaginations (Rokitansky-Aschoff sinuses), it may
be regarded as an in situ carcinoma. When stro-
mal invasion occurs, the cells grow in cords,
nests, and sheets and may form incomplete glan-
dular structures within a mucoid stroma (34). Infil-
trative submucosal growth can be a prominent
feature of signet-ring cell tumors and may occa-
sionally resemble linitis plastica of the stomach.
RG f Volume 21 ● Number 2
Figure 5. Mucinous adenocarcinoma. Photomicro-
graph (original magnification, ⫻40; hematoxylin-eosin
stain) shows small nests (arrow) of neoplastic epithelial
cells in pools of slightly basophilic mucin.
Figure 6. Clear cell adenocarcinoma. Photomicro-
graph (original magnification, ⫻400; hematoxylin-
eosin stain) shows a trabecular growth pattern of cells
with ample clear cytoplasm (arrow) and hyperchro-
matic nuclei. The fibrous stroma is scant with scattered
inflammatory cells.
Clear cell adenocarcinoma of the gallbladder is
composed of cords, sheets, nests, and trabeculae
of clear cells with well-defined cytoplasmic bor-
ders (Fig 6) (37) and may be confused histologi-
cally with metastatic renal cell carcinoma. How-
ever, clear cell adenocarcinomas may also contain
areas mixed with conventional adenocarcinoma
and mucin production, findings that help distin-
guish these tumors from renal cell carcinoma.
The remaining epithelial cell types occurring in
the gallbladder include adenosquamous carci-
noma, squamous cell carcinoma, small (oat) cell
carcinoma, and undifferentiated carcinoma. The
adenosquamous carcinoma contains a mixture of
Levy et al 299
Figure 7. Squamous cell carcinoma. Photomicro-
graph (original magnification, ⫻400; hematoxylin-
eosin stain) shows nests of well-differentiated, neoplas-
tic, keratinizing squamous cells that infiltrate the gall-
bladder wall. The fibrous stroma is scant.
malignant glandular and squamous components.
The pure squamous cell carcinoma constitutes
only 1% of all malignant gallbladder tumors and
consists of cords, islands, or sheets of malignant
squamous cells separated by dense fibrous stroma
(Fig 7) (34). These tumors most likely arise in
areas of previous squamous metaplasia, and their
histologic features may vary from anaplastic to
well-differentiated, keratinizing squamous cell
carcinoma. Small (oat) cell carcinomas of the
gallbladder are rare and highly aggressive tumors.
They are histologically identical to small cell car-
cinomas of the lung and gastrointestinal tract.
Paraneoplastic syndromes may be associated with
small cell carcinoma of the gallbladder, and
Cushing syndrome has been reported in associa-
tion with a corticotropin-secreting apudoma of
the gallbladder (38).
Gross Pathologic Features
The majority (68%) of gallbladder carcinomas are
diffusely infiltrating lesions, and the remainder
exhibit intraluminal polypoid growth (32%) (39).
Approximately 60% of tumors originate in the
gallbladder fundus, 30% in the body, and 10% in
the neck (34). Submucosal spread of infiltrating
carcinomas appears grossly as focal or diffuse ar-
eas of wall thickening, nodularity, or induration in
the gallbladder wall (Fig 8). In some cases of di-
rect invasion, a thick neoplastic wall encases the
gallbladder when direct extension to the liver has
occurred (34). In an autopsy series of 287 pa-
tients, direct extension to the liver was present in
65% of cases (39). The less common papillary
adenocarcinomas exhibit intraluminal polypoid
growth. This tumor is usually sessile and has a
cauliflower-like appearance (Fig 9) (34).
300 March-April 2001 RG f Volume 21 ● Number 2

Figures 8, 9. (8) Poorly differentiated adenocarcinoma. Photograph of a resected gallbladder (cut specimen)
shows innumerable gallstones and diffuse neoplastic mural thickening (arrows). Scale is in centimeters. (9) Papillary
adenocarcinoma. Photograph of a bisected gallbladder specimen shows the cauliflower-like intraluminal growth of a
papillary adenocarcinoma. Scale is in centimeters.

Figure 10. Porcelain gallbladder containing carcinoma and a fistula to the duodenum. (a) Abdominal radiograph
shows curvilinear calcification and an abnormal gas collection within the right upper quadrant of the abdomen.
(b) Image from an upper gastrointestinal series demonstrates a gallbladder-duodenal fistula, caused by invasive carci-
noma of the gallbladder (arrows).

Radiologic Features
Radiologic Evalua-
tion of the Primary Tumor
Abdominal radiography may be the initial exami-
nation for a patient with gallbladder carcinoma
who presents with abdominal distension or right
upper quadrant pain. Calcified gallstones or a
porcelain gallbladder may be present (Fig 10). In
rare cases, calcification precipitating in mucus
within the neoplastic glandular tissue may also be
visible on radiographs (40), and it is analogous to
calcium deposition in adenocarcinomas of the
colon and stomach. Abnormal collections of gas
in the right upper quadrant may be visible on ra-
diographs when the tumor has invaded adjacent
bowel and a fistula has formed (Fig 11). In some
cases, gas may also be present in the biliary tree.
The cross-sectional imaging patterns of gall-
bladder carcinoma have been described as a mass
replacing the gallbladder in 40%– 65% of cases,
focal or diffuse gallbladder wall thickening in
20%–30%, and an intraluminal polypoid mass in
15%–25% (41– 44).
Carcinomas that completely replace the gall-
bladder have irregular margins and heterogeneous
echotexture at ultrasonography (US). Heteroge-
neous echotexture reflects varying degrees of tu-
mor necrosis. Echogenic foci and acoustic shad-
owing associated with the tumor may be related
to coexisting gallstones, gallbladder wall calcifica-
tion (45), or tumoral calcification (Fig 12). Direct
RG f Volume 21 ● Number 2 Levy et al 301

Figure 11. Gallbladder carcinoma with erosion into the duodenum. (a) Abdominal radiograph
shows an abnormal collection of gas in the right upper quadrant containing a gas-fluid level.
(b) Image from an upper gastrointestinal series shows a duodenum-gallbladder fossa fistula.

Figure 12. Moderately well-differentiated adenocarci-

noma in a 70-year-old woman with right upper quadrant
pain and a history of gallstones. (a) Longitudinal sono-
gram shows a well-defined mass in the gallbladder fundus
(ⴱ) that produces ill-defined posterior acoustic shadowing.
Gallstones are also present. (b) Axial unenhanced com-
puted tomographic (CT) scan shows linear tumoral calci-
fications in the soft-tissue mass within the gallbladder.
(c) Photograph of the resected gallbladder (cut specimen)
shows the tumor mass (ⴱ) and numerous gallstones.
302 March-April 2001 RG f Volume 21 ● Number 2

Figure 13. Squamous cell carcinoma in a 64-year-

old woman. (a) Transverse sonogram shows diffuse and
irregular hyperechoic thickening of the gallbladder wall
(arrows), which is contiguous with the adjacent liver pa-
renchyma. There is a shadowing gallstone within the re-
sidual gallbladder lumen. (b) Autopsy photograph of the
liver and gallbladder (posterior view) shows direct invasion
of carcinoma into the adjacent liver parenchyma. The gall-
stones are enveloped by carcinoma. (c) Autopsy photo-
graph of the heart (cut specimen) shows hematogenous
myocardial metastases.

extension to the liver and biliary tree is a common

associated finding with large, advanced carcino-
mas. In these cases, the tumor is inseparable from
the adjacent liver (Fig 13).
Contrast material– enhanced CT in such cases
may demonstrate a hypoattenuating or isoattenu-
ating mass in the gallbladder fossa (Fig 14) and
soft-tissue invasion of the liver, with protrusion of
the anterior surface of the medial segment of the
left lobe (46). The tumor mass may contain low-
attenuation areas of necrosis. Areas of enhance-
ment reflect viable tumor (42). The low-attenua-
tion areas within the tumor mass or thickened
gallbladder wall may appear nodular (47). Biliary
obstruction at the level of the porta hepatis and
lymph node metastasis are frequent associated
findings. The location and characterization of
calcification within the gallbladder or tumor can
be well defined with CT (Fig 12b).
Wall thickening is the most diagnostically chal-
lenging of the three patterns because it mimics
the appearance of more common acute and
chronic inflammatory conditions of the gallblad-
der. Subtle areas of wall thickening may reflect
early carcinomas. However, they are difficult to
detect, since they may cause only mild elevation
of the mucosa when viewed sonographically (48).
Pronounced wall thickening (ie, ⬎1.0 cm) dem-
onstrated by US or CT (49), with associated mu-
ral irregularity or marked asymmetry should raise
concerns for malignancy or complicated cholecys-
titis (45,50). Use of contrast-enhanced CT is ex-
tremely helpful for distinguishing complicated
cholecystitis from gallbladder carcinoma (Fig 15)
(41,45,46). The CT demonstration of associated
lymphadenopathy, soft-tissue extension into the
liver, and evidence of hematogenous metastases
favors the diagnosis of gallbladder carcinoma (Fig
15b). Although magnetic resonance (MR) imag-
ing is typically not employed as a primary imaging
modality for the gallbladder, it may be useful in
cases of focal or diffuse mural thickening to dis-
tinguish gallbladder carcinoma from adenomyo-
matosis (51) and chronic cholecystitis (52).
RG f Volume 21 ● Number 2 Levy et al 303

Figures 14, 15. (14) Poorly differentiated mucinous adenocarcinoma in a 45-year-old man. (a) Trans-
verse sonogram shows an irregularly marginated hypoechoic mass in the gallbladder fossa. The mass is
contiguous with the liver, and there is shadowing emanating from the mass and a large amount of ascites.
(b) Axial contrast-enhanced CT scan shows a hypoattenuating mass in the gallbladder fossa with exten-
sion into the adjacent liver. Ascites and omental metastases (arrowhead) are present. (c) Autopsy photo-
graph of the liver (cut specimen) shows the gallbladder carcinoma invading the liver. There is a gallstone
in the residual gallbladder lumen. (15) Poorly differentiated adenocarcinoma in a 67-year-old man.
(a) Longitudinal sonogram shows heterogeneous, hypoechoic, diffuse thickening of the gallbladder wall.
There is peripancreatic lymphadenopathy (ⴱ) posterior to the gallbladder. (b) Axial contrast-enhanced
CT scan shows diffuse gallbladder wall thickening with a hypoattenuating mass extending into the adja-
cent liver parenchyma. There is a large peripancreatic lymph node (arrow). (c) Autopsy photograph of
the liver and gallbladder (cut specimen) shows tumor within the gallbladder extending into the adjacent
liver, hematogenous liver metastases, and periportal and peripancreatic lymph nodes (arrow).
304 March-April 2001 RG f Volume 21 ● Number 2

Figure 16. Moderately well-differentiated adenocarcinoma in a 55-year-old man. (a) Transverse sonogram shows
a well-defined, sessile hyperechoic mass (ⴱ) along the medial gallbladder wall with adjacent focal wall thickening (ar-
row) and pericholecystic fluid. (b) Axial contrast-enhanced CT scan shows the soft-tissue mass with focal wall thick-
ening, extension beyond the gallbladder wall (arrow), and pericholecystic fluid.

Figure 18. Squamous cell carcinoma in a 53-year-old

woman. (a) Axial T1-weighted MR image shows an
irregular hypointense mass within the gallbladder (ar-
row). (b) Gadolinium-enhanced axial T1-weighted im-
age shows irregular enhancement of the gallbladder car-
cinoma (arrow). (c) Multiplanar gradient-echo coronal
image shows the hypointense gallbladder carcinoma
invading the extrahepatic bile duct (arrow).
RG f Volume 21 ● Number 2
Figure 17. Papillary adenocarcinoma in an 80-year-old man. (a) Longitudinal sonogram demonstrates an ill-
defined echogenic mass (ⴱ) filling the gallbladder lumen. The mass was immobile with changes in patient position.
(b) Photograph of the resected gallbladder specimen shows the large intraluminal mass and associated gallstone.
Figure 19. Gallbladder carcinoma with contiguous
involvement of the transverse colon. Image from a
single-contrast barium enema study shows irregularity
and deformity to the superior aspect of the transverse
colon (arrows).
The less common intraluminal polypoid carci-
noma may exhibit a well-defined, round or oval
shape (Figs 12, 16) on cross-sectional images.
Sonographically demonstrating that the intralu-
minal mass is immobile with changes in patient
position allows one to distinguish tumor mass
from tumefactive sludge (Fig 17) (41). The tu-
mor may be hypoattenuating or isoattenuating on
CT scans. CT may more readily depict subtle
extension of the tumor beyond the wall of the
gallbladder (Fig 16b). MR imaging demonstrates
prolongation of the T1 and T2 relaxation times in
Levy et al 305
gallbladder carcinoma (53,54). Ill-defined early
enhancement is a typical appearance of these tu-
mors at dynamic gadolinium-enhanced MR imag-
ing (Fig 18) (52).
Radiologic Evalua-
tion of Tumor Extension
The most common mode by which gallbladder
carcinoma spreads to adjacent organs is direct
extension, followed by lymphatic and vascular
extension (55). Intraperitoneal (Fig 14b), intra-
ductal, and neural spread of tumor also occur.
The liver is the organ most frequently involved by
direct contiguous spread (65% of cases), followed
by the colon (15%) (Fig 19), duodenum (15%)
(Figs 10, 11), and pancreas (6%) (39). Contigu-
ous spread of tumor is facilitated by the thin gall-
bladder wall, which lacks a substantial lamina
propria and has only a single muscular layer. In
addition, the perimuscular connective tissue of
the gallbladder is continuous with the interlobular
connective tissue of the liver. This morphology
permits uninterrupted spread of tumor (6). The
tumor then spreads along portal tracts within liver
(56).
Radiographic studies such as a barium enema
study (Fig 19) and an upper gastrointestinal series
(Figs 10, 11) may demonstrate the findings of
adjacent bowel invasion. Extension of the primary
tumor into the liver or hepatoduodenal ligament
306 March-April 2001 RG f Volume 21 ● Number 2

Figure 20. Intrahepatic and periportal extension of adenocarcinoma in a 53-year-old woman. (a) Axial contrast-
enhanced CT scan shows intrahepatic extension of a gallbladder carcinoma, hepatoduodenal ligament spread, and
periportal lymphadenopathy (arrows). On a more superior section (not shown), there was bile duct dilatation.
(b) ERCP image shows a focal common bile duct stricture from periductal tumor extension.

is well depicted by CT and MR imaging. The CT
findings of tumor invasion into the hepatoduode-
nal ligament include well-defined nodular masses
caused by discrete lymph nodes; matted masses
due to confluent adenopathy; mixed, well-de-
fined, and confluent masses in various locations
along the hepatoduodenal ligament; and infiltrat-
ing, enhancing areas of soft-tissue attenuation
obscuring the portal vein margins (57). On MR
images, tumor extension has the same signal in-
tensity as the primary tumor (Fig 18c) (58).
Biliary dilatation is a common finding in gall-
bladder carcinoma, occurring in 38% of patients
in one series (58). Infiltrative tumor growth with
spread along the cystic duct to the extrahepatic
bile duct (Fig 20), lymph node enlargement, and
intraductal spread of tumor results in biliary dila-
tation and obstruction. Direct cholangiography
(endoscopic retrograde cholangiopancreatogra-
phy [ERCP], percutaneous transhepatic cholan-
giography, or intraoperative cholangiography)
may be performed in cases with biliary involve-
ment when the diagnosis of gallbladder carci-
noma is unsuspected or when therapeutic man-
agement of biliary obstruction is necessary.
Cholangiography may demonstrate malignant
strictures or obstruction involving the extrahe-
patic bile ducts, confluence of the right and left
hepatic ducts, and right lobe intrahepatic ducts
(Fig 21) (59). Associated findings from cholan-
giography include intraluminal gallbladder filling
defects that may represent tumor or stones, a
mass displacing and invading the gallbladder, and
intraductal filling defects that may represent tu-
mor or coexistent choledocholithiasis (Fig 21c,
21d).
The prevalence of lymphatic spread is high in
gallbladder carcinoma. Lymphatic metastases
progress from the gallbladder fossa through the
hepatoduodenal ligament to nodal stations near
the head of the pancreas (Fig 22). Three path-
ways of lymphatic drainage have been suggested:
the cholecystoretropancreatic pathway, the chole-
cystoceliac pathway, and the cholecystomesen-
teric pathway (60). The cystic and perichole-
dochal lymph nodes are the most commonly in-
volved at surgery (61) and are a critical pathway
RG f Volume 21 ● Number 2 Levy et al 307

Figure 21. Spectrum of ERCP findings in gallbladder carcinoma. (a) ERCP image of a 65-year-old woman with
well-differentiated adenocarcinoma shows cystic duct obstruction (arrow). (b) ERCP image of a 70-year-old woman
shows a filling defect in the gallbladder fundus from carcinoma and a hilar stricture at the confluence of the right and
left hepatic ducts from extension of carcinoma. (c) ERCP image of a 70-year-old man shows marked intrahepatic
duct dilatation from a hilar stricture due to gallbladder carcinoma. Intraductal stones are present in the common bile
duct. (d) ERCP image of an 80-year-old woman shows marked mass effect, intraductal extension of carcinoma, and
biliary dilatation from gallbladder carcinoma. There are stones within the residual gallbladder lumen (arrow).
308 March-April 2001
Figure 22. Adenocarcinoma in a 35-year-old woman.
(a, b) Axial contrast-enhanced CT scans show peripan-
creatic lymphadenopathy (arrow in a) and a focal mass in
the gallbladder fundus. (c) Photograph of the bisected
specimen shows the focal mass in the gallbladder fundus.
Cholesterolosis is also present (arrows).
to involvement of the celiac, superior mesenteric,
and para-aortic lymph nodes. The node of the
foramen of Winslow, the superior pancreatoduo-
denal node, and the posterior pancreatoduodenal
nodes are the most common nodes demonstrated
by CT (62). Positive lymph nodes are more likely
to be greater than 10 mm in anteroposterior di-
mension and have ringlike or heterogeneous con-
trast material enhancement (63). The masses pro-
duced by lymph node metastasis around the distal
common bile duct and pancreatic head may
mimic a pancreatic head carcinoma (45).
Hematogenous metastases are most commonly
seen in the liver (39). Pulmonary, skeletal, cardiac
(Fig 13c), pancreatic, renal, adrenal, and cerebral
metastases occur less frequently. Hematogenous
metastases to the liver are well depicted by CT
and MR imaging.
Staging, Therapy, and Prognosis
The TNM (Tables 2 and 3) (64) and modified
Nevin (Table 4) (65,66) classifications are used
for staging gallbladder carcinoma. There is very
little information in the current medical literature
on the accuracy of preoperative staging for gall-
bladder carcinoma. US is useful for detecting the
primary tumor and adjacent liver invasion, but it
cannot reliably depict the full extent of disease.
Bach et al (67) showed that only 37% of patients
with advanced disease were identified with US. In
addition, the potentially curable stage 1 cancers
are difficult to detect sonographically (48). Many
RG f Volume 21 ● Number 2
of these lesions are flat or only minimally elevate
the mucosa. Several authors have reported the
successful use of endoscopic US for evaluating
the depth of gallbladder carcinoma invasion
(68 –70).
CT is more useful than US for detecting lymph
node involvement, adjacent organ invasion, and
distant metastasis. CT does not reliably demon-
strate all regional lymph nodes, but, when abnor-
mally sized nodes (⬎10 mm) are present, it does
indicate that lymphatic spread has occurred (63).
In a retrospective study of 59 patients, the sensi-
tivity of CT in the detection of abnormal lymph
nodes was 36% for N1 nodes and 47% for N2
nodes; CT had a specificity of 99% for both N1
and N2 nodes (71). In the same study, CT had
a sensitivity of 100% in the detection of tumor
extension greater than 2 cm into the liver (T4
stage); however, its sensitivity in the detection of
less severe tumor extension into the liver (⬍2 cm
or T3 stage) was only 65% (71).
In general, the therapeutic options for gallblad-
der carcinoma are limited because of the late
stage of disease at presentation in most cases. In
addition, there is no standardized therapy for gall-
bladder carcinoma. Systemic or regional chemo-
therapy has had little success (2,72). Some re-
RG f Volume 21 ● Number 2 Levy et al 309

Table 2
Definition of TNM in Current AJCC Gallbladder Carcinoma Staging

Stage Definition
Primary tumor (T)
TX Primary tumor cannot be assessed
T0 No evidence of primary tumor
Tis Carcinoma in situ
T1 Tumor invades lamina propria (T1a) or muscle layer (T1b)
T2 Tumor invades perimuscular connective tissue; no extension beyond serosa
or into liver
T3 Tumor perforates the serosa (visceral peritoneum) or directly invades one
adjacent organ, or both (extension 2 cm or less into liver)
T4 Tumor extends more than 2 cm into liver, or into two or more adjacent
organs (stomach, duodenum, colon, pancreas, omentum, extrahepatic
bile ducts, any involvement of liver)
Regional lymph nodes (N)
NX Regional lymph nodes cannot be assessed
N0 No regional lymph node metastasis
N1 Metastasis in cystic duct, pericholedochal, or hilar lymph nodes (ie, in the
hepatoduodenal ligament)
N2 Metastasis in peripancreatic (head only), periduodenal, periportal, celiac,
or superior mesenteric lymph nodes
Distant metastasis (M)
MX Distant metastasis cannot be assessed
M0 No distant metastasis
M1 Distant metastasis
Note.—Adapted from references 64, 65, 75. AJCC ⫽ American Joint Committee on Cancer.

Table 3 Table 4
Stage Grouping in Current AJCC Gallbladder Modified Nevin Staging for Gallbladder
Carcinoma Staging Carcinoma

Stage Grouping Stage Description

0 Tis N0 M0
1 T1 N0 M0
2 T2 N0 M0
3 T1 N1 M0
T2 N1 M0
T3 N0 M0
T3 N1 M0
4a T4 N0 M0
T4 N1 M0
4b Any T N2 M0
Any T Any N M1
Note.—Adapted from references 64, 65, 75.
AJCC ⫽ American Joint Committee on Cancer.
ports have demonstrated an increase in survival
time for patients who underwent palliative or ad-
juvant radiation therapy (73,74). Although surgi-
cal resection is the mainstay of therapy, the extent
of resection for each stage of disease remains con-
troversial. Most authors agree that T1N0M0 dis-
ease requires a simple cholecystectomy. Aggres-
sive surgery (including cholecystectomy with en
bloc segmental hepatic resection, lymph node
1 In situ carcinoma
2 Mucosal or muscular invasion
3 Transmural direct liver invasion
4 Lymph node metastasis
5 Distant metastasis
Note.—Adapted from references 65, 66, 75.
dissection, and common bile duct resection and
reconstruction if necessary) is performed to pro-
vide adequate control of local disease and poten-
tial cure for patients with stage T1b or TNM
stage 2 and 3 carcinomas. It has been demon-
strated that there are no long-term survivors
among patients with node-positive disease treated
with aggressive surgery (75). These same authors
recommend that the presence of M1, N2, and N3
disease should preclude attempts at curative re-
section (75).
310 March-April 2001 RG f Volume 21 ● Number 2

Figure 23. Acute cholecystitis in a 19-year-old woman with a positive sonographic Murphy sign. (a) Transverse
sonogram shows nonshadowing gallstones, thickening of the gallbladder wall, and pericholecystic fluid. (b) Photo-
graph of the cut specimen shows diffuse purulent thickening of the gallbladder wall. The mucosa of the gallbladder is
hemorrhagic, and there are stones present.

Figure 24. Xanthogranulomatous cholecystitis in a 40-year-old woman

with chronic right upper quadrant pain. (a) Transverse sonogram of the
gallbladder fossa shows marked heterogeneous thickening of the gallblad-
der wall and narrowing of the gallbladder lumen (arrow). (b) Axial con-
trast-enhanced CT scan shows gallbladder wall thickening and soft-tissue
stranding in the gallbladder fossa. The gallbladder lumen is very small
(arrow). (c) Photograph of the bisected specimen shows fibrotic thicken-
ing of the gallbladder wall and narrowing of the gallbladder lumen.
RG f Volume 21 ● Number 2
Figure 25. Adenomyomatosis in a 48-year-old man with chronic right upper quadrant pain. (a) Longitudinal
sonogram shows diffuse gallbladder wall thickening and hyperechoic foci within the gallbladder wall that produce
ring-down artifact (arrow). (b) Photograph of the bisected specimen shows marked thickening of the gallbladder wall
and Rokitansky-Aschoff sinuses (arrows).
Laparoscopic cholecystectomy may inadver-
tently be performed in cases of gallbladder carci-
noma when tumor is unsuspected. Iatrogenic dis-
semination of gallbladder carcinoma in the perito-
neal cavity and port sites has been described in
the surgical and radiologic literature, with 45
cases reported to date (76 –78). Many authors
advocate re-exploration for those patients in
whom a T2 or T3 carcinoma was incidentally
found at cholecystectomy and excision of port
sites for those patients who underwent laparo-
scopic cholecystectomy (75,79).
The overall 5-year survival rates for patients
with gallbladder carcinoma are less than 5%, with
a median survival of less than 6 months (6,75).
The most important prognostic factors are histo-
logic type, histologic grade, and stage of the tu-
mor. Patients with papillary carcinomas have the
best survival time (median, 20 months) (Table 1)
(6).
Radiologic Differential Diagnosis
Gallbladder carcinoma manifesting as diffuse
gallbladder wall thickening has a differential diag-
nosis that includes the more common inflamma-
tory and noninflammatory causes of wall thicken-
ing. These conditions include heart failure, cir-
rhosis, hepatitis, hypoalbuminemia, renal failure,
and cholecystitis (Fig 23). Occasionally, a peri-
cholecystic abscess, gallbladder necrosis, or fistula
formation to adjacent bowel can complicate acute
cholecystitis. The findings in these cases may
Levy et al 311
simulate those of an aggressive neoplastic process.
Gallbladder carcinoma should be suspected when
there are features of a focal mass, lymphadenopa-
thy, hepatic metastases, and biliary obstruction at
the level of the porta hepatis (46).
Xanthogranulomatous cholecystitis is a
pseudotumoral inflammatory condition of the
gallbladder that radiologically simulates gallblad-
der carcinoma (47,80,81). The CT features of
xanthogranulomatous cholecystitis and gallblad-
der carcinoma overlap substantially; thus, these
entities cannot be reliably differentiated (47,80).
Both diseases may demonstrate gallbladder wall
thickening, infiltration of the surrounding fat, he-
patic involvement, and lymphadenopathy (Fig 24).
Adenomyomatosis is a common tumorlike le-
sion of the gallbladder with no malignant poten-
tial (34). It may involve the gallbladder in a focal,
segmental, or diffuse form. Its histologic features
include a proliferation of epithelial and mural ele-
ments, and Rokitansky-Aschoff sinuses are seen
as prominent infoldings of the epithelium. At US,
adenomyomatosis is characterized by focal or dif-
fuse gallbladder wall thickening and anechoic or
echogenic foci in the gallbladder wall (Fig 25)
(82,83). These echogenic foci may produce a
ring-down reverberation artifact (Fig 25a). Roki-
tansky-Aschoff sinuses are best visualized with
312 March-April 2001
Figure 26. Metastatic melanoma in a 45-year-old woman with right upper quadrant tenderness. (a) Longitudinal
sonogram shows a polypoid mass within the gallbladder. (b) Photograph of the bisected specimen shows melanotic
pigmentation in the gallbladder mass.
MR imaging performed with breath-hold tech-
nique and T2-weighted pulse sequences (51);
therefore, MR imaging can be useful for distin-
guishing this benign entity from gallbladder carci-
noma.
The differential diagnosis for those tumors that
manifest as an intraluminal polypoid mass in-
cludes adenomatous, hyperplastic, and choles-
terol polyps; carcinoid tumor; metastatic mela-
noma (Fig 26); and a hematoma within the gall-
bladder. The differential diagnosis for a mass
replacing the gallbladder fossa includes hepato-
cellular carcinoma, cholangiocarcinoma, and
metastatic disease to the gallbladder fossa.
Summary
Primary carcinoma of the gallbladder is a highly
aggressive malignancy that is found at a late stage
in the majority of affected patients. Early-stage
gallbladder carcinoma is most commonly an inci-
dental finding in patients who have undergone
cholecystectomy for inflammatory disease of the
gallbladder. The radiologic findings in early-stage
cancers are subtle and may mimic those of acute
or chronic cholecystitis. The radiologic findings
in advanced tumors reflect its behavior. Direct
extension to the liver and biliary tree, biliary ob-
struction, lymph node metastases, and hematoge-
nous metastases are characteristic findings of ad-
vanced cancers. Papillary adenocarcinoma has
the best prognosis of the histologic types and typi-
cally manifests as an intraluminal polypoid mass.
Knowledge of the varied appearances of gallblad-
der carcinoma at cross-sectional imaging, particu-
larly US and CT, is important so that the diagno-
sis can be considered preoperatively.
RG f Volume 21 ● Number 2
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