ADENOMYOSIS OF THE GALLBLADDER

ADENOMYOSIS
OF THE GALLBLADDER
Abbas Al-Kurd, MD
Department of Surgery, Hadassah-Hebrew University
Medical Center,
Mount Scopus, Jerusalem, Israel
Case 1 – 9/2008
• 54 yr old female
• PMHx: Hyperlipidemia
• Postprandial RUQ pain, radiating to back +
nausea
• Several months
• U/S – GB 2x7 cm. Wall severely thickened,
irregular, several echogenic foci. No stones.
Two LN’s at porta hepatis 0.7x1.5 cm.
• CT – Contracted GB, severe mural thickening,
irregular, several intramural cystic areas. No
invasion to liver. Two LN’s inferior to PV – 1.5
cm. No biliary dilation.
• CEA  3.28
• CA 19-9  8.35
• LFT’s nL
2/10/2008 – Laparotomy
• Hard GB mass, peritoneal aspect of GB
• Enlarged regional LN’s
• Liver normal
• Radical Cholecystectomy
Case 2 – 9/2012
• 56 yr old female
• PMHx – Hyperlipidemia, smoking
• RUQ pain + nausea, 3 months.
• U/S – SOL in GB, 1.3X2.4 cm, cystic areas
• DDx: GB Carcinoma vs Adenomyosis
• Markers  nL
4/9/2012 – Laparotomy
• 2 cm solid mass at hepatic aspect of the
fundus of GB
• Not clear if it invades liver
• Enlarged retroduodenal LN 2.5 cm
• Radical cholecystectomy
Case 3 – 7/7/2015
• 49 yr old female
• PMHx: Smoker
• RUQ pain, recurrent attacks since 3 months
• U/S:
• CEA  7.26
• CA 19-9  11.9
• LFT’s  nL
9/7/2015 – Laparotomy
• 3 cm soft mass at peritoneal aspect of
fundus/body
• No enlarged LN’s
• Radical Cholecystectomy
Gallbladder Adenomyomatosis
• Benign
• Relatively common
• Incidence: 2–8% (cholecystectomy specimens)
• More in females, 50’s – 60’s
• Rarely symptomatic
• 75 – 90% cholelithiasis
• Adenomyomatosis
• Adenomyosis
• Adenomyoma
• Hyperplastic cholecystosis
• Diverticular disease of GB
• Intramural diverticulosis of GB
• Cholecystitis cystica
• Cholecystitis glandularis proliferans
“Adenomyomatosis”
• Benign hyperplastic lesion characterized by:
– excessive proliferation of surface epithelium
– invagination into the thickened muscular layer
or deeper
– wall thickening
– intramural diverticulosis
– Rokitansky-Aschoff sinuses
Types
Annular
Fundal
Segmental
Diffuse
Diagnosis
• U/S
– Mural thickening
– Rokitansky-Aschoff
sinuses
– Comet-tail artifacts
– Twinkling artifacts (doppler)
• CT
– Mural thickening and enhancement
– Rokitansky-Aschoff sinuses
• MRI/MRCP
– Mural thickening, sinuses
– Pearl necklace sign
– Diamond ring sign
• N = 20
• Surgically proven adenomyomatosis
• Accuracy:
– U/S  66%
– CT  75%
– MRI  93%
• Addition of high mgHz imaging to conventional low
mgHz imaging
• Harmonics, compounding techniques, and speckle
reduction imaging
• 45-Adenomyomatosis
• 28-Carcinoma
Sensitivity – 80.0%
Specificity – 85.7%
Accuracy – 82.2%
• Adenomyomatosis  13
• Carcinoma  27
• Sensitivity:
– HRUS  73.1%
– MDCT  50.0%
– MRI  80.8%
Carcinoma Risk?
• Historically: benign condition
• Potential role in carcinogenesis?
Katoh T, Nakai T, Hayashi S, Satake T. Noninvasive carcinoma of
the gallbladder arising in localized type adenomyomatosis. Am J
Gastroenterol. 1988 Jun;83(6):670-4.
Kurihara K, Mizuseki K, Ninomiya T, Shoji I, Kajiwara S. Carcinoma
of the gall-bladder arising in adenomyomatosis. Acta Pathol
Jpn. 1993 Jan-Feb;43(1-2):82-5.
Sakurai T, Saji Y, Kazui K, Yamaga S, Hirose K, Shinohara T, Uchino
J. A case of early carcinoma of the gall-bladder arising
in adenomyomatosis detected by endoscopic ultrasonography.
Nihon Shokakibyo Gakkai Zasshi. 1995 Sep;92(9):1304-8.
Relationship between gallbladder carcinoma and
the segmental type of adenomyomatosis of the gallbladder.
Ootani T, Shirai Y, Tsukada K, Muto T.
Cancer. 1992 Jun 1;69(11):2647-52.
• 3197 consecutive cholecystectomies
• Adenomyomatosis 279 (8.7%)
– Segmental – 188
• 6.4% malignancy
• 3.1% malignancy in others
• P < 0.025
High risk of gallbladder carcinoma in elderly patients with
segmental adenomyomatosis of the gallbladder.
Nabatame N, Shirai Y, Nishimura A, Yokoyama
N, Wakai T, Hatakeyama K.
J Exp Clin Cancer Res. 2004 Dec;23(4):593-8.
• 4,560 consecutive cholecystectomies
• Segmental adenomyomatosis – 334 (7.3%)
• Carcinoma  6.6%
• Others  Carcinoma 4.3%
• More in age >60
Management
• No clear guidelines
• Symptomatic  Surgery
• Unclear diagnosis/possible malignancy  Surgery
• Approach?
Conclusion
• Benign
• Malignant potential?
• Radiologic diagnosis
• Differentiation from carcinoma
• Management  controversial