Carcinoma in a well-functioning gallbladder.

Abstract

Modern radiology of the gallbladder with its excellent contrast media and efficient spot-film technics (1) is especially suited to the easy demonstration of noncalculous filling defects. Herewith is reported an example of frank adenocarcinoma of the gallbladder with excellent concentration of the contrast medium, a rare observation (2). Figure 1 represents the gallbladder of a 45-year-old man with upper abdominal complaints compatible with gallbladder disease. Aside from several minute stones that gravitated to the fundus, there was a constant filling defect measuring 5 × 10 mm., apparently related to the medial wall. Roentgenologically, “a neoplasm could not be excluded.” Study of the surgical specimen by Dr. C. P. Barnette, formerly Associate Professor at Hahnemann Medical College, disclosed that this noncalculous filling defect was a frank “papillary adenocarcinoma, noninvasive” (Fig. 2). Noncalculous filling defects within the gallbladder can be divided into four groups as follows: 1. Metabolic (focal cholesterolosis): This group is the most numerous. The lesions are usually small and multiple, and sharply outlined; they tend to spare the fundus, and the concentration of contrast medium by the gallbladder is usually excellent. The filling defect represents focal subepithelial cholesterol deposits. 2. Inflammatory: Filling defects of inflammatory origin represent overgrowth of the epithelium toward the lumen of the gallbladder, under the stimulus of chronic infection. The concentrating power of the gallbladder is usually suboptimal. When the proliferation is directed within the wall, Rokitansky-Aschoff sinuses result. 3. Neoplastic: In addition to the rare mesenchymal growths (lipoma, fibroma, etc.), there are the much more important epithelial tumors of the gallbladder, those which are potentially malignant, such as adenoma and papilloma, and the frank carcinomas. The lesion in these cases is usually single. 4. Malformations: The dimpled hemispherical defect protruding into the lumen from the fundus of the gallbladder is the commonest example of this group. The lesion has been called by many names (3, 4), adenoma, adenomyoma, adenomyosis, cholecystitis glandularis proliferans, myoepithelial anomaly, all attesting to the wide variety of opinions concerning the pathogenesis—neoplasm, a special response to infection related to the Rokitansky-Aschoff sinuses, heterotopia, and failure in the normal orientation of the cells in the tip of the gallbladder bud. The author has recently seen a nonspecific filling defect in the gallbladder that proved to be due to aberrant pancreas, but this was well away from the fundus. While a differential diagnosis of these noncalculous filling defects within the gallbladder may be attempted on the basis of size, number, sharpness of outline, position, and function of the gallbladder, none of these criteria is sufficiently accurate to justify the risk of missing a potentially or frankly malignant lesion.