Roentgen features of carcinoma of the gallbladder on barium-meal examination.

Abstract

Carcinoma of the gallbladder comprises about 4.5 per cent of all carcinomas discovered on necropsy and is therefore one of the more frequent types of malignant neoplasm (1). Nevertheless, a correct preoperative diagnosis is rarely made. Except in those cases in which a small carcinoma is incidentally found during the course of cholecystectomy for calculous disease, cancer of the gallbladder is rarely detected clinically before the appearance of jaundice. Even in such patients, the clinical diagnosis is not likely to be made unless a solid mass in the right upper quadrant can be identified and related to the gallbladder. This can rarely be done with certainty, since masses in this region are more likely to be within the liver and due to metastases. Pain or discomfort is a frequent feature but is usually attributed to chronic cholecystitis and cholelithiasis. Since stones are present in 50 to 90 per cent of patients with carcinoma of the gallbladder, there is often a history of biliary tract disease which goes back for many years (2, 5, 10). In most instances, the clinical diagnosis is obstructive jaundice due to common duct stones or carcinoma of the pancreas. Roentgen examination has not been of outstanding value in making a specific diagnosis of carcinoma of the gallbladder. A carcinoma confined to the fundus, extending outward and downward, is not likely to produce any changes on barium-meal examination. In a few cases, there is suggestive evidence, on roentgen examination, of a soft-tissue mass in the region of the gallbladder within which are irregular gas collections (Fig. 1). Oral and intravenous cholecystography are not of assistance because of the presence of jaundice and resulting non-visualization. Special procedures, such as percutaneous cholangiography or cholecystography, may be of some help but are not in general use because of associated hazards (7). Since a majority of patients present with jaundice, the neoplastic process, by the time a barium-meal examination is done, has extended to involve the proximal portion of the gallbladder, the cystic duct, and the adjacent extrahepatic bile ducts. Positive findings are therefore usually present (2, 3, 7, 8). Unfortunately, however, these changes are easily misinterpreted, perhaps because of bias in favor of the more common carcinoma of the pancreas. In order to determine whether these errors could be avoided, all cases of carcinoma of the gallbladder seen at Mount Sinai Hospital (New York) over a period of five years were reviewed. In 16 of these adequate barium-meal examinations had been done and were available for review. Twelve of these patients showed obvious obstructive jaundice at the time of the examination. One patient presented with pyloric obstruction (Fig. 1) and another with evidence of obstruction of the colon.