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78
GASTROINTESTINAL IMAGING
Gallbladder Carcinoma and Its
­Differential Diagnosis at MRI:
What Radiologists Should Know
Camila Lopes Vendrami, MD
Michael J. Magnetta, MD
Pardeep K. Mittal, MD
Courtney C. Moreno, MD
Frank H. Miller, MD
RadioGraphics 2021; 41:78–95
https://doi.org/10.1148/rg.2021200087
Content Codes:
From the Department of Radiology, North-
western Memorial Hospital, Northwestern
University Feinberg School of Medicine, 676
N St Clair St, Suite 800, Chicago, IL 60611
(C.L.V., M.J.M., F.H.M.); Department of Radi-
ology, Medical College of Georgia, Augusta, Ga
(P.K.M.); and Department of Radiology and Im-
aging Sciences, Emory University, Atlanta, Ga
(C.C.M.). Presented as an education exhibit at
the 2019 RSNA Annual Meeting. Received April
22, 2020; revision requested June 4 and received
July 13; accepted July 16. For this journal-based
SA-CME activity, the authors, editor, and re-
viewers have disclosed no relevant relationships.
Address correspondence to F.H.M. (e-mail:
Frank.Miller@nm.org).
©
RSNA, 2020
SA-CME LEARNING OBJECTIVES
After completing this journal-based SA-CME
activity, participants will be able to:
„ Discuss the epidemiologic and histo-
logic features of gallbladder carcinoma.
„ Understand the spectrum of MRI find-
ings of gallbladder carcinoma.
„ Describe the spectrum of MRI findings
of mimics of gallbladder carcinoma.
See rsna.org/learning-center-rg.
Gallbladder carcinoma is the most common cancer of the biliary
system. It is challenging to diagnose because patients are often
­asymptomatic or present with nonspecific symptoms that mimic
common benign diseases. Surgical excision is the only curative ther-
apy and is best accomplished at early non–locally advanced stages.
Unfortunately, gallbladder cancer often manifests at late locally ad-
vanced stages, precluding cure. Early tumors are often incidentally
detected at imaging or at cholecystectomy performed for another
indication. Typical imaging features of localized disease include
asymmetric gallbladder wall thickening, polyps larger than 1.0 cm,
and a solid mass replacing the gallbladder lumen. Advanced tumors
are often infiltrative and can be confusing at CT and MRI owing
to their large size. Determination of the origin of the lesion is para-
mount to narrow the differential diagnosis but is often challenging.
It is important to identify gallbladder cancer and distinguish it from
other benign and malignant hepatobiliary processes. Since surgical
resection is the only curative treatment option, radiologist under-
standing and interpretation of pathways of nodal and infiltrative
tumor spread can direct surgery or preclude patients who may not
benefit from surgery. While both CT and MRI are effective, MRI
provides superior soft-tissue characterization of the gallbladder and
biliary tree and is a useful imaging tool for diagnosis, staging, and
evaluation of treatment response.
©
RSNA, 2020 • radiographics.rsna.org
Introduction
Gallbladder carcinoma is a relatively uncommon malignancy (1,2)
with poor prognosis when diagnosed at an advanced stage. The
5-year survival rate is estimated to be less than 5% for infiltrative
stage III or IV tumors (3). The prevalence varies worldwide from
1.5 per 10 000 in North America to 27 per 10 000 in South America
(1,2). The most common gallbladder tumors are epithelial in origin,
with 90% classified as adenocarcinomas (4). Rare tumors involv-
ing the gallbladder include carcinoid, sarcoma, lymphoma, and
metastases.
Patients are often asymptomatic or present with nonspecific
symptoms ranging from abdominal pain, anorexia, and weight loss to
jaundice, pruritus, and scleral icterus (5). Because symptoms, labora-
tory test results, and imaging findings are generally nonspecific, and
the only curative treatment option (surgical resection) is typically
offered in non–locally advanced cases, a high index of clinical and
radiologic suspicion is essential to reduce morbidity and mortality. In
this article, we review the epidemiologic, clinical, and pathologic fea-
tures of gallbladder carcinoma; present relevant imaging features and
staging at MRI; discuss pitfalls in image interpretation; and highlight
potentially distinguishing imaging features.
RG • Volume 41 Number 1
TEACHING POINTS
„ Gallbladder carcinoma is a relatively uncommon malignancy
with poor prognosis when diagnosed at an advanced stage.
The 5-year survival rate is estimated to be less than 5% for
infiltrative stage III or IV tumors. The prevalence varies world-
wide from 1.5 per 10 000 in North America to 27 per 10 000
in South America. The most common gallbladder tumors are
epithelial in origin, with 90% classified as adenocarcinomas.
„ There are three patterns of tumor spread: (a) directly into
the liver or adjacent organs, (b) within the subperitoneal
space, and (c) intraperitoneal. Direct infiltration of the liver is
the most common pattern of spread, estimated to occur in
42.9%–71.4% of cases.
„ At MRI, gallbladder carcinoma may manifest as an enhancing
solid or necrotic mass within or replacing the gallbladder lu-
men, focal or diffuse asymmetric gallbladder wall thickening,
or an intraluminal polypoid lesion. Irrespective of location, the
tumor is typically T1 hypo- to isointense to the surrounding
liver and heterogeneously T2 iso- to hyperintense to the liver,
with heterogeneous enhancement.
„ At MRI, careful assessment of the entire wall of the gallblad-
der is important to ensure that it remains smooth throughout
its entire internal and external course. Focal heterogeneous
intermediate to mildly high T2 signal intensity relative to liver
parenchyma and focal thickening with asymmetric enhance-
ment are important imaging features of gallbladder cancer.
Loss of tissue planes with adjacent structures can be an early
sign of direct invasive disease. Systematic assessment of the
gastroduodenal ligament (including the portal triad) and
gastrohepatic ligament for lymphadenopathy is paramount.
Lymph nodes are considered suspicious when pathologically
enlarged according to size criteria (>10 mm in the short axis)
or showing abnormal intrinsic signal intensity or morphology
at MRI. Assessment of the peritoneum is important to evalu-
ate for tumor implants. Typical locations for tumor deposits
include the subdiaphragmatic regions, gastrosplenic and
gastroduodenal ligaments, transverse mesocolon, Morison
pouch, and paracolic gutters, along the undersurface of the
anterior abdominal wall, along the pelvic sidewalls, and within
the dependent pelvis.
„ MRI is a helpful modality for differentiating benign from ma-
lignant gallbladder diseases. Mimics include a heterogeneous
group of diseases, such as the various forms of acute and
chronic cholecystitis, adenomyomatosis, lymphoma, pericho-
lecystic abscess, hepatocellular carcinoma, intrahepatic chol-
angiocarcinoma, metastases, tumefactive biliary sludge, and
carcinoid tumor.
Epidemiology and Risk Factors
Gallbladder carcinoma has a higher prevalence
in South America and Southeast Asia than in
Western populations (6). In the United States,
the prevalence is 1.3 per 100 000 person-years
and higher among Hispanics, Native Americans,
and Alaskan Natives (7). The average age at diag-
nosis is 71 years (8,9), with women affected three
times more frequently than men (5,7).
The most common risk factors for develop-
ment of gallbladder carcinoma are gallstones and
chronic cholecystitis (10). Up to 95% of gallblad-
der carcinomas are associated with gallstones
(11). Patients with gallstones larger than 2–3 cm
Lopes Vendrami et al 79
have the greatest risk of developing cancer (12).
The type of gallstone may also be important, with
cholesterol stones showing the greatest risk (13).
Gallbladder polyps can be true polyps or
pseudopolyps. Pseudopolyps typically represent
accumulation of cholesterol (focal adenomyoma-
tosis or cholesterolosis) or adherent immobile gall-
stones. True polyps may be nonneoplastic, benign
neoplastic, or malignant neoplastic. Nonneoplastic
polyps may be hyperplastic or inflammatory. Be-
nign neoplastic polyps may represent adenomas,
adenomyomas, leiomyomas, fibromas, or lipomas.
Malignant or benign neoplastic polyps with
malignant potential include adenocarcinoma,
squamous cell carcinoma, and mucinous cyst-
adenoma. While benign, adenomas are thought
to be premalignant, with progression to adeno-
carcinoma in an adenoma-carcinoma sequence
(14). Symptomatic gallbladder polyps of any size,
polyps with a fibrovascular stalk, or asymptomatic
polyps larger than 10 mm are typically referred to
a surgeon for consideration of cholecystectomy.
The risk of malignancy increases with the size of
the polyp, with moderate risk at 10 mm (15,16).
Polyps 6 mm and smaller are unlikely to har-
bor malignancy and may require no additional
follow-up (17). Although there is a lack of quality
evidence, one guideline suggests that polyps that
are 6–9 mm be followed at 6 and 12 months and
then yearly for 5 years to assess for growth (16).
The likelihood of malignancy increases in solitary
sessile polyps, polyps with growth at follow-up,
old age, polyps with associated gallstones, and
patients with polyps and concurrent primary
sclerosing cholangitis (18). Porcelain gallbladder,
defined as calcification of the gallbladder wall,
has been reported as a risk factor for gallbladder
cancer, but the incidence is thought to not be as
high as previously reported (19).
Additional risk factors include smoking (7),
high parity (20), elevated body mass index (21),
and chronic bacterial infection with Helicobacter
pylori or Salmonella (8). Ulcerative colitis is a
well-described risk factor for primary sclerosing
cholangitis and all biliary malignancies. Patients
with ulcerative colitis have a 10-fold risk of de-
veloping gallbladder carcinoma (4). Anomalous
pancreaticobiliary duct junction—a congenital
anomaly—occurs when the biliary and pancreatic
ducts join more proximally than normal and is
associated with an increase in all biliary tract can-
cers, including gallbladder carcinoma (8,22).
Gallbladder Anatomy
The gallbladder lies in a mid anteroinferior posi-
tion relative to the liver. It is intimately associated
with hepatic segments IVb and V at the lower
limit of the Cantlie line. The gallbladder is in
80 January-February 2021
close proximity to the duodenum, pancreas, and
transverse colon. Anatomically, it is divided into a
fundus, body, infundibulum, and neck.
The typical arterial blood supply is from a
single cystic artery arising from the right hepatic
artery, within the Calot triangle, and venous
drainage occurs via the liver bed or cystic vein
into the right portal system. The Calot triangle is
composed of the cystic artery, right hepatic duct,
and liver edge (23). The cystic duct connects the
gallbladder to the extrahepatic bile duct. The
point of insertion marks the division between the
common hepatic duct and common bile duct.
The cystic duct typically joins the extrahepatic
bile duct halfway between the porta hepatis and
ampulla of Vater (24).
Lymphatic drainage occurs to the cystic node
at the hilum, proceeding via the pericholedochal
lymphatics and nodes within the hepatoduode-
nal ligament. The anterior drainage and nodes
accompany the hepatic artery to the celiac artery.
The posterior drainage and nodes progress to the
retroduodenal and retropancreatic regions, then to
the para-aortic nodes, interaortocaval nodes, and
superior mesenteric nodes. Both the anterior and
posterior systems drain to the cisterna chyli and
ultimately to the left supraclavicular nodes (25).
There is considerable anatomic variability of
biliary and gallbladder parenchymal and vascu-
lar anatomy, ranging from interesting imaging
features to those that have important surgical im-
plications. Anatomic variations of the cystic duct
are described in the literature according to their
course, length, and site of insertion into the com-
mon hepatic duct. Proper knowledge of cystic
duct anatomy and its variants is helpful in inter-
pretation of disease processes as well as to avoid
iatrogenic injuries during surgical procedures.
It has been reported that preoperative MR
cholangiopancreatography provides useful infor-
mation regarding cystic duct anatomy and has a
preventive effect on iatrogenic injury during lapa-
roscopic cholecystectomy. Clinically important
variations include (a) low insertion of the cystic
duct, (b) parallel course of the cystic duct with the
common hepatic duct, (c) anterior or posterior
spiral course with medial insertion, (d) absent or
short cystic duct (length <5 mm), (e) aberrant
or accessory intrahepatic ducts draining into the
cystic duct, (f) aberrant drainage of the cystic duct
into the left or right hepatic duct, and (g) double
cystic duct (26).
Histologic Features
The wall of the gallbladder consists of the mu-
cosa, lamina propria, an irregular muscular layer
(1), perimuscular connective tissue, and serosa
(or visceral peritoneum) (2). There is no submu-
radiographics.rsna.org
cosa or muscularis propria. The connective tissue
along the hepatic surface is continuous with the
interlobular connective tissue of the liver (1).
Gallbladder carcinoma accounts for 98% of all
malignancies of the gallbladder and is epithelial
in origin (1). Approximately 90% are classified as
adenocarcinomas (4). Rare gallbladder malignan-
cies include carcinoid, sarcoma, lymphoma, and
metastases (1). Adenocarcinoma is characterized
microscopically by glands lined by columnar or
cuboidal cells that may contain mucin. On the
basis of the degree of gland formation, these
tumors are divided into well differentiated (>95%
gland formation; grade 1), moderately differ-
entiated (50%–95% gland formation; grade 2),
poorly differentiated (5%–49% gland formation;
grade 3), and undifferentiated (no gland forma-
tion; grade 4) (4).
Histologic variants of gallbladder cancer
include biliary-type adenocarcinoma (which
includes adenocarcinoma not otherwise speci-
fied, papillary, and micropapillary—approximately
75%), intestinal-type adenocarcinoma, clear cell
adenocarcinoma, small cell carcinoma, mucinous
carcinoma, signet-ring carcinoma, adenosquamous
carcinoma, and undifferentiated carcinoma (4).
Pathogenesis and Patterns of Spread
Gallbladder adenocarcinoma is a malignancy of
the biliary epithelial lining that spreads through
the layers of the gallbladder wall and into ad-
jacent structures. Gallstones result in chronic
irritation and inflammation of the gallbladder
epithelium, development of cellular dysplasia,
and then carcinoma in a dysplasia-carcinoma
sequence (13) over the course of 5–15 years
(15,27). Once carcinoma has developed, the tu-
mor is often locally aggressive with early invasion
of adjacent structures. This behavior has been
attributed to intrinsic tumor biology and lack of
a submucosal layer surrounding the gallbladder
wall (28). Lymph node and distant metastases
are often present at presentation. Sixty percent
of tumors arise in the fundus, followed by 30%
in the body and infundibulum and 10% in the
cystic duct (2).
There are three patterns of tumor spread:
(a) directly into the liver or adjacent organs,
(b) within the subperitoneal space, and (c) in­
traperitoneal. Direct infiltration of the liver is
the most common pattern of spread, estimated
to occur in 42.9%–71.4% of cases (29,30).
Subperitoneal spread occurs via mesenteric
planes and lymphatics. In this pattern, invasion
of the hepatoduodenal ligament and gastrohe-
patic ligament is common.
The hepatoduodenal ligament contains the
portal triad (proper hepatic artery, common bile
RG • Volume 41 Number 1
duct, and portal vein). The gastrohepatic liga-
ment connects the liver to the lesser curvature
of the stomach. Subperitoneal tumor spreads via
the hepatoduodenal ligament to the pancreas,
duodenum, and mesentery, while gastrohepatic
ligament tumor spreads to the stomach and
omentum (31).
Lymph node metastases occur in 25.7%–
64.4% of cases (29,30). Lymph node disease
advances to the celiac station from the anterior
drainage pathway and to the pancreaticoduo-
denal and para-aortic nodes from the poste-
rior drainage pathway (Fig 1). Intraperitoneal
spread is found in approximately 20% of cases
at surgery and occurs early in the disease. In
this type of spread, the tumor infiltrates through
the serosa of the gallbladder into the peritoneal
cavity (32).
Role of MRI and Protocol
The possible clinical scenarios associated with
manifestation of gallbladder carcinoma in-
clude (a) preoperative suspicion of malignancy,
(b) malignancy found during cholecystectomy
performed for a presumed benign cause, (c) inci-
dental malignancy found at pathologic examina-
tion after cholecystectomy (11), (d) malignancy
found at evaluation of right upper quadrant pain,
and (e) malignancy as an incidental finding at
imaging. Early-stage disease is generally seen
only when discovered incidentally at the time of
cholecystectomy or at pathologic evaluation of
the gallbladder specimen. Incidentally identified
carcinoma accounts for less than 1% of chole-
cystectomy specimens (10). Unfortunately, the
majority of cases of gallbladder carcinoma (75%)
are diagnosed when the disease is no longer
resectable (11).
Lopes Vendrami et al 81
Figure 1. N staging is determined by the num-
ber of metastatic lymph nodes. 1 = cholecysto-
retropancreatic pathway (main pathway) (or-
ange), 2 = cholecystoceliac pathway (blue), 3 =
cholecystomesenteric pathway (pink), A = cystic
duct node, B = porta hepatis node, C = node of
foramen of Winslow, D = superior retropancre-
aticoduodenal node, E = posterior pancreatico-
duodenal node (principal retroportal node), F =
paraaortic lymph node, G = superior mesenteric
lymph node, H = suprapyloric node, I = retroliga-
mentous node, J = paraceliac node. (Courtesy of
D. C. Botos.)
US is often the first imaging modality for
evaluating gallbladder disease. US has sensitivity
of 85% and overall accuracy of 80% in diagnos-
ing gallbladder cancer in locally advanced disease
(33). In cases where the tumor is flat or a malig-
nant polyp is sessile in the setting of cholelithi­asis,
US may miss the lesion (33). In addition, US
does not accurately demonstrate the full extent of
the disease and is notably limited in assessment
of metastases to both locoregional and distant
lymph nodes, abdominal viscera, and peritoneum
(34). Color Doppler US may help in diagnosis, as
malignancies are associated with higher blood flow
within the lesion.
CT and MRI are generally needed to evaluate
local extent, nodal disease, and metastatic dis-
ease (11). Multidetector CT is currently widely
available and has reported accuracy of up to
84% in determining the T stage (local extent) of
gallbladder carcinoma (35). CT is 85% accurate
in predicting resectability, with accurate depiction
of direct hepatic or vascular invasion, lymphade-
nopathy, and distant metastasis (36). PET/CT can
be useful to evaluate equivocal primary lesions,
detect occult metastases, and identify residual
tumor in the gallbladder bed after incidental
diagnosis of carcinoma after cholecystectomy (2).
MRI has higher sensitivity than CT for detecting
direct hepatic invasion with reported sensitivity
of 87.5%–100% (37,38), 92% for detection of
nodal metastasis, and 69% for detection of biliary
obstruction. In 11% of patients, it may underesti-
mate the depth of invasion (37).
The optimal MRI protocol for gallbladder
evaluation includes T1-weighted MRI of the
gallbladder with breath-hold spoiled gradient-echo
techniques to reduce respiratory motion artifact.
T2-weighted sequences, typically single-shot turbo
82 January-February 2021
Figure 2. Gallbladder adenocarcinoma in a 54-year-
old woman with weight loss and abdominal pain.
(a) Axial T2-weighted MR image shows a hetero-
geneous gallbladder mass (arrow) with gallstones.
(b) Axial T1-weighted image shows that the mass (ar-
row) is isointense to the liver parenchyma. (c) Axial
contrast-enhanced T1-weighted image shows hetero-
geneous enhancement of the mass (arrow). The mass
arising from the gallbladder and invading surrounding
fat was pathologically confirmed to be gallbladder ad-
enocarcinoma. The tumor was stage IV (T4) and unre-
sectable, with peritoneal and colonic involvement.
spin-echo sequences, are ideal for assessing soft-
tissue abnormalities in the wall of the gallbladder.
MR cholangiopancreatography with acquisition
methods such as half-Fourier rapid acquisition
with relaxation enhancement (RARE) and single-
shot fast turbo spin-echo and navigator-triggered
MR cholangiopancreatography are useful in
detection of bile duct invasion and evaluation of
biliary obstruction and allow avoidance of invasive
endoscopic retrograde cholangiopancreatogra-
phy (ERCP) unless intervention is planned (39).
Dynamic contrast-enhanced fat-suppressed T1-
weighted gradient-echo MRI improves character-
ization of the gallbladder wall and bile ducts, as
well as enables evaluation of the liver parenchyma
for tumor infiltration and metastatic disease.
Diffusion-weighted imaging (DWI) using fat-
suppressed single-shot echo-planar imaging in
the axial plane should be performed to improve
the sensitivity of tumor detection. B values of 50,
500, and 800 sec/mm2 are used at our institu-
tion. Apparent diffusion coefficient (ADC) maps
are routinely generated to decrease false positives
related to T2 shine through (37). Hwang et al (40)
reported use of gadoxetic acid–enhanced MRI for
staging of gallbladder carcinoma, with reported
improved assessment of focal liver invasion. In
our experience, conventional gadolinium-based
contrast agents are typically used for staging, with
radiographics.rsna.org
T2-weighted fat-saturated or T2-weighted images
being especially helpful in detecting invasion of
adjacent liver parenchyma.
MRI Findings
At MRI, gallbladder carcinoma may manifest as
an enhancing solid or necrotic mass within or
replacing the gallbladder lumen, focal or diffuse
asymmetric gallbladder wall thickening, or an
intraluminal polypoid lesion. Irrespective of loca-
tion, the tumor is typically T1 hypo- to isointense
to the surrounding liver and heterogeneously T2
iso- to hyperintense to the liver, with heteroge-
neous enhancement (Fig 2) (1,41). Functional
sequences such as DWI can be helpful in detec-
tion and staging of cancer, but the findings are
often nonspecific.
The most common manifestation of gallblad-
der cancer is a mass that arises from the gallblad-
der wall or replaces the gallbladder lumen or
fossa. This appearance is estimated to occur in
40%–70% of cases (Fig 3) (1,41). These tumors
commonly show early invasion of adjacent struc-
tures. This appearance may demonstrate hetero-
geneous enhancement, with delayed retention of
contrast material in areas of fibrosis. In patients
with weight loss or jaundice and replacement
of the gallbladder by a mass, gallbladder cancer
should be suspected.
RG • Volume 41 Number 1
Figure 3. Biopsy-proved papillary adenocarcinoma of the gallbladder in a 64-year-old woman. (a) Axial T2-weighted
image shows a lesion (arrow) that is mildly hyperintense relative to the liver parenchyma. (b) Axial contrast-enhanced T1-
weighted image shows heterogeneous enhancement of the lesion (arrow). The large tumor nearly filling the entire gall-
bladder was found to involve only the muscular layer (T1b). Radical cholecystectomy was performed with curative intent.
In 20%–30% of cases, gallbladder carcinoma
manifests as focal or diffuse asymmetric wall
thickening (1). When symmetric wall thicken-
ing is observed, findings may favor a benign
cause such as acute or chronic cholecystitis or
adenomyomatosis. In some cases, when the wall
thickening is asymmetric, it can be challenging
to distinguish focal or diffuse gallbladder wall
thickening of gallbladder carcinoma from acute
or chronic cholecystitis (Fig 4).
Gallbladder carcinoma manifests as a polypoid
lesion in 15%–25% of cases (Fig 5) (1). It is im-
portant to identify these lesions, as they are typi-
cally well differentiated and more likely to be con-
fined to the gallbladder muscular layer or mucosa
when identified early and potentially cured with
cholecystectomy. Patients are often asymptomatic,
and these lesions may be incidentally detected at
imaging studies such as US. MRI can be espe-
cially helpful when US does not allow distinction
of a larger gallstone from a polyp or cancer.
At MRI, stones typically have low signal inten-
sity on T2-weighted images and do not enhance
after administration of contrast material. Epithe-
lial lesions such as polyps or gallbladder cancer
do enhance after contrast material administra-
tion. In cases where the lesion is intrinsically T1
hyperintense, subtraction images may be helpful
for perceiving enhancement.
In the setting of porcelain gallbladder or
significant calcifications seen at US or CT, MRI
can be helpful by showing the presence of a mass
obscured by the calcifications. Suspicious associ-
ated MRI features in these settings include focal
gallbladder wall thickening, asymmetric wall
enhancement, and focal diffusion restriction.
Staging with MRI
Gallbladder carcinoma is staged according to
the TNM staging system (10). This system was
Lopes Vendrami et al 83
recently revised by the American Joint Committee
on Cancer (AJCC) Hepatobiliary Task Force (2).
The T category is based on the depth of tumor
penetration within or through the gallbladder wall.
T1 and T2 tumors are confined to the gallblad-
der. T2 is divided into T2a when on the peritoneal
side and T2b when on the hepatic side; it can be
difficult or impossible to differentiate these sub-
types at MRI. T3 tumors perforate the gallblad-
der serosa or penetrate into the liver or one other
adjacent organ. T4 tumors invade the hepatic
artery, main portal vein, or two or more extrahe-
patic organs. The N category is determined by the
number of metastatic lymph nodes (N1 = one to
three lymph node metastases, N2 = four or more
lymph node metastases) (Table) (2,42).
Radiologists play an important role in staging
gallbladder cancer, as they can guide or exclude
surgical management. Key decision points for ra-
diologists include differentiating organ-confined
disease from invasion of adjacent viscera; evalu-
ation for involvement of the infundibulum, neck,
or cystic duct; determination of nodal involve-
ment; and evaluation of peritoneal or subperito-
neal disease spread. At MRI, careful assessment
of the entire wall of the gallbladder is important
to ensure that it remains smooth throughout its
entire internal and external course.
Focal heterogeneous intermediate to mildly
high T2 signal intensity relative to liver paren-
chyma and focal thickening with asymmetric
enhancement are important imaging features
of gallbladder cancer. Loss of tissue planes with
adjacent structures can be an early sign of direct
invasive disease. Systematic assessment of the
gastroduodenal ligament (including the portal
triad) and gastrohepatic ligament for lymphade-
nopathy is paramount. Lymph nodes are con-
sidered suspicious when pathologically enlarged
according to size criteria (>10 mm in the short
84 January-February 2021 radiographics.rsna.org

Figure 4. Gallbladder cancer with liver invasion in a 60-year-old woman evaluated for liver lesions incidentally found
at US. (a) Axial T2-weighted image shows asymmetric wall thickening involving the gallbladder body (arrow). (b) Axial
contrast-enhanced T1-weighted image shows heterogeneous enhancement of the wall thickening (arrow). (c) Diffu-
sion-weighted image (b value = 500 sec/mm2) shows high signal intensity of the wall thickening (arrow) from restricted
diffusion. (d) On an apparent diffusion coefficient (ADC) map, the wall thickening is dark (arrow). The wall thickening
was surgically proved to be gallbladder cancer with liver invasion (T2NXM1).

Figure 5. Gallbladder carcinoma in a 63-year-old woman with an incidentally found polypoid gallbladder lesion.
(a) Axial T2-weighted image shows a 2.3-cm hypointense polypoid gallbladder lesion (arrow). (b) Axial contrast-
enhanced T1-weighted image shows enhancement of the polypoid mass (arrow). The mass was surgically proved to
be gallbladder carcinoma (T2NXM0).

axis) or showing abnormal intrinsic signal inten-
sity or morphology at MRI (Fig 6).
Assessment of the peritoneum is important
to evaluate for tumor implants. Typical locations
for tumor deposits include the subdiaphragmatic
regions, gastrosplenic and gastroduodenal liga-
ments, transverse mesocolon, Morison pouch,
and paracolic gutters, along the undersurface
of the anterior abdominal wall, along the pel-
vic sidewalls, and within the dependent pelvis.
Reported predictors of poor outcome in gallblad-
der cancer include advanced T stage, advanced
RG • Volume 41 Number 1 Lopes Vendrami et al 85

TNM Staging according to the Eighth Edition of the AJCC* Manual

Estimated 5-year
Stage T Category N Category M Category Survival (%)
0 Tis N0 M0 80–100
I T1a (lamina propria) N0 M0 80–100
T1b (muscularis) N0 M0 80–100
II T2a (peritoneal side) N0 M0 40–75
T2b (hepatic side) N0 M0 28–50
IIIa T3 N0 M0 8–28
IIIb T1, T2, T3 N1 M0 8
IVa T4 N0, N1 M0 7
IVb Any T N2 M0 4
Any T Any N M1 0–2
Source.—References 2 and 42.
*AJCC = American Joint Committee on Cancer.

Figure 6. Suspicious lymph nodes in a 65-year-old

man with right upper quadrant pain and weight loss.
(a, b) Axial T2-weighted image (a) and early contrast-
enhanced T1-weighted image (b) show a gallbladder
mass (arrow) invading the liver with extensive lymph-
adenopathy, including paraceliac nodes (arrowheads).
(c) Axial contrast-enhanced T1-weighted image shows
a ring-enhancing liver lesion (arrow) from metastasis.

cholecystitis, adenomyomatosis, lymphoma,

N stage, advanced overall stage, and histologic
differentiation. When considering the extent of
tumor resection, common bile duct involvement
is associated with worse long-term survival (43).
Mimics
MRI is a helpful modality for differentiating be-
nign from malignant gallbladder diseases. Mim-
ics include a heterogeneous group of diseases,
such as the various forms of acute and chronic
pericholecystic abscess, hepatocellular carcinoma,
intrahepatic cholangiocarcinoma, metastases,
tumefactive biliary sludge, and carcinoid tumor.
Diffusion-weighted imaging (DWI) can be
helpful in detection of cancer, but the findings
lack specificity. Evaluation of diffusion-weighted
images should include assessment for focal or
circumferential gallbladder and pericholecystic
signal intensity abnormalities as well as assess-
ment for intra-abdominal metastases. Intra-
luminal or asymmetric mural-based diffusion
restriction may be suggestive of malignancy
but can be seen in nonmalignant polyps (44).
Circumferential diffusion restriction can be seen
in acute or xanthogranulomatous cholecystitis.
Patients who develop perforated cholecystitis
86 January-February 2021
Figure 7. Metastatic gallbladder cancer in a 60-year-old
woman. (a) Axial T2-weighted image shows a heteroge-
neous mass in the liver extending from the gallbladder
(arrow). (b, c) Axial early (b) and delayed (c) contrast-
enhanced T1-weighted images show the gallbladder le-
sion with heterogeneous progressive enhancement of the
area of tumor infiltration into the adjacent liver (arrows)
as well as in a metastatic hepatic lesion (arrowhead).
can develop pericholecystic abscesses, which can
restrict diffusion.
Imaging studies that show liver invasion, he-
patic metastases, or enlarged regional lymph nodes
are more suspicious for malignancy (44). Stud-
ies have indicated that malignant processes show
lower signal intensity on apparent diffusion coef-
ficient (ADC) images than do benign processes
(0.97–1.83 3 10−3 mm2/sec vs 1.72–2.6 3 10−3
mm2/sec) (3,45–47), but the presence of overlap
limits definitive distinction on the basis of DWI.
Gallbladder Mass Filling or Replacing
Gallbladder Fossa
The differential diagnosis for this pattern of gall-
bladder cancer includes benign processes such as
pericholecystic abscess related to perforated acute
cholecystitis or primary and secondary hepatic
malignancies such as hepatocellular carcinoma,
cholangiocarcinoma, and metastatic disease aris-
ing from or invading into the gallbladder (48).
When a large lesion involving the gallbladder
fossa is detected, evaluation of the tumor origin is
often helpful (Fig 7). In cases where the origin is
not apparent, intrinsic tumor signal intensity and
enhancement characteristics as well as secondary
patient characteristics are often helpful to narrow
the differential diagnosis. Gallbladder cancer may
show progressive retained contrast material from
radiographics.rsna.org
the associated fibrous stroma. In contrast, favor-
ing an exophytic hepatocellular carcinoma is rea-
sonable in a cirrhotic patient with typical imaging
features of hypervascular early enhancement and
washout. Biopsy is often necessary to histologi-
cally confirm the diagnosis of large tumors.
Pericholecystic abscesses are often distin-
guished from gallbladder cancer on the basis of
an often fulminant acute clinical manifestation
similar to that of acute cholecystitis. Symptoms
include subacute to acute right upper quadrant
pain, sepsis, fever, and chills, as opposed to the
chronic to subacute pain and weight loss seen in
gallbladder cancer. The clinical distinction may
be helpful in radiologically challenging cases.
Abscesses typically develop in the setting of per-
forated cholecystitis. These cases show focal wall
discontinuity, particularly on contrast-enhanced
T1-weighted images (Fig 8) (49).
The “cluster” sign of multiple small adjacent
abscesses has been described at CT to suggest
abscesses over other hepatic masses (50) and can
also be seen at MRI. Abscesses may contain gas,
restrict diffusion, and lack central enhancement
after contrast material administration. While
shown to better advantage at CT, gas-containing
abscesses at MRI may be seen as small foci of
nondependent blooming hypointense signal on
in-phase T1-weighted images. The presence of
RG • Volume 41 Number 1 Lopes Vendrami et al 87

Figure 8. Acute and chronic cholecystitis with suspected perforation in a 67-year-old man with abdominal pain and
malaise. Cholecystitis is difficult to distinguish from gallbladder cancer at imaging. (a) Coronal T2-weighted image
shows an abnormal gallbladder with an intermediate-signal-intensity lesion (arrow) arising from the gallbladder fundus.
(b) Axial contrast-enhanced T1-weighted image shows heterogeneous soft tissue (arrow) arising from the gallbladder
fundus, from cholecystitis mimicking gallbladder cancer. Acute and chronic cholecystititis were confirmed at surgery.

restricted diffusion and fluid collections associ-
ated with abscesses and perihepatic inflammatory
changes can be helpful in the diagnosis.
Focal or Diffuse Wall Thickening
Acute uncomplicated cholecystitis is an inflam-
matory condition of the gallbladder in which
the cystic duct or gallbladder neck is obstructed,
resulting in infection and inflammation of the
gallbladder. This is generally associated with cho-
lelithiasis (51) but can be the result of any intrin-
sic or extrinsic compression of these structures or
functional obstruction. When untreated or in cer-
tain populations with underlying comorbidities,
the inflammation of the gallbladder progresses
with increased intraluminal pressures and results
in tissue hypoperfusion (52). In these cases, the
organ can become gangrenous and perforate.
MRI features of uncomplicated cholecysti-
tis include smooth symmetric gallbladder wall
thickening, adjacent reactive hepatic parenchymal
enhancement, distended or hydropic gallblad-
der, gallstones, and pericholecystic edema (51).
In emphysematous or gangrenous cholecystitis,
gas can be present in the wall of the gallbladder.
While best seen at CT, gas at MRI manifests
as focal or diffuse mural signal intensity loss
on in-phase T1-weighted images relative to the
opposed-phase images. In cases where there is
no wall gas, features of gangrenous cholecystitis
include transmural inflammation, perforation,
intraluminal membranes, and mucosal or wall
irregularity, which can mimic gallbladder cancer.
While the MRI appearance can simulate gallblad-
der carcinoma, clinically these patients are often
acutely ill and have underlying medical comor-
bidities such as diabetes mellitus, which may
favor gangrenous cholecystitis over gallbladder
carcinoma.
Chronic cholecystitis is a subacute condition
caused by functional or mechanical dysfunction of
the gallbladder. Calculous chronic cholecystitis re-
sults from chronic intermittent obstruction of the
cystic duct, resulting in low-grade inflammation of
the gallbladder. Acalculous chronic cholecystitis
is a functional abnormality where the gallbladder
inadequately empties in response to eating. Clini-
cally, patients with chronic cholecystitis present
with a history of biliary colic and a subacute his-
tory of dull right upper quadrant pain. Functional
assessment of the gallbladder is best performed
with cholecystokinin (CCK)–enhanced hepatobili-
ary iminodiacetic acid (HIDA) scintigraphy.
Imaging findings of chronic cholecystitis are
often nonspecific and generally comprise diffuse
wall thickening, mild restricted diffusion, and
smooth delayed wall enhancement. In contrast,
acute cholecystitis often shows increased gallblad-
der wall enhancement and associated hyperemia
and transient pericholecystic hepatic enhance-
ment (53). Distinguishing acute chole­cystitis,
chronic cholecystitis, and gallbladder carcinoma
can be challenging, as they may all be associated
with edema, wall thickening, and diffusion restric-
tion of the gallbladder wall. The clinical history is
important in distinguishing these conditions, as
acute cholecystitis generally manifests with acute
symptoms, but there may be overlap.
Findings on dynamic contrast-enhanced im-
ages have been reported to favor one diagnosis
over another, with smooth circumferential early
enhancement favoring acute cholecystitis and
smooth circumferential delayed enhancement
favoring chronic cholecystitis. In contrast, ir-
regular or focal early enhancement may suggest
gallbladder carcinoma (28). A greater solid mass
component may be seen in gallbladder cancer. In
these cases, evaluating the external margin of the
88 January-February 2021 radiographics.rsna.org

Figure 9. Xanthogranulomatous cholecystitis in a 68-year-old woman. (a) Axial T2-weighted image shows a het­
ero­geneously thickened gallbladder wall with multiple intramural lesions (arrows), which are iso- or hyperintense.
(b) Axial T1-weighted image shows hypointense cystic foci (arrow). (c, d) Axial early (c) and delayed (d) contrast-
enhanced T1-weighted images show mild arterial and marked delayed enhancement surrounding the cystic foci
(long arrow). There is mild surrounding hepatic parenchymal enhancement (short arrow), which is likely reactive.

arterial enhancement is important to determine
the local extent of the suspected tumor. Gangre-
nous acute cholecystitis could result in irregular
arterial enhancement of the gallbladder wall due
to focal regions of tissue necrosis. As such, these
imaging findings should always be interpreted in
the clinical context and potentially discussed with
the referring service in challenging cases (28).
Xanthogranulomatous cholecystitis is a rare
form of chronic cholecystitis characterized by
intramural nodules (51). It is an important mimic
of gallbladder carcinoma, both clinically and
radiologically. At imaging, it usually manifests as
focal or diffuse wall thickening with preservation
of inner mucosal enhancement (54). Xanthogran-
ulomatous cholecystitis has intermediate to mild
high signal intensity on T2-weighted images, with
areas of slight enhancement on early-phase images
and persistent enhancement on late-phase images,
corresponding to areas with fibrosis related to the
xanthogranulomas (Fig 9) (28).
It has been reported that the intramural nod-
ules show signal intensity loss on opposed-phase
images relative to in-phase images (55,56). Hence,
when fatty content is observed in intramural
nodules at chemical shift MRI, the diagnosis of
xanthogranulomatous cholecystitis should be
suggested. Necrosis or abscesses may appear as
areas of very high signal intensity on T2-weighted
images without enhancement (28). Xanthogranu-
lomatous cholecystitis and gallbladder carcinoma
generally cannot be distinguished at MRI, and
patients are referred for surgical assessment.
Hyalinizing cholecystitis is a rare recently
described variant of chronic cholecystitis (57),
characterized by replacement of the normal
configuration of the gallbladder wall by dense
and diffuse hyaline sclerosis replacing the normal
histologic structures, such that virtually no mu-
cosa or muscularis is discernible (58). Currently,
there is a paucity of literature describing specific
imaging findings for hyalinizing cholecystitis. The
imaging findings described are nonspecific and
mimic other findings of cholecystitis (57–59). The
diagnosis is generally made at surgical resection
and pathologic evaluation.
In our case, the MRI findings were interest-
ing and correlated with the pathologic findings.
There was marked wall thickening with low
signal intensity on T2-weighted images and lack
RG • Volume 41 Number 1 Lopes Vendrami et al 89

Figure 10. Pathology-proved hyalinizing cholecystitis

in a 63-year-old woman. (a) Axial T2-weighted image
shows circumferential thickening of the gallbladder
wall (arrow), which is hypointense relative to liver pa-
renchyma. (b) Axial T1-weighted image shows that the
gallbladder wall thickening is iso- or mildly hypointense
(arrow). (c) Axial contrast-enhanced T1-weighted im-
age shows no significant enhancement of the wall thick-
ening (arrow).

of enhancement, likely from hyaline fibrosis (Fig
10). Focal to extensive calcifications may also be
present in cases of hyalinizing cholecystitis, and it
is thought to be in the same disease spectrum as
porcelain gallbladder. Thus, hyalinizing chole-
cystitis is sometimes referred to as “incomplete
porcelain gallbladder” (58). Hyalinizing chole-
cystitis is more often associated with carcinoma
with aggressive behavior; however, an underlying
cancer can be radiologically occult (58).
Gallbladder adenomyomatosis is a common
acquired benign disease, found in up to 5%–8% of
cholecystectomy specimens (41,54). It is charac-
terized by hyperplastic changes of the gallbladder
wall with mucosal overgrowth, thickening of the
muscular wall, and presence of intramural diver-
ticula or sinus tracts (Rokitansky-Aschoff sinuses)
(60). Gallbladder adenomyomatosis may be focal,
segmental, or generalized. The focal subtype is
the most common variant and appears as a mass
or nodule, usually in the fundus (Fig 11). The
segmental or annular subtype appears as circum-
ferential annular narrowing of the gallbladder,
typically in the body. The diffuse subtype appears
as irregular thickening of the mucosa and muscu-
lar layer with Rokitansky-Aschoff sinuses (41).
On T2-weighted images, the “pearl necklace”
or “string of beads” sign (presence of Rokitansky-
Aschoff sinuses within the thickened gallbladder
wall) is accurate in distinguishing adenomyoma-
tosis from cancer and is better seen at MRI than
at CT (Fig 12) (28,37). This distinction can be
difficult at CT. In addition, the lesions do not
show any evidence of pericholecystic infiltration or
invasion of adjacent structures (60).
Primary lymphoma of the gallbladder is exceed-
ingly rare, accounting for 0.1%–0.2% of cases
(54,61). Imaging characteristics depend on the
pathologic classification but can be difficult to
distinguish from those of gallbladder adenocar-
cinoma. The presence of secondary lymphoma
of the gallbladder can be suspected when there is
involvement of other organs and lymph nodes.
High-grade lymphoma manifests as a solid
lesion within the gallbladder or irregular wall
thickening, while low-grade lymphoma manifests
as mild thickening of the gallbladder wall. In con-
trast to gallbladder adenocarcinoma (a disease of
the epithelium), lymphoma typically involves the
submucosa, potentially sparing the adjacent intact
mucosa (62). At MRI, lymphoma has low signal
intensity on T1-weighted images and high signal
intensity on T2-weighted images (61).
Other causes of diffuse gallbladder wall thick-
ening include hepatic or systemic diseases such
as portal hypertension, acute hepatitis, conges-
tive heart failure, hypoalbuminemia, and renal
failure (63).
90 January-February 2021 radiographics.rsna.org

Figure 11. Gallbladder adenomyoma mimicking gallbladder cancer in a 53-year-old woman. (a) Axial T2-weighted
image shows a focal mass (arrow) in the fundus that is hypointense with areas of high signal intensity from dilated
Rokitansky-Aschoff sinuses. (b) Axial fat-suppressed T1-weighted image shows that the mass (arrow) has a focus of
higher signal intensity. (c) Axial contrast-enhanced fat-suppressed T1-weighted image shows that the mass (arrow) has
fairly homogeneous enhancement, from hypervascular focal fundal adenomyomatosis mimicking gallbladder cancer.
(d) Image from MR cholangiopancreatography shows the characteristic outpouchings from dilated Rokitansky-Aschoff
sinuses (arrow), which distinguish the lesion from cancer.

Figure 12. Adenomyomatosis in a 71-year-old woman. (a) Axial contrast-enhanced T1-weighted image shows appar-
ent gallbladder wall thickening (arrow). (b) Image from MR cholangiopancreatography shows the “pearl necklace” sign
(arrows), which refers to the characteristically curvilinear arrangement of multiple round hyperintense outpouchings.

Polypoid Gallbladder Carcinoma
The differential diagnosis of a polypoid gallbladder
lesion includes both benign and malignant lesions,
including adenomatous polyp, hyperplastic choles-
terol polyp, tumefactive sludge (64,65), carcinoid
tumor, and metastasis in addition to gallbladder
cancer (48). MRI may be helpful to show en-
hancement, which favors a benign or malignant
polyp over a large gallstone or sludge. In addition,
the presence of hemorrhage can be difficult to di-
agnose at US, while at MRI it may be seen as high
signal intensity without enhancement.
RG • Volume 41 Number 1
Figure 13. Gallbladder metastasis in a 57-year-old man with a history of renal cell carcinoma. He had undergone left
nephrectomy. (a) Axial T1-weighted image shows an isointense small intraluminal gallbladder mass (arrow). (b) Axial
contrast-enhanced T1-weighted image shows marked enhancement of the mass (arrow). The mass showed growth
compared with its size on images 8 months earlier (not shown).
Tumefactive biliary sludge is composed of cal-
cium bilirubinate granules or cholesterol monohy-
drate crystal and/or calcium salts immersed in mu-
cus, a mixture of proteins and mucin (64). MRI
features include a well-defined masslike lesion,
high signal intensity on T1-weighted images, lack
of enhancement on postcontrast images (64,65),
variable signal intensity on T2-weighted images,
and lack of diffusion restriction (64). In difficult
cases, performing a short follow-up examination
(1 day to 2 weeks) can prove helpful, as the lesion
may disappear (64) or decrease in size (65).
Metastases to the gallbladder typically grow
as serosal implants with progression to polypoid
lesions. Patients with gallbladder metastases are
mostly asymptomatic; as a result, gallbladder me-
tastases are usually discovered only at autopsy or
incidentally at imaging (66). In Western popula-
tions, the most common tumor to metastasize to
the gallbladder is melanoma (50%–67% of cases)
(67). In Asian populations, the most common
source of metastasis to the gallbladder is gastric
cancer.
Metastases from melanoma, renal cell carci-
noma (Fig 13), or hepatocellular carcinoma may
manifest as polypoid lesions with enhancement
early after contrast material administration and
early washout (61). Imaging features depend on
the primary tumor and may appear similar to
those of the primary mass at imaging. Melanoma
may have high signal intensity on T1-weighted
images from melanin. Thus, comparison with re-
sults of remote prior examinations is often helpful
if the primary tumor was imaged with the same
modality before treatment or resection.
Carcinoid tumor of the gallbladder is ex-
tremely rare and difficult to diagnose before
surgery (68). In early stages, it appear as a
well-defined mass in the gallbladder fossa with
high signal intensity on T2-weighted images, low
Lopes Vendrami et al 91
signal intensity on T1-weighted images, and avid
early enhancement. As the tumor advances, it ap-
pears as a large mass in the gallbladder fossa and
infiltrates the liver. This tumor is associated with
necrotic, enlarged, enhancing metastatic lymph
nodes (69). Final diagnosis typically occurs
postoperatively with histologic and immunohisto-
chemical examination.
Management and Follow-up
According to the Surveillance, Epidemiology, and
End Results (SEER) database, favorable survival
of gallbladder cancer is associated with female
sex, Asian/Pacific Islander race, and treatment
with surgery or radiation therapy (70).
Surgical management of gallbladder cancer
is dependent on the stage of the disease. T1a
tumors or in situ disease and those where the
cystic duct margin is negative, diagnosed inciden-
tally after cholecystectomy, do not require further
surgical intervention. Stage I and II tumors are
potentially resectable with the intent to cure (Fig
14). After assessment for regional and peritoneal
nodal disease, tumors limited to the wall of the
gallbladder (T1b or T2) are recommended to
undergo radical cholecystectomy with en bloc
resection of adjacent liver parenchyma (71).
Stage III disease is usually considered locally
unresectable because of involvement of adjacent
organs or vascular invasion. Because of the dis-
tant metastases, stage IV tumors are also deemed
unresectable (11). These include T4 locally
advanced disease invading the hepatic artery,
portal vein, or two or more extrahepatic organs;
M1 disease positive for metastasis; peritoneal
metastasis or malignant ascites; N2 disease with
more than four nodal metastases; and extensive
hepatoduodenal ligament involvement. Surgical,
interventional, and medical treatment in these
cases is often palliative (10).
92 January-February 2021 radiographics.rsna.org

Figure 14. Gallbladder cancer in a 74-year-old man. (a) Axial nonenhanced CT image does not show a gall-
bladder mass. (b) Axial portal venous phase contrast-enhanced CT image shows an enhancing gallbladder mass
(arrow). (c) Axial nonenhanced T1-weighted image does not show the gallbladder mass. (d) Axial portal venous
phase contrast-enhanced T1-weighted image shows the enhancing gallbladder mass (arrow) without liver inva-
sion. (e) Axial fat-saturated T2-weighted image shows a low-signal-intensity mass (arrow) in the gallbladder
without liver invasion. At pathologic analysis, no tumor extension into the liver was found.

For T3 or T4 tumors, the extent of the primary
resection is debatable. Direct invasion of organs
adjacent to the gallbladder, duodenum, or colon
(Fig 15) is considered T3 disease; in these cases,
en bloc resection of adjacent organs is acceptable
but has not been associated with improved long-
term survival. Radical resection—which includes
major hepatectomy or common hepatic duct,
common bile duct, or vascular resection or recon-
struction—has not been associated with longer
disease-free or overall survival.
In cases that would not benefit from radical
resection, addition of laparoscopic​US and inter-
aortocaval lymph node frozen-section assessment
could potentially increase the detection rate of tu-
mors (71). Systemic chemotherapy and external-
beam radiation therapy have improved survival in
patients with negative resection margins, while no
added benefit of such therapy has been observed
in patients with positive resection margins. The
majority of patients present with unresectable
locally advanced stage IV disease. Patients with
metastatic or locally unresectable tumors have a
median survival rate of less than 6 months (10).
Gallbladder surgery may lead to complications
including abscess (0.14%–0.3%), hemorrhage
(0.11%–1.97%), bile leak (0.3%–0.9%), bile duct
injury (0.26%–0.6%), and bowel injury (0.26%–
0.6%) (72). Bile leakage can lead to formation
of a biloma, which is a collection of bile located
outside the biliary tree (73). Bilomas from bile
leaks can be confirmed with contrast-enhanced
MRI after administration of a hepatocyte-specific
agent such as gadoxetic acid. Port-site metastasis
is a major concern and the most common mode
of peritoneal dissemination after laparoscopic
cholecystectomy. The prevalence of tumor seed-
ing in port sites varies between 0% and 40% of
cases, with higher incidences related to gallblad-
der perforation at the time of surgery (74).
After complete excision, close follow-up with
contrast-enhanced MRI at 3- to 6-month inter-
vals for at least 5 years with subsequent yearly
MRI follow-up should be considered (10). Up
to 50% of tumors recur within 2 years of surgery
(Fig 16) (75). In addition to imaging surveil-
lance, clinical examination and laboratory studies
that include liver function tests and measurement
RG • Volume 41 Number 1 Lopes Vendrami et al 93

Figure 15. Gallbladder cancer in an 80-year-old woman with jaundice. (a, b) Axial fat-suppressed T2-weighted (a)
and contrast-enhanced T1-weighted (b) images show a mass (arrows) invading the duodenal bulb with dilatation
of the stomach. (c) Axial diffusion-weighted image (b = 500 sec/mm2) shows high signal intensity of the mass
(arrow) from restricted diffusion. (d) Axial apparent diffusion coefficient (ADC) map shows that the mass is dark
(arrows). The diagnosis was unresectable gallbladder tumor.

Figure 16. Tumor recurrence in a 61-year-old man with a history of gallbladder cancer who had undergone cho-
lecystectomy. (a) Axial T2-weighted image shows a hyperintense lesion in the gallbladder fossa (arrow). (b) Axial
contrast-enhanced T1-weighted image shows heterogeneous enhancement of the lesion (arrow), compatible with
local tumor recurrence.

of tumor markers (carcinoembryonic antigen,
cancer antigen 19-9, and cancer antigen 242)
may be pertinent for follow-up (10).
Conclusion
Gallbladder carcinoma is a highly aggressive ma-
lignancy with a poor prognosis. Imaging features
may overlap with those of common benign gall-
bladder diseases. It is often diagnosed at locally
advanced stages, and a high index of suspicion is
required for accurate early diagnosis.
MRI features of early disease include a focal
enhancing polypoid mass larger than 1.0 cm and
focal mural thickening in the absence of clinical
94 January-February 2021
cholecystitis. In these cases, surgical referral should
be considered. In cases of advanced disease, an en-
hancing mass is often noted to replace and expand
the gallbladder lumen with direct involvement of
the adjacent liver and biliary tree. There are often
local-regional lymph nodes and visceral and perito-
neal metastases.
MRI can be extremely helpful in accurate
detection, staging, and characterization of
gallbladder cancer. It is a useful tool for guiding
surgical management, assessing complications,
and surveying for recurrent disease after surgical
therapy.
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