Differential diagnosis of gallbladder cancer using positron emission tomography with fluorine-18-labeled fluoro-deoxyglucose (FDG-PET)

Gallbladder cancer

BACKGROUND

Gallbladder cancer (GC) is a relatively rare but highly lethal neoplasm. We review the epidemiology, etiology, pathology, symptoms, diagnosis, staging, treatment, and prognosis of GC.

METHOD

A Pubmed database search between 1971 and February 2007 was performed. All abstracts were reviewed and articles with GC obtained; further references were extracted by hand-searching the bibliography. The database search was done in the English language.

RESULTS

The accurate etiology of GC remains unclear, while the symptoms associated with primary GC are not specific. Treatment with radical cholecystectomy is curative but possible in only 10% to 30% of patients. For patients whose cancer is an incidental finding on pathologic review, re-resection is indicated, where feasible, for all disease except T1a. Patients with advanced disease should receive palliative treatment. Laparoscopic cholecystectomy is contraindicated in the presence of GC.

CONCLUSION

Prognosis generally is extremely poor. Improvements in the outcome of surgical resection have caused this approach to be re-evaluated, while the role of chemotherapy and radiotherapy remains controversial.

Xanthogranulomatous inflammatory strictures of extrahepatic biliary tract: presentation and surgical management

BACKGROUND

Xanthogranulomatous cholecystitis (XGC) is a benign, invasive variant of chronic cholecystitis. Invasion of common bile duct (CBD), termed as xanthogranulomatous choledochitis, may mimic malignancy. We describe clinico-pathological features and management of xanthogranulomatous inflammatory biliary strictures.

METHODS

A review of a prospectively maintained database for XGC was performed.

RESULTS

Out of 6,150 cholecystectomies performed, 620 patients had XGC (10% incidence). Four patients had biliary strictures with xanthogranulomatous choledochitis on final histology. All four patients presented with jaundice and history of cholangitis. Ultrasonography revealed gallstones and thick-walled gallbladder in all. Two patients had hilar strictures: one had mid-CBD stricture and one had a lower-CBD stricture with a dilated pancreatic duct. In all four patients, preoperative diagnosis of malignancy was entertained. Three patients underwent resection-CBD excision for mid-CBD stricture, pancreaticoduodenectomy for lower-end stricture, and right hepatectomy for hilar stricture with atrophy-hypertrophy complex. One patient with unresectable hilar stricture underwent hepaticojejunostomy.

CONCLUSION

Xanthogranulomatous choledochitis may be considered as one of the differential diagnosis in patients with biliary stricture especially in a geographical area with a high incidence of XGC, when a patient harbors gall stones and had thick-walled gall bladder on imaging. This stricture can be found anywhere in the biliary tree from hepatic hilum to the lower end. However, preoperative imaging and cytology are unreliable both in confirming the diagnosis or ruling out malignancy. Therefore, resection of the stricture should be attempted wherever feasible.

18F-fluorodeoxyglucose positron emission tomography influences management decisions in patients with biliary cancer

BACKGROUND

Although (18)F-fluorodeoxyglucose positron emission tomography (PET) has widespread clinical use, its role in cancers of the biliary tract is ill-defined. The aim of this study was to determine if preoperative PET provided additional staging information in patients with biliary tract cancer, beyond that obtained through conventional anatomic imaging. The role of PET in detecting disease recurrence after resection was also examined.

STUDY DESIGN

Between March 2001 and October 2003, 126 patients with biopsy-proved or presumed biliary tract cancer (intrahepatic or extrahepatic cholangiocarcinoma and gallbladder carcinoma) underwent PET in addition to standard imaging evaluation. Histologic confirmation of the diagnosis was used as the reference standard with which PET results were compared. Patient followup information and serial imaging were reviewed for progression of lesions detected by PET.

RESULTS

Of the 126 study patients, 93 (74%) underwent preoperative staging PET scans, the results of which changed the stage and treatment in 22 patients (24%): 15 of 62 (24%) with cholangiocarcinoma and 7 of 31 (23%) with gallbladder carcinoma. When used to assess for cancer recurrence (n=33), PET identified disease in 86% of patients but altered treatment in only 9%. So, of the entire study group, the findings of PET influenced management in 20% of patients (24% preoperative staging and 9% cancer recurrence). The sensitivity of PET for identifying the primary tumor was 80% overall: 78% for cholangiocarcinoma, 86% for gallbladder carcinoma.

CONCLUSIONS

Most biliary tract cancers are (18)F-fluorodeoxyglucose avid tumors. In patients with potentially resectable tumors based on conventional imaging, PET identified occult metastatic disease and changed management in nearly one-fourth of all patients. PET also helped confirm recurrent cancer after resection.

The use of imaging in the diagnosis and staging of hepatobiliary malignancies

This review addresses the optimal use of imaging in the diagnosis, staging, and treatment planning of patients with hepatobiliary neoplasms. We focus on primary liver cancers, including hepatocellular carcinoma and intrahepatic cholangiocarcinoma as well as extrahepatic biliary tract malignancies, including hilar cholangiocarcinoma and gallbladder cancer. In each section, we provide an overview of the staging requirements for each disease followed by a discussion of various imaging modalities that can be used to optimally stage the disease and plan therapy.

Distinguishing benign from malignant gallbladder wall thickening using FDG-PET

OBJECTIVE

Because thickening of the gallbladder wall is observed not only in patients with gallbladder cancer but also in those with benign diseases such as chronic cholecystitis and gallbladder adenomyosis, it is difficult to distinguish between benign and malignant gallbladder wall thickening by conventional techniques of diagnostic imaging such as computed tomography (CT), magnetic resonance imaging (MRI), and abdominal ultrasonography (US). In the present study, we attempted to distinguish between benign and malignant gallbladder wall thickening by means of fluorine-18-fluorodeoxyglucose (FDG)-Positron emission tomography (PET).

METHODS

FDG-PET was performed in 12 patients with gallbladder wall thickening detected by CT or US, to determine whether it was benign or malignant. Emission scans were taken, beginning 45 minutes after intravenous administration of FDG, and SUV was calculated as an indicator of glucose metabolism.

RESULTS

Of the 12 patients, 4 showed positive uptake of FDG in the gallbladder wall. Of these 4 patients, 3 had gallbladder cancer. The remaining one, who had chronic cholecystitis, had false-positive findings. The other 8 patients had negative uptake of FDG in the gallbladder wall. Two of these 8 underwent surgical resection, which yielded a diagnosis of chronic cholecystitis. The other 6 patients exhibited no sign of gallbladder malignancy and have been followed without active treatment.

CONCLUSIONS

FDG-PET appears able to distinguish between benign and malignant gallbladder wall thickening.

Gallbladder tuberculosis: False-positive PET diagnosis of gallbladder cancer

Gallbladder tuberculosis (GT) is an extremely rare disease, and very few cases have been reported in the literature. The first case of GT was described in 1870 by Gaucher. A correct preoperative diagnosis of GT is unusual, and it is frequently confused with various gallbladder diseases. We present a new case of a patient who underwent surgery with the preoperative diagnosis of gallbladder cancer after a false positive positron emission tomography scan in the diagnostic work-up.

Impact of integrated positron emission tomography and computed tomography on staging and management of gallbladder cancer and cholangiocarcinoma

BACKGROUND/AIMS

(1) To evaluate the diagnostic value of integrated positron emission and computed tomography (PET/CT) in comparison with contrast-enhanced CT (ceCT) to detect biliary tract tumors and associated distant and regional lymph node metastases and (2) to evaluate the impact of PET/CT on therapy management.

METHODS

From January 2001 to March 2005, each patient who was treated for a malignancy of the biliary tract underwent PET/CT examination in addition to the standard work-up imaging. Data were prospectively collected and analyzed in comparison with ceCT.

RESULTS

Sixty-one patients with malignancies of the biliary tract were included into the study. Diagnosis was proven in all patients either by histology or cytology. PET/CT detected all gallbladder cancers (n=14). PET/CT and ceCT provided a comparable accuracy for the primary intra- (n=14) and extra-hepatic cholangiocarcinomas (n=33). All distant metastases (12/12) were detected by PET/CT, but only 3/12 by ceCT (p<0.001). Regional lymph node metastases were detected by PET/CT and ceCT in only 12% vs. 24%. PET/CT findings resulted in a change of management in 17% of patients deemed resectable after standard work-up.

CONCLUSIONS

PET/CT is particularly valuable in detecting unsuspected distant metastases which are not diagnosed by standard imaging. Thus, PET/CT staging has an important impact on selection of adequate therapy.

Application of modern imaging methods in diagnosis of gallbladder cancer

The poor prognosis of gallbladder cancer (GBC) is related to its dissemination capacity and usually late diagnosis due to its non-specific clinical appearance. Recent improvements in hepatobiliary surgery have underlined the importance of an early specific diagnosis, which requires a multidisciplinary approach and, when possible, specialized equipment. The first step in an early diagnosis is to identify patients in the appropriate epidemiological setting (e.g., incidental finding, chronic cholecystitis) for the correct interpretation of test results. It is desirable to enhance the sensitivity of the initial ultrasound (US) examination by use of the appropriate technology in skilled specialist hands. When GBC is suggested by US findings, FDG-PET can be considered complementary to establish the benign/malignant nature of the lesion and to obtain a primary staging study. If GBC is confirmed, thin slice spiral CT can contribute valuable information on local spread. In this regard, recent hybrid PET-CT systems provide structural and functional information simultaneously and may offer early and accurate T, N, and M staging with an improved specificity.

Extended surgical resection for xanthogranulomatous cholecystitis mimicking advanced gallbladder carcinoma: A case report and review of literature

Xanthogranulomatous cholecystitis (XGC) is a destructive inflammatory disease of the gallbladder, rarely involving adjacent organs and mimicking an advanced gallbladder carcinoma. The diagnosis is usually possible only after pathological examination. A 46 year-old woman was referred to our center for suspected gallbladder cancer involving the liver hilum, right liver lobe, right colonic flexure, and duodenum. Brushing cytology obtained by endoscopic retrograde cholangiography (ERC) showed high-grade dysplasia. The patient underwent an en-bloc resection of the mass, consisting of right lobectomy, right hemicolectomy, and a partial duodenal resection. Pathological examination unexpectedly revealed an XGC.

Only six cases of extended surgical resections for XGC with direct involvement of adjacent organs have been reported so far. In these cases, given the possible coexistence of XGC with carcinoma, malignancy cannot be excluded, even after cytology and intraoperative frozen section investigation. In conclusion, due to the poor prognosis of gallbladder carcinoma on one side and possible complications deriving from highly aggressive inflammatory invasion of surrounding organs on the other side, it seems these cases should be treated as malignant tumors until proven otherwise. Clinicians should include XGC among the possible differential diagnoses of masses in liver hilum.

Applications of PET in Liver Imaging

Fluorodeoxyglucose PET (FDG-PET) imaging has an important role in determining if there are metastases to the liver and whether disease has spread beyond the liver. Such information is critical for planning surgical resections of liver metastases. The ability of FDG-PET quantitatively to estimate metabolic rates makes it an important tool for monitoring. With increasingly broad indications for FDG-PET imaging, it is expected that FDG-PET (and PET-CT) of the liver will play a growing and increasingly important role in detecting and monitoring treatment of tumors involving the liver.

Cancer de la vésicule biliaire révélé par un ictère dû a un thrombus tumoral endobiliaire

Main bile duct neoplasic thrombosis is a rare cause of jaundice in case of gallbladder cancer. We report the case of 27-year-old woman in whom the endoluminal biopsy of biliary thrombus confirmed the suspected diagnosis of gallbladder cancer. An initial laparoscopic exploration found a localized peritoneal carcinomatosis. However, in this exceptional situation with an unknown prognostic, a surgical procedure has been performed including hepatectomy IV-V with biliary principal bile duct removal, hepatico-jejunal anastomosis (Roux-en-Y), with complete resection of localized peritoneal carcinomatosis. Post-operative course were uneventful and this patient was asymptomatic under chemotherapy with a six month follow-up.