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Gallbladder Carcinoma: Radiologic-Pathologic Correlation¹

¹ From the Departments of Radiologic Pathology (A.D.L., C.A.R.), and Hepatic and Gastrointestinal Pathology (L.A.M.), Armed Forces Institute of Pathology, 6825 16th St NW, Bldg 54, Rm M-121, Washington, DC 20306-6000; the Department of Radiology and Nuclear Medicine, Uniformed Services University of the Health Sciences, Bethesda, Md (A.D.L.); and the Department of Radiology, University of Washington, Seattle (C.A.R.). Received; revision requested; revision received; accepted. Address correspondence to A.D.L. (e-mail: levya@afip.osd.mil).

View larger version (160K): [in a new window]   Figure 1.   Normal gallbladder. Photomicrograph (original magnification, x2; hematoxylin-eosin stain) shows the mucosa as a single layer of columnar epithelium with underlying lamina propria (solid arrows), irregular muscle layer (open arrows), and connective tissue (*).

View larger version (181K): [in a new window]   Figure 2a.   (a) Well-differentiated adenocarcinoma. Photomicrograph (original magnification, x100; hematoxylin-eosin stain) shows this well-differentiated adenocarcinoma is composed of variable-sized glands (arrows) that infiltrate the wall of the gallbladder. The glands are surrounded by a desmoplastic stroma. (b) Moderately well-differentiated adenocarcinoma. Photomicrograph (original magnification, x200; hematoxylin-eosin stain) shows mucosa lined by highly atypical epithelium consistent with high-grade dysplasia. Below the surface are malignant glands (arrows) and small clusters of tumor cells infiltrating the lamina propria. The stroma is scant, and there is a mild infiltrate of acute and chronic inflammatory cells.

View larger version (184K): [in a new window]   Figure 2b.   (a) Well-differentiated adenocarcinoma. Photomicrograph (original magnification, x100; hematoxylin-eosin stain) shows this well-differentiated adenocarcinoma is composed of variable-sized glands (arrows) that infiltrate the wall of the gallbladder. The glands are surrounded by a desmoplastic stroma. (b) Moderately well-differentiated adenocarcinoma. Photomicrograph (original magnification, x200; hematoxylin-eosin stain) shows mucosa lined by highly atypical epithelium consistent with high-grade dysplasia. Below the surface are malignant glands (arrows) and small clusters of tumor cells infiltrating the lamina propria. The stroma is scant, and there is a mild infiltrate of acute and chronic inflammatory cells.

View larger version (194K): [in a new window]   Figure 3.   Invasive papillary adenocarcinoma. Photomicrograph (original magnification, x20; hematoxylin-eosin stain) shows tumor invasion through the muscle layer and into the subserosal adipose tissue (arrowhead). The tumor is adjacent to large vessels (arrow) and nerves in the perimuscular connective tissue. The gallbladder wall is thickened and fibrotic.

View larger version (162K): [in a new window]   Figure 4.   Intestinal variant of well-differentiated adenocarcinoma of the gallbladder. Photomicrograph (original magnification, x10; hematoxylin-eosin stain) shows a predominance of goblet cells (arrows) lining the neoplastic glands that infiltrate the muscle layer. There is necrotic debris in the lumen of the glands.

View larger version (171K): [in a new window]   Figure 5.   Mucinous adenocarcinoma. Photomicrograph (original magnification, x40; hematoxylin-eosin stain) shows small nests (arrow) of neoplastic epithelial cells in pools of slightly basophilic mucin.

View larger version (209K): [in a new window]   Figure 6.   Clear cell adenocarcinoma. Photomicrograph (original magnification, x400; hematoxylineosin stain) shows a trabecular growth pattern of cells with ample clear cytoplasm (arrow) and hyperchromatic nuclei. The fibrous stroma is scant with scattered inflammatory cells.

View larger version (195K): [in a new window]   Figure 7.   Squamous cell carcinoma. Photomicrograph (original magnification, x400; hematoxylineosin stain) shows nests of well-differentiated, neoplastic, keratinizing squamous cells that infiltrate the gallbladder wall. The fibrous stroma is scant.

View larger version (103K): [in a new window]   Figures 8.   (8) Poorly differentiated adenocarcinoma. Photograph of a resected gallbladder (cut specimen) shows innumerable gallstones and diffuse neoplastic mural thickening (arrows). Scale is in centimeters.

View larger version (109K): [in a new window]   Figures 9.   (9) Papillary adenocarcinoma. Photograph of a bisected gallbladder specimen shows the cauliflower-like intraluminal growth of a papillary adenocarcinoma. Scale is in centimeters.

View larger version (158K): [in a new window]   Figure 10a.   Porcelain gallbladder containing carcinoma and a fistula to the duodenum. (a) Abdominal radiograph shows curvilinear calcification and an abnormal gas collection within the right upper quadrant of the abdomen. (b) Image from an upper gastrointestinal series demonstrates a gallbladder-duodenal fistula, caused by invasive carcinoma of the gallbladder (arrows).

View larger version (135K): [in a new window]   Figure 10b.   Porcelain gallbladder containing carcinoma and a fistula to the duodenum. (a) Abdominal radiograph shows curvilinear calcification and an abnormal gas collection within the right upper quadrant of the abdomen. (b) Image from an upper gastrointestinal series demonstrates a gallbladder-duodenal fistula, caused by invasive carcinoma of the gallbladder (arrows).

View larger version (150K): [in a new window]   Figure 11a.   Gallbladder carcinoma with erosion into the duodenum. (a) Abdominal radiograph shows an abnormal collection of gas in the right upper quadrant containing a gas-fluid level. (b) Image from an upper gastrointestinal series shows a duodenum-gallbladder fossa fistula.

View larger version (146K): [in a new window]   Figure 11b.   Gallbladder carcinoma with erosion into the duodenum. (a) Abdominal radiograph shows an abnormal collection of gas in the right upper quadrant containing a gas-fluid level. (b) Image from an upper gastrointestinal series shows a duodenum-gallbladder fossa fistula.

View larger version (130K): [in a new window]   Figure 12a.   Moderately well-differentiated adenocarcinoma in a 70-year-old woman with right upper quadrant pain and a history of gallstones. (a) Longitudinal sonogram shows a well-defined mass in the gallbladder fundus (*) that produces ill-defined posterior acoustic shadowing. Gallstones are also present. (b) Axial unenhanced computed tomographic (CT) scan shows linear tumoral calcifications in the soft-tissue mass within the gallbladder. (c) Photograph of the resected gallbladder (cut specimen) shows the tumor mass (*) and numerous gallstones.

View larger version (144K): [in a new window]   Figure 12b.   Moderately well-differentiated adenocarcinoma in a 70-year-old woman with right upper quadrant pain and a history of gallstones. (a) Longitudinal sonogram shows a well-defined mass in the gallbladder fundus (*) that produces ill-defined posterior acoustic shadowing. Gallstones are also present. (b) Axial unenhanced computed tomographic (CT) scan shows linear tumoral calcifications in the soft-tissue mass within the gallbladder. (c) Photograph of the resected gallbladder (cut specimen) shows the tumor mass (*) and numerous gallstones.

View larger version (141K): [in a new window]   Figure 12c.   Moderately well-differentiated adenocarcinoma in a 70-year-old woman with right upper quadrant pain and a history of gallstones. (a) Longitudinal sonogram shows a well-defined mass in the gallbladder fundus (*) that produces ill-defined posterior acoustic shadowing. Gallstones are also present. (b) Axial unenhanced computed tomographic (CT) scan shows linear tumoral calcifications in the soft-tissue mass within the gallbladder. (c) Photograph of the resected gallbladder (cut specimen) shows the tumor mass (*) and numerous gallstones.

View larger version (148K): [in a new window]   Figure 13a.   Squamous cell carcinoma in a 64-year-old woman. (a) Transverse sonogram shows diffuse and irregular hyperechoic thickening of the gallbladder wall (arrows), which is contiguous with the adjacent liver parenchyma. There is a shadowing gallstone within the residual gallbladder lumen. (b) Autopsy photograph of the liver and gallbladder (posterior view) shows direct invasion of carcinoma into the adjacent liver parenchyma. The gallstones are enveloped by carcinoma. (c) Autopsy photograph of the heart (cut specimen) shows hematogenous myocardial metastases.

View larger version (123K): [in a new window]   Figure 13b.   Squamous cell carcinoma in a 64-year-old woman. (a) Transverse sonogram shows diffuse and irregular hyperechoic thickening of the gallbladder wall (arrows), which is contiguous with the adjacent liver parenchyma. There is a shadowing gallstone within the residual gallbladder lumen. (b) Autopsy photograph of the liver and gallbladder (posterior view) shows direct invasion of carcinoma into the adjacent liver parenchyma. The gallstones are enveloped by carcinoma. (c) Autopsy photograph of the heart (cut specimen) shows hematogenous myocardial metastases.

View larger version (148K): [in a new window]   Figure 13c.   Squamous cell carcinoma in a 64-year-old woman. (a) Transverse sonogram shows diffuse and irregular hyperechoic thickening of the gallbladder wall (arrows), which is contiguous with the adjacent liver parenchyma. There is a shadowing gallstone within the residual gallbladder lumen. (b) Autopsy photograph of the liver and gallbladder (posterior view) shows direct invasion of carcinoma into the adjacent liver parenchyma. The gallstones are enveloped by carcinoma. (c) Autopsy photograph of the heart (cut specimen) shows hematogenous myocardial metastases.

View larger version (149K): [in a new window]   Figure 14a.   Poorly differentiated mucinous adenocarcinoma in a 45-year-old man. (a) Transverse sonogram shows an irregularly marginated hypoechoic mass in the gallbladder fossa. The mass is contiguous with the liver, and there is shadowing emanating from the mass and a large amount of ascites. (b) Axial contrast-enhanced CT scan shows a hypoattenuating mass in the gallbladder fossa with extension into the adjacent liver. Ascites and omental metastases (arrowhead) are present. (c) Autopsy photograph of the liver (cut specimen) shows the gallbladder carcinoma invading the liver. There is a gallstone in the residual gallbladder lumen.

View larger version (152K): [in a new window]   Figure 14b.   Poorly differentiated mucinous adenocarcinoma in a 45-year-old man. (a) Transverse sonogram shows an irregularly marginated hypoechoic mass in the gallbladder fossa. The mass is contiguous with the liver, and there is shadowing emanating from the mass and a large amount of ascites. (b) Axial contrast-enhanced CT scan shows a hypoattenuating mass in the gallbladder fossa with extension into the adjacent liver. Ascites and omental metastases (arrowhead) are present. (c) Autopsy photograph of the liver (cut specimen) shows the gallbladder carcinoma invading the liver. There is a gallstone in the residual gallbladder lumen.

View larger version (105K): [in a new window]   Figure 14c.   Poorly differentiated mucinous adenocarcinoma in a 45-year-old man. (a) Transverse sonogram shows an irregularly marginated hypoechoic mass in the gallbladder fossa. The mass is contiguous with the liver, and there is shadowing emanating from the mass and a large amount of ascites. (b) Axial contrast-enhanced CT scan shows a hypoattenuating mass in the gallbladder fossa with extension into the adjacent liver. Ascites and omental metastases (arrowhead) are present. (c) Autopsy photograph of the liver (cut specimen) shows the gallbladder carcinoma invading the liver. There is a gallstone in the residual gallbladder lumen.

View larger version (112K): [in a new window]   Figure 15a.   Poorly differentiated adenocarcinoma in a 67-year-old man. (a) Longitudinal sonogram shows heterogeneous, hypoechoic, diffuse thickening of the gallbladder wall. There is peripancreatic lymphadenopathy (*) posterior to the gallbladder. (b) Axial contrast-enhanced CT scan shows diffuse gallbladder wall thickening with a hypoattenuating mass extending into the adjacent liver parenchyma. There is a large peripancreatic lymph node (arrow). (c) Autopsy photograph of the liver and gallbladder (cut specimen) shows tumor within the gallbladder extending into the adjacent liver, hematogenous liver metastases, and periportal and peripancreatic lymph nodes (arrow).

View larger version (149K): [in a new window]   Figure 15b.   Poorly differentiated adenocarcinoma in a 67-year-old man. (a) Longitudinal sonogram shows heterogeneous, hypoechoic, diffuse thickening of the gallbladder wall. There is peripancreatic lymphadenopathy (*) posterior to the gallbladder. (b) Axial contrast-enhanced CT scan shows diffuse gallbladder wall thickening with a hypoattenuating mass extending into the adjacent liver parenchyma. There is a large peripancreatic lymph node (arrow). (c) Autopsy photograph of the liver and gallbladder (cut specimen) shows tumor within the gallbladder extending into the adjacent liver, hematogenous liver metastases, and periportal and peripancreatic lymph nodes (arrow).

View larger version (123K): [in a new window]   Figure 15c.   Poorly differentiated adenocarcinoma in a 67-year-old man. (a) Longitudinal sonogram shows heterogeneous, hypoechoic, diffuse thickening of the gallbladder wall. There is peripancreatic lymphadenopathy (*) posterior to the gallbladder. (b) Axial contrast-enhanced CT scan shows diffuse gallbladder wall thickening with a hypoattenuating mass extending into the adjacent liver parenchyma. There is a large peripancreatic lymph node (arrow). (c) Autopsy photograph of the liver and gallbladder (cut specimen) shows tumor within the gallbladder extending into the adjacent liver, hematogenous liver metastases, and periportal and peripancreatic lymph nodes (arrow).

View larger version (124K): [in a new window]   Figure 16a.   Moderately well-differentiated adenocarcinoma in a 55-year-old man. (a) Transverse sonogram shows a well-defined, sessile hyperechoic mass (*) along the medial gallbladder wall with adjacent focal wall thickening (arrow) and pericholecystic fluid. (b) Axial contrast-enhanced CT scan shows the soft-tissue mass with focal wall thickening, extension beyond the gallbladder wall (arrow), and pericholecystic fluid.

View larger version (132K): [in a new window]   Figure 16b.   Moderately well-differentiated adenocarcinoma in a 55-year-old man. (a) Transverse sonogram shows a well-defined, sessile hyperechoic mass (*) along the medial gallbladder wall with adjacent focal wall thickening (arrow) and pericholecystic fluid. (b) Axial contrast-enhanced CT scan shows the soft-tissue mass with focal wall thickening, extension beyond the gallbladder wall (arrow), and pericholecystic fluid.

View larger version (149K): [in a new window]   Figure 17a.   Papillary adenocarcinoma in an 80-year-old man. (a) Longitudinal sonogram demonstrates an illdefined echogenic mass (*) filling the gallbladder lumen. The mass was immobile with changes in patient position. (b) Photograph of the resected gallbladder specimen shows the large intraluminal mass and associated gallstone.

View larger version (147K): [in a new window]   Figure 17b.   Papillary adenocarcinoma in an 80-year-old man. (a) Longitudinal sonogram demonstrates an illdefined echogenic mass (*) filling the gallbladder lumen. The mass was immobile with changes in patient position. (b) Photograph of the resected gallbladder specimen shows the large intraluminal mass and associated gallstone.

View larger version (131K): [in a new window]   Figure 18a.   Squamous cell carcinoma in a 53-year-old woman. (a) Axial T1-weighted MR image shows an irregular hypointense mass within the gallbladder (arrow). (b) Gadolinium-enhanced axial T1-weighted image shows irregular enhancement of the gallbladder carcinoma (arrow). (c) Multiplanar gradient-echo coronal image shows the hypointense gallbladder carcinoma invading the extrahepatic bile duct (arrow).

View larger version (129K): [in a new window]   Figure 18b.   Squamous cell carcinoma in a 53-year-old woman. (a) Axial T1-weighted MR image shows an irregular hypointense mass within the gallbladder (arrow). (b) Gadolinium-enhanced axial T1-weighted image shows irregular enhancement of the gallbladder carcinoma (arrow). (c) Multiplanar gradient-echo coronal image shows the hypointense gallbladder carcinoma invading the extrahepatic bile duct (arrow).

View larger version (132K): [in a new window]   Figure 18c.   Squamous cell carcinoma in a 53-year-old woman. (a) Axial T1-weighted MR image shows an irregular hypointense mass within the gallbladder (arrow). (b) Gadolinium-enhanced axial T1-weighted image shows irregular enhancement of the gallbladder carcinoma (arrow). (c) Multiplanar gradient-echo coronal image shows the hypointense gallbladder carcinoma invading the extrahepatic bile duct (arrow).

View larger version (129K): [in a new window]   Figure 19.   Gallbladder carcinoma with contiguous involvement of the transverse colon. Image from a single-contrast barium enema study shows irregularity and deformity to the superior aspect of the transverse colon (arrows).

View larger version (164K): [in a new window]   Figure 20a.   Intrahepatic and periportal extension of adenocarcinoma in a 53-year-old woman. (a) Axial contrast-enhanced CT scan shows intrahepatic extension of a gallbladder carcinoma, hepatoduodenal ligament spread, and periportal lymphadenopathy (arrows). On a more superior section (not shown), there was bile duct dilatation. (b) ERCP image shows a focal common bile duct stricture from periductal tumor extension.

View larger version (136K): [in a new window]   Figure 20b.   Intrahepatic and periportal extension of adenocarcinoma in a 53-year-old woman. (a) Axial contrast-enhanced CT scan shows intrahepatic extension of a gallbladder carcinoma, hepatoduodenal ligament spread, and periportal lymphadenopathy (arrows). On a more superior section (not shown), there was bile duct dilatation. (b) ERCP image shows a focal common bile duct stricture from periductal tumor extension.

View larger version (178K): [in a new window]   Figure 21a.   Spectrum of ERCP findings in gallbladder carcinoma. (a) ERCP image of a 65-year-old woman with well-differentiated adenocarcinoma shows cystic duct obstruction (arrow). (b) ERCP image of a 70-year-old woman shows a filling defect in the gallbladder fundus from carcinoma and a hilar stricture at the confluence of the right and left hepatic ducts from extension of carcinoma. (c) ERCP image of a 70-year-old man shows marked intrahepatic duct dilatation from a hilar stricture due to gallbladder carcinoma. Intraductal stones are present in the common bile duct. (d) ERCP image of an 80-year-old woman shows marked mass effect, intraductal extension of carcinoma, and biliary dilatation from gallbladder carcinoma. There are stones within the residual gallbladder lumen (arrow).

View larger version (178K): [in a new window]   Figure 21b.   Spectrum of ERCP findings in gallbladder carcinoma. (a) ERCP image of a 65-year-old woman with well-differentiated adenocarcinoma shows cystic duct obstruction (arrow). (b) ERCP image of a 70-year-old woman shows a filling defect in the gallbladder fundus from carcinoma and a hilar stricture at the confluence of the right and left hepatic ducts from extension of carcinoma. (c) ERCP image of a 70-year-old man shows marked intrahepatic duct dilatation from a hilar stricture due to gallbladder carcinoma. Intraductal stones are present in the common bile duct. (d) ERCP image of an 80-year-old woman shows marked mass effect, intraductal extension of carcinoma, and biliary dilatation from gallbladder carcinoma. There are stones within the residual gallbladder lumen (arrow).

View larger version (144K): [in a new window]   Figure 21c.   Spectrum of ERCP findings in gallbladder carcinoma. (a) ERCP image of a 65-year-old woman with well-differentiated adenocarcinoma shows cystic duct obstruction (arrow). (b) ERCP image of a 70-year-old woman shows a filling defect in the gallbladder fundus from carcinoma and a hilar stricture at the confluence of the right and left hepatic ducts from extension of carcinoma. (c) ERCP image of a 70-year-old man shows marked intrahepatic duct dilatation from a hilar stricture due to gallbladder carcinoma. Intraductal stones are present in the common bile duct. (d) ERCP image of an 80-year-old woman shows marked mass effect, intraductal extension of carcinoma, and biliary dilatation from gallbladder carcinoma. There are stones within the residual gallbladder lumen (arrow).

View larger version (139K): [in a new window]   Figure 21d.   Spectrum of ERCP findings in gallbladder carcinoma. (a) ERCP image of a 65-year-old woman with well-differentiated adenocarcinoma shows cystic duct obstruction (arrow). (b) ERCP image of a 70-year-old woman shows a filling defect in the gallbladder fundus from carcinoma and a hilar stricture at the confluence of the right and left hepatic ducts from extension of carcinoma. (c) ERCP image of a 70-year-old man shows marked intrahepatic duct dilatation from a hilar stricture due to gallbladder carcinoma. Intraductal stones are present in the common bile duct. (d) ERCP image of an 80-year-old woman shows marked mass effect, intraductal extension of carcinoma, and biliary dilatation from gallbladder carcinoma. There are stones within the residual gallbladder lumen (arrow).

View larger version (140K): [in a new window]   Figure 22a.   Adenocarcinoma in a 35-year-old woman. (a, b) Axial contrast-enhanced CT scans show peripancreatic lymphadenopathy (arrow in a) and a focal mass in the gallbladder fundus. (c) Photograph of the bisected specimen shows the focal mass in the gallbladder fundus. Cholesterolosis is also present (arrows).

View larger version (139K): [in a new window]   Figure 22b.   Adenocarcinoma in a 35-year-old woman. (a, b) Axial contrast-enhanced CT scans show peripancreatic lymphadenopathy (arrow in a) and a focal mass in the gallbladder fundus. (c) Photograph of the bisected specimen shows the focal mass in the gallbladder fundus. Cholesterolosis is also present (arrows).

View larger version (109K): [in a new window]   Figure 22c.   Adenocarcinoma in a 35-year-old woman. (a, b) Axial contrast-enhanced CT scans show peripancreatic lymphadenopathy (arrow in a) and a focal mass in the gallbladder fundus. (c) Photograph of the bisected specimen shows the focal mass in the gallbladder fundus. Cholesterolosis is also present (arrows).

View larger version (127K): [in a new window]   Figure 23a.   Acute cholecystitis in a 19-year-old woman with a positive sonographic Murphy sign. (a) Transverse sonogram shows nonshadowing gallstones, thickening of the gallbladder wall, and pericholecystic fluid. (b) Photograph of the cut specimen shows diffuse purulent thickening of the gallbladder wall. The mucosa of the gallbladder is hemorrhagic, and there are stones present.

View larger version (116K): [in a new window]   Figure 23b.   Acute cholecystitis in a 19-year-old woman with a positive sonographic Murphy sign. (a) Transverse sonogram shows nonshadowing gallstones, thickening of the gallbladder wall, and pericholecystic fluid. (b) Photograph of the cut specimen shows diffuse purulent thickening of the gallbladder wall. The mucosa of the gallbladder is hemorrhagic, and there are stones present.

View larger version (142K): [in a new window]   Figure 24a.   Xanthogranulomatous cholecystitis in a 40-year-old woman with chronic right upper quadrant pain. (a) Transverse sonogram of the gallbladder fossa shows marked heterogeneous thickening of the gallbladder wall and narrowing of the gallbladder lumen (arrow). (b) Axial contrast-enhanced CT scan shows gallbladder wall thickening and soft-tissue stranding in the gallbladder fossa. The gallbladder lumen is very small (arrow). (c) Photograph of the bisected specimen shows fibrotic thickening of the gallbladder wall and narrowing of the gallbladder lumen.

View larger version (133K): [in a new window]   Figure 24b.   Xanthogranulomatous cholecystitis in a 40-year-old woman with chronic right upper quadrant pain. (a) Transverse sonogram of the gallbladder fossa shows marked heterogeneous thickening of the gallbladder wall and narrowing of the gallbladder lumen (arrow). (b) Axial contrast-enhanced CT scan shows gallbladder wall thickening and soft-tissue stranding in the gallbladder fossa. The gallbladder lumen is very small (arrow). (c) Photograph of the bisected specimen shows fibrotic thickening of the gallbladder wall and narrowing of the gallbladder lumen.

View larger version (140K): [in a new window]   Figure 24c.   Xanthogranulomatous cholecystitis in a 40-year-old woman with chronic right upper quadrant pain. (a) Transverse sonogram of the gallbladder fossa shows marked heterogeneous thickening of the gallbladder wall and narrowing of the gallbladder lumen (arrow). (b) Axial contrast-enhanced CT scan shows gallbladder wall thickening and soft-tissue stranding in the gallbladder fossa. The gallbladder lumen is very small (arrow). (c) Photograph of the bisected specimen shows fibrotic thickening of the gallbladder wall and narrowing of the gallbladder lumen.

View larger version (134K): [in a new window]   Figure 25a.   Adenomyomatosis in a 48-year-old man with chronic right upper quadrant pain. (a) Longitudinal sonogram shows diffuse gallbladder wall thickening and hyperechoic foci within the gallbladder wall that produce ring-down artifact (arrow). (b) Photograph of the bisected specimen shows marked thickening of the gallbladder wall and Rokitansky-Aschoff sinuses (arrows).

View larger version (124K): [in a new window]   Figure 25b.   Adenomyomatosis in a 48-year-old man with chronic right upper quadrant pain. (a) Longitudinal sonogram shows diffuse gallbladder wall thickening and hyperechoic foci within the gallbladder wall that produce ring-down artifact (arrow). (b) Photograph of the bisected specimen shows marked thickening of the gallbladder wall and Rokitansky-Aschoff sinuses (arrows).

View larger version (130K): [in a new window]   Figure 26a.   Metastatic melanoma in a 45-year-old woman with right upper quadrant tenderness. (a) Longitudinal sonogram shows a polypoid mass within the gallbladder. (b) Photograph of the bisected specimen shows melanotic pigmentation in the gallbladder mass.

View larger version (101K): [in a new window]   Figure 26b.   Metastatic melanoma in a 45-year-old woman with right upper quadrant tenderness. (a) Longitudinal sonogram shows a polypoid mass within the gallbladder. (b) Photograph of the bisected specimen shows melanotic pigmentation in the gallbladder mass.