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Arch Surg. 2008;143(11):1130.

Answer: Diffuse Adenomyomatosis of the Gallbladder
The "necklace appearance" of the mass was more clearly demonstrated on magnetic resonance imaging, representing bile in the Rokitansky-Aschoff sinuses. The gallbladder lumen was narrowed because of the hypertrophic mucosa and muscular wall. The bile was hyperintense on T1- and T2-weighted images. Diffuse adenomyomatosis of the gallbladder was indicated, but occult gallbladder cancer could not be excluded. A 9 x 6 x 4-cm pink gallbladder mass was resected. Narrowed lumen (7 x 1 x 0.7 cm) was apparent (Figure 2). Adenomyomatosis was diagnosed microscopically. There was no evidence of gallbladder cancer.

View larger version (118K): [in this window] [in a new window] [as a PowerPoint slide]   Figure 2. Photograph of the gross pathologic specimen obtained by cholecystectomy reveals hypertrophy of the muscular wall (*) and narrowing of the lumen (L).

Adenomyomatosis of the gallbladder is a relatively common disease that is found in 2% to 5% of specimens obtained at cholecystectomy.¹ Pathologically, it is defined by epithelial proliferation and hypertrophy of the muscularis of the gallbladder, with outpouching of the mucosa into the thickened muscular layer (Rokitansky-Aschoff sinuses).^1-2 The pathogenesis of this condition remains unknown. Nevertheless, gallbladder adenomyomatosis seems unlikely to be a congenital lesion because its incidence increases with age, with the majority of individuals with the disease in their 50s and 60s.³

Adenomyomatosis of the gallbladder has been defined as segmental, diffuse, and fundal in terms of morphology type. The segmental type in particular appears to be a predisposing factor for cholelithiasis.² Clinical features of this condition are similar to those of gallstones and/or cholecystitis. This disorder is increasingly being recognized in asymptomatic cases and incidentally during imaging investigation.⁴ Ultrasonography is the most widely used method for evaluating suspected gallbladder diseases; however, recent studies suggest that magnetic resonance imaging may be the more accurate diagnostic tool for gallbladder adenomyomatosis.^{1, 4}

What is the relationship between gallbladder carcinoma and adenomyomatosis of the gallbladder? Adenomyomatosis is currently considered to carry no risk of malignant change. However, there has been reported to be a strong association between gallbladder cancer and segmental-type adenomyomatosis of the gallbladder.⁵ Furthermore, a well-differentiated gallbladder carcinoma with mucin production can have cystic components that may mimic adenomyomatosis.⁶ In this patient, in addition to the clinically persistent symptoms, the imaging findings led us to perform cholecystectomy because of the possibility of occult cancer and the risk of malignancy.

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AUTHOR INFORMATION

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Correspondence: Ray-Hwang Yuan, MD, PhD, Department of Surgery, National Taiwan University Hospital, No. 7, Chung-Shan South Road, Taipei 100, Taiwan (yuan{at}ha.mc.ntu.edu.tw).

Accepted for Publication: January 26, 2007.

Author Contributions: Study concept and design: Liu and Yuan. Acquisition of data: Liu, Yang, and Lee. Analysis and interpretation of data: Liu and Yuan. Drafting of the manuscript: Liu and Yuan. Critical revision of the manuscript for important intellectual content: Yang, Lee, and Yuan. Administrative, technical, and material support: Yang and Lee. Study supervision: Yuan.

Financial Disclosure: None reported.

REFERENCES

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1. Haradome H, Ichikawa T, Sou H; et al. The pearl necklace sign: an imaging sign of adenomyomatosis of the gallbladder at MR cholangiopancreatography. Radiology. 2003;227(1):80-88. FREE FULL TEXT 2. Nishimura A, Shirai Y, Hatakeyama K. Segmental adenomyomatosis of the gallbladder predisposes to cholecystolithiasis. J Hepatobiliary Pancreat Surg. 2004;11(5):342-347. FULL TEXT | PUBMED 3. Zani A, Pacilli M, Conforti A, Casati A, Bosco S, Cozzi DA. Adenomyomatosis of the gallbladder in childhood: report of a case and review of the literature. Pediatr Dev Pathol. 2005;8(5):577-580. FULL TEXT | ISI | PUBMED 4. Yoshimitsu K, Honda H, Aibe H; et al. Radiologic diagnosis of adenomyomatosis of the gallbladder: comparative study among MRI, helical CT, and transabdominal US. J Comput Assist Tomogr. 2001;25(6):843-850. FULL TEXT | ISI | PUBMED 5. Ootani T, Shirai Y, Tsukada K, Muto T. Relationship between gallbladder carcinoma and the segmental type of adenomyomatosis of the gallbladder. Cancer. 1992;69(11):2647-2652. FULL TEXT | ISI | PUBMED 6. Yoshimitsu K, Irie H, Aibe H; et al. Well-differentiated adenocarcinoma of the gallbladder with intratumoral cystic components due to abundant mucin production: a mimicker of adenomyomatosis. Eur Radiol. 2005;15(2):229-233. FULL TEXT | ISI | PUBMED

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