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Hypoechoic area as an ultrasound finding suggesting subserosal invasion in polypoid carcinoma of the gall bladder

T Fujimoto, MD, SJSUM 1 Y Kato, MD 2 T Kitamura, MD, FJSUM 1 and T Hiratsuka, MD 1

1 Department of Surgery, Hiratsuka Gastroenterological Hospital, 3-2-16 Nishi-Ikebukuro. Toshima-ku, Tokyo 171-0021 2 Department of Pathology, Cancer Institute, 1-37-1 Kami-Ikebukuro, Toshima-ku, Tokyo 170-8455, Japan



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  		Figure 1. Transabdominal ultrasound shows an elevated lesion (white arrowheads), 25 mm x 20 mm x 11 mm in size, on the liver bed side of the gall bladder neck. Its shallow part is unevenly hyperechoic but its deep part is irregularly hypoechoic with an outermost hyperechoic layer thickened beneaththe lesion. At the peritoneal side of the neck there is another small elevated lesion (black arrows), 3–4 mm in height, with a normal outermost hyperechoic layer. The gall bladder contains a small amount of biliary sludge (black arrowheads) moving freely with changes in position.

 


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  		Figure 2. Fixed resected specimen. The left side is the neck. There are two elevated carcinomas, 12 mm (white arrows) and 30 mm (black arrowheads) in largest diameter, respectively, with a background of coarsely granular mucosa. The smaller represents a mucosal carcinoma on the peritoneal side, and the larger lesion is a carcinoma invading the shallow subserosa on the liver bed side. A black line (A) shows the maximum section of the lesion corresponding to the section in Figure 3Go. Coarsely granular mucosa represents dysplasia.

 


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  		Figure 3. Photomicrographs of the resected specimen (H&E). (a) Panoramic view of section A (Figure 2Go) shows a well differentiated papillary adenocarcinoma invading the shallow subserosa accompanied by abundant fibrosis and hyperplastic lymph follicles. Note that the subserosal adipose layer beneath the lesion is thickened and free from carcinoma, fibrosis or lymph follicles. (b) High power view of the shallow subserosa demonstrates small nests of adenocarcinoma accompanied by lymphocytic infiltration and fibrosis.

 




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