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British Journal of Radiology (2009) 82, e15-e19
© 2009 British Institute of Radiology
doi: 10.1259/bjr/30768802
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British Journal of Radiology 82 (2009),e15-e19 ©2009 The British Institute of Radiology

Primary malignant lymphoma of the gallbladder: a case report and literature review

A ONO, MD 1 S TANOUE, MD, PhD 2 Y YAMADA, MD 2 Y TAKAJI, MD 3 F OKADA, MD, PhD 2 S MATSUMOTO, MD, PhD 2 and H MORI, MD, PhD 2

1 Department of Radiology, Oita Prefectural Hospital, Bunyo, 476, Oita-shi, Oita, 870–0855, 2 Department of Radiology, Oita University Faculty of Medicine, Idaigaoka, 1-1, Hasama-machi, Yufu-shi, Oita, 879–5593, 3 Department of Radiology, Oita Tobu Hospital, Shimura, 765, Oita-shi, Oita, 870–0261, Japan

Correspondence: Asami Ono, Department of Radiology, Oita Prefectural Hospital, Bunyo, 476, Oita-shi, Oita, 870–0855, Japan. E-mail: asami{at}med.oita-u.ac.jp


   Abstract
Top
 Abstract
Introduction
 Case report
 Discussion
 References
 
Primary malignant lymphoma of the gallbladder is extremely rare and the associated radiological findings are not well described in the literature. We report a case of malignant lymphoma in the gallbladder wall of a 78-year-old woman. Pre-operative CT and MRI showed homogeneous submucosal thickening of the gallbladder wall with a preserved mucosal surface. These unique radiological findings may be useful for diagnosing malignant lymphoma of the gallbladder.


   Introduction
Top
 Abstract
 Introduction
Case report
 Discussion
 References
 
Although malignant lymphomas are thought to be malignant tumours of lymph nodes, 40% occur in extranodal tissues or organs. Most extranodal lymphomas originate from the gastrointestinal tract. Thus, the gallbladder is extremely rarely infiltrated by malignant lymphoma. In addition, this scenario is difficult to distinguish from a gallbladder carcinoma. In this report, we present the radiological findings from a case of primary malignant lymphoma of the gallbladder, and correlate the features with the histopathological findings.


   Case report
Top
 Abstract
 Introduction
 Case report
Discussion
 References
 
A 78-year-old woman presented with vomiting and right upper abdominal pain. The patient was referred to an institution related to ours, where she was initially diagnosed with post-operative ileus from a previous sigmoid colectomy for colonic perforation. However, abdominal ultrasonography revealed thickening of the gallbladder wall. Blood tests showed elevation of the soluble interleukin (IL)-2 receptor (3650 U ml–1) but other data were within normal limits. Physical examination showed no abnormal findings.

The pre-contrast CT images that followed showed irregular thickening of the gallbladder wall. Calcified stones were not observed within the gallbladder cavity (Figure 1aGo). Post-contrast dynamic CT showed laminar enhancement on the mucosal surface of the gallbladder wall. The submucosal layer showed strong enhancement in the arterial dominant phase and homogeneous enhancement in the parenchymal dominant phase (Figure 1b,cGo). Abnormal attenuation areas could also be seen along the intrahepatic portal vein. These lesions showed similar enhancement patterns to those of the submucosal lesion on the gallbladder wall. Multiple enlarged lymph nodes could be seen in the hepatoduodenal ligament and para-aortic region (Figure 1dGo). On MRI, the gallbladder wall showed low and high signal intensity on the T1 weighted and T2 weighted sequences, respectively, when compared with the surrounding normal liver parenchyma (Figure 2a,bGo).


Figure 1
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  		Figure 1. Pre-operative CT findings. (a) Pre-contrast CT demonstrates no calcified stones within the gallbladder cavity. (b,c) Dynamic CT shows laminar enhancement on the mucosal surface of the gallbladder wall (black arrows). Abnormal attenuation areas can be seen along the intrahepatic portal vein (white arrows) ((b) arterial phase; (c) parenchymal phase). (d) Multiple lymph node swelling can also be seen in the hepatoduodenal ligament (arrowheads).

 

Figure 2
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  		Figure 2. MRI findings. The gallbladder lesion shows low signal intensity on(a) a T1 weighted sequence and high intensity on (b) a T2 weighted sequence compared with the signal intensity of the liver parenchyma (b) (white arrows).

 
On the basis of these radiological findings, the patient was diagnosed with a malignant tumour of the gallbladder, with submucosal and perilymphatic infiltration. The patient subsequently underwent open cholecystectomy for a definitive histological diagnosis.

Histological findings using haematoxylin and eosin staining demonstrated lymphoid follicles with atypical lymphocytes that diffusely infiltrated the submucosa, muscularis and subserosa of the gallbladder wall, but preserved the mucosal layer (Figure 3a,bGo). Immunoperoxidase staining revealed that the tumour cells were malignant lymphocytes overexpressing bcl-2 and bcl-6 oncoprotein, and strongly expressing the B-cell-associated marker CD10. The definitive pathological diagnosis was follicular lymphoma of the gallbladder.


Figure 3
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  		Figure 3. Histological findings(haematoxylin and eosin staining). (a) Lymphocytes have infiltrated into the submucosa, muscularis and subserosa of the gallbladder wall (the loupe image). (b) Tumour cells are atypical lymphocytes and form lymphoid follicles (x200 and x400 (inset)).

 
Systemic chemotherapy was started as adjuvant treatment, with a subsequent response in size of the periportal and paraaortic lesions.


   Discussion
Top
 Abstract
 Introduction
 Case report
 Discussion
References
 
A wide variety of malignant tumours can arise in the gallbladder, with over 98% being adenocarcinomas but just 0.1–0.2% being malignant lymphomas [1–3]. Primary malignant lymphomas of the gallbladder are extremely rare, with just 27 cases so far reported [2–26]. However, few reports have correlated the radiological features of the primary malignant lymphoma with the pathological findings.

Based on the recent World Health Organization (WHO) classification (2001), the majority of reported cases of primary gallbladder lymphoma are of a mucosa-associated lymphoid tissue (MALT) type or diffuse large B cell type [18–26]. Only two cases of follicular lymphoma of the gallbladder have been reported [21, 24]. Previous reports suggest that the radiological features of gallbladder lymphoma depend upon their pathological classifications: high-grade lymphomas, such as diffuse large B cell type, tend to form a solid and bulky mass in the gallbladder or have marked and irregular wall thickening, whereas most of the low-grade lymphomas, such as MALT-omas or follicular lymphomas, show slight thickening of the gallbladder wall [18–26] (Table 1Go). Furthermore, half of the previously reported cases had gallstones. Lymphoid tissue cannot exist in the gallbladder; thus, it is thought that malignant lymphoma of the gallbladder is related to chronic inflammation, such as chronic cholecystitis associated with cholelithiasis. We pathologically diagnosed our case as low-grade follicular lymphoma, as it demonstrated mild and homogeneous wall thickening on radiological examination. These findings support its lower pathological grading, along with its cell proliferation and infiltration pattern.


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  		Table 1. Histological and radiological findings of primary malignant lymphoma of the gallbladder

 
MRI also depicted the pathological features. A report has previously referred to MR findings [26]; in this, gallbladder lesions showed low signal intensity on fat-suppressed T1 weighted sequences and high signal intensity on fat-suppressed T2 weighted sequences, compared with those of liver parenchyma. These findings were clearly seen in our case. Moreover, our case showed that atypical lymphocytes homogeneously infiltrated into the submucosal layer of the wall of gallbladder but that the mucosal surface was preserved. On T2 weighted sequences, the signal intensity of the gallbladder wall showed as homogeneous and slightly hypointense in comparison with the gallbladder carcinoma. The intact mucosa was also a characteristic finding of this tumour.

Our case showed both intrahepatic periportal lesions and para-aortic mass lesions on CT and MR images. By observing the changes after systemic chemotherapy, the lesions of the gallbladder and around the intra-extra hepatic portal vein were seen to regress. Thus, these findings suggest that the lesions were caused by lymphoma cell infiltration into the para-aortic and hepatobiliary lymphatic system, although this was not proven by pathological examination.

In conclusion, a primary gallbladder follicular lymphoma is a rare entity. The radiological finding — submucosal homogeneous wall thickening of the gallbladder — correlated well with the pathological findings of homogeneous tumour cell infiltration within the submucosa.

Received for publication September 13, 2007. Revision received November 23, 2007. Accepted for publication November 29, 2007.


   References
Top
 Abstract
 Introduction
 Case report
 Discussion
 References
 

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This Article
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Right arrow Articles by MORI, H

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