CT diagnosis of gallbladder adenomyomatosis: importance of enhancing mucosal epithelium, the “cotton ball sign”

  • Hyun Kyung Yang
  • Jeong Min Lee
  • Mi Hye Yu
  • Sang Min Lee
  • Jinyoung Park
  • Na Young Han
  • Kyoungbun Lee
  • Jin-Young Jang
  • Joon Koo Han
Hepatobiliary-Pancreas

ABSTRACT

Objectives

To determine the diagnostic value of the cotton ball sign and other CT features in patients with gallbladder (GB) wall thickenings (WTs).

Methods

Three blinded readers reviewed the preoperative CT and MR images of 101 patients with pathologically confirmed GB adenomyomatosis (GA) (n = 34) and other benign (n = 29), malignant (n = 41), and premalignant (n = 2) GBWTs. Three readers analysed the morphological features of GBWT and presence of the “cotton ball sign”, defined as fuzzy grey dots in GBWT or a dotted outer border of the inner enhancing layer on contrast-enhanced (CE) CT. In addition, the “pearl necklace sign” on MR was analysed.

Results

In the GA group (n = 34), prevalence of the cotton ball sign and pearl necklace sign was 74% (25/34) and 44% (15/34), respectively. Presence of the cotton ball sign, smooth contour of the mucosa, double-layering enhancement, and enhancement degree weaker than the renal cortex on CT images were significant predictors of benign GBWT (p < 0.01). When differentiating GA from GB malignancy or premalignancy, accuracy of the cotton ball sign and pearl necklace sign was 81% (62/77) and 74% (57/77), respectively.

Conclusion

The cotton ball sign on CE-CT showed higher sensitivity and comparable specificity to those of the pearl necklace sign in differentiating GA from malignancy.

Key Points

• Prevalence of the cotton ball sign on CT was 74% in gallbladder adenomyomatosis.

• The cotton ball sign was useful in differentiating gallbladder adenomyomatosis from gallbladder cancer.

• The cotton ball sign was more sensitive than the pearl necklace sign for adenomyomatosis diagnosis.

Keywords

Gallbladder diseases Adenomyoma Gallbladder neoplasms Diagnosis, differential Tomography, X-ray computed 

Abbreviations

CE

Contrast enhanced

CT

Computed tomography

GA

Gallbladder adenomyomatosis

GB

Gallbladder

GBWT

Gallbladder wall thickening

GRE

Gradient echo sequence

HU

Hounsfield unit

MDCT

Multi-detector computed tomography

MRCP

Magnetic resonance cholangiopancreatography

MRI

Magnetic resonance imaging

PVP

Portal venous phase

RAS

Rokitansky-Aschoff sinus

US

Ultrasound

Notes

Compliance with ethical standards

Guarantor

The scientific guarantor of this publication is Jeong Min Lee.

Conflict of interest

The authors of this manuscript declare no relationships with any companies, whose products or services may be related to the subject matter of the article.

Statistics and biometry

No complex statistical methods were necessary for this paper.

Informed consent

Written informed consent was waived by the Institutional Review Board.

Ethical approval

Institutional Review Board approval was obtained.

Methodology

• retrospective

• diagnostic or prognostic study

• performed at one institution

Supplementary material

330_2018_5412_MOESM1_ESM.docx (28 kb)
ESM 1 (DOCX 28 kb)

References

  1. 1.
    Kim SJ, Lee JM, Lee JY et al (2008) Analysis of enhancement pattern of flat gallbladder wall thickening on MDCT to differentiate gallbladder cancer from cholecystitis. AJR Am J Roentgenol 191:765–771CrossRefPubMedGoogle Scholar
  2. 2.
    Bonatti M, Vezzali N, Lombardo F et al (2017) Gallbladder adenomyomatosis: imaging findings, tricks and pitfalls. Insights Imaging 8:243–253CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Hammad AY, Miura JT, Turaga KK, Johnston FM, Hohenwalter MD, Gamblin TC (2016) A literature review of radiological findings to guide the diagnosis of gallbladder adenomyomatosis. HPB (Oxford) 18:129–135CrossRefGoogle Scholar
  4. 4.
    Kim JH, Jeong IH, Han JH et al (2010) Clinical/pathological analysis of gallbladder adenomyomatosis; type and pathogenesis. Hepatogastroenterology 57:420–425PubMedGoogle Scholar
  5. 5.
    Cariati A, Cetta F (2003) Rokitansky-Aschoff sinuses of the gallbladder are associated with black pigment gallstone formation: a scanning electron microscopy study. Ultrastruct Pathol 27:265–270CrossRefPubMedGoogle Scholar
  6. 6.
    Mariani PJ, Hsue A (2011) Adenomyomatosis of the gallbladder: the "good omen" comet. J Emerg Med 40:415–418CrossRefPubMedGoogle Scholar
  7. 7.
    Joo I, Lee JY, Kim JH et al (2013) Differentiation of adenomyomatosis of the gallbladder from early-stage, wall-thickening-type gallbladder cancer using high-resolution ultrasound. Eur Radiol 23:730–738CrossRefPubMedGoogle Scholar
  8. 8.
    Chantarojanasiri T, Hirooka Y, Kawashima H, Ohno E, Kongkam P, Goto H (2017) The role of endoscopic ultrasound in the diagnosis of gallbladder diseases. J Med Ultrason (2001) 44:63–70CrossRefGoogle Scholar
  9. 9.
    Ching BH, Yeh BM, Westphalen AC, Joe BN, Qayyum A, Coakley FV (2007) CT differentiation of adenomyomatosis and gallbladder cancer. AJR Am J Roentgenol 189:62–66CrossRefPubMedGoogle Scholar
  10. 10.
    Yoshimitsu K, Honda H, Jimi M et al (1999) MR diagnosis of adenomyomatosis of the gallbladder and differentiation from gallbladder carcinoma: importance of showing Rokitansky-Aschoff sinuses. AJR Am J Roentgenol 172:1535–1540CrossRefPubMedGoogle Scholar
  11. 11.
    Haradome H, Ichikawa T, Sou H et al (2003) The pearl necklace sign: an imaging sign of adenomyomatosis of the gallbladder at MR cholangiopancreatography. Radiology 227:80–88CrossRefPubMedGoogle Scholar
  12. 12.
    Mirbagheri SA, Mohamadnejad M, Nasiri J, Vahid AA, Ghadimi R, Malekzadeh R (2005) Prospective evaluation of endoscopic ultrasonography in the diagnosis of biliary microlithiasis in patients with normal transabdominal ultrasonography. J Gastrointest Surg 9:961–964CrossRefPubMedGoogle Scholar
  13. 13.
    Imazu H, Mori N, Kanazawa K et al (2014) Contrast-enhanced harmonic endoscopic ultrasonography in the differential diagnosis of gallbladder wall thickening. Dig Dis Sci 59:1909–1916CrossRefPubMedGoogle Scholar
  14. 14.
    Miyazaki T, Yamashita Y, Tsuchigame T, Yamamoto H, Urata J, Takahashi M (1996) MR cholangiopancreatography using HASTE (half-Fourier acquisition single-shot turbo spin-echo) sequences. AJR Am J Roentgenol 166:1297–1303CrossRefPubMedGoogle Scholar
  15. 15.
    Hwang JI, Chou YH, Tsay SH et al (1998) Radiologic and pathologic correlation of adenomyomatosis of the gallbladder. Abdom Imaging 23:73–77CrossRefPubMedGoogle Scholar
  16. 16.
    Clouston JE, Thorpe RJ (1991) Case report--CT findings in adenomyomatosis of the gallbladder. Australas Radiol 35:86–87CrossRefPubMedGoogle Scholar
  17. 17.
    Chao C, Hsiao HC, Wu CS, Wang KC (1992) Computed tomographic finding in adenomyomatosis of the gallbladder. J Formos Med Assoc 91:467–469PubMedGoogle Scholar
  18. 18.
    Stunell H, Buckley O, Geoghegan T, O'Brien J, Ward E, Torreggiani W (2008) Imaging of adenomyomatosis of the gall bladder. J Med Imaging Radiat Oncol 52:109–117CrossRefPubMedGoogle Scholar
  19. 19.
    Altman DG (1990) Practical statistics for medical research. CRC pressGoogle Scholar
  20. 20.
    van Breda Vriesman AC, Engelbrecht MR, Smithuis RH, Puylaert JB (2007) Diffuse gallbladder wall thickening: differential diagnosis. AJR Am J Roentgenol 188:495–501CrossRefPubMedGoogle Scholar
  21. 21.
    Levy AD, Murakata LA, Rohrmann CA Jr (2001) Gallbladder carcinoma: radiologic-pathologic correlation. Radiographics 21:295–314 questionnaire, 549-255CrossRefPubMedGoogle Scholar
  22. 22.
    Baron RL (1991) Computed tomography of the biliary tree. Radiol Clin North Am 29:1235–1250PubMedGoogle Scholar
  23. 23.
    Zissin R, Osadchy A, Shapiro-Feinberg M, Gayer G (2003) CT of a thickened-wall gall bladder. Br J Radiol 76:137–143CrossRefPubMedGoogle Scholar
  24. 24.
    Westra WH (2003) Surgical pathology dissection: an illustrated guide, 2nd edn. Springer, New YorkCrossRefGoogle Scholar
  25. 25.
    Bang SH, Lee JY, Woo H et al (2014) Differentiating between adenomyomatosis and gallbladder cancer: revisiting a comparative study of high-resolution ultrasound, multidetector CT, and MR imaging. Korean J Radiol 15:226–234CrossRefPubMedPubMedCentralGoogle Scholar
  26. 26.
    Adusumilli S, Siegelman ES (2002) MR imaging of the gallbladder. Magn Reson Imaging Clin N Am 10:165–184CrossRefPubMedGoogle Scholar
  27. 27.
    Imai H, Osada S, Sasaki Y et al (2011) Gallbladder adenocarcinoma with extended intramural spread in adenomyomatosis of the gallbladder with the pearl necklace sign. Am Surg 77:E57–E58PubMedGoogle Scholar
  28. 28.
    Yoshimitsu K, Irie H, Aibe H et al (2005) Well-differentiated adenocarcinoma of the gallbladder with intratumoral cystic components due to abundant mucin production: a mimicker of adenomyomatosis. Eur Radiol 15:229–233CrossRefPubMedGoogle Scholar
  29. 29.
    Rice J, Sauerbrei EE, Semogas P, Cooperberg PL, Burhenne HJ (1981) Sonographic appearance of adenomyomatosis of the gallbladder. J Clin Ultrasound 9:336–337CrossRefPubMedGoogle Scholar
  30. 30.
    Raghavendra BN, Subramanyam BR, Balthazar EJ, Horii SC, Megibow AJ, Hilton S (1983) Sonography of adenomyomatosis of the gallbladder: radiologic-pathologic correlation. Radiology 146:747–752CrossRefPubMedGoogle Scholar
  31. 31.
    Brambs HJ, Wrazidlo W, Schilling H (1990) The sonographic image of gallbladder adenomyomatosis. Rofo 153:633–636CrossRefPubMedGoogle Scholar
  32. 32.
    Boscak AR, Al-Hawary M, Ramsburgh SR (2006) Best cases from the AFIP: Adenomyomatosis of the gallbladder. Radiographics 26:941–946CrossRefPubMedGoogle Scholar

Copyright information

© European Society of Radiology 2018

Authors and Affiliations

  1. 1.Department of RadiologySeoul National University HospitalSeoulKorea
  2. 2.The Joint Department of Medical ImagingMount Sinai Hospital-University Health Network-Women’s College Hospital, University of TorontoTorontoCanada
  3. 3.Department of RadiologySeoul National University College of MedicineSeoulKorea
  4. 4.Department of RadiologyKonkuk University School of MedicineSeoulKorea
  5. 5.Department of RadiologyHallym University Sacred Heart HospitalAnyangKorea
  6. 6.Department of RadiologyDongnam Institute of Radiological and Medical SciencesBusanKorea
  7. 7.Department of PathologyNational Cancer CenterGoyangKorea
  8. 8.Department of PathologySeoul National University HospitalSeoulKorea
  9. 9.Department of SurgerySeoul National University HospitalSeoulKorea

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