How Can We Identify T1 or Shallow T2 Gallbladder Carcinoma Using Ultrasound? Comment on Okaniwa, S. How Can We Manage Gallbladder Lesions by Transabdominal Ultrasound? Diagnostics 2021, 11, 784.

I am keenly interested in ultrasound diagnosis of the invasion depth of gallbladder carcinoma (GBC) [...].

What condition does gallbladder tumor with a deep hypoechoic area suggest except T2 carcinoma?

Conventional transabdominal ultrasound depicts a flat-elevated lesion 15 mm in diameter in the body of the gallbladder. The lesion (arrow) consists of a superficial hyperechoic part and a deep hypoechoic area, accompanied by an irregular outermost hyperechoic layer. A hyperechoic spot (arrowhead) is noted in the deep hypoechoic area.

Polypoid gallbladder tumors with a deep hypoechoic area and a conically thickened outermost hyperechoic layer suggest shallow T2 carcinoma.

BACKGROUND: Ultrasound findings of shallow T2 gallbladder carcinoma (GBC) with a favorable prognosis are not known. PURPOSE: To confirm the criteria for ultrasound diagnosis of shallow T2 GBC. MATERIAL AND METHODS: A detailed analysis of ultrasound and pathological correlation was conducted in two patients with pT1 GBC and seven with shallow pT2 GBC (subserosal-invasion depth ≤ 2 mm) at our institution from January 1988 to December 2017. RESULTS: A polypoid gallbladder tumor with a deep hypoechoic area represented a papillary adenocarcinoma invading the subserosa accompanied by abundant fibrosis and lymphocytic infiltration. Two cases of pT1 GBC did not present a deep hypoechoic area, whereas all seven cases of shallow pT2 GBC did. One case of pT1b GBC and four cases of pT2 GBC showed conical thickening of the outermost hyperechoic layer, whereas one case of pT1a GBC and three cases of pT2 GBC presented no change of the layer thickness. All shallow T2 GBCs showing a conically thickened outermost hyperechoic layer provided good postoperative prognoses. CONCLUSION: Ultrasound images of shallow T2 GBC show a deep hypoechoic area with conical thickening or unchanging of an outermost hyperechoic layer. The former demonstrates pulling up the top of the layer at first and then thinning later as carcinoma invades with enlargement of the hypoechoic area, whereas the latter thinning of the layer from the beginning. Polypoid gallbladder tumors with a deep hypoechoic area and a conically thickened outermost hyperechoic layer suggest shallow T2 GBC and may provide good postoperative prognoses.

Acute appendicitis with a neuroendocrine tumor G1 (carcinoid): pitfalls of conservative treatment.

A man in his early thirties presented to our clinic with right lower abdominal pain. Computed tomography (CT) and ultrasonography (US) revealed a swollen appendix and an appendicolith. Abscess formation was not observed but ongoing appendiceal rupture was not ruled out. Three months after successful conservative therapy, the lumen of the apical portion was kept dilated and laparoscopic interval appendectomy was performed. No tumorous findings were observed macroscopically. However, histology revealed many tiny nests infiltrating the submucosa, muscular layer, and subserosa at the root of the appendix. An appendiceal neuroendocrine tumor G1 (NET G1; carcinoid) was diagnosed immunohistologically. Neither CT nor US visualized the tumor because of its non-tumor-forming but infiltrative growth. In conclusion, after successful conservative treatment, interval appendectomy should be considered to uncover a possible appendiceal NET G1 (carcinoid), particularly when dilatation of the distal lumen is kept under observation.