HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Full Text Full Text (PDF) Submit a response Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Haradome, H. Articles by Hachiya, J. Search for Related Content PubMed PubMed Citation Articles by Haradome, H. Articles by Hachiya, J.

The Pearl Necklace Sign: An Imaging Sign of Adenomyomatosis of the Gallbladder at MR Cholangiopancreatography¹

¹ From the Department of Radiology, Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka, Tokyo 181, Japan (H.H., A.N., J.H.); and Department of Radiology, Yamanashi Medical University School of Medicine, Japan (T.I., H.S., T.Y., T.A.). Received August 9, 2001; revision requested October 10; revision received May 9, 2002; accepted July 24. Address correspondence to H.H. (e-mail: haradome@ff.iij4u.or.jp).

View larger version (162K): [in a new window]   Figure 1. Diffuse adenomyomatosis of the gallbladder in a 43-year-old man. Oblique fat-saturated multisection MRCP image with half-Fourier single-shot turbo SE sequence (repetition time msec/echo time msec, 30,000/97 [effective]; flip angle, 180°) shows very small cystic structures (arrows). This finding was named the pearl necklace sign. Multiple gallbladder stones (arrowheads) are also seen. D = duodenum.

View larger version (30K): [in a new window]   Figure 2. Composite ROC curves compare the observers’ confidence in differentiating adenomyomatosis of the gallbladder from gallbladder cancer by using the pearl necklace sign at each modality. MRCP images and the combination of MRCP and arterial phase MR images (AP MR) were superior to arterial phase CT (AP CT) or arterial phase MR images (P < .01) in differentiating adenomyomatosis of the gallbladder and gallbladder cancer. Differences were not statistically significant for the mean Az values between MRCP images and the combination of MRCP and arterial phase MR images, although there was a trend toward superiority with the latter.

View larger version (210K): [in a new window]   Figure 3a. Segmental adenomyomatosis of the gallbladder in a 66-year-old man. (a) Transverse arterial phase MR image with fast low-angle shot sequence (147/6, 90° flip angle) clearly shows focal wall thickening of the gallbladder and small cystic structures (Rokitansky-Aschoff sinuses; straight arrows). Uniform gallbladder wall thickening due to accompanied chronic cholecystitis is also seen (curved arrow). However, multiple stones are not shown. (b) Transverse fat-saturated multisection MRCP image with a single-shot fast SE sequence (30,000/80 [effective], 180° flip angle) also demonstrates small cystic structures (the pearl necklace sign) within segmental wall thickening and multiple stones in the fundus of the gallbladder (arrowheads). Although both images clearly demonstrate cystic structures within segmental wall thickening, multisection MRCP image can show more small-size cystic structures (arrows) than the arterial phase MR image.

View larger version (176K): [in a new window]   Figure 3b. Segmental adenomyomatosis of the gallbladder in a 66-year-old man. (a) Transverse arterial phase MR image with fast low-angle shot sequence (147/6, 90° flip angle) clearly shows focal wall thickening of the gallbladder and small cystic structures (Rokitansky-Aschoff sinuses; straight arrows). Uniform gallbladder wall thickening due to accompanied chronic cholecystitis is also seen (curved arrow). However, multiple stones are not shown. (b) Transverse fat-saturated multisection MRCP image with a single-shot fast SE sequence (30,000/80 [effective], 180° flip angle) also demonstrates small cystic structures (the pearl necklace sign) within segmental wall thickening and multiple stones in the fundus of the gallbladder (arrowheads). Although both images clearly demonstrate cystic structures within segmental wall thickening, multisection MRCP image can show more small-size cystic structures (arrows) than the arterial phase MR image.

View larger version (166K): [in a new window]   Figure 4a. Fundal adenomyomatosis of the gallbladder in a 66-year-old man. (a) Coronal multisection MRCP image with single-shot fast SE sequence and without fat saturation (30,000/80 [effective], 180° flip angle) clearly shows a cluster of multiple cystic structures (the pearl necklace sign; arrows) in the fundus of the gallbladder. Very small mural stone (arrowhead) is also seen. (b) On transverse arterial phase CT image, a cluster of multiple cystic structures, which is clearly shown on the multisection MRCP image, is not evident.

View larger version (131K): [in a new window]   Figure 4b. Fundal adenomyomatosis of the gallbladder in a 66-year-old man. (a) Coronal multisection MRCP image with single-shot fast SE sequence and without fat saturation (30,000/80 [effective], 180° flip angle) clearly shows a cluster of multiple cystic structures (the pearl necklace sign; arrows) in the fundus of the gallbladder. Very small mural stone (arrowhead) is also seen. (b) On transverse arterial phase CT image, a cluster of multiple cystic structures, which is clearly shown on the multisection MRCP image, is not evident.

View larger version (163K): [in a new window]   Figure 5a. Fundal adenomyomatosis of the gallbladder in a 70-year-old man. (a) Transverse unenhanced CT image shows a small intramural stone (arrow) with a calcification in the thickened fundus of the gallbladder wall. Calcified gallbladder stones are also seen. (b) Transverse arterial phase CT image demonstrates heterogeneous enhancement in a thickened fundus of the gallbladder wall. (c) Transverse fat-saturated multisection MRCP image with single-shot fast SE sequence (30,000/80 [effective], 180° flip angle) shows multiple small cystic structures (the pearl necklace sign; arrows), which are not identified on the CT image, in a thickened fundus of the gallbladder wall. Although on CT images, thickened fundus of the gallbladder wall apparently may mimic tumor, MRCP image can help to distinguish between adenomyomatosis and tumor because it clearly demonstrates multiple small cystic structures. However, the Rokitansky-Aschoff sinus with an intramural stone, which can be seen on CT images, is not visible on the multisection MRCP image because the Rokitansky-Aschoff sinus is fully compacted with the intramural stone. B = common bile duct, K = right kidney, and L = lumen of gallbladder.

View larger version (169K): [in a new window]   Figure 5b. Fundal adenomyomatosis of the gallbladder in a 70-year-old man. (a) Transverse unenhanced CT image shows a small intramural stone (arrow) with a calcification in the thickened fundus of the gallbladder wall. Calcified gallbladder stones are also seen. (b) Transverse arterial phase CT image demonstrates heterogeneous enhancement in a thickened fundus of the gallbladder wall. (c) Transverse fat-saturated multisection MRCP image with single-shot fast SE sequence (30,000/80 [effective], 180° flip angle) shows multiple small cystic structures (the pearl necklace sign; arrows), which are not identified on the CT image, in a thickened fundus of the gallbladder wall. Although on CT images, thickened fundus of the gallbladder wall apparently may mimic tumor, MRCP image can help to distinguish between adenomyomatosis and tumor because it clearly demonstrates multiple small cystic structures. However, the Rokitansky-Aschoff sinus with an intramural stone, which can be seen on CT images, is not visible on the multisection MRCP image because the Rokitansky-Aschoff sinus is fully compacted with the intramural stone. B = common bile duct, K = right kidney, and L = lumen of gallbladder.

View larger version (131K): [in a new window]   Figure 5c. Fundal adenomyomatosis of the gallbladder in a 70-year-old man. (a) Transverse unenhanced CT image shows a small intramural stone (arrow) with a calcification in the thickened fundus of the gallbladder wall. Calcified gallbladder stones are also seen. (b) Transverse arterial phase CT image demonstrates heterogeneous enhancement in a thickened fundus of the gallbladder wall. (c) Transverse fat-saturated multisection MRCP image with single-shot fast SE sequence (30,000/80 [effective], 180° flip angle) shows multiple small cystic structures (the pearl necklace sign; arrows), which are not identified on the CT image, in a thickened fundus of the gallbladder wall. Although on CT images, thickened fundus of the gallbladder wall apparently may mimic tumor, MRCP image can help to distinguish between adenomyomatosis and tumor because it clearly demonstrates multiple small cystic structures. However, the Rokitansky-Aschoff sinus with an intramural stone, which can be seen on CT images, is not visible on the multisection MRCP image because the Rokitansky-Aschoff sinus is fully compacted with the intramural stone. B = common bile duct, K = right kidney, and L = lumen of gallbladder.

View larger version (134K): [in a new window]   Figure 6a. Gallbladder carcinoma in a 63-year-old man. (a) Transverse arterial phase CT image shows focal wall thickening with marked enhancement (arrows) in the neck of the gallbladder. (b) Oblique single-section MRCP image with single-shot fast SE sequence (/800 [effective], 180° flip angle) shows segmental wall thickening (arrowheads) in the neck of gallbladder. This finding seemingly mimics segmental adenomyomatosis of the gallbladder. Small cystic structures in segmental thickening (the pearl necklace sign), however, are not seen. The final histologic diagnosis of the resected specimen was invasive gallbladder carcinoma.

View larger version (126K): [in a new window]   Figure 6b. Gallbladder carcinoma in a 63-year-old man. (a) Transverse arterial phase CT image shows focal wall thickening with marked enhancement (arrows) in the neck of the gallbladder. (b) Oblique single-section MRCP image with single-shot fast SE sequence (/800 [effective], 180° flip angle) shows segmental wall thickening (arrowheads) in the neck of gallbladder. This finding seemingly mimics segmental adenomyomatosis of the gallbladder. Small cystic structures in segmental thickening (the pearl necklace sign), however, are not seen. The final histologic diagnosis of the resected specimen was invasive gallbladder carcinoma.