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Year : 2006  |  Volume : 16  |  Issue : 4  |  Page : 499-501
Aggressive adenocarcinoma of gallbladder with distant metastases and venous thrombosis at initial presentation


Department of Radiodiagnosis & Imaging and Pathology, Vardhman Mahavir Medical College & Safdarjung Hospital New Delhi, India

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Date of Submission05-Apr-2006
Date of Acceptance10-Aug-2006
 

Keywords: Carcinoma gallbladder, distant metastases, venous thrombosis, initial presentation

How to cite this article:
Rawat N S, Negi A, Sangwan S, Sharma U, Thukral B B, Saxena N C. Aggressive adenocarcinoma of gallbladder with distant metastases and venous thrombosis at initial presentation. Indian J Radiol Imaging 2006;16:499-501

How to cite this URL:
Rawat N S, Negi A, Sangwan S, Sharma U, Thukral B B, Saxena N C. Aggressive adenocarcinoma of gallbladder with distant metastases and venous thrombosis at initial presentation. Indian J Radiol Imaging [serial online] 2006 [cited 2019 Aug 22];16:499-501. Available from: http://www.ijri.org/text.asp?2006/16/4/499/32255

   Introduction Top


Primary carcinoma of the gallbladder is uncommon; however it is the most common malignancy of the biliary tract [1]. Gallbladder carcinoma usually causes death due to extensive local disease much before distant metastases can manifest [2]. We report a rare case of aggressive adenocarcinoma of gallbladder with not only distant metastases to liver, lungs and bilateral adrenals but also deep venous thrombosis at initial presentation. These lesions were cytologically confirmed.


   Case report Top


A 60-year-old female presented to our hospital with abdominal pain on and off since last six months and anorexia of recent onset. Clinical examination revealed hepatomegaly and a tender and hard lump in the right hypochondrium. Laboratory investigations showed deranged liver function tests. Chest radiograph was normal. Ultrasound revealed hepatomegaly and a large ill defined predominantly echogenic mass in liver with calcific focus in it. Gallbladder could not be seen separately from the mass. Multiple hypoechoic lesions were seen in both lobes of liver [Figure - 1]. Obstructive dilatation of intrahepatic biliary radicals was noted. Bilateral adrenal masses were noted. For further evaluation, CT scan was carried out which confirmed our ultrasound findings. Hepatomegaly with presence of a large ill-defined heterogeneous mass with central necrosis involving both the hepatic lobes was noted. A concentric rim of calcification with soft tissue component in it was seen in the region of gallbladder fossa [Figure - 2]. Multiple hypodense lesions were seen in both hepatic lobes. Post contrast scans revealed mild peripheral enhancement of the mass. Dilated intrahepatic biliary channels were seen. Bilateral adrenal masses showed heterogeneous appearance and mild peripheral enhancement on post contrast scans. An enhancing mural nodule was also noted in left adrenal lesion [Figure - 3]. Bilateral femoral venous thrombosis was seen as central filling defects with peripheral enhancement of walls [Figure - 4]. On CT Chest multiple small rounded opacities were seen in both lung fields. On imaging alone it was difficult to ascertain whether it was primary malignancy of liver or of gallbladder or whether the adrenal masses were metastatic in nature or not. Ultrasound guided FNAB of adrenal masses was suggestive of metastatic adenocarcinoma that was similar to the cytology of primary mass-an adenocarcinoma of gallbladder [Figure - 5]. No specific therapy could be instituted and the patient died within three weeks of diagnosis.


   Discussion Top


Primary carcinoma of the gallbladder is uncommon; however it is the most common malignancy of the biliary tract [1]. Gallbladder carcinoma mostly metastases to liver, lymph nodes, adjacent organs and peritoneum [1],[2],[3]. Metastases from carcinoma of gallbladder commonly affect the liver, regional and paraaortic nodes and adjacent organs [3]. Adrenal metastases and venous occlusion due to tumour thrombus are unusual in newly diagnosed gallbladder carcinoma patients. Median survival rate in patients of carcinoma gallbladder with distant metastases is only 3 to 4 months and these patients may not be offered any intervention [2]. Though Sons et al [4] have described a high incidence of distant metastases in carcinoma gallbladder in autopsy series, only a few isolated cases of distant metastases in live patients at initial presentation have been reported in the literature. These include metastases to lung [3], bone [2], Scalp [5].

We report an unusual case of aggressive gallbladder carcinoma where at the time of presentation patient had extensive metastases to liver, lungs and bilateral adrenals that too without any lymphnodal enlargement. The patient also had femoral venous occlusion due to thrombosis. Cytological confirmation of mass lesion and adrenal lesions was obtained by ultrasound guided FNAB. In our case there was not only direct invasion of liver from carcinoma gallbladder but also presence of multiple distant metastatic lesions in both hepatic lobes possibly secondary to haematogenous spread. On CT, there was presence of a concentrically calcified lesion with soft tissue component inside it, which could either be due to gallbladder calculus or another possibility could be of porcelain gallbladder through which the mass burst into liver parenchyma. Presence of calcification suggested that the pathology was of long standing duration. Obstructive dilatation of intrahepatic biliary channels was seen. Multiple small nodular opacities were seen in both the lung fields. Cytological evaluation of these lesions could not be carried out because of patient's condition. These were assumed to be metastatic deposits. A large study of lung biopsies conducted in patients with multiple nodules in the setting of a single known primary cancer confirmed that such lesions almost invariably represented metastases and that biopsy was seldom useful or necessary [6]. Bilateral adrenal masses were seen in our patient. These masses showed heterogeneous attenuation with thick irregular rim of peripheral enhancement which favoured the diagnosis of adrenal metastases [7]. An enhancing eccentric nodule was noted in left adrenal. Though bilateral metastatic involvement of adrenals is well known but carcinoma of gallbladder is an unusual primary site.

On contrast enhanced CT scan, bilateral femoral veins showed filling defects with ring like enhancement of vessel wall on contiguous multiple slices. Femoral venous thrombosis was diagnosed using the criteria described by Shah et al in 1999 [8]. No reports of association of adrenal metastases with femoral venous thrombosis have been described till date. US guided FNAB was carried out from primary mass lesion, liver lesion and bilateral adrenal masses for cytological confirmation. Investigators have reported high accuracy of role of ultrasound guided FNAB [7].

This case reports the uncommon metastatic potential of newly diagnosed gallbladder carcinoma and highlights the role of imaging in assessing the possibilities of distant metastases to adrenal glands and also venous thrombosis at the time of presentation.

 
   References Top

1.Inoue T, Shiraki K, Fuke H et al. Cardiac metastases of gallbladder carcinoma. World J Gastroenterol 2005 April 7; 11(13):2048-2049.  Back to cited text no. 1    
2.Misra S, Chaturvedi A, Misra NC. Carcinoma gall bladder presenting with skeletal metastases. Indian Journal of Gastroenterology 1997; 16:74.  Back to cited text no. 2  [PUBMED]  
3.Puneet, Khanna R, Mohan Kumar, Khanna AK. Carcinoma gallbladder presenting as metastatic lung disease. Indian Journal of Gastroenterology 1999; 18:44.  Back to cited text no. 3    
4.Sons HU, Borchard F, Joel BS. Carcinoma of the gall bladder. Autopsy findings in 287 cases and review of the literature. Journal of Surgical Oncology 1985; 28:199- 206.  Back to cited text no. 4    
5.Pandey M, Aryya NC, Pradhan S, Asthana AK, Gautam A, Shukla VK. Carcinoma of the gallbladder presenting as scalp tumour. Eur J Surg Oncol 1998; 24(6): 605-607.  Back to cited text no. 5    
6.Patz EF Jr, Fidler J, Knelson M et al. Significance of percutaneous needles biopsy in patients with multiple pulmonary nodules and a single known primary malignancy. Chest 1995; 107:601-4.  Back to cited text no. 6    
7.Korobkin M, Francis RI. Imaging of adrenal masses. Urologic Clinics of North America 1997; 24 (3): 603 - 622.  Back to cited text no. 7    
8.Shah A, Buckshee N, Yankelevitz DF, Henschke CI. Assessment of deep venous thrombosis using routine pelvic CT. AJR 1999; 173:659-663.  Back to cited text no. 8    

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Correspondence Address:
N S Rawat
25 - B, Pocket A - 10, Kohinoor Apartments, Kalkaji Extension, New Delhi - 110019
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-3026.32255

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    Figures

  [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5]

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    Introduction
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