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ABDOMINAL IMAGING Table of Contents   
Year : 2003  |  Volume : 13  |  Issue : 1  |  Page : 37-39
Disseminated osteoblastic skeletal metastases from carcinoma of gall bladder - a case report

Departments of Radiology and Imaging, University College of Medical Sciences (Delhi University) and Guru Te Bahadur Hospital Delhi, India

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Skeletal metastases from carcinoma of the gall bladder are rare, and majority of these are osteolytic. We report a case of purely osteoblastic metastases from carcinoma of the gall bladder.

Keywords: Gall Bladder, Carcinoma, Metastasis

How to cite this article:
Kumar A, Bhargava S K, Upreti L, Kumar J. Disseminated osteoblastic skeletal metastases from carcinoma of gall bladder - a case report. Indian J Radiol Imaging 2003;13:37-9

How to cite this URL:
Kumar A, Bhargava S K, Upreti L, Kumar J. Disseminated osteoblastic skeletal metastases from carcinoma of gall bladder - a case report. Indian J Radiol Imaging [serial online] 2003 [cited 2021 Feb 28];13:37-9. Available from:

   Introduction Top

Disseminated blood borne metastases from carcinoma of the gall bladder are uncommon and occur late in the course of the disease. Of all the distant sites that can be involved by the metastatic disease, the skeletal system is the least commonly involved [1]. The metastases to the skeletal system is mainly purely osteolytic with osteoblastic lesions being extremely rare. We hereby present a case report of a carcinoma of the gall bladder with disseminated purely osteoblastic secondaries in the skeletal system.

   Case report Top

A 45 year old male patient presented to our hospital with complaints of pain in the right hypochondrium for 3 months and generalized bony pain in the chest and back for 1 month. There was no other significant history. On examination, a hard lump was palpable in the right hypochondrium. Mild icterus was also present. There was mild tenderness in the vertebral column. No other significant finding was noted.

Laboratory investigations revealed a raised serum bilirubin (5 mg%), mainly conjugated. Serum alkaline phosphatase was also raised. An ultrasound examination [Figure - 1] of the abdomen revealed a hypoechoic ill defined mass occupying the gall bladder lumen. The margins with the liver were suggesting infiltration. Few gall stones were seen embedded in the mass. Two small hypoechoic lymph nodes were seen at the porta hepatis causing compression of the common hepatic duct (CHD) and mild dilatation of the intraheptic biliary radicals. No other abnormality was noted in the abdomen.

X-ray of the chest, dorsolumbar spine and pelvis were obtained which revealed multiple sclerotic lesions in the ribs, vertebrae and pelvis. On enquiring, the patient gave a history of having few two year old skiagrams of the chest, which were taken during the course of treatment for a chest infection. Subsequent review of these skiagrams did not reveal any bony abnormality. A contrast enhanced CT scan of the abdomen and chest was carried out which confirmed the findings of carcinoma of the gall bladder [Figure - 2]. Images in bone window settings showed multiple sclerotic bone lesions in the iliac bones and vertebral bodies [Figure - 2][Figure - 3]. There was no parenchymal or mediastinal lesion in the thorax. An extensive search was carried out to rule out any other co-existing primary neoplastic lesion. It included serum prostate specific antigen levels, sonography of the testes, upper gastrointestinal endoscopy and double contrast barium enema. These investigations were normal.

An ultrasound guided FNAC of the gall bladder mass revealed a moderately differentiated adenocarcinoma. Biopsy of a sclerotic lesion in the right 9th rib done under general anaesthesia revealed metastatic adenocarcinoma. Thus a diagnosis of carcinoma of the gall bladder causing osteoblastic secondaries was made. The patient is receiving chemotherapy in the form of 5 FU and mitomycin and is under follow up for the last seven months. His bone pain and jaundice have decreased.

   Discussion Top

Arminski[1] in his classical article reviewed various aspects of gall bladder carcinoma. He stated that primary carcinoma of the gall bladder spreads by extension and by metastases, the former occurring earlier and more often. Direct extension of the lesion may occur by any of the four modes: perivascular, intravascular, perineural or by invasion of the nerve trunk proper. The liver is most frequently involved by direct extension, with incidence ranging from 60-90%. Other organs commonly affected are bile ducts, duodenum, stomach, colon, omentum, abdominal wall, pancreas and portal vein. Metastases occur most frequently to the liver (76-86%), while regional lymph nodes are involved in about 60% of the cases. According to the author, metastases occur to practically every organ including liver, lymph nodes, adrenal, kidney, spleen, brain, breast, thyroid, heart and uterus, those to the skeletal system are least frequent.

When vascular invasion occurs, it leads to localized involvement of the liver in the neighbourhood of the primary lesion rather than disseminated multiple nodules [2]. Disseminated metastases occur late in the course of the disease and are probably due to invasion of the retroperitoneal veins.

Koo jarley et al[3] found bone metastases in only 2 out of 100 cases of metastatic carcinoma of the gall bladder studied by them. The rarity of bony metastases from primary carcinoma has been documented by other authors[1],[4],[5],[6]. According to yochumand rowe[7], among cases of skeletal metastases from the carcinoma of the gall bladder, 90% are purely osteolytic and 10% are mixed lytic and blastic type with purely osteoblastic lesions being unknown.

The tumors that are known to produce osteoblastic bone secondaries in an adult male patient include prostate, lung, testes, mucin secreting adenocarcinoma of the GIT osteosarcoma, chondrosacroma and rarely renal carcinomas. To the best of our knowledge, there has been no prior report of purely osteoblastic metastatic lesions from adenocarcinoma of the gall bladder. Our case is also unique in the respect that no other organ system was involved in the metastatic spread.

   References Top

1.Arminski tc. Primary carcinoma of gall bladder. Cancer 1949; 2: 379-398.  Back to cited text no. 1    
2.Fahim rb, Mcdonald jr. Carcinoma of the gall bladder - A study of its modes of spread. Annals of surgery. 1962; 156: 114-124.  Back to cited text no. 2    
3.Jarley koo, john wong, frank cy, cheng and gb ong. carcinoma of the gall bladder. British journal of surgery. 1981; 68: 161-165.  Back to cited text no. 3    
4.liebowitz hr. primary carcinoma of the gall bladder. Am j. digest. Dis. 1939-1940; 6: 381-387.  Back to cited text no. 4    
5.mattson h. carcinoma of the gall bladder: study of sixty cases. Minnesota med. 1942; 25: 985-988.  Back to cited text no. 5    
6.rolleston hd and mcnee jw. Diseases of the liver, gall bladder and bile ducts, 3rd ed. London. The Macmillan co. 1929: 691.  Back to cited text no. 6    
7.yochum tr and rowel j. tumor and tumor like processes. In: yochum tr and rowel j, ed. Essentials of skeletal radiology. 1st edn. Baltimore, Maryland, USA. Williams and Wilkins, 1987; 975-1192.  Back to cited text no. 7    

Correspondence Address:
S K Bhargava
Departments of Radiology and Imaging, University College of Medical Sciences (Delhi University) and Guru Te Bahadur Hospital, E-3, Dilshad Garden, Delhi-110095
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Source of Support: None, Conflict of Interest: None

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

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