J Clin Ultrasound 19:380-382, July/August 1991
Case Report
Late Solitary Abdominal Wall Metastasis from an Incidental Carcinoma of the Gallbladder: Ultrasound Demonstration Alka Kumar, MD, John Henry MacGregor, FRCP(C), and Shashi Aggarwal, MD
Carcinoma of the gall bladder is the most common malignant lesion of the biliary tract' and is notorious for its poor prognosis. While this is largely due to the late presentation seen in most cases, even early cases, serendipitously discovered at pathology, fare only marginally better because of the propensity for early disseminati~n.~,~ We report one such patient with an incidentally discovered carcinoma of the gall bladder who presented 3 years later with an isolated metastasis at an unusual site. CASE REPORT
A 64-year-old woman presented in 1986 with recurrent attacks of right upper quadrant pain. An ultrasound examination revealed a small contracted gall bladder with multiple calculi and a minimally thickened wall. A diagnosis of chronic cholecystitis with cholelithiasis was made. A routine cholecystectomy was subsequently performed. Examination of other intra-abdominal organs did not show any abnormality. The gall bladder was not opened at surgery as there was no suspicion of tumor. On subsequent gross pathologic examination, a small papillary growth (2.5 cm x 1.5 cm) was found within the gall bladder. Histology revealed a well-differentiated papillary adenocarcinoma localized to mucosa and lamina propria with vascular invasion, but without involvement of muscularis or serosa. The patient returned in October 1989 with a slightly painful lump in the right upper quad-
rant. Examination revealed a mobile, firm mass in the right subcostal region extending below the previous surgical incision. Ultrasound examination revealed it to be predominantly cystic with a mural nodule (Figure l),and located either just beneath or within the abdominal wall. No other abnormalities were identified; specifically, no mass was seen in the gall bladder fossa or liver, and there were no enlarged retroperitoneal lymph nodes. At surgery, a thick-walled, irregular mass containing cloudy fluid was removed from underneath the fascia of the anterior abdominal wall (Figure 2). There was no invasion of surrounding organs. A careful search of the abdominal cavity did not reveal any other metastases. Histology confirmed the presence of well-differentiated adenocarcinoma metastatic from gall bladder. DISCUSSION
From the Department of Radiology, Victoria General Hospital, Halifax, Nova Scotia, Canada B3H 2Y9. For reprints contact Alka Kumar, MD a t present address: Department of Radiology, The Totonto Hospitals- Western Division, 399 Bathurst Street, Toronto, Ontario M5T 2S8, Canada.
Carcinoma of the gall bladder may spread by any of the following routes: lymphatic, vascular, intraperitoneal spread, neural, ductal, and direct e x t e n ~ i o nThe . ~ vascular route is second only to the lymphatic route as a means of ~ p r e a d The .~ route of spread in our patient was most likely via the draining veins, as demonstrated histologically. In contrast to other abdominal viscera that drain primarily into the portal circulation, the venous drainage of the gall bladder ends primarily in the adjacent liver substance, whence it empties into the hepatic vein.4 This implies that should blood-borne metastases occur, the liver would almost always be involved. Vascular invasion has the potential to metastasize carcinoma of gall bladder to practically every organ.5 Abdominal wall involvement in carcinoma of the gall bladder generally occurs by direct exten-
380
0 1991 by John Wiley & Sons, Inc.
CCC 0091-2751/91/060380-02 $04.00
LATE SOLITARY ABDOMINAL WALL METASTASIS
381
FIGURE 1. Ultrasound scan demonstrating the metastasis. The lesion is superficial and is predominantly cystic except for an eccentric solid nodule (arrow) i n the dependent wall.
FIGURE 2. The bisected gross surgical specimen showing the irregular cavity with the solid nodule VOL. 19, NO. 6. JULYiAUGUST 1991
382
CASE REPORT: KUMAR ET AL.
~ i o nwhich , ~ is possible only when there is transmural involvement of the gall bladder by neoplasm. This could not have been the case in our patient as the carcinoma had not invaded muscularis. Moreover, the spread via the vascular route manifested as an apparently isolated metastasis to the abdominal wall, without liver involvement is extremely unusual. A review of ultrasound literature did not reveal any documentation of abdominal wall metastasis from carcinoma of the gall bladder. The unusual location of this metastatic lesion makes this case noteworthy. In addition, the ultrasound findings presented an interesting differential diagnosis. Metastatic disease was prime consideration, but lack of any involvement of the liver or mass in the gall bladder fossa was unusual. The presence of a principally cystic mass related to the abdominal wall and close to the site of original incision suggested the presence of an incarcerated hernia, which was the provisional clinical diagnosis prior to the ultrasound study. The absence of peristalsis on real-time ultrasonography and irregular wall of the cystic structure did not support the clinical diagnosis. The possibility of an inflammatory mass was also in the differential because of the fluid component; however, this did not fit with the clinical presentation. In summary, carcinoma of the gall bladder is an aggressive malignancy that often recurs even after the apparent successful removal of small localized lesions. The typical modes of spread and patterns of metastasis are well known, but
awareness of unusual location and atypical ultrasound morphology can help the sonographer in recognizing metastatic disease and facilitating an early diagnosis. Ultrasonography is frequently employed in following patients with a history of carcinoma of the gall bladder, and recognition of patterns of spread and variable ultrasound appearance of metastases will help in assessment of these patients. ACKNOWLEDGMENT
We thank Dr. D. A. Malatjalian, Associate Professor of Pathology, Victoria General Hospital and Dalhousie University, for his assistance, and Mrs. Louise MacDonald for her help in the preparation of the manuscript. REFERENCES 1. Thorbjarnarson B: Carcinoma of biliary tree-I, carcinoma of gallbladder. NY State J Med 75:550, 1975. 2. Frank SA, Spjut HJ: Inapparent carcinoma of the gallbladder. A m Surg 33:367, 1967. 3. Beltz WR, Condon RE: Primary carcinoma of the gallbladder. Ann Surg 180:180, 1974. 4. Fahim RB, McDonald JR, Richards JC, et al: Carcinoma of the gallbladder: A study of its modes of spread. Ann Surg 156:114, 1962. 5. Arminski TC: Primary carcinoma of the gall bladder: A collective review with the addition of twenty-five cases from the Grace Hospital, Detroit, Michigan. Cancer 2:379, 1949.
JOURNAL OF CLINICAL ULTRASOUND
Case Report
Late Solitary Abdominal Wall Metastasis from an Incidental Carcinoma of the Gallbladder: Ultrasound Demonstration Alka Kumar, MD, John Henry MacGregor, FRCP(C), and Shashi Aggarwal, MD
Carcinoma of the gall bladder is the most common malignant lesion of the biliary tract' and is notorious for its poor prognosis. While this is largely due to the late presentation seen in most cases, even early cases, serendipitously discovered at pathology, fare only marginally better because of the propensity for early disseminati~n.~,~ We report one such patient with an incidentally discovered carcinoma of the gall bladder who presented 3 years later with an isolated metastasis at an unusual site. CASE REPORT
A 64-year-old woman presented in 1986 with recurrent attacks of right upper quadrant pain. An ultrasound examination revealed a small contracted gall bladder with multiple calculi and a minimally thickened wall. A diagnosis of chronic cholecystitis with cholelithiasis was made. A routine cholecystectomy was subsequently performed. Examination of other intra-abdominal organs did not show any abnormality. The gall bladder was not opened at surgery as there was no suspicion of tumor. On subsequent gross pathologic examination, a small papillary growth (2.5 cm x 1.5 cm) was found within the gall bladder. Histology revealed a well-differentiated papillary adenocarcinoma localized to mucosa and lamina propria with vascular invasion, but without involvement of muscularis or serosa. The patient returned in October 1989 with a slightly painful lump in the right upper quad-
rant. Examination revealed a mobile, firm mass in the right subcostal region extending below the previous surgical incision. Ultrasound examination revealed it to be predominantly cystic with a mural nodule (Figure l),and located either just beneath or within the abdominal wall. No other abnormalities were identified; specifically, no mass was seen in the gall bladder fossa or liver, and there were no enlarged retroperitoneal lymph nodes. At surgery, a thick-walled, irregular mass containing cloudy fluid was removed from underneath the fascia of the anterior abdominal wall (Figure 2). There was no invasion of surrounding organs. A careful search of the abdominal cavity did not reveal any other metastases. Histology confirmed the presence of well-differentiated adenocarcinoma metastatic from gall bladder. DISCUSSION
From the Department of Radiology, Victoria General Hospital, Halifax, Nova Scotia, Canada B3H 2Y9. For reprints contact Alka Kumar, MD a t present address: Department of Radiology, The Totonto Hospitals- Western Division, 399 Bathurst Street, Toronto, Ontario M5T 2S8, Canada.
Carcinoma of the gall bladder may spread by any of the following routes: lymphatic, vascular, intraperitoneal spread, neural, ductal, and direct e x t e n ~ i o nThe . ~ vascular route is second only to the lymphatic route as a means of ~ p r e a d The .~ route of spread in our patient was most likely via the draining veins, as demonstrated histologically. In contrast to other abdominal viscera that drain primarily into the portal circulation, the venous drainage of the gall bladder ends primarily in the adjacent liver substance, whence it empties into the hepatic vein.4 This implies that should blood-borne metastases occur, the liver would almost always be involved. Vascular invasion has the potential to metastasize carcinoma of gall bladder to practically every organ.5 Abdominal wall involvement in carcinoma of the gall bladder generally occurs by direct exten-
380
0 1991 by John Wiley & Sons, Inc.
CCC 0091-2751/91/060380-02 $04.00
LATE SOLITARY ABDOMINAL WALL METASTASIS
381
FIGURE 1. Ultrasound scan demonstrating the metastasis. The lesion is superficial and is predominantly cystic except for an eccentric solid nodule (arrow) i n the dependent wall.
FIGURE 2. The bisected gross surgical specimen showing the irregular cavity with the solid nodule VOL. 19, NO. 6. JULYiAUGUST 1991
382
CASE REPORT: KUMAR ET AL.
~ i o nwhich , ~ is possible only when there is transmural involvement of the gall bladder by neoplasm. This could not have been the case in our patient as the carcinoma had not invaded muscularis. Moreover, the spread via the vascular route manifested as an apparently isolated metastasis to the abdominal wall, without liver involvement is extremely unusual. A review of ultrasound literature did not reveal any documentation of abdominal wall metastasis from carcinoma of the gall bladder. The unusual location of this metastatic lesion makes this case noteworthy. In addition, the ultrasound findings presented an interesting differential diagnosis. Metastatic disease was prime consideration, but lack of any involvement of the liver or mass in the gall bladder fossa was unusual. The presence of a principally cystic mass related to the abdominal wall and close to the site of original incision suggested the presence of an incarcerated hernia, which was the provisional clinical diagnosis prior to the ultrasound study. The absence of peristalsis on real-time ultrasonography and irregular wall of the cystic structure did not support the clinical diagnosis. The possibility of an inflammatory mass was also in the differential because of the fluid component; however, this did not fit with the clinical presentation. In summary, carcinoma of the gall bladder is an aggressive malignancy that often recurs even after the apparent successful removal of small localized lesions. The typical modes of spread and patterns of metastasis are well known, but
awareness of unusual location and atypical ultrasound morphology can help the sonographer in recognizing metastatic disease and facilitating an early diagnosis. Ultrasonography is frequently employed in following patients with a history of carcinoma of the gall bladder, and recognition of patterns of spread and variable ultrasound appearance of metastases will help in assessment of these patients. ACKNOWLEDGMENT
We thank Dr. D. A. Malatjalian, Associate Professor of Pathology, Victoria General Hospital and Dalhousie University, for his assistance, and Mrs. Louise MacDonald for her help in the preparation of the manuscript. REFERENCES 1. Thorbjarnarson B: Carcinoma of biliary tree-I, carcinoma of gallbladder. NY State J Med 75:550, 1975. 2. Frank SA, Spjut HJ: Inapparent carcinoma of the gallbladder. A m Surg 33:367, 1967. 3. Beltz WR, Condon RE: Primary carcinoma of the gallbladder. Ann Surg 180:180, 1974. 4. Fahim RB, McDonald JR, Richards JC, et al: Carcinoma of the gallbladder: A study of its modes of spread. Ann Surg 156:114, 1962. 5. Arminski TC: Primary carcinoma of the gall bladder: A collective review with the addition of twenty-five cases from the Grace Hospital, Detroit, Michigan. Cancer 2:379, 1949.
JOURNAL OF CLINICAL ULTRASOUND
