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Carcinoma of the gallbladder is considered a disease with a grim prognosis, due primarily to frequent locoregional recurrence after surgery and poor disease-specific survival and overall survival. It is a particularly common malignancy among women in North India. 1 Primary gallbladder cancer usually spreads by direct invasion and via the lymphatics. The incidence of the latter varies from 35%–75%. 2 Distant metastasis is usually due to hematogenous spread. Anminski, in an excellent review of data in the world literature published in 1949, observed that gallbladder carcinoma has been reported to metastasize to virtually every organ in the body,3 a finding that has been corroborated by other authors.4,5 The spread to various distant organs, though vascular in etiology, probably occurs in the late stages of the disease via the systemic and retroperitoneal veins and, until recently, was thought to be of little or no surgical significance. Hence, evaluation for distant metastasis is not routinely considered if the disease remains locoregionally confined. We report a case of otherwise resectable gallbladder carcinoma that presented with painful osseous metastasis.
A 40-year-old woman presented with a history of dyspeptic symptoms and dull, aching, chronic back pain for 1 year. She also had a history of significant anorexia and weight loss. Physical examination revealed a fixed, hard, 8 × 7 cm mass in the region of the left scapula (Figure 1). Breast and thyroid examinations were unremarkable. Abdominal examination revealed a hard palpable gall bladder. Abdominal imaging with ultrasound and magnetic resonance imaging (MRI) revealed a mass in the fundus and body of the gallbladder with cholelithiasis. Radiographs revealed a lytic lesion in the left scapula (Figure 2). A technetium-99 (99mTc) radiolabelled bone scan revealed intense uptake of isotope in the left suprascapular area (Figure 3). Fine needle aspiration cytology from the suprascapular lesion revealed adenocarcinoma (Figure 4).
In view of the disseminated nature of her disease, the patient was offered the option of chemoradiotherapy. She declined and was subsequently lost to follow-up.
It is unusual for patients with otherwise resectable carcinoma of the gallbladder to present with painful osseous metastasis. Radiography and bone scan was suggestive of the nature of the lesion, but diagnosis of metastasis was confirmed by aspiration cytology from the mass. A review of the literature revealed that cases of extra-abdominal metastasis of gallbladder carcinoma to bone,6 skin,7 central nervous system,8 and heart9 have been reported in cases of unresectable disease. Metastasis to the scapula associated with resectable carcinoma gallbladder, however, is reported for the first time.
Carcinoma of the gallbladder is often associated with a dismal prognosis owing to increased propensity for metastasis via multiple routes. Early hematogenous spread can occur via retroperitoneal veins and render it incurable.
We acknowledge the support of the Departments of Nuclear Medicine, Radiology & Pathology, All India Institute of Medical Sciences (AIIMS), New Delhi.